Sarcoidosis is an immune mediated chronic inflammatory disorder that is best characterized by non-caseating granulomas found in one or more affected organs. The COVID-19 pandemic poses a challenge for clinicians caring for sarcoidosis patients who may be at increased risk of infection compared to the general population. With the recent availability of COVID-19 vaccines, it is expected that clinicians raise questions regarding efficacy and safety in sarcoidosis. However, studies examining safety and efficacy of vaccines in sarcoidosis are lacking. In this review, we examine the current literature regarding vaccination in immunocompromised populations and apply them to sarcoidosis patients. The available literature suggests that vaccines are safe and effective in patients with autoimmune disorders and in those taking immunosuppressive medications. We strongly recommend the administration of COVID-19 vaccines in patients with sarcoidosis. We also present a clinical decision algorithm to provide guidance on vaccination of sarcoidosis patients against COVID-19. Sarcoidosis is an immune-mediated chronic inflammatory disorder characterized by the formation of non-caseating granulomas in one or more affected organs. These granulomas are hypothesized to be the result of a maladaptive inflammatory response to an unknown antigen in individuals who are genetically susceptible , 2. SarcSince the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the vector responsible for COVID-19, over 130 million cases have been reported globally with over 2.8 million deaths as of April 2021 . Given tOur knowledge of the pathophysiology of COVID-19 has evolved at a rapid pace since the start of the pandemic. SARS-CoV-2 targets the ACE2 receptor found in the nasopharynx, oropharynx, and lung through its numerous viral structural spike (S) proteins. After SARS-CoV-2 infiltrates the body, it rapidly replicates, spreads, and in some cases, can cause significant organ damage . AlthougIt is inconclusive based on the current available literature if patients with sarcoidosis are at increased risk of contracting COVID-19. A study by Baughman et al., in which risks and outcomes of COVID-19 in sarcoidosis patients were evaluated via self-reported questionnaire, found that the overall rate of COVID-19 was 2.23% or 22,308 cases per million from April to July 2020. Notably, this was higher than the rate of 1,060 cases per million in the USA at the time. However, a subset analysis comparing rates of COVID-19 in sarcoidosis patients and the general population in the same locality over the same time period revealed the rate of infection was similar in both groups . In anotThe current literature suggests that patients with sarcoidosis are at increased risk for worse COVID-19 outcomes. In the same study by Baughman et al., it was found that the rate of hospitalization for sarcoidosis patients with COVID-19 was 15.8%, with one third of those patients requiring ICU care . AdditioThere is limited and conflicting data on the efficacy of vaccination in sarcoidosis patients. In a small case-control study involving 48 sarcoidosis patients and 33 healthy controls, it was found that 50% of sarcoidosis patients did not mount an adequate antibody response to diphtheria vaccination compared to 23% of healthy controls . ConversA major concern regarding the efficacy of vaccination in sarcoidosis is the impact of immunosuppressive medications on mounting an appropriate immune response. Of particular interest are glucocorticoids, which are first-line for treatment of sarcoidosis. Other agents include methotrexate, commonly utilized as a steroid-sparing alternative, and biologic medications such as TNF-alpha inhibitors and B-cell depleting therapy, which may be necessary for refractory disease . To provA meta-analysis of 13 studies involving 886 RA patients evaluated rates of seroprotection, which is defined as attainment of antibody titers above a predetermined level, after influenza vaccination. The rates of seroprotection were similar between RA patients on glucocorticoids and healthy controls . Other iThe European League Against Rheumatism (EULAR) offers several salient guiding principles regarding the vaccination of patients with autoimmune inflammatory diseases: (1) vaccination should be administered during periods of quiescent disease, (2) vaccines should ideally be administered prior to planned immunosuppression and (3) non-live vaccines can be administered safely while patients are on systemic glucocorticoids and disease-modifying antirheumatic drugs . RegardiVaccine development is a process that typically takes anywhere from 10 to 15 years under usual circumstances. However, a COVID-19 vaccine was granted emergency use authorization in the USA by the Food and Drug Administration (FDA) on December 11, 2020, approximately 12 months after the first reported case . The remBesides availability, the largest challenges facing COVID-19 vaccination in sarcoidosis are safety and efficacy. The mRNA COVID-19 vaccines, which currently have the most extensive data and are currently being distributed most widely, demonstrated exceptional efficacy in phase III trials  , 30. PhaPhase III trials show a favorable safety profile for both COVID-19 mRNA vaccines, characterized mainly by short-term, mild-to-moderate pain at the injection site, fatigue, and headache. Serious systemic adverse events were rare for both vaccines and included mostly fevers, fatigue, myalgias, and arthralgias , 30. PhaAnother safety concern with the novel vaccines is a phenomenon known as vaccine-associated disease enhancement (VAED), in which the immune response to the vaccine may be causally linked to more severe adverse outcomes upon infection compared to infection without prior vaccination. This is a phenomenon which has rarely been encountered with existing vaccines or viral infections, but should be kept in mind with any new vaccine . Phase IIn the face of these challenges, it is advised to follow the current CDC recommendations and recent guidance from the American College of Rheumatology (ACR) to vaccinate patients with rheumatic diseases in the absence of any contraindications , 32. As The COVID-19 pandemic offers unique opportunities to develop a greater understanding of novel vaccine technologies in patients with sarcoidosis and other diseases with immune dysfunction; aside from mRNA vaccines, DNA based vaccines are also currently being developed . AdditioCOVID-19 may also offer valuable insights into immunologic mechanisms implicated in sarcoidosis: autophagy is essential for the clearance of bacterial, viral, and inorganic cellular debris. Prior studies have found the spontaneous formation of sarcoidosis-like granulomas in mouse models with knock-out mutations involving rapamycin activation in macrophages, suggesting a role for autophagy in the pathophysiology of sarcoidosis . Recent https://redcap.research.cchmc.org/surveys/?s=TJXWAK4FCJ.Lastly, the current pandemic may allow us to improve health disparities regarding vaccination administration and readiness among different populations. Compared with the rate of COVID-19-related deaths among non-Hispanic White individuals  and adjusting for age, the mortality rate relative to population size is 3.4-fold higher among Black individuals , 3.3-fold higher among Indigenous and Latino communities , 2.9-fold higher among Pacific Islander individuals , and 1.3-fold higher among Asian populations  . Women aThe safety and efficacy of COVID-19 vaccination in sarcoidosis is yet to be determined. However, in light of the severity of the COVID-19 pandemic and the increased risk of severe pulmonary outcomes in sarcoidosis, we strongly recommend that patients with sarcoidosis receive COVID-19 vaccination. Prior studies have shown that vaccines are effective and safe in patients with autoimmune diseases and in those taking immunosuppressive medications. It is important to be cognizant of each patient's immunosuppressants and to counsel patients on risks and benefits of adjusting immunosuppressive regimens in preparation for COVID-19 vaccination. As immunocompromised patients were excluded in the trials for COVID-19 vaccines, careful surveillance must be continued to confirm efficacy and determine the safety profile in these patients. While there are no data available for specific populations with autoimmune disease, the ACR and EULAR have issued practice recommendations for immunocompromised patients , 32.The COVID-19 pandemic offers several opportunities especially in furthering our knowledge of immune responses to vaccination in patients taking immunosuppressives. Additionally, COVID-19 offers a model to allow us to better understand molecular mechanisms that may be implicated in sarcoidosis. We must also use this opportunity to improve attitudes toward vaccination by listening to patient concerns and with each clinical interaction present additional safety and efficacy data to our patients, especially in minority populations.MM wrote and edited the manuscript. MM and NS created the figure. RB, MJ, PK, AC, RN, EL, DC, and WD provided comments and suggestions. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Immune checkpoint inhibitors have brought long-term survival benefit in advanced non-small cell lung cancer patients without driver gene mutations. Even after withdrawal of immunotherapy for a maximum of two years, some patients still benefit from this therapy and the reason is not fully clear. Results from several neoadjuvant trials indicated that in resectable lung cancer patients, neoadjuvant immunotherapy or chemo-immunotherapy led to major or complete pathological responses in a high proportion of tumors. Here we report a case of a brain-metastatic lung squamous cell carcinoma patient who received supratentorial tumor resection and thoracic surgery after chemo-immunotherapy, and achieved a pathological complete response (pCR) in both lesions. This case indicated that pCR can also happen in advanced-stage lung cancer patients receiving chemo-immunotherapy, which may be the reason for long-term benefit of those patients. Immune checkpoint inhibitors (ICIs), represented by anti-programmed cell death-1 (PD-1) and anti-programmed cell death 1igand-1(PD-L1) antibodies, have already become one of the standard treatment options for advanced non-small cell lung cancer (NSCLC) patients without driver gene mutations. The maximum duration of immunotherapy treatment for advanced lung cancer patients is about 2 years . HoweverA 61-year-old male patient with a 40 pack-year history of cigarette smoking was admitted to our department in Nov 2017. Chest CT scanning found a right lung mass (about 10cm in diameter) , which was shown to have a satisfactory consistency to detect tissue TMB compared with whole-exome sequencing(WES) tests . In a reAfter 4-cycles of chemo-immunotherapy, the patient developed severe neurological symptoms, so he had to undergo supratentorial tumor resection to relieve the symptoms. In most cases, the aggravation of the neurological symptoms usually indicates the progression of the brain lesions. However in this case, it was surprising that the pathological result of brain tumor surgery showed flaky necrosis areas between the glial background, the necrosis areas were scattered in epithelioid cell remnants and focal calcification, and lymphocytosis was found around the peripheral blood vessels, indicating the brain lesion of the patient achieved pCR just after 4-cycles of chemo-immunotherapy. Considering that the infarction and neurological symptoms were induced by brain edema rather than brain tumor progression, we speculated that immunotherapy was still effective for treating the patient’s brain metastatic lesion, which was in accordance of the previous reports . On the The patient recovered well after