The emergency department (ED) serves as the main source of care for patients who are victims of interpersonal violence. As a result, emergency physicians across the nation are at the forefront of delivering care and determining dispositions for many at-risk patients in a dynamic healthcare environment. In the majority of cases, survivors of interpersonal violence are treated and discharged based on the physical implications of the injury without consideration for risk of reinjury and the structural drivers that may be at play. Some exceptions may exist at institutions with hospital-based violence intervention programs (HVIPs). At these institutions, disposition decisions often include consideration of a patient’s risk for repeat exposure to violence. Ideally, HVIP services would be available to all survivors of interpersonal violence, but a variety of current constraints limit availability. Here we offer a scoping review of HVIPs and our perspective on how risk-stratification could help emergency physicians determine which patients will benefit most from HVIP services and potentially reduce re-injury secondary to interpersonal violence. Firearm and interpersonal violence have costly downstream effects that continue to burden the health of many communities across the nation. In the United States from 2006 through 2014, over 700,000 emergency department (ED) visits were related to firearm violence.In this article, we discuss injury recidivism and HVIP in survivors of interpersonal violence, current management strategies for disposition of victims of interpersonal violence including a scoping review of hospital-based violence intervention programs, and considerations of how to improve outcomes. Ultimately, we advocate for research to develop a clinical decision tool that can be used in the emergency department to identify those at highest risk for reinjury and those that would benefit most from focused intensive intervention. In this paper, we will refer to “interpersonal violence” as a term that includes penetrating injuries and assault, but excludes intimate partner violence and self-harm. We will also use the terms “injury recidivism” and “reinjury” interchangeably to refer to repeat injuries suffered by those who were previously survivors of interpersonal violence.High rates of injury recidivism have been well documented in urban settings for decades. As early as the 1980s, Henry Ford Hospital in Detroit, Michigan identified that survivors of violent trauma had a 44% rate of recurrent traumatic injury with a 5-year mortality rate of 20%.Despite the high rate of injury recidivism, the disposition of survivors of interpersonal violence is driven primarily by medical history, physical exam, labs, and imaging used to assess the extent of physical injury. At most institutions, the potential for repeat traumatic injury does not factor into the decision of whether or not a patient is dispositioned home or whether additional resources are indicated. Exceptions to this include an increasing number of hospitals located in cities with high rates of interpersonal violence that are pioneering HVIPs to reduce the risk of reinjury. At the majority of these institutions, HVIPs offer services to all individuals and do not tailor care based on risk of reinjury.We chose a scoping review for this project to provide a preliminary overview of the existing gaps in the literature. We utilized the PRISMA-ScR checklist to adhere to methodically build and summarize our findings.Our research question aimed to review studies that measure the impact that HVIPs have on injury recidivism. We organized our results by study design and summarize significant results and concordant discussion sections.Our search was designed to capture primary research that explored the impact of HVIPs on injury recidivism. We explored two comprehensive libraries (Pubmed and SCOPUS) with relevant MeSH terms and keywords, i.e. “injury recidivism”, “hospital-based violence intervention programs”. One reviewer (GNW) performed a search and screening of all abstracts identified in PubMed. A second reviewer (AMD) performed a search and screening of all abstracts identified in SCOPUS. We restricted search to English language, United States, and time period of January 2000 to December 2018. We then built an Endnote library that included all of the selected research articles. To ensure we extracted the appropriate research for our paper, we examined the bibliography of all selected papers accordingly and added any additional findings.What do we already know about this issue?Survivors of interpersonal violence are more likely to be repeat victims of violence with high rates of associated mortality. Risk-stratification tools have helped determine who receives limited resources in other disease states.What was the research question?We examined the current literature on hospital-based violence intervention programs (HVIP) to understand their role in reducing injury recidivism and explore the role of risk-stratification tools to predict reinjury.What was the major finding of the study?The effect of HVIPs is promising but inconclusive. Longitudinal research, risktools, and trainee education may improve their effectiveness.How does this improve population health?A risk-stratification tool that identifies the patients who would most benefit from HVIP services would mitigate the downstream implications – physical, mental, and financial – for patients as well as their communities.We included primary research papers that reported implementation of hospital-based violence intervention programs through the ED or hospital with a defined patient population, intervention, and follow-up period. Our outcome measures included either injury recidivism or other potential markers of experience with violence including attitudes toward violence, criminal offenses, and additional parameters focused on future injury reduction.The primary author (GNW) reviewed the title and abstract extracted from PUBMED of each article to assess relevance to our research question. AMD reviewed title and abstracts extracted from SCOPUS. Both AMD and GNW each reviewed the full text to assess the methodology and strength of each study. Studies were extracted from SCOPUS by AMD then abstracts reviewed separately by GNW.For each study, we tabulated the year of publication, authors, sample size, location, intervention, design, follow-up, and primary and secondary outcomes. See  We summaWe reviewed 727 publications, of which 16 articles met our inclusion criteria.  identification of risk factors for reinjury; 2) internal validation; 3) external validation; and 4) feasibility and implementation studies. Based on clinical experience and existing medical literature, criteria would need to be identified that are both predictive of injury recidivism and practically implementable in the ED by physicians or other staff members that are found in an average ED. Approaches that require intensive inpatient or specialized case management interventions will be severely limited in their generalizability.Literature suggest that certain social determinants of health and structural drivers such as: 1) male gender; 2) black race; 3) low socioeconomic status; 4) zip code; and 5) uninsurance/Medicaid, are risk factors for injury recidivism.39Other literature suggest structural risk factors such as prior incarceration lead to increased risk of injury. A study of black men who were part of a Baltimore HVIP found increased rates of hospitalization due to repeat injury in individuals with previous incarceration  and report of using a weapon or being in a fight in the past year .Finally, a recent study based on experiences from the WAP at San Francisco General Hospital proposed a clinical tool called the violent reinjury risk assessment instrument (VRRAI).The SaFETy and VRRAI are two potential clinical tools, in addition to others yet developed, that should be considered for further internal and external validation. Ultimately, feasibility and implementation studies must be considered to ensure that the risk stratification tool achieves the intended goals, including reduction of injury recidivism, associated mortality, and cost through targeted interventions.We recognize that the ultimate outcome of such risk stratification may not prove worthwhile. Research may find that a risk stratification tool proves no more useful than clinical gestalt. Furthermore, implementation studies may find that even the lowest risk survivors of interpersonal violence still benefit from intervention. Nonetheless, we believe that in order to facilitate research that allows the growth and cost effective implementation of violence intervention programs, the development of a comprehensive risk stratification tool is a critical first step. While most EPs are exposed to penetrating trauma during their training, many are not accustomed to evaluating risk for reinjury and may benefit significantly from an evidence-based decision aid to inform their clinical decision-making. Furthermore, stratification tools and their partnership with successful HVIP may address other unmet social needs such as employment, housing, or substance use. For example, Bell et al noted that when HVIPs are associated with community partners that work to address health insurance, legal issues, and return to school, injury recidivism dropped significantly.13Finally, we recognize that EPs develop many of their practice patterns during residency. With this in mind, we feel it is essential that graduate medical education incorporate formalized teaching on how to consider risk factors for reinjury in clinical decision-making. The Model of the Clinical Practice of Emergency Medicine (EM model) acknowledges that residents should be able to recognize age, gender, ethnicity, barriers to communication, socioeconomic status, and other factors that affect patient management. Currently, however, there are no specific recommendations that address the role of social determinants of health in survivors of interpersonal violence.Our paper has several limitations. First, scoping reviews do not formally evaluate the quality of evidence and are thus more descriptive. We tried to reduce the bias of descriptive pitfalls by adhering closely to PRISMA-ScR standards and having several reviewers screen independently. Secondly, scoping reviews are prone to selection bias. We attempted to safeguard against selection bias by including several keywords that would capture a broad array of HVIP-related studies and adhering closely to our inclusion criteria during the review. Lastly, due to lack of formal analysis due to the heterogeneity of end points evaluated by studies collected we deemed a scoping review would be best equipped for the current landscape.Emergency physicians lack an evidence-based tool to help identify and manage patients at high risk for reinjury. Future research should continue to identify social and structural risk factors for injury recidivism and explore how these factors might help build a risk-stratification tool. HVIPs have shown promise in reducing physical, mental, and financial costs of reinjury however more high levels studies are needed to further understand the overall impact. Until HVIPs are more universally available, emergency physicians should be empowered through education and clinical decision aids in identifying at-risk patients who could most benefit from these services to not only reduce injury recidivism but also further explore the impact of ED and HVIP collaboration in addressing interpersonal violence.


