Are prices of hospital services disclosed under the new federal hospital price transparency rule correlated with total costs of hospital-based care among commercially insured individuals?In this cross-sectional study of 4 545 809 hospital-based encounters for shoppable care in 2018, health care entities that billed for their services independently from the hospital were frequently involved in care delivery, and their reimbursements comprised substantial portions of the total costs of care. The disclosed hospital prices were weakly correlated with the reimbursements of independent health care entities.These findings suggest that prices disclosed under the new regulation may have limited value to patients attempting to make cost-conscious health care choices. This cross-sectional study assesses the likelihood of correlation between prices disclosed under the new Centers for Medicare & Medicaid Services hospital price sharing regulation and total costs of care among commercially insured individuals. To improve health care price transparency and promote cost-conscious selection of health care organizations and practitioners, the Centers for Medicare & Medicaid Services (CMS) required that hospitals share payer-specific negotiated prices for selected shoppable health services by January 2021. While this regulation improves price transparency, it is unclear whether disclosed prices reflect total costs of care, since many hospital-based services are delivered and billed separately by independent practitioners or other health care entities.To assess the extent to which prices disclosed under the new hospital price transparency regulation are correlated with total costs of care among commercially insured individuals.This cross-sectional study used a large database of commercial claims from 2018 to analyze encounters at US hospitals for shoppable health care services for which price disclosure is required by CMS. Data were analyzed from November 2020 to February 2021.Whether the service was billed by the hospital or another entity.Outcomes of interest were the percentage of encounters with at least 1 service billed by an entity other than the hospital providing care, number of billing entities, amounts billed by nonhospital entities, and the correlation between hospital and nonhospital reimbursements.r = −0.11  to r = 0.53 .The study analyzed 4 545 809 encounters for shoppable care. Independent health care entities were involved in 7.6%  to 42.4%  of evaluation and management encounters, 15.9%  to 22.2%  of laboratory and pathology services, 64.9%  to 87.2%  of radiology services, and more than 80% of most medicine and surgery services. The median (IQR) reimbursement of independent practitioners ranged from $61 ($52-$102) to $412 ($331-$466) for evaluation and management, $5 ($4-$6) to $7 ($4-$12) for laboratory and pathology, $26 ($20-$32) to $210 ($170-$268) for radiology, and $47 ($21-$103) to $9545 ($7750-$18 277) for medicine and surgery. The reimbursement for services billed by the hospital was not strongly correlated with the reimbursement of independent clinicians, ranging from This cross-sectional study found that independent practitioners were frequently involved in the delivery of shoppable hospital-based care, and their reimbursement may have represented a substantial portion of total costs of care. These findings suggest that disclosed hospital reimbursement was usually not correlated with total cost of care, limiting the potential benefits of the hospital price transparency rule for improving consumer decision-making. However, obtaining meaningful price information before receiving care has historically been difficult for patients, and existing price transparency tools have struggled to gain traction.While this regulation improves health care price transparency to a degree, patients seeking care may still be unable to obtain accurate estimates of total costs in advance of their care, as many services integral to hospital-based care are delivered and billed separately by independent practitioners or health care entities who are not subject to this regulation. The objective of this study is to assess the extent to which disclosed prices under the new hospital price transparency rule are correlated with total costs of care among commercially insured individuals.STROBE) reporting guideline for cross-sectional studies.This cross-sectional study was deemed exempt from institutional review board review and informed consent by Emory University because we used deidentified data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology  for services specified by Current Procedural Terminology (CPT) or Healthcare Common Procedures Coding System codes was determined based on typical patterns of care. Additionally, we identified a set of common ancillary services for which patients could be billed in connection with provision of each shoppable service , one of few national multi-insurer commercial health insurance claims databases providing a large sample of claims for individuals covered by employer-sponsored plans across the United States, which cover the preponderance of the commercially insured population in the US. The 2018 data include 27 087 740 enrolled individuals aged 0 to 64 years from all 50 states, the District of Columbia, and Puerto Rico. To assemble service packages for which patients were billed, we first identified hospital-based encounters for shoppable care using relevant CPT, Healthcare Common Procedures Coding System, or Diagnosis-Related Group codes for the 70 CMS-specified services. Then, we extracted claims submitted for patients on the same day (for outpatient encounters) or during the same hospital stay (for inpatient encounters) that satisfied the ancillary-service inclusion criteria, as described in eTable 1 in the For each service package, we identified health care entities that billed for care using anonymized taxpayer identification numbers included on individual claims and calculated their reimbursement. We used 4 metrics to assess the extent to which disclosed prices under the new hospital price transparency rule were likely to reflect total costs of care. First, we calculated the percentage of encounters that involved at least 1 service billed by an entity other than the hospital. This outcome measures the prevalence of billing for a single episode of care by multiple health care entities, which inherently means that disclosure of hospital prices gives patients an incomplete estimate of the total costs of their care. Second, to examine how many entities a patient would have to contact to obtain an estimate of the total costs of care, we assessed the number of billing entities other than the hospital involved in care delivery. Third, we assessed the reimbursement amounts billed by nonhospital entities, which the CMS regulation does not require to be publicly disclosed. We summarized the findings in terms of absolute dollar amounts and as percentages of the publicly disclosed hospital reimbursements. Finally, to evaluate whether the disclosed price for the hospital-billed services is correlated with the nondisclosed cost of care by independent health care entities, we calculated the Pearson correlation coefficients between the hospital and nonhospital reimbursement