supratentorial tumor resection and received pembrolizumab monotherapy regularly for 2 years. Lung lesion of the patient kept stable and PET-CT showed no metastases, indicating that he had the opportunity to undergo radical resection of lung cancer. Surprisingly, a pCR response was found on the postoperative pathological examination of lung tumor. Actually the lung lesion of the patient had already obviously diminished (about 10cm in Diameter to 4.6cm*3.6cm) after 4-cycles of chemo-immunotherapy and kept stable without significant changes during the process of pembrolizumab monotherapy. It is also worth wondering whether the pCR of a metastatic lesion could predict pathologic response of primary tumor, which may aid in decision making of the multidisciplinary panel discussion.Supported by NCCN guidelines, PET-CT is considered to be relatively better method to predict curative effect of neoadjuvant immunotherapy in NSCLC , 11. HowFinally, it’s also worth considering that even though the patient didn’t receive any treatment after radical resection of pulmonary carcinoma and stopped immunotherapy for nearly 1.5 years in the current case, no reoccurrence of tumor was found in the latest re-examination and he has survived for more than 3.5 years since the first detection of advanced LSCC. The result of CA-209003, which has the longest follow up reported so far, indicated that 5-year OS rate was 16% for ICIs-treated NSCLC patients, while it is unknown why some patients still have long-term survival benefits after stopping after chemo-immunotherapy in this clinical trial . ThroughIn summary, we present the first case of an advanced LSCC patient with brain metastasis who achieved a pCR after chemo-immunotherapy, which may guide treatment options and explain the reasons why some patients still have long-term survival benefits even after chemo-immunotherapy withdrawal.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the ethics committee of Daping Hospital, Army Medical University. Written informed consent was obtained from the participant for the publication of this case report.YH, LL, and CH worked on the conception and design of the case report. CH, LL, NLi, NLu, and SH collected data on patient- reported outcome. QM performed analysis of pathologic results. MJ collected image data of the patient. FP and YY performed molecular analysis. YH, CH, LL and QM wrote and revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by a National Natural Science Foundation of China . Funding from Daping Hospital .Authors FP and YY were employed by Origimed.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: The aims of the present study were to examine the prediction of the threat and coping appraisal utilizing an extended protection motivation theory (PMT) for the motivation to have COVID-19 vaccination and the influence of various information sources on coping appraisal among university students in China. Methods: The sample comprised 3145 students from 43 universities in China who completed an online survey including PMT constructs as well as constructs added to PMT. The PMT constructs comprised motivation to have COVID-19 vaccination, threat appraisal, and coping appraisal. The extended PMT constructs comprised knowledge about mechanisms and information sources of COVID-19 vaccination. Results: Perceived severity of COVID-19 was positively associated with motivation to have COVID-19 vaccination. Receiving information concerning COVID-19 vaccination from medical personnel was associated with greater self-efficacy, response efficacy, and knowledge, whereas receiving information concerning COVID-19 vaccination from coworkers/colleagues was associated with less response efficacy and knowledge. Receiving online information concerning COVID-19 vaccination was associated with greater response cost of vaccination efficacy and less knowledge. Conclusions: This study supported the prediction of perceived severity in the PMT for motivation to have COVID-19 vaccination among university students in China. Vaccination information sources have different effects on students’ coping appraisal of COVID-19 vaccination. The coronavirus disease 2019 (COVID-19) pandemic has continued to impact multiple domains of human lives since its emergence at the end of 2019 ,4,5,6. AIn order to use psychological factors effectively to enhance an individual’s acceptance to vaccination, the use of applied theory is important. Webb and Sheeran synthesized the empirical evidence concerning health behavior changes and found that the use of a theory can assist the healthcare providers in designing an effective intervention for behavior change . TherefoResearch has applied PMT ,22 to exA systematic review confirmed that perceived high severity, high vulnerability, high response efficacy, high self-efficacy, and low response costs contributed to high motivation to have vaccination for influenza during the 2009 pandemic . ResearcThe application of PMT in explaining the motivation to have COVID-19 vaccination warrants further studies for several reasons. First, although a recent Swiss study applying PMT demonstrated that individuals show a unified way of determining their motivation to have six different vaccinations , it is uThird, research has shown that the sources from which individuals obtain information on vaccination play a crucial role in their attitudes and behaviors in relation to vaccination ,31,32. AUniversity students experience a variety of challenges during the COVID-19 pandemic; they may experience interruption of academic learning and routine lives on campus, lose on-campus jobs, disconnect from friends and partners, and struggle with the isolation in lockdown or quarantine . ResearcBased on the PMT, all factors and derived hypotheses of the extended PMT model are summarized in Hypothesis 1(H1).The motivation to have COVID-19 vaccination will have significant positive relationships with perceived severity of COVID-19, perceived susceptibility to COVID-19, perceived efficacy of the vaccine (response efficacy), confidence in an individual’s ability to obtain a vaccination (self-efficacy), and knowledge about the mechanisms of vaccination, as well as a significant negative relationship with perceived response costs of COVID-19 vaccination.Hypothesis 2a(H2a).Various information sources concerning COVID-19 vaccination will have different associations with various components of coping appraisal and knowledge.Hypothesis 2b(H2b).Self-efficacy, response efficacy, response costs and knowledge will mediate the association between information sources and motivation to have COVID-19 vaccination.The inclusion criteria for participant eligibility were that individuals had to be (i) studying in a university in mainland China during the survey period, and (ii) young adults . The study utilized an online survey. The research team engaged the help of college counselors in different universities to help disseminate the online survey to eligible participants via their respective online social communities. The survey period was between 5 and 16 January 2021, and the study protocol was approved by the Institutional Review Board of the Jianxi Psychological Consultant Association (IRB ref: JXSXL-2020-DE22) before the research team approached the college counselors. A total of 3145 students from 43 universities voluntarily participated and all of them provided online informed consent. All the survey items were completed with no missing data because the online survey could only be submitted when all the items were answered. Moreover, the sample size of 3145 achieved sufficient power from the a priori sample size calculation with the following considerations: type I error at 0.05; power at 0.95; degrees of freedom at 15; null RMSEA at 0; and alternative RMSEA at 0.05. From the aforementioned considerations, 750 participants were deemed to be sufficient.The measures used in the present study are listed in The PMT measure included threat appraisal (two items for perceived severity of COVID-19 and four items for perceived vulnerability to COVID-19), self-efficacy in having COVID-19 vaccination (one item), response efficacy of COVID-19 vaccination (six items), response cost of COVID-19 vaccination (three items) and knowledge about the mechanism of COVID-19 vaccination (three items). A higher score on each item indicates a higher level of threat appraisal, self-efficacy, response efficacy, response cost, and knowledge.There were seven sources of COVID-19 vaccination information identified in the present study. These were via the internet, traditional media , friends, family, coworkers/classmates, on-site training events concerning COVID-19 , and medical personnel. Each source was assessed using one item rated on a three-point Likert scale. A higher score on each item indicates receiving COVID-19 vaccination information more from that source.Motivation to have COVID-19 vaccination was assessed using two items. A higher score on each item indicates a higher level of motivation to have COVID-19 vaccination.As well as the aforementioned PMT variables, the online survey asked several demographic questions, including the participants’ age, program of study , and level of education (undergraduate or postgraduate).t-tests and χ2 tests were used to compare the characteristics of the present sample with those of the Chinese university students. Pearson correlation coefficients were then used to examine the bivariate associations between the studied variables that were tested in the proposed model. Because of multiple comparisons made in the Pearson correlations, the significance level for the Pearson correlations was adjusted using Bonferroni method with p < 0.0005 indicating significant correlation. Structural equation modelling (SEM) using diagonally weighted least squares estimator was utilized to examine whether the collected data fit with the proposed model. More specifically, different sources of COVID-19 vaccination information were proposed to be the explanatory factors of PMT components , except for the threat appraisal , and knowledge about the mechanism of COVID-19 vaccination. All PMT components and knowledge were proposed to be the explanatory factors of the motivation to have COVID-19 vaccination. Therefore, PMT components  and knowledge were treated as mediators in the proposed model, and the mediation effects were tested using the Sobel test to examine whether such effects were significant. To evaluate the model fit, the fit indices included a nonsignificant χ2 test (where significance level was set at p < 0.05), a comparative fit index (CFI) > 0.95, a Tucker–Lewis index (TLI) > 0.95, a root mean square error of approximation (RMSEA) < 0.06, and a standardized root mean square residual (SRMR) < 0.08 [t-value higher than 1.96 indicates significance. Moreover, the proposed model was tested for the entire participants; then, stratified according to the study major . The SEM was conducted using LISREL 8.7.Means, medians, and frequencies were calculated to understand the descriptive statistics of participants’ characteristics and their scores on the studied variables. One-sample ) < 0.08 . For medn = 3062; 96.2%). Moreover, the majority of the participants were studying in a major subject not related to the health field  and slightly over half of the participants were females . As compared with the university students in China, the present sample was slightly older , but comparable in gender distribution , educational level , and study major . Characteristics of the participants are shown in The zero-order bivariate correlations between the studied variables are presented in 2 test . With the supported fit indices, path coefficients of the tested model were examined (p < 0.001). Self-efficacy, response efficacy, response cost, and knowledge were