The variables that influence the selection of a preparative regimen for a pediatric hematopoietic stem cell transplant procedure encompasses many issues. When one considers this procedure for non-malignant diseases, components in a preparative regimen that were historically developed to reduce malignant tumor burden may be unnecessary. The primary goal of the procedure in this instance becomes engraftment with the establishment of normal hematopoiesis and a normal immune system. Overcoming rejection becomes the primary priority, but pursuit of this goal cannot neglect organ toxicity, or post-transplant morbidity such as graft-versus-host disease or life threatening infections. With the improvements in supportive care, newborn screening techniques for early disease detection, and the expansion of viable donor sources, we have reached a stage where hematopoietic stem cell transplantation can be considered for virtually any patient with a hematopoietic based disease. Advancing preparative regiments that minimize rejection and transplant related toxicity will thus dictate to what extent this medical technology is fully utilized. This mini-review will provide an overview of the origins of conditioning regimens for transplantation and how agents and techniques have evolved to make hematopoietic stem cell transplantation a viable option for children with non-malignant diseases of the hematopoietic system. We will summarize the current state of this facet of the transplant procedure and describe the considerations that come into play in selecting a particular preparative regimen. Decisions within this realm must tailor the treatment to the primary disease condition to ideally achieve an optimal outcome. Finally, we will project forward where advances are needed to overcome the persistent engraftment obstacles that currently limit the utilization of transplantation for haematopoietically based diseases in children. Since its first attempts in the 1950s, allogeneic hematopoietic stem cell transplantation (HSCT) has rapidly evolved over time  Organ damage from the preparative regimen, 2.) Sequelae from the transplant course such as mucositis, infection, or excessive bleeding, 3.) Chronic GVHD, 4.) Toxicity from other medications administered   ATGAM (horse polysera) 2. Thymoglobulin (rabbit polysera). ATGAM has been utilized for many more years than the rabbit formulation , but theAnti-T lymphocytes globulin, derived from rabbit polysera from immunization with a Jurkat T cell leukemia line, is also gaining in popularity , 33, 34.A humanized monoclonal antibody against CD52, alemtuzumab has been shown to target T and B cells, NK cells, and antigen-presenting cells. It has been incorporated into several reduced intensity preparative regimens and has been used successfully for immunodeficiencies, hemophagocytic lymphohistiocytosis, lysosomal storages disease, thalassemia and sickle cell disease. Like other anti-lymphocyte products, it is associated with an increased risk for infections . HoweverRecent investigations have begun to examine T cell co-stimulation blockade as an additional means of immunosuppression to both reduce the risk of rejection and GVHD. Abatacept, a CTLA4-Ig agents can block the CD28-CD80/86 interactions needed for T cell activation has been incorporated into newer preparative regimens . PrelimiOther chemotherapy agents which were initially advanced into preparative regimens have not sustained their presence in modern day treatments for non-malignant diseases due to their inherent toxicities and the lack of a need for their anti-neoplastic activity. Platinum agents, other alkylating agents, anthracyclines, are examples of agents that have not sustained their presence in modern day regimens .Lacking the necessity of eradicating malignant cells, the transplant physician contemplating HSCT for a patient with a non-malignant disease must take several considerations into account which may or may not be specific to the patient’s disease state. These include: 1) What are the specific vulnerabilities of a particular disease population that lead to transplant related complications from the preparative regimen selection? 2) How has the patient’s primary disease and the corresponding treatment to treat that disease impacted the patient’s vital organs? 3) What are the barriers to achieve engraftment which would guide minimizing the intensity of the preparative regimen? 4.) What are other immunological features beyond rejection that influence transplant outcome? Thoughtful consideration for each of these variables will optimize the course of the patient.The different diseases which are considered for HSCT have different clinical phenotypes which are linked to problems, some which are severe. Although a successful HSCT procedure may ultimately alleviate the condition, specific elements of a particular preparative regimen may exacerbate a patient’s clinical condition to serious levels. An appreciation of the specific vulnerabilities for a particular disease will provide insight for thoughtful decision making to select a preparative regimen (The natural history of a particular disease may lead to organ compromise that may make the patient less tolerant to preparative regimens with specific toxicities. For instance, patients with leukodystrophies with substantial demyelination of the CNS may not tolerate TBI or high doses of neurotoxic chemotherapy such as busulfan , 67. A pThe barriers to engraftment are primarily immunologic, with its magnitude dictated by the patient’s underlying disease and past treatment history , 57, 71.Other disease states that are amenable to HSCT may in fact have intact immune systems. In contrast to patients with malignancies in which prior chemotherapy exposure may reduce the likelihood for rejection, non-malignant diseases, such as lysosomal storage diseases, leukodytrophies, and hemoglobinopathies may require preparative regimens with substantial immunosuppressive properties, perhaps even requiring fully myeloablative regimens , 72, 82.Conditions of bone marrow failure further illustrate the complexities of choosing the right preparative regimen. Aplastic anemia, typically a disease of T cell mediated destruction of the hematopoietic system, is a condition where prior blood product exposure may sensitize the donor to an even greater risk of rejection . AlternaBeyond rejection, the immune system plays a central role in the clinical course of the transplanted patient. The expansion of alloreactive T cells will ultimately result in varying degrees of GVHD, and will have a substantial impact on both long term toxicity and treatment related mortality. Simultaneously, the newly reconstituting immune system is striving to achieve a protective state against infections, building new B and T cell repertoires while priming to new antigens , 86–90. It is apparent from this review that many challenges confront the clinician when choosing a preparative regimen for a transplant candidate. Over the past several decades, investigators have reported their successes and challenges exploring different strategies (Considerations of the vulnerabilities of the primary disease, the clinical status of the individualized patient, the essential needs of overcoming rejection yet temporizing GVHD and life threatening infections must all be weighed in making the appropriate decision for the patient. Unfortunately, despite over three decades of experience, there is no “formula” that can be utilized to assemble a combination of agents that will give a predictable outcome fulfilling the needs of both the clinician and the patient. Large scale studies with detailed reports of outcomes and toxicities provide our only resource to guide the clinician to make thoughtful decisions for their patient. Further research with well-designed clinical trials with full characterization of outcomes are needed to enhance our understanding of this topic.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Romantic relationships are an essential element of healthy living. Although difficulties in love are encountered often, it seems that three kinds of behaviors in a romantic relationship are more susceptible to physical or psychiatric disorders: playing , suffering (major depressive disorder or suicide), and stalking (violence or homicide). Oxytocin plays an important role in pair-bonding. Elevated plasma oxytocin concentrations have been observed in new lovers when compared with singles. It is hypothesized that those who display these dangerous behaviors in a romantic relationship might possess specific oxytocin receptor gene aberrancy and the resultant deviant pair-bonding pattern is likely to recur in successive relationships. It is postulated that a blunted oxytocin surge might be observed in playing, whereas exaggerated oxytocin surge might be observed in suffering and stalking. The distinction between suffering and stalking might stem from the difference in their aggression tendencies. Those who suffer displays aggression toward self, while those who stalk displays aggression toward others. The exaggerated oxytocin concentrations in people who suffer and people who stalk might not be suppressed by the discouraging attitudes of their partners and might be maintained by rumination. Considering the whole-body influence of oxytocin, intranasal oxytocin application or gene therapy should be used exclusively for those who display these dangerous behaviors and not for the general population. Future research is warranted to confirm this hypothesis with analysis of modifiers such as gender. PsychINFO and Pubmed were searched for peer-reviewed studies published between the first available year and August 31st, 2020 with the search terms: (“oxytocin”) AND (“relationship” OR “pair” OR “bond” OR “love” OR “mate”). Studies were included if they met the following criteria: (1) published in English; (2) published in a peer-reviewed journal (3) relevant to the hypothesis. The author then examined the titles and abstracts of the retrieved studies to decide the appropriateness of the inclusion.Love is an essential element of life. Romantic relationships have a profound effect on life. Stable intimate bonds are associated with physical and psychological health, whereas relationship failure is linked to physical and emotional distress . RelatioOxytocin is synthesized in the paraventricular nucleus and the supraoptic nucleus of the hypothalamus, which project into the posterior pituitary where oxytocin is released into the periphery and throughout the forebrain . OxytociIn human studies, elevated plasma oxytocin levels have been associated with early stage of love, affectionate communication, intimacy, and light touch in romantic relationships. In 2012, Schneiderman et al. examined plasma oxytocin levels in 163 young adults and reported that oxytocin levels were significantly higher in new lovers than in single adults .OXTR)  in the oxytocin receptor gene . However, people who suffer tend to be depressed (aggression toward self), whereas people who stalk might harass or threaten their partners (aggression toward others).According to a 2019 research based on data gathered from 554 participants in the German Family Panel study, behavior patterns in subsequent romantic relationships tend to remain stable . ConsequPlaying is postulated to be defined as feeling empty and constantly seeking new partners in the majority (more than 80%) of the past romantic relationships. People who display playing do not have strong feelings toward their partners which is distinct from suffering and stalking. Despite having significant emotional, familial, and social impacts, only a few infidelity studies have been conducted in humans . Based oConsequently, it is hypothesized that the player might display a relatively blunted oxytocin elevation during a romantic relationship with frequent incidences of infidelity. Despite having a relatively low level of oxytocin, the player might display an exaggerated dopamine system, which makes the mating cues inherently rewarding. Mating and addiction involve similar neural mechanisms  and multSuffering is postulated to be defined as obsessively thinking