components. Statistical significance for correlation coefficients is indicated by 95% CIs that do not cross 0. The analysis was completed using SAS statistical software version 9.4 (SAS Institute). Data were analyzed from November 2020 to February 2021.The final sample consisted of 4 545 809 hospital encounters with shoppable service packages. The sample size by service type is reported in eTable 2 in the The number of entities involved in care generally increased with service package complexity . Among sWhen entities that billed for care independently from the hospital were involved in care delivery, their aggregate reimbursement both in dollars and as a percentage of the hospital portion of costs was often nontrivial . For exar = −0.11  for routine electrocardiogram to r = 0.53  for a major cardiothoracic procedure.We also found that the reimbursement amount for services billed by the hospital, ie, the price that would be disclosed under the CMS hospital price transparency rule, was not strongly correlated with the reimbursement of independent entities . The cor11 For example, some state-level price transparency tools have focused on publishing within-hospital mean prices, but these aggregated prices are not necessarily relevant to individual patients.2 Other initiatives required hospitals to publish charges, but those amounts rarely reflect the actual costs of care or potential cost-sharing responsibility for insured patients.10 Moreover, most price transparency tools offer price estimates for individual health care services , but not prices for entire episodes of care.10 Owing to these limitations and poor communication about them to patients, uptake of price transparency tools has been low7 and their availability has not been associated with lower health care spending.14This cross-sectional study found that practitioners who billed for care independently were frequently involved in the delivery of shoppable hospital-based care, and their reimbursement represented a substantial portion of the total cost of care. Many health care price transparency initiatives and tools have been developed to encourage patients to shop for more cost-effective care and decrease health care spending but have yielded low awareness, offered limited information, and had little evidence that they meaningfully influenced patient behavior.15 the regulation still leaves several important gaps that limit patients’ ability to engage in meaningful price discovery. First, the regulation applies only to hospitals, while many shoppable health care services can be provided in other care delivery settings .18 Patients may still be unable to obtain prices of care in those settings. Second, the regulation requires price disclosure for a limited number of health care services. Patients seeking other types of care may still be unable to obtain useful price estimates. Third, the regulation requires price disclosure for 300 shoppable services, 70 of which are specified by the regulation, while selection of the remaining 230 services is left to individual hospitals at their discretion. Thus, for some health care services, patients may find prices at some local hospitals but not others, limiting their ability to make an informed choice. Finally, prices of shoppable service packages reported by hospitals do not include prices of integral services delivered by practitioners who are not hospital employees. Our analysis highlights just how problematic this final issue can be for price transparency, severely limiting the value to patients of the disclosures required under the CMS hospital price transparency rule. Specifically, this study documents how often independent entities were involved in delivery of select shoppable hospital-based services, the amount of total reimbursements that would not be publicly disclosed under the CMS hospital price transparency rule, and whether disclosed hospital prices were correlated with this undisclosed portion of the total reimbursements.The CMS hospital price transparency rule addresses some of these challenges. Specifically, the regulation requires hospitals to publicly disclose plan-specific negotiated rates, including packages of ancillary services that are often provided by the hospital in conjunction to the main shoppable service. Nevertheless, aside from poor hospital adherence to the new requirements,The root cause of incomplete price transparency is fragmentation of health care delivery and billing. A single hospital-based health care encounter from the patient’s perspective often consists of multiple services, some of which are provided by practitioners who are hospital employees, while others are provided by practitioners who deliver care at the hospital facility but contract with payers independently. Our study documents that independent entities were frequently involved in hospital-based care delivery. Their involvement was most common in medicine and surgery services and radiology services, less so in evaluation and management and laboratory and pathology services. The additional cost of independent practitioner reimbursement may create an unexpected and considerable financial burden for patients. While the median reimbursement of independent entities for laboratory and pathology services was low , it amounted to hundreds or thousands of dollars for most medicine and surgery services .21 Because out-of-network bills can be quite high, this troublesome market failure also stemming from the fragmentation of health care delivery has been addressed by legislative actions on the state and federal levels.22Providing patients with incomplete price estimates may not be problematic if they seek to undergo an expensive procedure at an in-network hospital and are guaranteed that no out-of-network entities will be involved in care delivery. Because hospital services tend to be costly and federal regulations impose limits on patients’ annual out-of-pocket spending on in-network care, patients may reach their annual out-of-pocket maximums with the portion of costs billed by the hospital alone, leaving the remaining undisclosed costs of services from independent in-network entities to health plans. However, involvement of out-of-network entities in care delivered at in-network hospitals is relatively common.25 the chance of receiving care from entities that bill separately from the hospital is likely to decrease. While this trend can eventually lead to improved price transparency, vertical integration also leads to increased prices and spending for outpatient care.27 Nevertheless, our findings demonstrate that independent entities were frequently involved in hospital-based care delivery, and their reimbursement, the undisclosed component of the total cost of care, could be meaningful to patients, especially to those enrolled in high-deductible health plans who seek to undergo a procedure with total practitioner reimbursement that is lower than their annual deductible or out-of-pocket maximum.As US health care delivery is becoming increasingly vertically integrated,28 Insurance companies have most of the necessary information needed to estimate individual patients’ out-of-pocket costs for nearly any service at their disposal, such as negotiated rates for individual health care services, lists