not significantly associated with motivation to have COVID-19 vaccination. The results only partially supported H1.The tested model had satisfactory data-model fit , except for the significant χexamined . Regardip = 0.01), information from coworkers/classmates to response efficacy of vaccination , information from medical personnel to response efficacy , information from the internet to response cost of vaccination , information from on-site training to response cost , information from the internet to knowledge , information from traditional media to knowledge , information from coworkers/classmates to knowledge , information from academic training to knowledge , and information from medical personnel to knowledge . These results supported H2a.Receiving information concerning COVID-19 vaccination from medical personnel to self-efficacy to have COVID-19 vaccination  and knowledge concerning the mechanism of COVID-19 vaccination did not significantly predict the motivation to have COVID-19 vaccination. Unlike other vaccines that were developed over a long period (often many years), the COVID-19 vaccines were developed very quickly. Although governments around the world expect vaccination to minimize the spread of COVID-19, individuals may feel uneasy about COVID-19 vaccination and may be unsure about vaccination efficacy in mitigating the harm posed by COVID-19 and personal ability to have COVID-19 vaccination. Individuals may also have little understanding of adverse effects of COVID-19 vaccination. Given that individuals may activate a threat appraisal first and a coping appraisal later when they are confronted with a threat , individPrevious studies have shown that receiving vaccination information from formal and informal sources may have different effects on individuals’ coping appraisal of vaccination ,31. The It is worth noting that receiving online information concerning COVID-19 vaccination was associated with greater response cost of vaccination efficacy and less knowledge. The internet has been a major source of COVID-19 information, especially during the period of lockdown. However, a lot of online information concerning COVID-19 lacks scientific rigor . Online The present study had a few limitations that should be noted. First, the participants in the study were recruited via convenience sampling, which restricts the generalizability of the present findings. The use of this sampling method also meant the number of students approached was unknown  and the response rate was unable to be estimated. Second, given that information concerning COVID-19 vaccination is released on a daily basis, university students’ threat and coping appraisals, knowledge, and motivation to have COVID-19 vaccination may change over time. The cross-sectional design of the study also limited the possibility to capture such changes. Third, although the participants’ knowledge about the mechanism of COVID-19 vaccination was evaluated, participants’ accuracy of knowledge could not be confirmed. Additionally, the survey did not assess participants’ experiences of previous exposure to COVID-19 and was unable to determine the influence of previous exposure to COVID-19 on their motivation to get vaccinated. In addition to information sources, factors such as physical and mental health that may influence individuals’ threat and coping appraisals and motivation to have COVID -19 vaccination also warrant further study. Finally, the most important limitation of the present study concerns the restriction of internet use in mainland China. The authorities and the government in mainland China prohibit the use of some websites ; therefore, participants in the present study might not have full freedom to obtain all the COVID-19-related information they require. In this regard, the hypotheses relating to information sources concerning COVID-19 vaccination may not have been correctly answered by the present study’s participants. Therefore, future studies are warranted among other samples  to corroborate the present study’s findings.The present study found that perceived severity of COVID-19 significantly predicted university students’ motivation to have COVID-19 vaccination in China. Receiving information of COVID-19 vaccination from medical personnel, the internet, and coworkers/colleagues had different effects on university students’ coping appraisal and knowledge of vaccination. Based on the results, it is recommended that government health departments invite medical personnel to introduce COVID-19 threats in a balanced way to promote individuals’ awareness as well as the benefits and costs of receiving vaccination to enhance individuals’ appraisal of COVID-19 vaccination. It is also recommended that further studies based on PMT are needed to examine other factors related to motivation and behaviors that would increase the uptake of COVID-19 vaccination.


This review intends to provide an overview on the role of halide anions in the development of the research area of asymmetric anion-binding organocatalysis. Key early elucidation studies with chloride as counter-anion confirmed this type of alternative activation, which was then exploited in several processes and contributed to the advance and consolidation of anion-binding catalysis as a field. Thus, the use of the halide in the catalyst–anion complex as both a mere counter-anion spectator or an active nucleophile has been depicted, along with the new trends toward additional noncovalent contacts within the HB-donor catalyst and supramolecular interactions to both the anion and the cationic reactive species. Halogens and the respective anionic halides occupy an essential role in natural and chemical processes –4. WhileHowever, following the advances in anion coordination and supramolecular chemistry –11, thisN1 or SN2 pathway.In the early stages of anion-binding-catalysis development, some reactions might have potentially been mistaken to be hydrogen-bond catalyzed ,23. WhilFor enantioselective purposes, solvation of the ion pair is crucial for obtaining high stereoinduction. While more polar solvents give solvent-separated or solvent-shared ion pairs – in which the components have their own solvent shells –, nonpolar solvents are more likely to lead to contact-ion pairs. As such, the cation and anion are in closer proximity as one solvent shell is shared. If a chiral catalyst binds then to the anion, a chiral contact-ion pair can be formed, which is necessary for the transfer of the chiral information to the product. As a consequence, most of the reported methods embracing enantioselective anion-binding catalysis rely on the use of nonpolar solvents such as ethers or aromatic compounds.1) with a thiourea catalyst  that is then able to attack the benzaldehyde for product 2 formation.The concept of anion-binding catalysis was first penned by Schreiner et al. in 2006, who realized the acetalization of benzaldehyde  wi4 in the presence of acetyl chloride and 2,6-lutidine, where the chiral thiourea catalyst 6 was employed to enable good yields and enantioselectivities  through alteration of the N-substituent of the pyrrole substrate and the acylating reagent quinolinium intermediate II. Hence, the reaction would follow a SN1-type mechanism via anion-binding catalysis. In Jacobsen’s report, the acylating agent 2,2,2-trichloroethyl chloroformate (TrocCl) and nucleophilic silyl ketene acetals were employed to obtain the dihydroisoquinolines 22 in good yields and enantioselectivities up to 92% ee. The Takemoto group with their system also achieved yields up to 78% and enantioselectivities up to 97% ee, using phenyl chloroformate as the acylating reagent and vinylboronic acids as the nucleophiles in the presence of sodium bicarbonate.During this early period, the group of Jacobsen also reported an asymmetric thiourea-catalyzed Reissert reaction of isoquinolines 21  36]. Th. Th21 -intermediate reacts faster than its opposing enantiomer, allowing for excellent yields up to 95% and high enantioselectivities up to 91% ee.In 2014, Jacobsen et al. developed a highly enantioselective selenocyclization reaction of olefins nd donor  16]. Al. Al26, umeso-aziridines 29. In their work, the bifunctional phosphinothiourea catalyst 31 promoted the C–N bond cleavage by hydrochloric acid upon initial protonation  over the 1-naphthyl (54) to the 4-pyrenyl (55) substituent led to improved yields from 12% to 72% and enantioselectivities from 25% to 94% ee.Inspired by cationic terpene-type cyclization cascades, Jacobsen’s group turned their attention to the structure and properties of the chiral part of thiourea catalysts by introducing extended π-groups. A series of thiourea catalysts on of 51  69]. Mo. Mo53–5558 with a dibenzothiophene functionality serves as a dual H-bond donor and Lewis base to facilitate the cyclization of hydroxylactams 56. Thus, indolizine and quinolidizine frameworks 57 were accessed in excellent yields up to 93% and enantioselectivities up to 94% ee. Increased aromaticity proved again to be essential for achieving high enantioselectivities. Additionally, Lewis base activation of the allylsilane substrates through the thiourea sulfur atom is proposed to be crucial, while the urea analog of the catalysts proved less efficient and led to diminished reactivity and stereoselectivity. Further mechanistic studies corroborated this hypothesis as more electron-rich allylsilane derivatives were consumed slower despite being inherently more nucleophilic.In 2016, this cation–π strategy was further employed for the development of an enantioselective aza-Sakurai cyclization  70]. In. In70]. 59  and also a detriment in enantioinduction was observed with 76% and 46% ee, respectively.Besides the introduction of cation–π interactions in anion-binding catalyst design, bisthiourea catalysts have been applied with the aim of accelerating certain catalytic reactions. In this regard, the group of Seidel reported in 2016 an enantioselective HCl co-catalyzed oxa-Pictet–Spengler reaction employing bisthiourea catalyst thiourea  51]. Th. Th72 be73) was more closely examined  into the pyrrolidine moiety of the initial catalyst design, the amide is conformationally constricted to the (Z)-rotamer .–76.73) wpathways . Moreove-rotamer . Consequamer [77  [76]. Duosphates .80 by covalently linking it into the more rigid macrocycle 81 . The reaction was found to proceed stereospecifically with inversion of the anomeric configuration and, therefore, being dependent on the configuration of the electrophilic partner 78. With this observation, the reaction was concluded to proceed via a SN2 mechanism. However, mechanistic investigations revealed the existence of a competing SN1 pathway featuring an oxocarbenium cation, which explains the formation of the minor diastereoisomer  with silylketene acetals  catalyst systems. Hence, the possibility of employing the catalyst-bound halide anions in the key ion pair complexes as active nucleophiles were also featured. Though less explored so far than their use as simple, inert counter-anions to build the ion pair, this approach provides new possibilities and substantially broadens the synthetic applicability of anion-binding catalysis. Finally, the evolution from simple H-bonding to complex halide anion-binding catalyst designs has been outlined. Recent reports show that synthetic and computational research become more intertwined, and a trend towards multiple noncovalent interactions, as well as supramolecular chemistry, might be in-bound soon.Based on the tremendous developments in this field thus far, important advances in the understanding of complex anion-binding processes, the design of more potent, efficient catalysts, and the development of innovative activations and reactions can be certainly envisioned to be further evolved in the near future.