about one's partner or ex-partner with at least one of the depressive symptoms listed in the DSM-V major depressive disorder criteria in the majority (more than 80%) of the past romantic relationships. Stalking is postulated to be defined as following, harassing or threatening one's partner or ex-partner in the majority (more than 80%) of the past romantic relationships. People who display both suffering and stalking are classified to the stalking group as stalking is assumed to be a more advanced stage than suffering .In contrast to people who play, those who suffer and those who stalk are hypothesized to display exaggerated oxytocin surge during a discouraging romantic relationship, which is possibly related to their aberrant oxytocin receptor gene. Two interesting questions arise: how do they maintain their passion despite the disappointing attitude of their partners and what constitutes the difference between the sufferer and the stalker?To date, most of the research exploring the biological basis of attachment has analyzed data on an individual basis and very few studies have adapted the dyad as the unit of analysis . HoweverOxytocin exerts its effect in a context-dependent manner, resulting in either prosocial behaviors or aggression. Consequently, depending on the individual characteristics, exaggerated oxytocin levels might lead to inner aggression (suffering) or outer aggression .It is postulated that those who suffer are vulnerable to depression. Rumination is similar to mental preoccupation. It enhances the re-experience of the cognitive, affective, motivational, and physiological consequences of the distress. It has been found to function as a moderator between depressive symptoms and oxytocin . TherefoDespite of the limited literature, stalking is a serious problem associated with a high frequency of violence (25–40% of the cases) committed by the stalkers toward their victims . MoreoveIf left untreated, people who display dangerous behaviors in a romantic relationship might suffer from severe health or social issues such as sexually transmitted diseases, depression, and crime. A large study has shown that depressive symptoms vary according to the related life events. Breakups are associated with high levels of sadness, anhedonia, appetite loss, and guilt. Those who have no history of adverse life events frequently report fatigue and appetite gain, but less sadness . ConsequTo date, preliminary studies have shown both facilitating effects (such as enhancement of positive communication behavior) and aggravating effects  of intranasal oxytocin on romantic relationship . This inOxytocin receptors are expressed throughout the gastrointestinal tract and the heart, suggesting possible whole-body impact of intranasal oxytocin . ConsequIn conclusion, it is hypothesized that people who display the aforementioned types of dangerous behaviors might possess specific oxytocin receptor gene aberrancy, resulting in deviant pair-bonding pattern that is likely to recur in successive relationships. Blunting of oxytocin surge might be found in those who play, whereas an exaggerated oxytocin surge might be observed in people who suffer and people who stalk in a romantic relationship. The exaggerated oxytocin response in those who suffer and those who stalk are possibly maintained by rumination. Intranasal oxytocin application or gene therapy could be considered for these people.To test this hypothesis, 100 physically healthy volunteers who have just ended a romantic relationship might be recruited and divided into four groups, namely control group, playing group, suffering group, or stalking group based on the aforementioned postulated definitions. Plasma oxytocin concentration measurement and general mental health assessment might be performed for every participant. Half of the participants from the playing group, the suffering group, and the stalking group will receive intranasal oxytocin administration in a randomly assigned and double-blind fashion. Although there is no consensus on the intranasal oxytocin regimen, a systematic review indicates no adverse outcomes when delivered in doses of 18–40 IU for short term use . ParticiModifiers such as gender might be considered. It is also necessary to consider the menstrual cycle phases of the female participants in the future study since a meta-analysis has indicated a significant increase of plasma oxytocin concentration from the early follicular phase to ovulation and a significant decrease from ovulation to the mid-luteal phase . FurtherAlthough oxytocin is believed to be the major neurobiological factor in a romantic relationship, other factors  have been reported in the literature. Despite the paucity of related studies, some possible interaction between these factors and oxytocin have been indicated: oxytocin might induce release of dopamine and decrease release of cortisol . It is pThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.J-YC developed the hypothesis and wrote the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The field of assisted reproductive technology is shaped and changed constantly by advances in science and cutting-edge innovations. In a quest to maximise outcomes, add-on interventions are often adopted and utilised prematurely while the principles of evidence-based medicine seem to be less strictly adhered to. In this review we will attempt to summarise the latest evidence about some of the adjuvants. Known also as treatment add-ons, adjuvants or adjuncts are additional, optional, treatment steps that may be offered on top of standard fertility treatments. The topic of add-ons has been heavily debated as many consider such treatments unfounded.However, one has to agree that the very reason that this kind of treatments exists, and new innovative treatments keep emerging, is the challenge faced by the clinicians along with the frustration experienced by those trying to conceive.in vitro fertilisation (IVF) industry is already worth billions of dollars and is booming so there seems to be no easy answer to this question.When clinics start offering such treatments a Pandora’s box opens, as the question then would be where one draws the line. Worldwide the As the debate regarding the provision of add-ons is ongoing, several regulatory bodies and professional learned societies have released guidance and statements urging the public to be cautious and to question the use of such treatment modalities. Among those bodies are the Royal College of Obstetricians and Gynaecologists (RCOG) and Human Fertilisation and Embryology Authority (HFEA) in the UK, and the Australian-based Victorian Assisted Reproductive Treatment Authority (VARTA). The issue of add-ons has been under the spotlight even by investigative undercover journalists who have condemned the practice of some private clinics.Large randomised trials in IVF are very hard to pursue as patients are very keen to try novel or already established empirical therapies and therefore being randomised to a placebo arm is unappealing for them. For most of the add-ons presented in this publication, the available evidence is suboptimal, and better-designed studies are essential to give conclusive answers. We will therefore refrain from repeating the same argument separately for each treatment modality. We will also not elaborate on strategies used in order to improve success rates such as: freeze-all, routine use of ICSI for non-male factor infertility, preimplantation genetic testing for all cycles, continuous monitoring of the embryos (time lapse imaging), testing for endometrial receptivity or endometrial microbiome, and advanced sperm selection techniques such as intracytoplasmic morphologically selected sperm injection (IMSI), physiological ICSI (PICSI), and sperm head’s birefringence. It is our belief that these do not strictly speaking constitute adjuvants to treatment, and the decision regarding their use may be influenced by other factors. Instead we will try to focus on what we consider as ‘pure’ add-ons to treatment.The idea of a using a substance that could facilitate blastocyst implantation originates in the early days of IVF. Fibrin sealants have failed to demonstrate significant improvement in clinical outcomes; however, lately the spotlight has been on a specific culture medium with added hyaluronan, marketed as EmbryoGlue. Hyaluronan is a glycoprotein which is well known to provide a high viscosity environment in the uterus. It has also been observed that the synthesis of intrauterine hyaluronan increases before implantation and goes back to near basal levels after. The latest Cochrane review of 3898 participants from 17 randomised control trials (RCTs) demonstrated moderate-quality evidence for an improvement in clinical pregnancy rates (CPR) and live birth rates (LBR), with an associated increase in multiple pregnancy rate, when transfer medium was supplemented with hyaluronan. The published evidence may be suggestive of a beneficial effect of the use of hyaluronan-supplemented embryo transfer media , but its popularity is fading. Chemical, mechanical, laser-assisted hatching, or even drilling of the zona could in theory aid a hardened zona to break and thus facilitate the transfer of metabolites, growth factors, and signals between the embryo and the endometrium.Reviews on assisted hatching have reported statistically significant increases in CPR but no evidence for a difference in LBR. The latest meta-analysis of studies on assisted hatching included 36 RCTs with 6459 participants and found that assisted hatching gave a significant increase in CPR, but in the 15 RCTs that looked at LBR there was no evidence of benefit from assisted hatching .Failure of oocyte activation is thought to be an important cause of fertilisation failure following conventional ICSI. Artificially inducing oocyte activation by the use of calcium ionophores has been trialled for women with previous low or total failed fertilisation in previous ICSI cycle(s). The suggested physiological mechanism of action is by increasing calcium ion concentration around the ooplasm immediately following sperm–oocyte fusion, although oocyte activation is very complex and therefore the understanding is not complete.2) has also been reported.The most widespread AOA agents used in human ART are two Ca2þ-selective ionophores—ionomycin and A23187 —although a protocol using strontium chloride  have been used to promote successful invasion of trophoblasts in the presence of antiphospholipid syndrome. Low-molecular-weight heparin’s favourable pharmacological profile is the obvious reason why it is almost exclusively used in the context of ART, and therefore we will mostly focus on evidence regarding LMWH. The role of heparin in women suffering from thrombophilia who are undergoing assisted conception treatment is established, but its use in the general IVF population is still a grey area. One meta-analysis that included RCTs of women with repeated implantation failure (RIF) after ≥3 failed embryo transfer cycles  is predominantly being used for treating cases with thin endometrium. A retrospective study suggested enhancement of endometrial development in 70% of patients, while high implantation and pregnancy rates were achieved in a cohort of poor-prognosis patients  can induce oxidative stress and lead to cell damage or death. Cells have antioxidant mechanisms which regulate this process in order to achieve homeostasis, but often it becomes unbalanced. High levels of free radicals are thought to affect the reproductive function; therefore, antioxidants are increasingly being used over the counter by patients but also recommended by clinicians to improve natural reproductive potential and IVF outcomes.In male infertility their role is relatively well documented, and recently the term male oxidative stress infertility (MOSI) has been suggested as a distinct category . HoweverThe presence of a dominant Th1 phenotype is a common finding in women with recurrent miscarriages and implantation failure. An antioxidant diet regime has been shown to improve the cytokine ratio and therefore may indirectly lead to improved reproductive outcomes . One