of health care facilities and practitioners available in relevant health care markets, as well as information on patients’ plan benefit design, including amounts that patients already paid toward their annual deductibles and out-of-pocket maximums.Given the fragmented health care system, are there opportunities to improve on existing price transparency efforts to provide more comprehensive and accurate estimates of the total costs of care for patients? As long as patient cost-sharing is a function of practitioner reimbursement , all health care entities involved in care delivery should be subject to price transparency requirements. Obtaining prices of health care, and especially out-of-pocket cost estimates for insured patients is most practical from insurers, not care entities.29 which will become partially effective in 2023 and fully effective in 2024, will require non-grandfathered commercial health plans to provide patients with personalized estimates of out-of-pocket costs for individual health care services by all types of in-network health care entities. However, even this regulation has notable limitations. First, the regulation will not improve health care price discovery for individuals enrolled in grandfathered plans or uninsured individuals. Additional efforts will be needed to achieve health care price transparency for all. Second, patients seeking to obtain an accurate estimate of their out-of-pocket costs will be expected to anticipate what individual services will constitute the planned health care encounter. This would be a challenging task for experienced health care experts, let alone nonexpert patients. As such, patients may still receive partial price information even under this prospective regulation. Insurers could take the lead on creating reliable packages of services across entities involved in episodes of care to provide their enrollees with useful price information before receiving care. Moreover, employers may demand such a service from insurers as a means of cost containment.Efforts to obtain out-of-pocket cost estimates from health plans have already been introduced. The Transparency in Coverage rule,13 Claims with these codes are commonly billed by practitioners in a broad range of clinical specialties for outpatient visits to address a variety of health care needs. Because the lists of potential ancillary services depend on the reasons for each visit or consultation, for these broadly applicable evaluation and management services, we constructed only minimal service packages. As such, our quantifications of the associated hospital and nonhospital reimbursements for these services are likely underestimated. Additionally, we used a large national convenience sample of commercial insurance claims to perform this analysis, and as such, our findings may not generalize to hospitals or insurers not included. However, given the large size of the database, we are confident in our ability to draw broad conclusions about the implications of the CMS hospital price transparency rule for commercially insured patients using hospital care in the US.This study has some limitations. The composition of service packages likely varies not only across hospitals, but also within hospitals, depending on contracts between payers and health care entities, and patient-specific circumstances. We constructed service packages using applicable claims that were billed to patients on the same day or during the inpatient stay as the main shoppable service. However, some health systems may also include services provided to the patient before or after the main service  in their disclosed price estimates, and in such cases, the reimbursement amounts for services billed by the hospital and those billed by entities other than hospital would be higher than our estimates. Additionally, the set of shoppable evaluation and management services specified in the CMS rule includes various durations of new patient office or other outpatient visit  and patient office consultation .This cross-sectional study found that independent practitioners who billed for their services separately were frequently involved in the delivery of shoppable hospital-based care. In some encounters, such as most laboratory and pathology services, the undisclosed reimbursements of independent practitioners were relatively low; thus, the disclosed hospital prices could be beneficial to consumers. In other encounters, such as some evaluation and management services, radiology services, and most medicine and surgery services, the reimbursement of independent practitioners was often nontrivial and could create a substantial financial burden for patients who may not expect to receive additional bills beyond those from the hospital. The CMS hospital price transparency rule has recently begun requiring hospitals to publicly disclose plan-specific negotiated rates for a set of shoppable health care procedures and ancillary services provided to patients by hospital-employed practitioners. However, services integral to hospital-based care may be delivered and billed separately by independent practitioners or health care entities, which are not subject to this regulation. As such, health care price transparency remains an elusive goal that will require further innovation.


High resolution Imaging-based approaches such as large-scale fluorescence 3D imaging offer significant advantages because they allow preservation of tissue architecture and provide a definition of the spatial context of each cell. We recently described the Volumetric Tissue Exploration and Analysis cytometry tool which enables an interactive analysis, quantitation and semiautomated classification of labeled cells in 3D image volumes. We also established and demonstrated an imaging-based classification using deep learning of cells in intact tissue using 3D nuclear staining with 4′,6-diamidino-2-phenylindole (DAPI). In this mini-review, we will discuss recent advancements in analyzing 3D imaging of kidney tissue, and how combining machine learning with cytometry is a powerful approach to leverage the depth of content provided by high resolution imaging into a highly informative analytical output. Therefore, imaging a small tissue specimen will yield big scale data that will enable cell classification in a spatial context and provide novel insights on pathological changes induced by kidney disease.Advances in cellular and molecular interrogation of kidney tissue have ushered a new era of understanding the pathogenesis of kidney disease and potentially identifying molecular targets for therapeutic intervention. Classifying cells  We willx and y axis, where specific gates could be drawn based on a threshold such as fluorescent label intensity  and biological interpretation (particularly when specific distribution patterns start to emerge). Multiple software tools  have been developed to perform image analysis, and can be used for tissue cytometry  or spatial parameters. Frequently, the nuclei are used as fiduciaries for the cells because: (1) nuclear staining can be easily incorporated into most experimental designs, and (2) nuclei can be consistently segmented using several standard approaches . The segntensity . Two keyytometry . We haveytometry , which wytometry . Potentiytometry , understytometry , quantifytometry , study cytometry ,b. Largeytometry . TherefoSince multiple parameters can be extracted for each single cell using high resolution multiplexed imaging, advancing the analytical approach to take into account the effect of all these parameters in thousands of cells becomes a big data problem. It is then reasonable to incorporate machine learning algorithms to help cluster, classify and visualize cell subtypes into the analytical space. Indeed, the extensibility of VTEA to incorporate available libraries of machine learning algorithms is a significant development that enables a semi-automated unsupervised classification of cells . We demoMultiplexing various probes into one imaging experiment offers significant advantages for cell classification based on particular labels. For example, using highly multiplexed detection such as imaging mass cytometry or co-detection by indexing allows the classification of multiple cell subtypes . HoweverAgnostic discovery is the exploration process for the identification and localization of novel kidney cell subtypes induced by injury. In an agnostic discovery scenario, obtaining labeled cell examples for the injury cell subtypes is a hard task for many reasons: first, the nature of injury to the morphology of kidney cells due to disease is unknown so accurate labeling is difficult; second, we may not yet have a suitable marker for such cells, which makes us unable to correctly label them using cytometry; finally, due to lack of knowledge regarding the injury it is even hard for us to know the definite count of number of possible injury subtypes. While lack of labeled data makes agnostic discovery a difficult task, recent advances in supervised classification can help us in this regard .In supervised classification, identifying novel classes (example: novel injury states) for which no examples are available in the training data (ground truth datasets used in training machine learning classifier) has received wide-spread attention from the machine learning community in recent years. There are different approaches for solving such machine learning tasks. Most prominent among these is called zero-shot learning (ZSL), which is well studied by the deep learning community . ZSL is For zero-shot learning, the number of novel classes along with side-information  about all the classes needs to be provided upfront. During training, the learning algorithm utilizes the side information to compensate for the lack of labeled data for the unknown class. Spatial neighborhood data around a cell can be used as side-information. For instance, we expect that the concentration of inflammatory immune cells (such as neutrophils or T-cells) around injured kidney cells would be higher, and hence, such side information will be relevant for classifying injured kidney cell subclass instances. Another potential candidate for side information is to use data from alternate modality, say, single cell RNA sequencing and/or spatial transcriptomics data. Using such data will not only help us identify novel kidney cells, but also will provide more information regarding the pathways that control the injury progression in the kidney cells over time. A challenge of zero-shot learning is that it requires that the number of novel classes is known during training time, which is often not feasible for agnostic discovery. In that case, Bayesian non-exhaustive classification can be used. Using Bayesian technique, it learns some parametric probability distribution for the known classes. During inference, it identifies instances which are far away from the distribution of the known classes and create a new class along with its probability distribution. Generally, Dirichlet process Gaussian Mixture Model is used for non-exhaustive classification . The chaThe novel imaging-based approaches discussed to characterize cell types and subtypes in human kidney tissue specimens are very promising. However, it is also important to discuss some of the challenges and limitations that need to be addressed to make these methodologies more robust and accessible. First, variation in tissue processing practices and fixation may alter the quality of the tissue and the downstream imaging data. The effects of changes in tissue processing on the ability to classify cells using tissue cytometry and machine learning are unknown. Fortunately, collaborative studies (such as the KPMP consortium) that are focused on interrogating kidney tissue biopsy specimens are rigorously standardizing tissue acquisition and processing, which would allow to set standards and perform comparison with data acquired from archived tissues originating from other sources . Second,virtual multiplexing,” which could classify most cell types in situ within kidney tissue and allow the agnostic discovery of novel cell types based on imaging. For the kidney, imaging and analyzing tissue will certainly become a very important issue!We highlighted in this mini-review advances in tissue cytometry of kidney tissue, emphasizing novel analytical approaches that transform imaging-based data into highly quantifiable big data outputs that can also be used for discovery while incorporating the richness of the spatial context. These advances are crucial to understand kidney disease, which frequently displays regional heterogeneity at the cellular and molecular levels. Leveraging novel machine learning approaches will allow unbiased discoveries such as novel cell types and subtypes which are spatially anchored and linked to other features that allow biological interpretation. In the future, we anticipate that with relatively few labels, the combination of tissue cytometry with machine learning will enable a form of enhanced “All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Marine multicellular organisms host a diverse collection of bacteria, archaea, microbial eukaryotes, and viruses that form their microbiome. Such host-associated microbes can significantly influence the host’s physiological capacities; however, the identity and functional role(s) of key members of the microbiome (“core microbiome”) in most marine hosts coexisting in natural settings remain obscure. Also unclear is how dynamic interactions between hosts and the immense standing pool of microbial genetic variation will affect marine ecosystems’ capacity to adjust to environmental changes. Here, we argue that significantly advancing our understanding of how host-associated microbes shape marine hosts’ plastic and adaptive responses to environmental change requires (i) recognizing that individual host–microbe systems do not exist in an ecological or evolutionary vacuum and (ii) expanding the field toward long-term, multidisciplinary research on entire communities of hosts and microbes. Natural experiments, such as time-calibrated geological events associated with well-characterized environmental gradients, provide unique ecological and evolutionary contexts to address this challenge. We focus here particularly on mutualistic interactions between hosts and microbes, but note that many of the same lessons and approaches would apply to other types of interactions. This Essay argues that in order to truly understand how marine hosts benefit from the