Life was once normal before the first announcement of COVID-19’s first case in Wuhan, China, and what was slowly spreading became an overnight worldwide pandemic. Ever since the virus spread at the end of 2019, it has been morphing and rapidly adapting to human nature changes which cause difficult conundrums in the efforts of fighting it. Thus, researchers were steered to investigate the virus in order to contain the outbreak considering its novelty and there being no known cure. In contribution to that, this paper extensively reviewed, compared, and analyzed two main points; SARS-CoV-2 virus transmission in humans and detection methods of COVID-19 in the human body. SARS-CoV-2 human exchange transmission methods reviewed four modes of transmission which are Respiratory Transmission, Fecal–Oral Transmission, Ocular transmission, and Vertical Transmission. The latter point particularly sheds light on the latest discoveries and advancements in the aim of COVID-19 diagnosis and detection of SARS-CoV-2 virus associated with this disease in the human body. The methods in this review paper were classified into two categories which are RNA-based detection including RT-PCR, LAMP, CRISPR, and NGS and secondly, biosensors detection including, electrochemical biosensors, electronic biosensors, piezoelectric biosensors, and optical biosensors. The Coronaviridae family to which the Coronavirus belongs is also a part of the Nidovirales order and is the subfamily of Orthocoronavirinae. The subfamily of Orthocoronavirinae consists of four types which are delta (δ) beta (β), alpha (α), and gamma (γ) coronavirus as shown in Preliminary studies on Coronaviruses were reported in the 1930s. In contrast, the human type of the virus named (HCoVs) was first discovered in the 1960s. Until recently, seven types of the virus have been discovered including the HCoVs-NL63 and HCoVs-229E 229E (α-Corona viruses) and HCoVs-OC43, HCoVs-HKU1 (β-Corona viruses), severe acute respiratory syndrome-CoV (SARS-CoV), and Middle East respiratory syndrome-CoV (MERS-CoV), and SARS-CoV-2 which was discovered in 2019 ,6.Coronaviruses were mostly known to infect animals of mammal species and birds; it is only recently that they have infected humans. The latest research reported seven types of the Coronavirus that can infect humans, four of which are . These viruses are reported to cause a respiratory system infection, in which symptoms include coughing, sore throat and coryza. Other reported symptoms that are less likely to occur are pneumonia, bronchiolitis, and bronchitis, whereas three of them MERS-CoV, SARS-CoV and SARS-CoV-2 result in illnesses with fluctuating severity to the human respiratory system. The severity ranges from the common cold to incurable pneumonia ,8,9,10.In 2002, severe acute respiratory syndrome (SARS) was reported first in China and soon after affected other countries worldwide. The virus caused infection in human respiratory system organs that were incurable and therefore fatal in most cases ,12,13. TA decade later a new variation of the virus known as (MERS-CoV) Middle East respiratory syndrome started spreading in the Middle East in 2012; the first fatality reported was at the hospital in Jeddah, Kingdom of Saudi Arabia ,18,19. TIn December 2019, seven years after the appearance of MERS-CoV, a new case of virus infection was reported in Wuhan, China. The virus was named by the World Health Organization (WHO) the 2019 novel Coronavirus (2019-nCoV). The name was later changed to SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), based on its similarities to SARS-CoV. The WHO named the disease caused by the virus infection as COVID-19 . Based oHowever, the enforced strategies are not a permanent solution as they will have unfavorable impacts on the economy, education, food system including mental wellbeing . In respThe genomic structure and proteins of SARS-CoV and SARS-CoV-2 viruses have similarities more than differences. Both viruses reported being spherical single-stranded RNA viruses that are known to have protein spikes that are protruding from the virion surface. This characteristic in the virus shape gave it its name, Coronavirus, driven from the Latin word corona due to its resemblance to the crown shape ,39.SARS-CoV-2 genome consists of 29,903 nucleotides that are significantly similar to SARS such as SARS-CoV that infects bats by 81% nucleotides resemblance. Both viruses have a unique replication approach considering their large RNA genome with none segmented positive-sense RNA genome featuring a shape of 5′cap and 3′ poly (A) tail. The unique structure of the virus allows the replicase polyproteins to understand the genome for translating 2/3 of the genome encodes nonstructural proteins (NSPs). In contrast, the remaining 1/3 encodes for structural and auxiliary proteins. There are four main structural proteins known as (S) spike, (M) membrane, (E) envelope and nucleocapsid (N) proteins. Furthermore, PP1a and PP1b are viral replicas created by the virus are later customized into 16 mature NSPs ,41. The The S protein in the virus that weighs about 180 kDa molecular units and is 20 nm long is possibly a target for inhibition of viral entrance and the growth of antibody-based therapeutics to prevent the disease. The protein comprises two subunits which are S1 and S2. The S1 receptor is for binding, which contains the receptor-binding domain (RBD), which identifies and binds to its receptor angiotensin-converting enzyme 2 (ACE2), which is found in the epithelial cells of the lungs. The S2 subunit for membrane fusion, by undertaking specific conformational modifications, induces membrane fusion, which enables viral entry into the host cell. This protein is the chief focus of neutralizing antibodies, which in response prevents infection and further dissemination by stopping binding to ACE2 ,43.The E protein is a small membrane protein that manages virion construction and has added effects on the affected host cells. During the host cell infection, the E protein controls the stress response in the cell which, as a result, modifies the virulence of the virus leading to caspase-mediated cell death. The M protein is the amplest in the viral envelope, this protein is essential to the virion particles creation. N protein helps in creating the virial nucleocapsid by forming complexes with the genome RNA within the viral membrane. Both M and N proteins play an important role in RNA replication .With the emergence of COVID-19, different detection techniques were developed in the pursuit of containing the rapidly spreading virus by identifying prospective patients using image processing, artificial intelligence, biosensors and others.Image processing was utilized for the detection of COVID-19; an Image processing technique based on interferometry that uses the phenomenon of interference of waves was developed to detect COVID-19 . ResearcArtificial intelligence has also been widely used in the medical community and, without doubt, was used to detect COVID-19 patients; AI-based techniques were successfully used to diagnose and classify COVID-19 by studying and analyzing X-ray and CT scan images . AI has Deep learning techniques were used to automatically diagnose affected patients which helped radiologists with suspected patients’ diagnoses . A COVNeAn automatic COVID-19 detection approach based on deep learning that applies multilayer-Spatial Convolutional Neural Network CNN was successfully proposed, which can identify affected patients by scanning chest X-ray images and CT scans . AnotherDetection techniques merged AI with other approaches for COVID-19 detection; a study presented a joint approach including electrochemical biosensing of SARS-CoV-2 empowered by AI to produce bioinformatics that is needed for an early patient’s diagnosis . A hybriSimilarly, biosensors were used to detect COVID-19 patients; the MERS-CoV detection approach was developed using an LSPR biosensor with surface-enhanced Raman scattering (SERS) multiplex . AnotherOther strategies for COVID-19 detection were also recorded; a device was developed to detect COVID-19 in a single reaction using a multiples RT-qPCR assay . AnotherThis review studied and analyzed a collection of literature focused on the current viral virus known as COVID-19, which have been divided into two main categories: Transmission COVID-19 Human Exchange and detection techniques of COVID-19 virus. The first category has four subcategories which are Respiratory Transmission, Fecal–Oral Transmission, Ocular Transmission and Vertical Transmission. The second category has two subcategories for detection techniques which are: a. Based on an RNA method that includes next generation sequencing, RT-PCR, LAMP and CRISPR; b. Based on a biosensor that includes electrochemical biosensor, electronic biosensor, piezoelectric biosensor, and optical biosensor as shown below in The literature was collected using several search engines which were PubMed, WOS, Scopus, Science direct, IEEE Xplore, as well as Google scholar.With the emergence of the COVID-19 virus, much research has proved that it is transmittable between humans. In order to contain the pandemic, the need to understand the virus’s various modes of transmission is crucial. This section elaborates four human-to-human transmission modes, which are respiratory transmission and fecal–oral transmission. Both are the most popular modes of transmission. Ocular transmission and vertical transmission are also possible modes of transmission; the first one is less common, while the last one is not yet confirmed.Collectively the recently discovered coronaviruses which are SARS-CoV, MERS-CoV, and SARS-CoV-2 share the effect of infection in the respiratory tract . PrimaryAlthough the spread of COVID-19 through droplets, surface contact and aerosolized transmission has been well-publicized, the fecal–oral route is yet another identified method of transmission. According to a meta-analysis by the New England Journal of Medicine, it was found that fecal viral shedding continues throughout the disease, even after nasopharyngeal tests appear negative. Moreover, gastrointestinal symptoms seem to be common for COVID-19 patients, with a prevalence of approximately 18% ,93. ReseRecent studies indicate that tears are a potential source for this infection and that the conjunctiva may maintain viral replication for a long period . AnotherThe human eye could be the entry portal for the virus to enter the body, the eye’s cornea, and conjunctiva form the ocular mucosa surface, which is prone to infection in close proximity with infected people or contaminated hands. Considering the human body anatomy where the eyes mucus is linked to the respiratory system through the nasolacrimal duct, the eyes could be the entry point of COVID-19 . A ChineSARS-CoV-2, resulting in COVID-19 disease, emerged as a third coronavirus epidemic at the end of 2019. Despite the fact that scientific evidence suggests that women are less likely than men to become infected with COVID-19 . PregnanTransmissions through the human exchange are Respiratory, Fecal–Oral, Ocular and Vertical. Each transmission is compared in Both Respiratory and Fecal–Oral Transmission probability are more likely to happen, they also have a higher possibility of transmission. The entry organs are mouth and nose in Respiratory Transmission via direct and indirect transmissibility approach, while in Fecal–Oral Transmission it is the mouth via indirect transmissibility approach. Both transmissions as well as Ocular transmission can happen for both genders men and women and both have confirmed cases as well as Ocular transmission.Ocular and Vertical transmission is less likely to happen while Vertical Transmission has the rarest possibility and is yet to be confirmed. The virus entry organ in the ocular transmission is the Eyes via direct and indirect contact whereas in Vertical transmission it is the uterus via direct contact and it can only affect pregnant females.The recent pandemic of COVID-19 