of Mitochondrial dysfunction is implicated with ovarian aging in both animal and human models. Preliminary work suggested that supplementation with CoQ-10 may reverse this process . It has Finally, it should be stressed that some ROS are signalling molecules in cellular signalling pathways, and therefore lowering their numbers may not be beneficial. It seems that both extremes—oxidative and antioxidative stress—are undesired, and blindly prescribing antioxidant supplements without an accurate determination of the oxidative stress may be too simplistic and counterproductive .There is no doubt that the immune regulation of the dialogue between the endometrium and the embryo during implantation is fundamental. The so-called immunological paradox of pregnancy though is still not well understood . Women dTests used to identify irregularities in the regulation of reproductive immunology such as peripheral blood NK (pbNK) cell number and activity and uterine NK (uNK) cell number and activity are gaining popularity. The relevance of some of these tests is questionable as there is a lack of consensus on the methods used for measuring and reporting as well as lack of a clear definition of a ‘normal’ range or what constitutes a ‘high’ cell count for either pbNK or uNK cells .A systematic review found no significant difference in the pbNK cell number and activity in women with or without implantation failure or miscarriage after ART. The authors concluded that the prognostic value of routine testing for pbNK cells is unclear. The implantation rates in women with or without elevated uNK cells in the two studies included in this review were comparable . Below wDifferent regimes of oral prednisolone or dexamethasone are being prescribed as an adjuvant to IVF. It has been proposed that glucocorticoids may improve the intrauterine environment due to the anti-inflammatory and immune-suppressive activity by acting as immunomodulators to normalise the cytokine expression profile and by reducing the uNK cell count and activity in the endometrium, thus suppressing endometrial inflammation . A CochrThere have been several studies though looking into more specific groups of women having IVF and treated with steroids alone or combined with other medications, like women with RIF or recurrent miscarriages or even women with abnormal immune testing such as elevated NK cells, or the presence of anti-cardiolipin antibodies, thyroid peroxidase antibodies, and anti-nuclear antibodies. One meta-analysis on the use of corticosteroids in women undergoing IVF with elevated pbNK cells found only one study which demonstrated an increase in CPR with prednisolone . The quality of evidence was considered low to indicate improved IVF outcomes . AnotherInfusion of intralipids is used for parenteral nutrition and is a fatty emulsion containing soya bean oil, egg yolk, phospholipids, glycerine, and water. It is also used in emergencies to treat systemic toxicity induced by local anaesthetics. Increasingly it is being used for women with failed IVF attempts and abnormal NK cell activity .A double-blind randomised control trial of 296 women with secondary infertility, recurrent miscarriage, and elevated pbNK cells showed no increase in CPR in the group of women who were treated with intralipid infusion . AnotherA retrospective study of women who received intralipids infusion due to elevated pbNK cells failed to identify any benefit, and a cost-effectiveness analysis deemed that the treatment was not cost-effective .Therefore, despite the relatively low cost of the intervention and the good safety profile, the evidence for its use is lacking, and prospective patients should be made aware of this.Theories regarding the potential mechanisms of actions of i.v. immunoglobulin (IVIg) include inhibition of pbNK cell numbers and/or activity, correction of abnormal Th1/Th2 ratio, but also non-specific immunomodulation leading to enhancement of immunological tolerance. A systematic review published in 2013 included 10 studies and a total of 835 women who received IVIg as adjuvant treatment to IVF. A significantly higher implantation rate , CPR , and LBR  were reported, as well as a significantly lower miscarriage rate . Although this review showed that IVIg use was favourable for all reproductive outcomes, the quality of the retrospective studies included was variable, including a mixture of patients with recurrent implantation failure, unexplained infertility and recurrent miscarriages, several dosing regimes, and co-treatment with other add-ons .A more recent systematic review and meta-analysis of the available evidence regarding immunotherapy  identifiAn exaggerated Th1 response is thought to be detrimental to the process of embryo implantation and has been linked to infertility; therefore, elevated tumour necrosis factor (TNF) levels have been targeted for therapeutic correction in patients with a raised Th1/Th2 ratio. A potential reproductive benefit of anti-TNF-α agents, adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicaid) has been proposed in infertile women with abnormal immunological parameters. A small retrospective case–control study of women with Th1/Th2 cytokine elevation reported a LBR of 73% in 41 patients who received IVIg and adalimumab, 50% in 6 patients who received adalimumab alone, and no live birth in 5 patients who received neither . Anti-TNG-CSF is a cytokine that stimulates neutrophilic granulocyte proliferation and differentiation. It has been proposed as an important factor for embryo extravillous trophoblast cells invasion and adequate placentation. It has been used for patients with RIF but also for those with thin endometrium. Despite a rapidly increasing interest over recent years, the actions of G-CSF are still not clarified. Existing studies are very heterogeneous, include different regimes and routes of administration (intrauterine versus subcutaneous), and their interpretation should be carried out with caution. Two very recent attempts to systematically review results from these studies reported conflicting results. Zhang and colleagues reviewed 10 studies of various design and demonstrated improved CPR with the use of G-CSF in IVF cycles regardless of the route of administration for cases with RIF . On the Dehydroepiandrosterone (DHEA) is an endogenous steroid hormone produced primarily in the adrenal glands, gonads, and brain. It is difficult to distinguish it from its sulphated product, and it is known to decline with advancing chronological age. It is believed that it can enhance follicular function by increasing the production of insulin-like growth factor-1 (IGF-1) and augmenting oestradiol production in granulosa cells, acting as a precursor of androstenedione and testosterone in the ovarian theca cells. In addition, it has been suggested that pre-treatment with DHEA can reduce embryo aneuploidy, possibly by improving the ovarian micro-environment in which follicular maturation occurs .A worldwide survey conducted in 2010 revealed that over one‐quarter of specialists add DHEA as an adjuvant to IVF treatment for anticipated low responders. A dosing regime of 25 mg three times daily is standard and has been used in most of the available studies which makes evidence less heterogeneous.A plethora of publications on the positive effects of DHEA on ovarian response, embryo quality, and pregnancy outcomes in poor responders undergoing IVF are available. Nevertheless, there is still no consensus regarding its perceived benefit, and many of the available studies have been subsequently criticised by others. A large RCT investigating 12 weeks of DHEA supplementation in 104 poor responders compared with 104 controls found an insignificantly higher pregnancy rate in the control group .Conversely, a Cochrane review revealed higher ongoing pregnancy rates and LBR following DHEA use; however, the benefit was not statistically significant  when studies with high risk of performance bias were excluded .The DITTO (Dehydroepiandrosterone Intervention to Treat Ovarian Aging) single-center RCT included a small number of subjects (25 versus 27 in each arm) and failed to demonstrate any benefit from the use of DHEA in women with diminished ovarian reserve undergoing IVF .Other attempts for meta-analyses that followed failed to be conclusive. Qin and colleagues suggested significantly increased CPR for patients with diminished ovarian reserve who were pre-treated with DHEA when data from nine studies of various design were included. There was, however, no significant increase when the data were restricted to RCTs . A laterIt is interesting that for the anticipated normal responder population a well-designed double-blind RCT did not report any difference in number of oocytes or ovarian response after 12 weeks of DHEA . HoweverThe absence of significant side effects should not be considered as an argument to recommend routine use of DHEA. Nevertheless, it is difficult to stop patients self-medicating especially since DHEA is readily available online and over the counter. Counselling is essential for patients, and it seems that the use of DHEA will not stop unless any new solid evidence, which dictates otherwise, becomes available.Growth hormone (GH) is a requisite of normal puberty, appears to have a role in ovarian function, and is proposed to have a modulatory action on the effect of FSH on granulosa cells by up-regulating the local synthesis of IGF-1. This in turn is thought to enhance the effect of gonadotrophin action at the level of both the granulosa and theca cells. Although the potential role of GH in ART has been recognised and studied for more than three decades, over the recent years a newfound interest has emerged, and GH has again become a popular topic. A Cochrane review published in 2010 included 10 RCTs with a total of 440 subjects . The autIn 2015, an updated meta-analysis reported results in line with previous evidence. The results showed a significant improvement in terms of mature oocytes retrieved and number of embryos available for transfer by GH supplementation in poor responders. However, there was no significant difference in CPR . In someThe latest meta-analysis regarding the use of GH in controlled ovarian stimulation (COS) was published in 2017 . It inclAlthough injury to the endometrium prior to embryo transfer is not strictly speaking an adjuvant to IVF, we have included it in our review as it is an intervention which has gained a lot of interest over the recent years. The theory behind it was that it may positively affect implantation by inducing the release of factors such as cytokines, interleukins, and growth factors in the endometrium. The most common and easily available procedure was via the use of a pipelle known as ‘endometrial scratching’. After many published studies a RCT was conclusive in showing that endometrial scratching does not confer any benefit to reproductive outcomes, including LBR . An alteThere are obviously more interventions used in IVF cycles that could be described as adjuvants, but our review cannot exhaust them all. Platelet-rich plasm injection in the ovaries, mitochondrial replacement therapy (spindle transfer), melatonin, mitochondria DNA load measurement, among others, may prove to live up to the hype in the future.argumentum ad ignorantiam’ is a famous informal fallacy in logic.For most interventions mentioned in this document (summarized in But, before we reject any add-on shown not to work or we embrace others where evidence is favourable, we need to ascertain its effect in patients with a specific profile that might be modulated by the treatment under consideration. Novel diagnostic technologies are emerging that will enhance our understanding of the nature and determinants of reproductive functions. These technologies pave the way to a personalised approach in medicine and promise to help us identify specific patients who may benefit or be harmed by an intervention. Dismissing adjuvants altogether may pose the risk of keeping us stuck in the ‘one-size-fits-all’ clinical paradigm. Until then keeping an open mind and being honest and transparent with the patient is the best way forward.