immense diversity of microbes, we need to expand towards long-term, multi-disciplinary research focussing on few areas of the world’s ocean that we refer to as “natural experiments,” where processes can be studied at scales that far exceed those captured in laboratory experiments. Aliivibrio fischeri [It is widely recognized that host-associated microbes play profound roles in the health of their marine hosts and the ecosystems they inhabit. Although some such interactions with microbes are transient, many are more persistent and can be generally described as symbioses. Symbioses come in many flavors including parasitism, commensalism, and mutualism see , and, infischeri ).Acclimatization: The process by which an organism becomes accustomed to new environmental conditions during its lifetime.Adaptation: A heritable trait of an organism that increases its fitness in its surrounding environment. In comparison to acclimatization, adaptations will be passed on to the next generation.Convergent evolution: Independent origins of similar features in different organisms in response to separately experiencing similar selective pressures. Importantly, convergently originated features, also known as analogous features, were not present in the common ancestor of the taxa in question.Genetic drift: Change in the relative frequency of genotypes due to random variation in reproduction. Such drift is more common in small populations and leads to changes in genotype frequencies independent of adaptive forces.Host–microbe coevolution: During host–microbe coevolution, multicellular hosts and their associated microbes show a concerted and heritable response to an environmental change.Homologous recombination: The process by which two pieces or stretches of DNA that are very similar in their sequence physically align and exchange nucleotides.Horizontal gene transfer: The unidirectional movement of DNA, usually only small fractions of a genome, from one organism to another. Though this generally occurs more frequently within species than between, it can also occur across vast evolutionary distances.Metagenomics: Studies of the genetic material of communities of organisms.Phenotypic plasticity: Phenotypic plasticity is the ability of a specific genotype to produce more than one phenotype in response to a changing environment during an individual’s lifetime. These phenotypic changes may include an organism’s behavior, morphology, physiology, or other features. Phenotypic plasticity is adaptive if it increases an individual’s survival and if the ability is passed on to the next generation.Symbioses: Symbioses are broadly defined as intimate interactions between at least two organisms where at least one of them benefits. We focus here specifically on mutually beneficial interactions  between multicellular eukaryotes and their associated microbes. These interactions may include disease resistance, predator avoidance, and nutrition. These interactions will ultimately increase host survival and fitness.Experimental studies are, however, intrinsically limited in several ways. They limit themselves to a small number of experimentally tractable hosts and microbes, and, in doing so, fail to account for the enormous complexity of interactions and variation that exist in nature between multiple hosts and their multitudes of associated microbes. Short-lived experiments  cannot replicate the scales of time and space involved in the potential coevolution of hosts and microbes . AttemptHere, we demonstrate the value of moving beyond taxon-centric approaches to studying host–microbe associations in their natural evolutionary and ecological context. We suggest intensifying long-term research in well-documented “natural experiments”. Such natural experiments, including well-calibrated geological events  and environmental gradients where multiple hosts and associated microbes are subjected to the same range of environmental conditions, can be particularly useful . These pRiftia tubeworms, and Astomonema nematodes [Marine organisms have evolved complex structural, behavioral, and chemical mechanisms to regulate the presence, abundance, and activity of their microbial associates. Hosts can limit colonization by transient opportunistic microbes that would use space and resources without providing any benefits, and some hosts can even block pathogens entirely –19. Hostematodes ,26. AlthSeveral approaches have been proposed to identify key microbes or functions within complex host microbiomes (reviewed in ). The moTo instigate this new approach, we recommend strategically intensifying research within a few ocean regions. This entails collecting large scale data on host-associated microbes across phylogenetically diverse sets of co-occurring host organisms, together with data on surrounding free-living microbes  through time in areas where the surrounding abiotic environment and community dynamics have been well characterized. A regionally focused and coordinated approach will allow identifying environmental sources and hosts that serve as reservoirs of key host-associated microbial taxa and genes. Long-term investments in research on particular communities of hosts and microbes will also help establish links between changes in core microbiome composition, environmental factors, ecosystem function, and resilience. Public archival of genomic data and samples  collected from a few intensively studied ocean regions will foster transformative discoveries on dynamic host–microbe relationships. Habitat-forming corals, sponges, seagrasses, and mangrove trees are important focal groups, since breakdowns in the associations between these species and their microbiomes likely disproportionately influence other taxa and ecosystem functions. However, this should not come at the expense of research on more inconspicuous and overlooked, yet functionally important taxa that comprise the majority of the oceans’ biological diversity  Resistance: the microbiome continues performing its functions and the host does not lose or gain fitness; (3) Acclimatization: the newly formed microbial community in conjunction with host phenotypic plasticity enable the individual host to adjust and maintain performance under changing environmental conditions , pathogens, anthropogenic disturbances , and acute and chronic stressors ,37. Theynditions ; and (4)eritable .The role that host-associated microbes play in their host’s response to environmental change is also influenced by their mode of transmission . While vSeveral key bottlenecks currently impede our understanding of how host-associated microbes drive the initial response as well as long-term, evolutionary adaptation to climate change–related disturbances in hosts with diverse microbial communities. First, changes in microbiomes that confer adverse or beneficial outcomes for the host cannot be distinguished from natural variability without adequate measures of host phenotypes that covary with fitness. Unlike photosymbiotic organisms that exhibit quantifiable phenotypic responses to stress , the early signs of physiological stress are difficult to observe and measure in the vast majority of marine host–microbe associations. Second, studies are rarely designed to disentangle causes from effects. Before–after