has drawn attention to the high importance of rapid and accurate diagnostic assays. In parallel to the outbreak, researchers from different areas worldwide have worked together for such assays, concurrently to other many assays that are approved along with the ones that are yet clinically validated. Various techniques of Coronavirus detection have been studied to detect potential patients, in this paper we elaborate on two main methods which are Ribonucleic Acid (RNA)-based techniques and Biosensor techniques.Molecular diagnostic assays are the leading group of tests used to diagnose COVID-19, mainly using RNA to detect the SARS-CoV-2 virus in patients. The latest detection techniques of COVID-19 RNA, including those still in the development stage, are CRISPR and next-generation sequencing (NGS). Another detection method which is the current golden standard technique is reverse transcription-polymerase chain reaction (RT-PCR) as well as the second most used method which is known as loop-mediated isothermal amplification (LAMP). This section thoroughly explains the previously mentioned techniques and their applications in the efforts of COVID-19 detection.Technologies along with bioinformatics played a significant role in changing the conventional research on viral pathogens and attracting attention to the field of virus diagnosis . Recent NGS is based on massively parallel sequencing, meaning that billions of short DNA fragments are sequenced simultaneously producing short sequence “reads” rendering dramatically reduced time and cost of sequencing . This teRT-PCR is the most reliable and gold standard method for the identification of COVID-19 infection . becauseThere are two types of RT-PCR testing; the first type uses a single tube containing the required primers to execute the whole process of RT-PCR reaction, the other type is known as two-step, whereby it requires more than one tube to complete the test by doing separate reverse transcription and amplification reactions while offering higher flexibility and accuracy than the other test type. It demands fewer starting materials as well as allowing multiple targets quantification using cDNA stocks. Nevertheless, the first type is more appealing for its quick setup and limited sample handling .Accuracy and specificity are the reason why RT-PCR is widely used despite its expensive price, time-consuming test duration as well as the need for experienced staff .The second in popularity for COVID-19 detection after PCR testing is LAMP testing, PCR testing requires two primers (one in the front and one in the back section), which presents a challenge for LAMP testing that occurs in designing primers and their conflict prevention. Whereas, the LAMP technique needs four or six primers that divide the target sequence into three regions in the forward section and the other three in the back section making a total of six regions. LAMP process is favored because it is executed in an isothermal condition which is an affordable and rapid method. Furthermore, numerous researches reported the application of the LAMP method for coronaviruses detection ,127,128.LAMP works on molecular amplification techniques, by rapidly amplifying the genomic material using high efficiency. This technique primarily uses targeted DNA that is synthesized at a stable temperature of 60–65 °C achieved by using explicitly modeled primer sand enzyme (DNA polymerase) that uses strand displacement activity rather than heat denaturation which is used in PCR techniques and within 60 min or less the targeted sequence is amplified to more than 109 copies resulting in the shape of cauliflower including a stem and a loop form of DNA with many inverted repetitions .Researchers combined the techniques of reverse transcription and LAMP (RT-LAMP) and produced a detection method that is characterized by being one-step with the high-throughput method of detection for finding the RNA of SARS-CoV-2 with 100 copies/reaction of an RNA virus. By applying this method the results will be given in 30 min which makes it suitable for POC test and screening application for its simplicity and rapidness compared to RT-qPCR and its needlessness for complicated equipment .Clusters of regularly interspaced short palindromic repeats (CRISPR) possess a frequent series of nucleotides and tiny-scaled spacer sequences. CRISPR-associated proteins known as CAS acts as the nuclease enzymes. Both are used as a bacterial defense system to protect from unknown invaders and are extensively used in RNA modification, therapy using gene alteration, and viral genome detection. Over the last few years, CRISPR has been widely utilized in the field of Vitro diagnostics due to its allele accuracy which is significant in its successful implementation and delivering high accuracy detection and treatment .Several types of research were conducted using CRISPER-based detection systems for SARS-CoV-2 virus detection. For example, a study reported the successful development of a CRISPR-Cas13a-based mobile phone assay that is non-amplified to detect SARS-CoV-2 by testing extracts of RNA taken from nasal swaps. The assay attained ~100 copies/µL sensitivity in less than an hour . AdditioThis paper studied the detection of Coronavirus using RNA via RT-PCR, LAMP, NGS, and CRISPR Nowadays, researchers are focusing on developing detection tools using biosensors techniques due to their sensitivity, mobility and miniaturization. This section explains four widely used biosensors techniques which are electrochemical biosensors, electronic biosensors, piezoelectric biosensors and optical biosensors.Electrochemical biosensors are biological concentrations of information that are converted into an analytically relevant signal by using a current or voltage . These bIn a recent study focused on SARS-CoV-2 detection, researchers proposed the detection of COVID-19 N-gene using an antifouling electrochemical biosensor. The biosensor is assembled based on electropolymerized polyaniline (PANI) nanowires combined with lately designed peptides. The biosensor detects the N-gene by using biotin-labeled probes that are immobilized onto peptide-coated PANI nanowires, creating an electrochemical interface that is antifouling and susceptible. The recorded detection limit of this biosensor was shallow at (3.5 fm) .A biosensing device based on field-effect transistors (FETs) consists of a three-electrode structure containing the source, drain, and gate and was developed for the detection of small molecules and the diagnosis of viral diseases. The FET is an electric biosensor that detects changes in surface potential after the target molecule binds to the biorecognition element immobilized on the highly conductive chip surfac . For insAn electronic biosensor device based on FET was developed for the detection of COVID-19 related viruses in clinical samples. The sensor was prepared by covering graphene sheets used in the FET with a unique antibody to the spike protein of SARS-CoV-2. The three determinants of the device’s performance are using a cultured virus, antigen protein, and nasopharyngeal swab specimens from infected patients. The resulting device is a super-sensitive immunological diagnostic method for COVID-19 with minimum sample preparations .Piezoelectric biosensors are a collection of analytical devices operated based on recording affinity interaction. A piezoelectric platform or piezoelectric crystal is known as a sensor part that works on the basis of oscillations change that results from the mass tied on the piezoelectric crystal surface .Piezoelectric biosensors technology is commonly used to detect hormones, cells, bacteria, viruses, and to study a wide range of interactions on a biomolecular level. This tech offers immediate and unlabelled transduction with high susceptibility, simplicity, and velocity ,155. In High sensitivity and selectivity are benefits of optical biosensors. They can provide precise detection based on a variety of signals, including absorption, refraction, reflection, dispersion, infrared, polarisation, chemiluminescence, fluorescence, phosphorescence, and so on . In the Four types of optical biosensors , and fiber optic) will be thoroughly described in this section.Starting with the up to date known largest group of sensors Fluorescence-based optical biosensors, its popularity is credited to the accessibility of countless fluorescent probes, high quality and fitting optical instruments . This biA detection stripe assay based on fluorescent immunochromatographic was built to detect N proteins in a duration of 10 min using samples of nasopharyngeal aspirate and urine with a 68–98% sensitivity rate . Another−1. Thus, it exhibited exceptional selectivity in the existence of different respiratory viruses in human bio serum [Another auspicious platform for pathogens, as well as COVID-19 N gene detection biosensors, is SPR-based biosensors, owing to their characteristic of label-free real-time sensing . An addiio serum .In addition, the localized surface plasm coupling fluorescence (LSPCF) fiberoptic biosensor was developed to combine a sandwich immunoassay with the SARS coronavirus LSP detection technique. The SARS-CoV N protein can detect very low concentrations (~1 pg/mL) in serum from the LSPCF fiber-optic biosensor .Biosensors that use fiber optics are another type of optical biosensor. A device made from fibers is used in the field of optical science to measure biological species  . To deteCOVID-19 detection methods based on biosensor usage were thoroughly analyzed by comparing 11 research reported studies from the year 2004 up till now, including the detection of SARS-CoV, MERS-CoV and COVID-19. The detection techniques that were extensively explained previously are like any other techniques have their advantage and limitations. RNA-based detection techniques  advantages include specificity and sensitivity. In comparison, limitations include the need for extracting RNA from clinical samples and the inability to detect already recovered patients. On the other hand, biosensors advantages include affordability for both electrochemical and electronic sensors, whereas for piezoelectric and optical advantages include rapidness, specificity and sensitivity. The common limitation for electrochemical and electronic is that both are time-consuming. Below, The COVID-19 pandemic is ongoing globally and is yet to be contained; simultaneously, research in enhancing methods of preventing the spread is persistent. This review article compiled and studied research concerning the recently discovered COVID-19 virus that is rapidly morphing and highly transmittable between humans. This article addressed the pre-mentioned issue by comparing and analyzing SARS-CoV-2 transmission methods between humans and detection methods utilized to detect COVID-19. Human-to-human exchange transmission through the respiratory system proved to be the most efficient method of transmission, followed by fecal–oral transmission. Rare cases were recorded for the ocular transmission method, whereas vertical transmission has not yet been confirmed. In synchronization with the virus’s rapid spread, advancements in the detection techniques with effective diagnoses were urgently needed by clinicians. This paper gives a comprehensive review of COVID-19 virus detection techniques based on RNA and biosensors. RNA-based methods included the golden standard testing set by WHO known as RT-PCR and RT-LAMP. The latter is deemed a possible proper substitute due to it being more economical and rapid compared to RT-PCR. Last but not least, the paper reviewed the latest advancements in detection techniques using biosensors for SARS-CoV-2 detection, by using target genes in clinical samples which are the Spike (S) protein, Nucleocapsid (N) protein as well as Antigen sputum, and IgM antibody. Biosensors are proven to be rapid, sensitive, precise, mobile, economical, and have the ability for miniaturization. Therefore, COVID-19 detection using biosensors is innovative and promising.