It is now widely accepted that animals may express and perceive emotions. This capacity has an adaptive value because it allows animals to respond to various situations quickly and appropriately thus facilitating their survival and increasing their reproductive success. Through spontaneous mimicry, animals can share their emotional mood and this appears to be particularly fruitful when the relationships are not inhibited by rank rules and when animals build and maintain their bonds through cooperation and social affiliation. Dogs represent a very good model to test hypotheses about the importance of mimicry in regulating emotional sharing because they can be tested at both intra- and inter-specific levels. The intra-specific evidence will help us to understand what the social cognitive potential is at the basis of the evolution of the emotional “intimacy” between dogs and their human companions.Canis lupus familiaris), a valid example of empathic predisposition towards individuals belonging both to the same and the different species. We contrast available findings on RM and YC in dog–dog and dog–human dyads with those in wolf–wolf dyads, in order to investigate if the ability to emotionally engage with conspecifics (wolf–wolf and dog–dog) is evolutionary rooted in canids and if provides the basis for the development of inter-specific emotional sharing (dog–human).Involuntary synchronization occurs when individuals perform the same motor action patterns during a very short time lapse. This phenomenon serves an important adaptive value for animals permitting them to socially align with group fellows thus increasing integration and fitness benefits. Rapid mimicry (RM) and yawn contagion (YC) are two behavioral processes intermingled in the animal synchronization domain. Several studies demonstrated that RM and YC are socially modulated being more frequently performed by individuals sharing close relationships. This evidence highlights the relation between RM/YC and emotional contagion that is the capacity of two or more individuals to share the same affective state. In this review, we try to delineate a possible developmental trajectory of emotional sharing phenomena by using, as a model species, the domestic dog ( Behavioral non-conscious synchronization is widespread among animals, including humans. It occurs when individuals engage in the same motor action during a very tight time window and when they are spatially close ,2. SynchThe behavioral synchronization domain includes two phenomena that are still debated topics in human and non-human animal studies: Rapid Mimicry (RM) and Yawn Contagion (YC) . Even thRM and YC seem to intermingle with emotional contagion which is defined as “the tendency to automatically mimic and synchronize expressions, vocalizations, postures, and movements with those of another person’s and, consequently, to converge emotionally” . EmotionThe expression and perception of emotions in non-human animals seem to be adaptive because these skills allow them to respond quickly and appropriately to unpredictable situations thus increasing their survival and fitness ,15. AccoCanis lupus lupus) and dogs (Canis lupus familiaris) [Beyond primates, cohesive and cooperative societies also characterize several social carnivores such as wolves (iliaris) ,18. Compiliaris) . Dogs deiliaris) . One of iliaris) . The capiliaris) ,12 can biliaris) , (2) abiiliaris)  and (3) iliaris) ,24,25. TAlthough rapid mimicry (RM) and yawn contagion (YC) are different behavioral phenomena, there is evidence that they rely on similar mechanisms. In this theoretical framework, the dyad composed by interacting subjects is considered as an “interactive unit” in which coordinating actions and possibly shared emotions create a shared identity ,27. ReacPlay may represent one of the most fertile social contexts in which the alignment–reward system  is unveiConsidering canids, RM has been found in dogs . During A recent study  examininAfter demonstrating that both play bow and relax-open mouth were rapidly mimicked by the players, Palagi and co-authors  showed tempathic gradient being greatest in response to friends, then acquaintances, and lastly strangers. As pointed out, play offers a positive and safe “environment” in which subjects can implement not only their physical skills, but also their emotional capacities [A further important issue to explore would be whether the administration of oxytocin increases the mimicry response also when the interacting subjects are unfamiliar. Indeed, as it occurs in humans , the levpacities . The abipacities . Even ifpacities , during Up to now, no quantitative data are available on dog–human facial mimicry during play, even though some anecdotic observations seem to suggest the presence of the phenomenon . However, other forms of mimicry have been investigated between dogs and their owners; for example, Sümegi et al.  found noMotor mimicry often implies an eye-to-eye contact between the interactans that can have consequences in creating an emotional bridge between partners. Nagasawa et al.  demonstrTaking together, all these findings suggest that motor, physiological, psychological, and hormonal mimicry phenomena are intertwined factors that may depend more on social closeness than on phylogenetic relatedness. This shared interspecies communication, which is at the basis of social attachment, could be a promising starting point for expanding the investigation of motor resonance phenomena  between dogs and humans. Interestingly, mutual gazing or chemical/motor mimicry between hand-raised wolves and their care-takers were not confirmed . Are wolEvolutionary Social Competence that is the complex system of specific prosocial and coercive behavioral skills showed by interacting individuals of a given species. Probably, wolves with more human-like social competence gradually increased the closeness and affiliation with humans which, in turn, positively evaluated the presence of a companion animal with well-matched social and communicative skills. It has been suggested that during dog domestication the reduction in the environmental stress and the increase in inter-specific social interactions could alter the expression of genes via an epigenetic modulation that led to changes in social brain systems and behaviors [Miklósi and Topál , pointedehaviors ,62. To reach a clear picture of the evolution of rapid mimicry phenomena we need to understand if they have been shaped by the artificial selection operated by humans or if they are evolutionarily rooted in the line of social carnivores. The next challenge is to focus on the occurrence and social modulation of the rapid mimicry phenomena during intra-specific interactions in wolves. This will help understand the proximate causes of the evolutionary processes at the basis of the development of automatic mimicry and synchronization skills not only in dogs’ ancestors but also in dog–human communication exchange. Spontaneous yawning is a primitive stereotyped motor action pattern, that once triggered, is uncontainable and unstoppable . It cannContagious yawning, a behavioral act involuntarily induced by viewing or listening other’s yawns , is consIn 2008, Joly-Mascheroni and co-authors  evidenceIn order to discriminate between the two possible proximate causes (empathy vs anxiety) of yawn contagion in dogs, Romero and co-workers  carried Recently, by investigating the possible relation between yawn contagion and the empathic gradient Kis and colleagues  providedIf the occurrence of contagious yawning and its proximate causes have been investigated in the dog–human relationship, no studies are available on the phenomenon of yawn contagion between dogs. Is the phenomenon of yawn contagion exclusively linked to dog–human interactions because of the domestication process or is this motor resonance phenomenon deeply rooted in social carnivores and simply transferred from conspecifics to human partners in the domestic dogs?A study carried out by Romero and colleagues  on captiWolves, the ancestors of dogs, constitute cohesive family group whose members actively and cooperatively participate to the pack life creating a sort of “division of labor” system ,88. As hIn conclusion, to understand the role of the domestication process and artificial selection operated by humans in shaping the emotional contagion of dogs (rapid mimicry and yawn contagion), we should focus not on the possible presence and distribution of these phenomena between hand-reared wolves and humans but, instead, between the different wolf pack members . Long-teAs for dogs, we should focus on the different breeds. By selecting the most recent (less human-oriented) and ancient breeds (more human-oriented) as models we can evaluate to what extent the artificial selection has operated in shaping the mimicry phenomena. To reach the goal, observational studies on groups of dogs belonging to the same breed and experimental studies including dogs of different breeds and their owners are necessary.