studies correlate seemingly altered microbial communities with perturbations or diseases, often without establishing causality in the relationship ,49. ThirBolstering our understanding of the mechanisms of host–microbe evolution requires investing resources into long-term multidisciplinary research on diverse communities of hosts and microbes distributed across well-characterized environmental gradients. Rigorously designed comparative population genomic studies and field experiments  combined with measures of host phenotypes using methods such as in situ imaging , immunolNatural experiments are past events or gradients that allow researchers to explore biological patterns and processes on spatial and temporal scales that far exceed those possible in the laboratory. Natural experiments may or may not be created or altered by humans and have been the bread and butter of natural historians, biogeographers, and evolutionary biologists for decades. Building on this substantial body of conceptual work, we propose that natural experiments can also enlighten our understanding of the evolution and ecology of host-associated microbes and their hosts. We present examples of natural experiments where the outcomes of complex interactions can be observed with replication to provide insights into the processes underlying host–microbe evolution. Our examples focus on well-characterized systems where host evolution has already been well explored, thereby allowing “tests” that approach the rigor of laboratory experiments. We expect that studying natural experiments like these will allow general principles of host–microbe evolution to emerge when repeated patterns are observed within a system or across different systems.The formation of the Isthmus of Panama presents an unparalleled opportunity for exploring the roles of biogeographic isolation and environmental change in structuring host-associated microbes . In the Ocean gateways that remain open today also present unique attributes suitable for natural experiments. The narrow Strait of Bab al Mandab connects the warm and saline semi-enclosed Red Sea with the open and more variable Arabian Sea. The Red Sea is host to many endemic species (5% to 13% endemic across a range of taxa ), while Other important biogeographic regions characterized by unique environmental conditions, long-term data collection, and good scientific infrastructure include the Great Barrier Reef , the BalNovel habitats such as remote island archipelagos that formed over relatively recent geological history also offer exceptional opportunities to study evolutionary processes in marine and terrestrial host-associated mutualistic microbes. Initially barren, shallow coastal areas were colonized by marine organisms from neighboring areas that subsequently evolved in conditions that are often drastically different from their native environments. Three archipelagos in particular, Hawai’i and Marquesas, located at the periphery of the Indo-Pacific region, and the Galapagos in the TEP, have provided tremendous opportunities to study evolution through comparative phylogeography . All thrMarine communities are changing rapidly in the face of climate change and other anthropogenic activities . The phyUnderstanding what changes in host-associated microbes mean for the maintenance of marine communities and ecosystems requires measurements that go far beyond the typical life span of a publicly funded scientific project. The integration of microbial sampling into long-term ecological monitoring programs across key geographic locations will help us identify important core and transient host-associated microbes and provide the fundamental basis for mechanistic studies. Researchers should focus on the vast majority of marine animals and plants that are able to interchange microbial partners, genes, and functions with surrounding microbial communities. The future of marine ecosystems around the globe may in part depend upon the ability of marine organisms to dip into the enormous pool of microbes and harness their remarkable genetic potential.


The surgical management of brain tumors is based on the principle that the extent of resection improves patient outcomes. Traditionally, neurosurgeons have considered that lesions in “non-eloquent” cerebrum can be more aggressively surgically managed compared to lesions in “eloquent” regions with more known functional relevance. Furthermore, advancements in multimodal imaging technologies have improved our ability to extend the rate of resection while minimizing the risk of inducing new neurologic deficits, together referred to as the “onco-functional balance.” However, despite the common utilization of invasive techniques such as cortical mapping to identify eloquent tissue responsible for language and motor functions, glioma patients continue to present post-operatively with poor cognitive morbidity in higher-order functions. Such observations are likely related to the difficulty in interpreting the highly-dimensional information these technologies present to us regarding cognition in addition to our classically poor understanding of the functional and structural neuroanatomy underlying complex higher-order cognitive functions. Furthermore, reduction of the brain into isolated cortical regions without consideration of the complex, interacting brain networks which these regions function within to subserve higher-order cognition inherently prevents our successful navigation of true eloquent and non-eloquent cerebrum. Fortunately, recent large-scale movements in the neuroscience community, such as the Human Connectome Project (HCP), have provided updated neural data detailing the many intricate macroscopic connections between cortical regions which integrate and process the information underlying complex human behavior within a brain “connectome.” Connectomic data can provide us better maps on how to understand convoluted cortical and subcortical relationships between tumor and human cerebrum such that neurosurgeons can begin to make more informed decisions during surgery to maximize the onco-functional balance. However, connectome-based neurosurgery and related applications for neurorehabilitation are relatively nascent and require further work moving forward to optimize our ability to add highly valuable connectomic data to our surgical armamentarium. In this manuscript, we review four concepts with detailed examples which will help us better understand post-operative cognitive outcomes and provide a guide for how to utilize connectomics to reduce cognitive morbidity following cerebral surgery. Modern glioma surgery has advanced based on the understanding that maximal tumor resection improves overall survival . While aAnatomical familiarity with specific cortical structures and advancements in multimodal imaging have allowed neurosurgeons to minimize surgically induced neurologic deficits related to major functions including language and motor skills. However, such notions are still often unable to explain the subtle deficits seen in patients with higher-order cognitive functions nor can it explain the heterogeneity in cognitive outcomes with lesions located in traditionally “non-eloquent” tissue , 5–7. Onlocalizationist views that suggest isolated cortical regions