The value of using comprehensive but cumbersome coding instruments to assess therapeutic competency is unclear. Shorter, more general instruments may enable more research in this important area. The aim of this study was therefore to psychometrically evaluate a shorter version of the Cognitive Therapy Scale-Revised (CTSR) and to compare it with the full-length version.A four-item coding instrument (the CTSR-4) was derived from the CTSR. Four experienced psychotherapists used the CTSR-4 to assess 50 fifteen-minutes samples from audio-recorded CBT sessions. The criterion validity of the CTSR-4 was analyzed by comparing the results with previously expert-rated CTSR scores from the same sessions, and the inter-rater agreement between the three coders was calculated.The CTSR-4 showed good criterion validity (ICC = .71–.88) when compared to the expert ratings of the complete CTSR, and the inter-rater agreement was adequate (ICC = .64–.79).A condensed version of the CTSR, used to assess CBT competence from shorter samples of therapy sessions, is moderately reliable and may provide similar results as the full-length version. According to preliminary analyses, the CTSR-4 has potential as a low-cost alternative to assess CBT competency in both research and psychotherapist training. Over the years, much effort has been put into conceptualizing and defining psychotherapy competence in order to make it measurable , 2. ThesThe Cognitive Therapy Scale (CTS) , or its A possible explanation for the inconclusive associations between CBT competence and patient outcome could be other mediating variables, such as the therapeutic alliance . AnotherExisting frameworks for psychotherapy competence propose a handful of general competencies, including theoretical knowledge, and the ability to engage patients, establish a working relationship, and transform theoretical knowledge into clinical practice , 27. CBTBriefer and more general instruments for CBT competence may both be more efficient and cost-effective. An important research question is therefore whether such less resource-consuming measures of therapy competence can show adequate psychometric properties. The aim of this study was to assess the criterion validity and inter-rater agreement of the CTSR-4, a brief instrument derived from the CTSR.The criterion validity of the CTSR-4 was assessed by comparing scores from the CTSR-4 with previously independently assessed CTSR scores of the same CBT sessions. The inter-rater reliability of the CTSR-4 was assessed by comparing scores between independent coders for each session sample.The CTSR-4 was derived directly from the CTSR . The CTSFour coders participated in this study. Two coders (A and B) assessed all 50 session samples while two coders (C and D) coded 20 and 30 session samples respectively. All coders had advanced level training in psychotherapy, had previously used the CTSR, and three of them were teaching university CBT courses and providing clinical supervision. The coders met for five to ten 90-min training sessions in different compositions, during which the CTSR-4 was discussed, and twelve audio recorded CBT sessions were coded independently and compared. Discrepancies in coding results were discussed to reach a consensus before the next training session. These recordings were only for training and were not used for further analyses. Over the training sessions, the inter-rater agreement increased among the coders and was eventually deemed adequate to independently code sessions. Inter-rater agreement could not be adequately statistically analyzed in the small training sample. Each coder received the manual and scoring sheets, and was instructed to listen to and independently assess the fifteen-minute session samples, and use approximately a total of 20 min for each assessment. The coders had additional meetings throughout the coding period to discuss the CTSR-4 items.The 50 CBT sessions were randomly drawn from a set of 120 audio-recorded sessions, previously coded in full by independent expert raters using the CTSR. The expert raters were two CBT supervisors with more than fifteen years of clinical experience. They had had formal training in using the CTSR, and several years of experience in using the CTSR in psychotherapy training and supervision but were not part of the research team. The recorded CBT sessions were collected from six therapists working in open psychiatric care and included patients with different mood disorders and related problems. All therapists and patients had provided informed consent to participate in the study, and the study was approved by the Regional Ethics Committee Board (No. 2018/1735-31/3). The therapy sessions followed standard practice and comprised interventions and procedures common in mainstream CBT, such as Socratic dialogue, cognitive exercises, behavioral experiments, exposure exercises, problem-solving, and homework assignments. For this study, five minutes from the start (minutes 0–5) middle , and the end  were extracted for a total session sample of 15 min from each of the 50 CBT recordings. The recordings were blindly selected but edited so that only actual treatment time was included . Each edited 15-min recording was then given a random identifying number and provided to three of the four independent coders. Each recording was thus randomly distributed and coded by three of the four coders.To be able to compare the results from the four items of the CTSR-4 with the full CTSR, the mean for the corresponding item scores from the CTSR was calculated. The scores were then rounded off to the nearest 0.5-value to facilitate statistical comparisons. To assess the criterion validity and inter-rater reliability of the CTSR-4, a two-way, random effects, absolute agreement model of Intra-Class Correlation (ICC) was used , 33. ForThe CTSR-4’s and the CTSR’s mean values are summarized in Table The ICC for the CTSR expert raters and each CTSR-4 coder ranged from 0.71 to 0.88 Table  for the The inter-rater agreement for the four coders ranged from 0.64 (Structure and Relation) to 0.79 (Concept) in the single measure analysis, and between 0.84 (Structure and Relation) to 0.92 (Concept) in the average measure analysis Table . This coThe aims of this study were to assess the criterion validity and inter-rater agreement of the CTSR-4 when evaluating short samples of CBT sessions. The validity was assessed by comparing the results from four CTSR-4 coders with previously expert-rated CTSR scores. The results showed ICC-values between 0.71 and 0.88, indicating a good level of agreement . While tThe inter-rater reliability results also indicated moderate to good agreement for the single measures, and good to excellent agreement for the average measures . Again, The CTSR-4 was created by merging the original twelve items of the CTSR into four, generating a more global measure of CBT competence. Previous studies indicate high to very high internal consistency of the CTSR (i.e., the original study of the CTSR found alpha values of 0.92 to 0.97 . In eithA limitation of this study was the small number of coders, and the restricted number of sessions assessed. The four coders had advanced level training in CBT, and long experience in clinical work and supervising CBT therapists. It is still unclear to what degree their experiences and training may have affected their assessments, and to what degree the results can be generalized to coders with lower levels of experience and training . SimilarTaken together, this study shows that a new shorter instrument, such as the CTSR-4, derived from the CTSR, can provide satisfactory criterion validity and inter-rater reliability when evaluating samples of CBT sessions. The correlations between the coders’ and the expert raters’ scores were all in the good range, indicating that the CTSR-4 can be used to efficiently rate CBT competence in a similar way as CTSR. Since the CTSR-4 comprise only four items, and can be used to analyze 15-min samples of CBT sessions, the instrument may facilitate further research of CBT competence and therapist training. Future studies need to confirm the conclusions in larger samples as well as investigate possible associations between CBT competence and patient outcomes.


These characteristic ions are generated either by an optimised in-source fragmentation in a full scan Orbitrap measurement or by optimised HCD fragmentation. Additionally, five different filters are included in the design of method. Finally, data-dependent MS/MS experiments on specifically preselected precursor ions are performed. The utility of the methods is demonstrated by analysing cultures of the denitrifying betaproteobacterium “Aromatoleum” sp. strain HxN1 anaerobically grown with hexanoate. We detected 35 acyl-CoAs in total and identified 24 of them by comparison with reference standards, including all 9 acyl-CoA intermediates expected to occur in the degradation pathway of hexanoate. The identification of additional acyl-CoAs provides insight into further metabolic processes occurring in this bacterium. The sensitivity of the method described allows detecting acyl-CoAs present in biological samples in highly variable abundances.Analysis of acyl coenzyme A thioesters (acyl-CoAs) is crucial in the investigation of a wide range of biochemical reactions and paves the way to fully understand the concerned metabolic pathways and their superimposed networks. We developed two methods for suspect screening of acyl-CoAs in bacterial cultures using a high-resolution Orbitrap Fusion tribrid mass spectrometer. The methods rely on specific fragmentation patterns of the target compounds, which originate from the coenzyme A moiety. They make use of the formation of the adenosine 3′,5′-diphosphate key fragment (The online version contains supplementary material available at 10.1007/s00216-021-03318-3. Acyl coenzyme A thioesters (acyl-CoAs) possess an energy-rich thioester bond, which can trigger carbon-carbon bond activation and its cleavage in a diverse range of enzymatic reactions. Due to these properties, acyl-CoAs are intermediates in many different metabolic processes such as β-oxidation of fatty acids, amino acid degradation and the tricarboxylic acid cycle. Acyl-CoAs are also important in secondary metabolism, like biosynthesis of polyketide and non-ribosomal peptide antibiotics , 2. ProfAmong the techniques used for the detection and identification of acyl-CoAs, the one utilised most extensively is high-performance liquid chromatography (HPLC) coupled with mass spectrometry (MS). In contrast to more or less standardised MS methods, the HPLC methods applied in these approaches may be rather variable, especially with respect to the eluents used, which also may have a direct influence on the separation of isomers. The importance of isomer separation has already been discussed, highlighting the fact that one-third of naturally occurring CoA thioesters currently listed in the KEGG database are isobaric in terms of nominal masses . Notablym/z 428.0365) is common to all thioesters + monoisotopic ions (m/z up to 500) was below 1 ppm for all detected compounds  were variable. We were also able to distinguish M+2 isotopes  at the resolution of 500,000, which served as an additional criterion for the characterisation of synthetic acyl-CoA standards + ion is the most abundant, followed by the ion m/z 428.0365. The same pattern was observed for all analysed acyl-CoAs, including the reference standards, independent of the structure of the acyl rest. Importantly, we have not observed any fragment ions resulting from the acyl rest in agreement with all previously published data [+ and [M+H-506.9952]+. Only compounds within a deviation below 1 ppm are being taken into consideration. All compounds with odd m/z values of the [M+H]+ ion from the suspect screening list are neglected. This list is amended by acyl-CoAs, which are expected to occur in a given biological sample considering the available information on the metabolic processes of interest in combination with the applied cultivation condition(s), in particular the substrate provided. For the biological samples used in this study, all acyl-CoAs targeted in this sense (see below) were already detected by the suspect screening and thus incorporated in the inclusion list.As the result of the suspect screening, a list . This list includes the start and end times for each target compound, which are adjusted according to the corresponding retention times of reference standards or retention times of acyl-CoAs detected during the suspect screening, respectively. The main aim is to confirm the presence and identity of acyl-CoAs detected in the suspect screening, including the “expected” acyl-CoAs, and to compare their retention behaviours and fragmentation patterns with those of reference standards . The list of all standards, their accurate mass deviations and relative intensity  of identified compounds in both biological samples are shown in Table 4