Intense recent interest in understanding how the human gut microbiome influences health has kindled a concomitant interest in linking dietary choices to microbiome variation. Diet is known to be a driver of microbiome variation, and yet the precise mechanisms by which certain dietary components modulate the microbiome, and by which the microbiome produces byproducts and secondary metabolites from dietary components, are not well-understood. Interestingly, despite the influence of diet on the gut microbiome, the majority of microbiome studies published to date contain little or no analysis of dietary intake. Although an increasing number of microbiome studies are now collecting some form of dietary data or even performing diet interventions, there are no clear standards in the microbiome field for how to collect diet data or how to design a diet-microbiome study. In this article, we review the current practices in diet-microbiome analysis and study design and make several recommendations for best practices to provoke broader discussion in the field. We recommend that microbiome studies include multiple consecutive microbiome samples per study timepoint or phase and multiple days of dietary history prior to each microbiome sample whenever feasible. We find evidence that direct effects of diet on the microbiome are likely to be observable within days, while the length of an intervention required for observing microbiome-mediated effects on the host phenotype or host biomarkers, depending on the outcome, may be much longer, on the order of weeks or months. Finally, recent studies demonstrating that diet-microbiome interactions are personalized suggest that diet-microbiome studies should either include longitudinal sampling within individuals to identify personalized responses, or should include an adequate number of participants spanning a range of microbiome types to identify generalized responses. Microbiome features and metabolites have been increasingly linked to states of health and disease , 2, and High interindividual variation in both dietary intake and microbiome composition contribute to our poor understanding of the relationships between the foods we eat and how they impact the bacterial communities that reside within our bodies . It is dBilophila wadsworthia has been identified in animal models as potentially important for the development of inflammatory bowel diseases in genetically susceptible individuals  or self-administered single day food records or 24-h dietary recalls. Each of these methods is prone to reporting errors and is associated with advantages and disadvantages, as has been reviewed extensively elsewhere . ImportaAccurately measuring and assessing dietary intake using self-report and nutritional biomarkers is challenging , 37. WheDietary measurement by FFQ has both advantages and disadvantages , 40. TheDespite the identification of some signals from microbiome studies that use FFQs for dietary analysis, the technique is simply not specific enough to untangle the complex relationships between foods and the microbiome. We have shown previously that microbiome composition more closely covaries with food intake, not nutrient intake , indicatIn instances where researchers recognize the need to collect more finely resolved dietary information, it is common in the microbiome literature to read about techniques that use researcher-developed food questionnaires, independently created app-based collection methods , 48, andIn the current dietary record collection environment, different dietary collection tools and FFQs rely on different underlying databases, which makes comparison across studies and cohorts difficult, if not almost impossible. Even within the English speaking regions of the Americas, United Kingdom, and Australasia, food records are ultimately mapped back to different databases depending on the software tools used for analysis . Each da9 colony forming units [CFU] vs. 1 × 106 CFU in a day's worth of meals)  . Considef meals) . IdeallyAs the number of longitudinal microbiome studies steadily increases in the literature, controlling for within-individual variation is an increasingly important consideration during study design. Here we present reasoning that supports including multiple consecutive microbiome samples per study timepoint or phase, and multiple days of dietary history prior to each microbiome sample whenever feasible; thus capturing longitudinal change within an individual by measuring changes over time or before and after a dietary intervention, while also using repeated sampling around set timepoints to control for within-person variation. To support these recommendations, we provide suggestions for microbiome sample collection, transport, and storage for diet-microbiome studies and explore questions that researchers designing studies in this space should consider.Diet explains around 5–20% of the variation in microbiome , 62, 63.Increasing sample size will boost power to identify diet-induced microbiome differences but does little to account for the dynamic nature of the microbiome. Increasingly, data support the need for repeated sampling of the microbiome to account for intra-individual variation with 3–5 daily sequential fecal samples in aggregate providing better results over single samples in inflammatory bowel disease cohorts  and in hPrevotella-dominant, to increase power. In study designs for dietary interventions where the length of the intervention required makes a cross-over design difficult, stratified randomization or an interspersed treatment design that incorporates baseline microbiome could make parallel arm studies more feasible. As an alternative, selection for a specific baseline microbiome phenotype should improve the ability to assess how interventions depend on the presence of particular microbes. As a thought experiment, we consider the situation of studying a specific prebiotic. A researcher in this situation may want to choose only people who have the targeted microbe that is expected to be enriched by that prebiotic, or to choose people who have a low abundance of fiber-degrading microbes to see how the intervention affects that subgroup. Importantly, microbial phenotyping at baseline would allow for randomization into study arms using a stratification design that incorporates baseline microbiome composition, thereby avoiding the situation where after randomization clusters of individuals with similar microbial compositions are assigned to the same treatment arm  until they can be stored appropriately at −80°C in a research facility. Immediate sample storage at −80°C is considered the gold standard regardless of the presence of a preservative. In most human studies, practical considerations around the timing of bowel movements, location relative to the research facility, or availability of refrigeration requires the use of a preservative to prevent microbial growth in these samples. Preservatives can allow samples to be stored at ambient temperatures for as long as 60 days without impacting technical reproducibility ; althoug gut kit . Many pr gut kit , however gut kit . OverallChoosing a DNA sequencing technique for the analysis of collected fecal samples is another important consideration. When selecting a method, the desired taxonomic and functional resolution required to address study hypotheses should be carefully considered. The primary sequencing methods available for microbiome classification are 16S amplicon sequencing and metagenomic sequencing. The 16S ribosomal RNA gene is conserved across bacteria and contains nine hypervariable regions (V1-V9) that have amassed changes throughout evolutionary history. Amplification and sequencing of the variable regions within this gene   allows fAn alternative to 16S sequencing is deep whole metagenomic shotgun sequencing, which involves the sequencing of all microbial genomes in a sample. This method provides resolution to species level of taxonomy, and can also detect eukaryotic species and viruses to provide information on other microbes in a sample . AmplifiFor observational studies where dietary intake is considered as a confounder for the microbiome outcome of interest, the decision to collect dietary data is driven by different factors than when dietary intake is the exposure of interest. We do not think that all microbiome studies need to collect dietary data. In many well-designed microbiome studies it may not be necessary to collect dietary data and the decision to collect dietary data should be weighed carefully with the researchers' hypotheses and planned analyses. In observational studies where diet will be a clear confounder that cannot be controlled for through other study design parameters, investigators should collect detailed information about diet.There are additional factors causing personalization of diet-microbiome interactions. Of particular importance is the effect of transit time on microbiome-diet study planning and analysis. Transit time has been shown to affect the microbiome directly. Fukuyama et al. conducted a longitudinal study on human participants receiving an intervention to induce iso-osmotic diarrhea, a less extreme method to mimic a physiological disturbance of gut microbiome than antibiotic-induced cleanse, and revealed that rapid transit time affects microbiome composition. This study pointed out that although rapid transit, usually resulting from diarrhea, can cause dysbiosis, the gut microbiome communities revert to their pre-cleanout states within ~5 days after the cleanout, depending on the specific strains of bacteria . BecauseWe recommend the collection of dietary recalls or records from 2-3 days prior to the sample collection period . In a coDietary intake is more variable than microbiome composition both within and between people , and stuEven if we are able to account for baseline microbiome differences with study design and pre-study microbiome-typing, we may also want to account for differences in habitual dietary intake at baseline. One way to control for variation in dietary intake in microbiome studies would be to switch participants onto an identical, standardized baseline diet prior to the intervention period. In practice, this is not trivial because the shift to the standardized diet can have its own effects on the microbiome, and thus may obscure the effects of the intervention. For example, Gurry et al. used a meal replacement beverage (Ensure) in an attempt to standardize the diet of their cohort prior to testing the effects of specific foods and supplements, but changing participants to this standardized beverage induced changes to their gut microbiomes including some diversity loss, and the changes were not consistent across all participants . From thstabilizing diet, rather than by standardizing diet. This ensures consistency of individual diet during microbiome-focused intervention studies but does not attempt to modify habitual diet. The simplest approach is to ask participants to maintain their normal diet. More complex approaches would assign each subject to a specific constrained diet based on their own recent dietary intake data. Ultimately the best dietary approach will be study-dependent, and should be considered carefully when planning interventions to improve the ability to draw strong conclusions.Based on currently available information, we recommend controlling variation in dietary intake by Dietary intervention studies are likely the best way to understand the impact of dietary components on the microbiome, but themselves come with some caveats. Cross-over intervention studies, where each participant undergoes both the target intervention and the control arm, with a washout period between treatments, is the most optimal study design for studying the effects of a dietary intervention because each participant acts as their own control. Cross-over designs have been successfully implemented in diet-microbiome studies , 24, 95,Many studies have assessed the intake of grains and grain products , 100, anThe short-term impact of diet on the microbiome beta-diversity is well-known, while the finer details and specific impacts of individual foods are still poorly understood. Results from mouse models revealed that large changes in diet can cause rapid gut microbiome compositional changes within a small number of days , 108. InAn additional consideration for planning dietary intervention studies where study foods will be provided to the study participants is preference. It is imperative to know whether a study participant will be willing to eat all of the study foods and meals provided. Ideally, the study meal plans, with all the intended ingredients and preparation methods, should be clearly explained in advance, and potential participants should be asked during screening whether they are willing to follow all study protocols, to prevent the recruitment of non-compliant participants. If substitutions need to be made after the participant has already been recruited into the study, these substitutions may impact the effects of the intervention on the microbiome. For example, in a recent study we tested the effects of a Mediterranean style diet compared to a fast food diet of burgers and fries . Even inDietary interventions with microbiome outcomes should include placebos and blinding where possible; these considerations are not unique to microbiome studies . When diUltimately, the results of even extremely well-controlled dietary intervention studies are likely to be affected by personalized diet-microbiome interactions. The individual variation across people's microbiomes arises from a combination of factors beginning in infancy, likely including birth mode and antibiotic exposure , 65. IndtrnL-P6 marker gene (Participant compliance and the cost of participant time remain an obstacle for researchers to attain authentic dietary information in a practical way. Improvement in dietary assessment by shortening the time of data collection and reducing participant workload would improve the overall quality of dietary intervention trials. Recent work has applied the technique of metabarcoding to evaluate the plant component of diet from stool samples using the ker gene . Similarker gene , 116; deker gene  and waysIdeally, researchers could follow a meal through the gut and collect data about that meal and the microbial community changes that are induced by it. Technology that allows easier sampling throughout the gastrointestinal tract using capsules to capture information directly from within the small intestine and colon is a promising advance . The ideMost of the technology-based approaches for dietary assessment still depend on self-reported dietary intake . The comGiven the still-emerging technologies in dietary assessment, exploration of alternative methods of collecting dietary data is an important area of future work. In the short-term, we may need to shift the paradigm in dietary assessment from a nutrition-centric perspective to a microbiologist-centric perspective and to design and validate a microbiome-focused food intake questionnaire. A tool like this should divide foods into groups that have particular relevance for the microbiome based on fiber type or phytocompound composition known or suspected to affect the microbiome. There may be other proxies that we can capture as latent variables for diet that discard previous dietary norms and assumptions such as macronutrients and kilocalories while still collecting key information relevant to microbiome analysis. There is likely also a role for nutritional biomarkers or blood metabolites to characterize individual diet-microbiome interactions, particularly when personalization is considered relative to microbiome changes . CombineIn this article, we have presented a variety of considerations including both practical recommendations that can be immediately incorporated into studies and aspirational recommendations that will require greater effort for implementation . UltimatBioRender.com.AJ wrote the manuscript and created the figures. JZ, JK, and AS wrote sections of the manuscript and assisted with figure planning. DK and AZ planned the review and contributed to editing and revising the manuscript. All authors read and approved the submitted version. All figures were created with AJ and DK have received research support from General Mills. AJ has received speaking fees from Abbott Nutrition. DK serves as CEO of CoreBiome, a company involved in the commercialization of microbiome analysis. CoreBiome is now a wholly owned subsidiary of OraSure. These interests have been reviewed and managed by the University of Minnesota in accordance with its Conflict of Interest policies. 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.