Pancreatic cancer remains a significant public health problem with an ever-rising incidence of disease. Cancers of the pancreas are characterised by various molecular aberrations, including changes in the proteomics and genomics landscape of the tumour cells. Therefore, there is a need to identify the proteomic landscape of pancreatic cancer and the specific genomic and molecular alterations associated with disease subtypes. Here, we carry out an integrative bioinformatics analysis of The Cancer Genome Atlas dataset, including proteomics and whole-exome sequencing data collected from pancreatic cancer patients. We apply unsupervised clustering on the proteomics dataset to reveal the two distinct subtypes of pancreatic cancer. Using functional and pathway analysis based on the proteomics data, we demonstrate the different molecular processes and signalling aberrations of the pancreatic cancer subtypes. In addition, we explore the clinical characteristics of these subtypes to show differences in disease outcome. Using datasets of mutations and copy number alterations, we show that various signalling pathways previously associated with pancreatic cancer are altered among both subtypes of pancreatic tumours, including the Wnt pathway, Notch pathway and PI3K-mTOR pathways. Altogether, we reveal the proteogenomic landscape of pancreatic cancer subtypes and the altered molecular processes that can be leveraged to devise more effective treatments. Pancreatic cancer remains one of the deadliest malignancies ,2. Its iStudies of many cancers, including those of the breast, ovary and colon, have shown that the transcriptome is poorly correlated to the proteome, with only 10%-20% of the variation in protein level explained by mRNA transcription levels ,26. ReceWe applied unsupervised K-means clustering with a squared Euclidean metric to the proteomics data of the pancreatic cancer samples available in the TCGA to identify two consistent clusters of patients tumours  34]. On. On34]. We found a similar distribution of tumours of various grades  and the We found that of the patients afflicted with subtype-1 tumours, 38% were disease-free at the end of the follow-up, whereas 62% of the patients had a disease that either progressed or recurred, with only 19% of these patients surviving by the end of the follow-up period. For patients afflicted with subtype-2 tumours, 31% were disease-free at the end of the follow-up, whereas 57% of the patients had a disease that either progressed or recurred, with only 17% of them surviving by the end of the follow-up periods .However, after comparing the median disease-free survival (DFS) period, we found that the duration was shorter for patients afflicted with subtype-2 tumours (DFS = 13.5 months) than for patients with subtype-1 tumours   to extraAmong the GO molecular processes, we found that the subtype-1 tumours were enriched for, among others, the GO terms associated Purine Nucleotide Triphosphate Binding, ATP Binding and among others .mTOR signalling” forms a network whose nodes are significantly upregulated in subtype-1 tumours and are previously linked to oncogenesis, but in this case, we suggest that this is likely only correct in subtype-1 tumours and not in subtype-2 tumours  in pancreatic cancer. Focusing only on the Consensus Cancer Genes , we founInterestingly, we observed that the mutations in SMAD4 and those in CDKN2A tended towards being mutually exclusive  . Th. Th66]. We downloaded the 2019 KEGG database and 2021 GO molecular enrichment. Then for each gene set within each database, we modified the gene sets by returning only the genes present in our proteomic dataset, thus limiting the gene background to genes only present in the proteomic data. Finally, we used Gene set enrichment analysis (GSEA)  to deterNext, we retrieved known protein-protein interactions from the University of California Santa Cruz Super pathway, the Kinase Enrichment Analysis, and Chromatin Immunoprecipitation Enrichment Analysis –72. ThenWe evaluated the scope of gene alterations in the pancreatic subtypes using the mutation (single nucleotide polymorphisms and indels) data and copy number alterations data. First, we combined these two gene alteration data. Then we returned only genes that are associated with human cancers using information from the Sanger Consensus Cancer Gene Database . FurtherThe Kaplan-Meier method was used to estimate overall survival and the duration of progression-free survival between the current subtype-1 and the subtype-2 of pancreatic cancer . FurtherWe used MATLAB version 2020a to perform all the analyses presented here. Fisher’s exact test was used to test for associations between categorical variables. The Welch test and the Wilcoxon rank-sum tests were used to compare differences in the tumour subtypes for the continuous variables among the various categories. We considered comparison as statistically significant when p-values are < 0.05 for single comparisons and when the Benjamini-Hochberg adjusted p-values are < 0.05 for multiple comparisons.S1 FigThe node represents the percentage of each gene mutations and copy number alterations in  subtype-1 and  in subtype-2 pancreatic tumours. The nodes are coloured according to the types of genes: Blue nodes for tumour suppressor genes and red for oncogenes. The interaction types are as given in the figure legend.(TIF)Click here for additional data file.S2 Fig(a) Evaluating the optimum number of clusters: The plot displays the Calinski-Harabasz evaluation method [(b) Range of values assessed by the Bayesian optimisation objective function to select the optimal machine learning hyperparameters for the Kernel naïve Bayes supervised learning model [n method . The optng model ,78.(TIF)Click here for additional data file.S1 File(XLSX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.S3 File(XLSX)Click here for additional data file.S4 File(DOCX)Click here for additional data file.S5 File(DOCX)Click here for additional data file.


In the 5-year time span, 467 patients underwent MMII; of them, 98 patients (21%) had a history of prior neurosurgery and recurring seizures. Of the 467 patients, 425 patients underwent ICEEG implantation with further CT co-registration to identify the electrode locations. A total of 351 patients eventually underwent surgery after MMII, including 197 patients (56%) with non-lesional MRI and 223 patients (64%) with extra-temporal lobe epilepsy. Among 269 patients with 1-year post-operative follow up, 134 patients (50%) had remained completely seizure-free. The most common histopathological finding is focal cortical dysplasia. Our study illustrates the usefulness of MMII to enhance SEEG electrode trajectory planning, assist non-invasive/invasive data interpretation, plan resection strategy, and re-evaluate surgical failures. Information presented by MMII is essential to the understanding of the anatomo-functional-electro-clinical correlations in individual cases, which leads to the ultimate success of presurgical evaluation of patients with medically intractable focal epilepsies.Multimodal image integration (MMII) is a promising tool to help delineate the epileptogenic zone (EZ) in patients with medically intractable focal epilepsies undergoing presurgical evaluation. We report here the detailed methodology of MMII and an overview of the utility of MMII at the Cleveland Clinic Epilepsy Center from 2014 to 2018, exemplified by illustrative cases. The image integration was performed using the Curry platform (Compumedics Neuroscan For patients with medically intractable focal epilepsies, surgery is currently their best option for seizure control . A succeMultimodal image integration (MMII) refers to the procedure that co-registers imaging data from multiple sources into the same space by an automated, computerized process. It is important to note that although results from each test can be reviewed separately within its own platform without MMII, and an experienced user can mentally fuse the localization results, MMII offers a more straightforward way for visualization, which often makes data review more convenient, more efficient and less prone to human errors. This process is especially helpful when the patient's head is positioned differently for different tests, and when anatomical landmarks are difficult to identify due to differing imaging planes. The potential value of MMII has been illustrated in a few previous studies; however, the software used were typically made in-house or based on research tools, limiting their use to academic centers –5. Here,This is a single-center retrospective study approved by the Cleveland Clinic institutional review board. We reviewed all the data reconstructed with the MMII workflow between 2014 and 2018. All patients had medically intractable focal epilepsy and were considered for ICEEG implantation and/or surgical resection. The strategy for ICEEG implantation or direct surgery was discussed in a patient management conference (PMC) based on multimodal data including scalp video-EEG, MRI, PET, ictal SPECT and MEG. If ICEEG was deemed necessary and pursued, the ICCEG findings were discussed at another PMC, in which the final surgical resection/ablation strategy was determined.™, Charlotte, NC, USA). The data structure was organized as databases, with each modality stored as one data folder/file within the database. DICOM images with different scanners were in general compatible with the platform, making it the most universal image format for communication among different vendors/modalities. When each modality was imported for the first time, an initialization process was needed to set the parameters, followed by image coregistration. The parameters and procedures optimized for each modality are detailed in the following sections. The workflow runs on a regular PC; the 3D rendering of cortical surface runs more smoothly with advanced graphics card.The MMII workflow was carried out on FDA-approved software platform Curry 7 . The 3D T1-weighed Magnetization Prepared Rapid Acquisition with Gradient Echo (MPRAGE) volumetric sequence was used as the “base image volume,” which is used as an underlay, on which images from all the other modalities are coregistered to. For example, other sequences of different MRI contrasts such as 2D/3D FLAIR and 2D T2-weighted images can be coregistered to the 3D T1-weighted base image by automated full-volume registration . This is shown in The standard clinical functional MRI (fMRI) examination consisted of four paradigms: one motor and three language tasks . For fMRI maps, motion of images obtained by an echo-planar imaging (EPI) sequence was firstly corrected using Siemens PACE software (VB15). Then, statistical maps were generated and superimposed on top of T1-weighted MPRAGE images that were typically acquired in the same fMRI scan. This T1-weighted MPRAGE image set was then imported and coregistered with the base image volume, and the same transformation matrix was applied to the statistical maps to ensure accurate coregistration.Fluorodeoxyglucose (FDG)-PET (FDG-PET) scans were performed on Biograph PET CT . The attenuation corrected PET images were superimposed onto the base image volume by the “show thresholded” function (MRI transparency set to 75%) after adjusting PET histogram to full range. This is shown in SPECT images were acquired on a Siemens  Symbia dual-head camera. The interictal perfusion image, ictal perfusion image, and a T1-weighted MPRAGE data set were used as input to the SISCOM methodology, yielding ictal-interictal subtracted z-score images that were coregistered with the T1-weighted MPRAGE . This T1MEG data were recorded from a 306-channel whole-head MEG system  and source localization analysis was performed using the vendor NeuroMag software . Individual spike analysis was performed on data segments containing visually identified epileptiform discharges . The locTo visualize vasculatures, CT-angiography (CTA) and/or MR-angiography (MRA) images were obtained and coregistered to the base image volume; image contrast was adjusted so that when overlaid, major vessels were visible.http://www.nmr.mgh.harvard.edu/) and then imported for visualization. The pial surface files were first transformed to Curry surface format, and then spatially coregistered with the base image volume. Once the coregistration is complete, each point on the cortical surface was linked to the coronal, axial and sagittal views.The cortical surface was generated by Freesurfer  and posterior commissure (PC). The AC, PC and midsagittal (MS) points were first identified on the T1-weighed base image volume. Then, the boundary box of the brain was delineated on the sagittal view  and axial view . The Talairach coordinates were defined with a proportional system consistent with its original definition . SpecifiAfter all images from the non-invasive modalities were fused and Talairach coordinates defined, trajectories of SEEG could be planned based on any chosen modality that had localization value to the case . An entrA high-resolution CT was taken immediately after the ICEEG implantation , and the images were used to indicate the location of the implanted electrodes. After fusing with the T1-weighted base image, all electrode contacts were segmented from the CT , and stored as a list of localize points with coordinates for the electrode contacts. The contacts were individually named and displayed in an interactive fashion. This is shown in Since the non-invasive modalities were all registered to the same space of the T1-weighted base image volume, once the post-implantation CT image was co-registered to the base image volume, direct comparison between the ICEEG data and the non-invasive evaluation data was immediately feasible. This facilitates straightforward comparisons of the localization results from non-invasive modalities with the interictal and ictal findings from ICEEG.After considering all the non-invasive and ICEEG data, the proposed resection area can be interactively drawn (as “pass markers”) on the 3D T1-weighted base MRI  to include ictal onset contacts and other pertinent areas thought to be the putative epileptogenic zone. The drawings can also be segmented as voxel mesh shown in 3D view together with the cortical surface . FinallyFor patients with recurring seizures after the first operation, re-evaluation for a potential reoperation can be a worthwhile attempt , 14. To MRI postprocessing using the voxel-based morphometric analysis program (MAP) method  generateIn total, 467 patients underwent MMII from 2014 to 2018. All patients who received ICEEG had MMII; in addition, MMII was also used to generate pre-implantation hypothesis for ICEEG, and in the face of highly concordant non-invasive data, can often lead to direct surgery. In the 467 patients who underwent MMII, all (100%) had MRI; 425 (91%) had PET; 334 had SPECT (72%) and 264 (57%) had MEG. Ninety-eight patients (21%) had prior neurosurgery, including resective/disconnective/ablative surgery for epilepsy, other resections for brain tumor/vascular malformation/post-traumatic lesions, etc. After MMII was performed, 425 of the 467 patients (91%) further underwent ICEEG implantation, including 396 cases with SEEG, 28 cases with subdural grids and depth electrodes placement and 1 case with subdural and depth electrodes implantation followed by SEEG . Among them 285 patients had resections, 26 patients had neuromodulation and 40 patients had laser ablation. Among the 269 patients with at least one-year postoperative follow-up, 134 patients (50%) had remained completely seizure-free at 1 year. Pathology from the resected 285 patients included FCD in 168, hippocampal sclerosis in six, tumor in six, vascular malformation in two, gliosis in 46, double pathology in 21 and other non-specific findings in 36.A 26-year-old right-handed male with medically intractable focal epilepsy since the age of 4 was evaluated for surgery. Seizure semiology was characterized by axial tonic → left face clonic → right arm clonic → secondary generalization. Both interictal and ictal scalp EEG localized to the left frontotemporal region. The 3T MRI was negative. MRI postprocessing using the MAP method on both 3T clinical MRI and 7T research MRI showed a suspicious lesion with subtle gray-white blurring at the bottom of an accessory sulcus in the left pars triangularis , which wA 11-year-old right-handed female presented with a history of medically intractable seizures starting at the age of 4 years. Birth and developmental history were unremarkable. She had previously undergone right frontal and central resection at an outside hospital at the age of 9 years without seizure reduction and developed left hemiparesis postoperatively. The majority of seizures started during sleep and semiology showed bilateral tonic stiffening, followed by face clonic and then generalized clonic seizures. Scalp EEG showed interictal sharp waves involving the right parietal-temporal regions, and ictal pattern arising from the right posterior temporal-parietal region with rapid spread bilaterally. No focal abnormality was found on the previous and repeated MRIs. Interictal MEG activity was localized to the right frontoparietal operculum, on the inferior margin of the prior resection cavity ; anotherA 30-year-old, right-handed male presented with medically intractable epilepsy for 21 years, with daily nocturnal seizures characterized by tremor-like twitching of the right arm, occasionally followed by asymmetric facial pulling more on the right, and then dialeptic seizures. Epileptiform activities were seen over the left frontotemporal region on scalp EEG interictally and ictally. Both 3T/7T MRI and MAP analysis were normal. PET revealed prominent hypometabolism in the left inferior frontal region . Ictal SSurgical treatment of intractable focal epilepsy is challenging, especially for patients with non-lesional MRI, previously failed surgery, or deep epileptogenic foci. The process of integrating non-invasive and invasive data from all available diagnostic modalities in one single platform, is crucial to generate, inform, dispute or add to the electroclinical hypothesis before arriving at a surgical strategy. The ability to display modalities both 2D and 3D provides an optimal way to interpret the epileptic networks based on the “anatomo-electro-clinical” concept , which iICEEG is frequently performed for epilepsy patients with negative MRI (63% in our cohort) or patients with ETLE (64% in our cohort), when non-invasive tests are not concordant or inconclusive for the localization of EZ . SEEG isEstablishment of anatomo-electro-clinical correlations necessary for the localization of the EZ is crucial in the course of the invasive evaluation. With MMII, complex spatial relationships among the implanted electrodes, structural and functional imaging findings, and eloquent regions of interest can be more conveniently visualized. Therefore, interpretation of the interictal and ictal invasive findings could be straightforwardly carried out in conjunction with the non-invasive modalities. For example, when the coverage of invasive EEG is judged to be inadequate, the integrated MEG findings can provide a synoptic view of whole-brain activities, and “fill in the gaps” where there are no electrodes implanted . As anotRe-revaluation of patients with previously failed epilepsy surgery is a challenging process, and this population occupied 21% in our cohort. Re-operation might have increased risks of neurological or surgical complications, and in the meantime faced with more difficulties in localizing EZ or delineating the margins of EZ , 26. MMIThe past decade has seen tremendous growth of novel imaging and image processing techniques. Before adopting these techniques into clinical use, validation of the results is crucial to minimize the false positive findings. This was illustrated in Case 1, where the subtle lesion detected by MRI postprocessing was validated by the MEG and ICEEG standard-of-care findings. Other novel structural imaging techniques, such as ultra-high-field structural 7T MRI and MR fingerprinting, can also be compared and validated by findings from clinical tests (non-invasive and invasive) within the MMII platform, to gain more insight on the epileptogenic relevance of the additional structural findings yielded by the new imaging techniques , 27.Our study aimed at reporting the MMII methodology and illustrating the clinical value of MMII, and was not designed to quantitatively evaluate the efficacy of MMII in epilepsy surgery, due to its retrospective nature. This is an inherent limitation of the current study. While fully understanding this limitation, it may be helpful to compare the postsurgical seizure outcome in a similar cohort from literature. The best study for this comparison is perhaps the one we previously published , which eMultimodal image integration is a valuable tool to understand the anatomo-functional-electro-clinical correlations in individual cases during the presurgical evaluation process. It substantially enhances the assessment of non-invasive modalities, providing essential information for generating surgical hypotheses. It also assists planning of SEEG electrode trajectories, interpretation of invasive data, design of the final resection, re-evaluation of surgical failures and validation of novel research tools. All these aspects could contribute to the ultimate success of presurgical evaluation of patients with medically intractable focal epilepsies. Multimodal image integration should be performed as a standard process and take a more prominent role in epilepsy presurgical evaluation.The datasets generated for this article are not readily available because the data may contain protected health information for patient care. Requests to access the datasets should be directed to wangi2@ccf.org.The studies involving human participants were reviewed and approved by Cleveland Clinic IRB. Written informed consent from the patients/ participants or patients/participants legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) and/or minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.LJ: data collection and analysis and manuscript drafting. JC: data analysis and manuscript drafting. JB, HM, WB, and IN: clinical data interpretation and critical revision. AA: study concept and design, methods development, clinical data interpretation and critical revision. RB: study concept and design and methods development. ZIW: study concept and design, data collection and analysis, clinical data interpretation, manuscript drafting, critical revision, and study supervision. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.