What is mentoring? Mentoring is defined as a professional relationship in which an experienced person assists another in developing specific skills and knowledge enhancing the mentee’s professional and personal growth. Mentoring benefits include: Knowledge transfer, creating a mentoring culture, and challenging the mentee to move beyond their comfort zone. Carmel and Paul (2015) describe self-selected mentoring as a process in which a mentee identifies a potential mentor based on similarities in interests and need. Findings indicated mentees experienced opportunities in career advancement, expanded thinking, scholarly confidence, facilitation of a collaborative culture, and understanding the importance of goal setting. Mentoring as a health promotion or intervention strategy has become widespread in communities. Two mentoring approaches will be discussed: a traditional format with students and faculty in academia, another utilizing an intergenerational approach with Latinx and Native American families. Recommendations will be discussed in terms of underlying core similarities across the venues.


Enhancing performance levels of athletes during training and competition is a desired goal in sports. Quantifying training success is typically accompanied by performance diagnostics including the assessment of sports-relevant behavioral and physiological parameters. Even though optimal brain processing is a key factor for augmented motor performance and skill learning, neurodiagnostics is typically not implemented in performance diagnostics of athletes. We propose, that neurodiagnostics via non-invasive brain imaging techniques such as functional near-infrared spectroscopy (fNIRS) will offer novel perspectives to quantify training-induced neuroplasticity and its relation to motor behavior. A better understanding of such a brain-behavior relationship during the execution of sport-specific movements might help to guide training processes and to optimize training outcomes. Furthermore, targeted non-invasive brain stimulation such as transcranial direct current stimulation (tDCS) might help to further enhance training outcomes by modulating brain areas that show training-induced neuroplasticity. However, we strongly suggest that ethical aspects in the use of non-invasive brain stimulation during training and/or competition need to be addressed before neuromodulation can be considered as a performance enhancer in sports. Athletes typically need to invest a lot of effort and strenuous successive practice over many years. As a rule of thumb, according to Ericsson et al.  or functional near-infrared spectroscopy (fNIRS) have been extensively used to assess brain-behavior relationships over the lifespan. Based on these investigations, we know that the brain adapts its function and structure according to environmental changes on a very short time scale  study by Naito and Hirose  providedBeyond financial and infrastructural aspects, one crucial limitation in the use of MRI for neurodiagnostics is that sport-specific movements cannot be performed due to the spatial limitations inside the MRI bore and its high susceptibility to motion artifacts . The major advantages of this method are on the one hand its portable application and on the other hand its high temporal resolution   spatial resolution (van Gerven et al., Despite its limitations described above, previous studies have demonstrated that fNIRS is an appropriate and reliable method for measuring neural activity during simple and complex motor tasks (Leff et al., Apart from quantifying brain function and structure in athletes, the question remains whether neuroplasticity in athletes is training-induced or an epiphenomenon of genetic predisposition. To address this question, several longitudinal training interventions have been conducted over the past decade (Draganski et al., Apart from these exciting insights, however, the key limitation of the aforementioned studies is that MRI assessments did not allow online measurements of functional neuroplasticity during motor skill learning and/or training of motor abilities in athletes. Therefore, fNIRS seems to be particularly suitable to quantify functional neuroplasticity systematically during training processes. Here, it seems to be important to assess the temporal dynamics of training-induced neuroplasticity during sport-specific training in real-world settings and its behavioral relevance. This knowledge in turn might be used to control and/or optimize training success in various sports disciplines. Furthermore, neurodiagnostics in sports could also be used in the field of talent diagnostics. Here, certain particularities in brain function and/or structure of young athletes might be used as a predictor for their potential of becoming an elite athlete, their prerequisites to acquire specific skills or to improve motor performance or even their suitability to a specific sports discipline.Identifying training-induced neuroplasticity is a prerequisite for targeted neuromodulation to augment motor performance and/or sport-specific skills see . Here, nFor example, a single tDCS session has been shown to increase motor performance or skill learning (Nitsche et al., Neuromodulation to augment performance in sports is no science fiction. Several opinion papers and systematic review and meta-analysis articles discussed the feasibility of tDCS as a performance enhancer in athletes (Bolognini et al., Regardless of these open methodological questions, it is by no means clear if tDCS outside highly controlled laboratory settings is at all effective in boosting performance during competition, especially in highly trained athletes. On the one hand, tDCS is known to induce very variable effects on a behavioral level (Bashir et al., In summary, we suggest that neurodiagnostic tools such as MRI, EEG or fNIRS should be implemented in performance diagnostics in sports. Since optimal brain processing is a key factor for efficient motor control and performance, characterizing adaptational brain alterations as a consequence of systematic training might open novel perspectives to augment training success in athletes. Therefore, a desirable goal of future neurodiagnostics is to identify brain networks that contribute to performance improvement in general and, beyond that, brain networks that are particularly responsible for the execution of specific sports disciplines. Furthermore, neurodiagnostics might help to identify youth athletes with the potential of becoming elite athletes. Additionally, neuromodulation might be an alternative way to optimize training outcomes by a selective modulation of performance-relevant brain regions. However, it first has to be shown that tDCS in athletes is at all capable of enhancing motor skill learning and/or motor performance, and if so, that this is performance-relevant and beneficial in specific sports disciplines. Finally, the development and application of neuromodulation in sports must be accompanied by a continuous discussion concerning framework conditions such as ethical aspects, risks, and implementation in the field.All authors contributed to the manuscript, reviewed it, approved the final version content and agree to be accountable for all aspects of the work. All persons designated as authors qualify for authorship, and all those who qualified for authorship are listed.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.


The concept of trained immunity has recently emerged as a mechanism contributing to several immune mediated inflammatory conditions. Trained immunity is defined by the immunological memory developed in innate immune cells after a primary non-specific stimulus that, in turn, promotes a heightened inflammatory response upon a secondary challenge. The most characteristic changes associated to this process involve the rewiring of cell metabolism and epigenetic reprogramming. Under physiological conditions, the role of trained immune cells ensures a prompt response. This action is limited by effective resolution of inflammation and tissue repair in order to restore homeostasis. However, unrestrained activation of innate immune cells contributes to the development of chronic inflammation and tissue destruction through the secretion of inflammatory cytokines, proteases and growth factors. Therefore, interventions aimed at reversing the changes induced by trained immunity provide potential therapeutic approaches to treat inflammatory and autoimmune diseases like rheumatoid arthritis (RA). We review cellular approaches that target metabolism and the epigenetic reprogramming of dendritic cells, macrophages, natural killer cells, and other trained cells in the context of autoimmune inflammatory diseases. Vertebrate immunity is coordinated by a complex interplay of physical and chemical barriers , humoral factors and different cell types that reacts to the continuous exposure to diverse internal and external stimuli. Traditionally, the responses to these challenges have been classified as two independent systems, innate and adaptive immunity.Innate immunity has been classically defined as a rapid and nonspecific response that comprises biochemical and cellular mechanisms that are present before infection and are considered the first line of defense. It is triggered within minutes after infection but does not generate immune memory because their effectors are germline-encoded. Its main components are the complement system, myeloid cells , natural killer (NK) cells or innate lymphoid cells (ILCs), responsible for molecular recognition and antigen presentation, phagocytosis and elimination of pathogens. In contrast, adaptive immunity is carried out by B and T lymphocytes and has been described as slow and specific. It takes days or weeks to generate an adequate humoral and cellular response, mediated by genetic rearrangement and clonal selection. This results in antigen-specific responses that can induce lasting immune memory.This dichotomy has changed in recent years and both immune arms are currently considered highly intertwined and collaborative. The dogma establishing the innate system as nonspecific and incapable of adaption or develop immunological memory has been replaced by a model where phagocytosis, microorganism removal or lysis of infected cells are considered as one more specific response. This has been due, at least in part, to the discovery of Pathogen Associated Molecular Patterns (PAMPs), essential microbial components, and the endogenous signs of damage , which are recognized through the constitutive expression of different families of Pattern-Recognition Receptors (PRRs)  thus allowing the implementation of an adequate response depending on the type of molecules that are recognized –4.Anopheles, Drosophila, and the mealworm beetle T. molitor ” has been termed “innate immune memory” or “trained innate immunity” in vertebrates .Exposure of innate immune cells to a stimulus through PRRs, promotes a series of long-term modifications that involve rewiring of cell metabolism and epigenetic reprogramming. Since several metabolites function as signalling molecules or cofactors for the enzymes responsible of epigenetic changes, these two processes are closely related . DependiMost cells use aerobic respiration as their main source of ATP under homeostatic conditions. In the case of the cells of the immune system, there are important metabolic differences depending on the cell type or its activation state . WhereasRecent studies suggest that other metabolic pathways also play an important role in cell reprogramming, such as the fatty acid synthesis pathway, which produces cellular stress and activates innate immunity responses. For example, cellular accumulation of unsaturated fatty acids  induces a pro-inflammatory phenotype in macrophages due to uncoupling of mitochondrial respiration and production of inflammasome components such as IL1-α . Likewisvia inflammatory cytokines or TLR ligands, rapidly increases its expression and acts as an activator of inflammation through the down regulation of phosphatases of various signalling pathways  –26. ThisThe origin and development of autoimmune diseases is mainly attributed to an excessive and sustained response to autoantigens mediated by B and T cells. On the other hand, they are also characterized by excessive inflammation and there is strong evidence that innate immunity reprogramming is one contributing factor.Under physiological conditions, the action of the innate immune response is curtailed by an effective resolution of inflammation and the induction of tissue repair but when the system is dysregulated and the cellular response gets uncontrolled chronic inflammation and tissue destruction, mediated by inflammatory mediators , ensue . In thisin vitro  and 3-BP (3-bromopyruvate), that block glycolysis by inhibiting pathway-limiting enzymes, have shown protection in animal models of arthritis and Systemic lupus erythematosus (SLE) , 33. Thein vitro . Lack ofConversely, the fact that mTOR inhibitors, such as metformin and rapamycin, are already used in the clinic for the treatment of transplant rejection and glycemic control make them more attractive candidates to target trained immunity. Metformin synergizes with 2-DG in the treatment of lupus mice  and has As in the case of glycolytic inhibitors, the lack of cell specificity makes difficult to evaluate an intrinsic effect on trained immunity. To circumvent this limitation, the application of HDL-based nanobiologics has been used successfully to target mTOR inhibitors to macrophages in the context of transplantation .In vitro and in vivo studies show how the administration of products of arachidonic acid metabolism  can serve as a therapeutic strategy in those diseases where osteoclastogenesis is deregulated, such as rheumatoid arthritis (RA)  ; treatmetis (RA) .Reverting the epigenetic modifications that occurred during the immunity training to normal values using different inhibitors can potentially be used for the treatment of inflammatory and autoimmune diseases . InhibitBiologics currently used in the clinic for the treatment of autoimmune diseases can also have an impact on trained immunity. For example, Lin and colleagues have described that TNF inhibitors etanercept and adalimumab suppress the expression of CC-chemokine ligand 2 (CCL2) in monocytes by regulating histone acetylation and trimethylation, changes that correlate with RA activity .IL-1β associated with increased inflammasome activity may also serve as a target to actively suppress trained immunity. The observation that monocytes from patients with autoimmune and autoinflammatory diseases showed increased released of IL-1β than healthy individuals , 59 promGranulocyte-macrophage colony-stimulating factor (GM-CSF) is a major cytokine in the development of trained immunity . SeveralIt has been proposed that trained immunity can be beneficial against SARS-CoV2 infection . In thisConversely, the presence of previous inflammatory diseases and the excessive inflammatory response triggered by SARS-CoV2 infection are poor prognostic factors in COVID-19 progression  and, givin vivo use of molecules that target myeloid cells and their progenitors. The compounds used to regulate trained immunity show toxicity, low bioavailability and some adverse effects related to immunity. More suitable approaches are needed to reduce side effects and increase specific targeting.The reprogramming of the innate immune memory can provide an excellent therapeutic target in autoimmune inflammatory diseases, allowing to restore the balance between hyperinflammation and immunodepression and to achieve therapeutic benefits. However, there are limitations to the GC and CM conceived the review, searched databases, and drafted the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the Ministerio de Ciencia e Innovación to CM (Programa Juan de la Cierva IJCI-2016-27666).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.


Social anxiety disorder (SAD) is a common and serious psychiatric condition that typically emerges during adolescence and persists into adulthood if left untreated. Prevailing interventions focus on modulating threat and arousal systems but produce only modest rates of remission. This gap in efficacy suggests that most mainstream treatment concepts do not sufficiently target core processes involved in the onset and maintenance of SAD. This idea has further driven the development of new theoretical models that target dopamine (DA)-driven reward circuitry and motivational deficits that appear to be systematically altered in SAD. Most of the available data linking systemic alterations in DA neurobiology to SAD in humans, although abundant, remains at the level of correlational evidence. Accordingly, the purpose of this brief review is to critically evaluate the relevance of experimental work in rodent models that link details of DA function to symptoms of social anxiety. We conclude that, despite certain systematic limitations inherent in animal models, these approaches provide useful insights into human biomarkers of social anxiety including that (1) adolescence may serve as a critical period for the convergence of neurobiological and environmental factors that modify future expectations about social reward through experience dependent changes in DA-ergic circuitry, (2) females may show unique susceptibility to social anxiety symptoms when encountering relational instability that influences DA-related neural processes, and (3) separate from fear and arousal systems, the functional neurobiology of central DA systems contribute uniquely to susceptibility and maintenance of anhedonic factors relevant to human models of SAD. Social anxiety disorder (SAD) is a common and debilitating psychiatric disorder predominantly characterized by persistent fear of one or more social or performance situations . PrevailMus musculus is a common and highly social mouse species that engages in frequent reciprocal social behavior such as communal nesting, parenting behaviors, territorial scent marking, and aggression  paradigm is perhaps the most common social stress paradigm in rodents, and consists of establishing a dominance–subordination relationship between two mice by placing an experimental animal (intruder) into the home cage of a larger and more aggressive conspecific , a brain structure heavily implicated in reward processing . Using ochniques . Susceptchniques . These fchniques  and/or rchniques .Socially avoidant behaviors stemming from social defeat also appear to generalize across various environmental contexts, suggesting that responses to social defeat may be observed in situations unrelated to prior SDS experiences. For example, mice who witnessed the social defeat of another mouse spend significantly less time interacting with other mice, and demonstrate reduced time engaging in social behaviors with conspecifics . FurtherThese findings collectively highlight both the general utility of the SDS paradigm in interrogating social stress–reward interactions in mice as well as the potential to inform developmental theories of SAD in humans e.g., . The parSocial instability paradigms involve a complete disruption of social hierarchies within an animal’s environment by randomly changing the cage composition of residents . This reThe social instability paradigm, like SDS, has not only been linked to anxiety-like behaviors and reduced social interaction, but also to a more generalized form of anhedonia. For example, this paradigm increases rates of avoidance across general novel stimuli, which includes, but is not limited to, avoidance of social interaction . AdditioAlthough research comparing the effects of social instability to other forms of stress is relatively sparse, a number of investigations have revealed that the effects of social instability stress in particular may be sex-specific. For example, an early study by Along similar lines, gender differences in humans with SAD have long been acknowledged [see Social isolation paradigms involve the separation of experimental animals into individual housing during weaning until adulthood. Isolation functionally prevents normative social interaction over the course of development, ultimately producing anxiety-like behaviors that appear to be socially specific, such as avoidance of conspecifics, increased ultrasonic vocalizations , and reduced approach-related behaviors to novel mice . HoweverThis paradigm similarly may have translational relevance for human isolative behaviors. While only one study in humans has specifically identified social isolation as a risk factor , other sIn summary, this review draws three broad human-relevant conclusions from experimental manipulations of the social environment in mice: (1) adolescence is likely a critical period for the convergence of neurobiological sensitivity with environmental factors to entrench future expectations about social reward through experience dependent modification of DA-ergic circuitry, (2) females may show unique susceptibility to social anxiety symptoms when encountering instability of relational social hierarchies mediated by DA-related neural processes, and (3) separate from fear and arousal systems, the functional neurobiology of central DA systems contribute uniquely to susceptibility and maintenance of anhedonic factors relevant to providing clues for human models of SAD, thus warranting the investigation of new treatment avenues specifically related to the modification of these systems.in vivo disease systems across species. On the one hand, these and related criticisms continue to drive vigorous debate regarding the relevance of animal models to the study of human neuropsychiatric disorders (e.g., Seminal theories of SAD have been largely couched in cognitive and behavioral terms that presuppose causal roles for the uniquely human capacity for propositional and abstract thought e.g., , particurs e.g., . On the rs e.g., , thus fuCC, HS-T, MG, and JR were involved in the conception, drafting, and revisions of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.