are dedicated to specialized functions, these networks are functionally and structurally organized in a way that minimizes cost while maximizing information transfer between cortical regions to carry out complex human thinking and behavior. Connectomics in turn provides us an improved understanding of the organization and functional relevance of human cortical and subcortical anatomy (The Human Connectome Project (HCP) recently provided a highly detailed neuroanatomical map of human cerebral cortex allowing a reappraisal of our classical modular maps of the human brain . The HCP anatomy , 17. As  anatomy , 19. HowIn the current paper, we discuss and provide evidence for four concepts which we believe can advance the neurosurgical community toward improving patient morbidity and cognitive functioning following cerebral surgery. Furthermore, we review these promising avenues in light of current neurosurgical practices and the current limitations faced. In order to reduce the cognitive footprint of cerebral surgery on the neurosurgical patient, we discuss the following:Concept 1.Preserve the core of networks whenever possibleConcept 2.Consider the full brain ramifications of the actionConcept 3.Move our thinking toward individual circuitsConcept 4.Consider the possibility that we can change the brain connectomePatients with gliomas experience impairments in executive functioning, speed, and memory prior to any treatment and are inherently at increased risks for further neuropsychological decline after surgery . As discIt is unclear whether anatomical location of the lesion can predict specific neurocognitive deficits. The Glioma Outcome Project showed that functional decline, with the exception of language, is not associated with the dominance of the hemisphere where the tumor is located. This suggests that neurocognitive decline may be based on more complex networks involving both hemispheres as the infiltrative tumor continues to grow . Relatedfunctionally interconnected between time series  that interconnect those anatomical domains  can be safely performed on patient structural connectivity graphs before or after surgery and then analyzed with measures of global efficiency to understand how a patient might be affected by a specific surgical decision or to understand beneficial avenues for subsequent neurorehabilitation  project was proposed by the US National Institute of Mental Health (NIMH) to classify mental illnesses that are based on dimensions of observable behavioral and neurobiological measures . It shifThis tool from the psychiatry world can be leveraged to study neurocognitive changes after craniotomies as the literature in this regard is mostly based on the description of clinical symptoms, such as the DSM criteria for psychiatric illnesses. The application of the RDoC framework will differ in the neurosurgical field in that we can negate more developmental trajectories and environmental influences. The system includes several broad functional domains, such as negative valence, positive valence, cognitive systems, systems for social processes, arousal/modulatory systems, and sensorimotor systems . Each re: is there enough plasticity and redundancy in global cerebral networks that abnormal connections can be augmented to reduce neurocognitive or physical deficits? The answer to this question is a resounding “yes,” but with caveats.Tumor resection inherently causes harm in some patients due to the locations of their pathology. If the human brain is composed of networks and each network is composed of various nodes, the question remainsThe brain can demonstrate a high capacity for cerebral plasticity following a number of cortical and subcortical insults. Although, most of our current understanding of cerebral plasticity comes from stroke patients and less so in glioma patients . FollowiHowever, what about faster growing lesions such as in glioblastoma (GBM)? It is important to note that there exists pathophysiological differences in strokes and gliomas which may explain the ability for cortical reorganization following acutely growing GBM lesions in specific instances  is a form of non-invasive brain stimulation that applies repeated magnetic pulses extracranially to generate an electrical current in the cortex. This in turn provokes electrophysiological changes in the target area and correlated brain networks . Given tImportantly, as reiterated throughout the current manuscript, different patients can present with different disease subtypes demonstrating unique clinical symptoms localizing to different brain networks. Despite these complex relationships, fortunately, individualized connectomic-based TMS target selection is possible and provides an important area of future research which has been previously barren. Fox et al. illustrated the feasibility of single-subject, connectivity-guided TMS targeting within regions of the left DLPFC in two patients with depression . FurtherExamples above for connectome-based neurorehabilitation are mostly focused on rTMS to restore network synchrony; however, similar applications and results have been demonstrated with other modulatory treatments as well. A common method of modulating brain activity is with deep brain stimulation (DBS) of subcortical structures. Unsurprisingly, the most effective DBS subcortical targets demonstrate strong connectivity to the most effective TMS cortical targets for a number of disorders . For insImportantly, similar limitations exist in both modalities in that their current utilization is also hampered by the lack of understanding of brain networks in different disease states and the limited validation of these connectomic-based treatments in individual patients with specific clinical phenotypes. It would be logical to select a node that serves as an important modulatory hub for altering the state of a network. However, what remains to be elucidated is target identification in many of these clinical disorders, and especially in rTMS, if the stimulation should be excitatory or inhibitory. Further, it has to be taken into account that if a crucial fiber tract  is destroyed, no amount of neuromodulation will likely be able to salvage that function. Repetitive TMS, among other modulatory treatments, hold promise for neurorehabilitation, but their application will first require further improvements in our understanding of network disruptions following intracerebral surgeries.Neurocognitive decline is common after intracerebral surgeries. Outside the context of language and motor skills, the mechanisms underlying declines in various neurological domains are not well-studied likely due to our previous lack of understanding of the complete structural and functional brain connectome. It is prudent for neurosurgeons to reimagine the brain as a confluence of networks, rather than an organ comprised of isolated regions dedicated or not dedicated to specialized functions. Brain connectomics provide the neurosurgeon further information on the relationships between tumor, neuroanatomy, and cognitive functions which can be leveraged to maximize our perioperative decisions while minimizing neurocognitive declines following intracerebral surgeries. Furthermore, such connectomic-based decisions provide novel opportunities to optimize post-operative neurorehabilitation via network augmentation, and advance the field using a common research framework that can be refined over time. However, as we appropriately move toward ideas such as “disconnection surgery” and connectome-based neurorehabilitation, further work must be done together in the neuroscience and neurosurgical communities.ND, BB, and JY: writing—original draft and writing—review and editing. MS: conceptualization, methodology, and supervision. All authors contributed to the article and approved the submitted version.MS is the Chief Medical Officer of Omniscient Neurotechnology, however this does not pose a conflict of interest in this study. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The goal of modern medicine is to cure disease and alleviate human suffering. In this endeavor, research has progressed at tremendous pace, allowing for revolutionary therapies that have improved the human condition and provided cures for diseases previously thought to be incurable. Our knowledge of the immunological processes necessary for the maintenance of health has never been more informed and immunotherapy has become a mainstay of therapy for a variety of health conditions.Across almost all infectious and malignant disease states, recovery requires a robust and targeted immune response. Immune effector elimination of target cells may be achieved by a variety of mechanisms such as the Perforin/Granzyme pathway or through ligands such as Fas Ligand, TNFα and the Tumor Necrosis Factor Related Apoptosis Inducing Ligand (TRAIL) –14. Thesin-vitro settings, were unfortunately disappointing in clinical trials [Of these death-inducing ligands, TRAIL has shown promise as a potential therapy. In the setting of cancers and chronic infections such as HIV, TRAIL has become recognized as an important immune effector molecule and an exciting avenue for therapeutic opportunity –5, 10. Tl trials .In the setting of HIV infection, acutely infected cells were seen to be resistant to paracrine TRAIL-mediated apoptosis, an investigation into which lead to the discovery a dominant negative splice variant of TRAIL known as TRAILshort. This 11kDA, 101-amino acid protein was first identified in HIV-infected cells and is a splice variant of full-length TRAIL, containing exons 1, 2, and 5, with exons 3 and 4 absent. TRAILshort’s exclusion of cysteine 230 prohibits its trimerization; therefore, disrupting TRAIL inducing death . This prIn consideration of recent developments that identified that TRAILshort is present in CD4 cells from HIV naïve patients , the speThe presence of TRAILshort in human malignant tissue was confirmed by both RNA ISH and immunohistochemistry (IHC), and while TRAILshort message was confined to malignant cells, TRAILshort protein was detected diffusely in the microenvironment, indicating a much wider affected footprint than the primary malignant tissue. The antagonism of TRAILshort by a targeted antibody was found to improve the ability of immune effector CD8 T Cells in clearing tumor cells in contrast to the effectors alone. Additionally, it was demonstrated that the presence of TRAILshort antibody significantly reduced tumor burden in mice that received treatment compared to those that did not.The combination of these findings indicates a complex but significant role played by TRAILshort in the pathogenesis of disease. It remains to be elucidated if all the effects of TRAILshort are simply an antagonism of TRAIL-TRAIL receptor binding through competition for the cognate receptor or if TRAILshort exerts independent deleterious effects on immune effector cells through independent signaling mechanisms.Full length TRAIL has been described as possessing several non-apoptotic functions across various cell types, mediated through the TRAIL: TRAIL-receptor axis. TRAIL has been shown suppress T Cell activation and cell proliferation by affecting T cell receptor signaling , increasThis contrasting myriad of both pro- and anti-inflammatory functions indicate the scope of the issue posed by TRAIL signaling in disease states. The contrasting effects thus far observed seem to be indicative that very selective micro-environmental and cell phenotypic conditions modulate the downstream effects of TRAIL signaling. This recent study therefore provides a platform for the expansion of TRAIL research in new directions and details a novel protein that may, in-part, precipitate the progression of disease and antagonize the mechanisms that serve to control it. Evidence thus far has revealed the increased expression of TRAILshort in cancerous cells and infected cells. Further studies are required to determine which cells specifically produce TRAILshort in a PBMC population, which may allow for better understanding of TRAILshort biology. Additionally, the observations thus far suggest that TRAILshort may be involved in protecting diseased cells from TRAIL mediated cell apoptosis facilitating their survival, however, given the myriad of signaling cascades that TRAIL has been described to induce, it stands to be determined if TRAILshort may induce similar phenotypes, affect T cell function, promote disease progression, and prove a hindrance to immune mediated therapeutic efforts.


Life (ISSN 2075-1729) has highlighted the world-wide research from a multi-professional perspective within the neurosciences. With an increasing number of people living with the disease [Idiopathic intracranial hypertension (IIH) is an enigmatic disorder characterized by raised intracranial pressure (ICP) with no known cause and it affects both children and adults . There iife ISSN 075-1729 Diagnosing and managing IIH can be challenging  and selePediatric IIH can be particularly challenging in pre-pubertal minors. Gilbert et al. analysed a case-control study utilizing MRI findings to build a framework for risk stratification for the diagnosis of pediatric IIH. Whilst prospective validation of their model is required, this analysis defined a cut-off point for the perioptic nerve sheath diameter (>5.2 mm) which, when measured according to the technique outlined, had a high sensitivity and specificity for detection of papilledema in pediatric IIH . Mehr etOptical coherence tomography (OCT) imaging of the optic nerve head is the corner stone for longitudinal monitoring of papilledema. Optic disc drusen, and peripapillary hyperreflective ovoid mass-like structures (PHOMS) can make it challenging to interpret quantitative indices alone as they can cause significant elevation of the optic nerve head. Wibroe et al. used a standardized protocol to image the optic nerve head and found that optic disc drusen were no more commonly found, as compared to rates seen in the general population. Importantly nearly one third demonstrated hyperreflective lines, which the authors propose as a consequence of optic disc crowding, with four fifths having PHOMS by three months with no statistical difference in the retinal nerve fibre layer global thickness or in the macular ganglion cell volume compared to patients without PHOMS .In adults with IIH there are well known co-morbidities such as obesity ,3, mentaDefining and characterizing the intracranial pressure abnormality in IIH is important. With the ability to measure pulse amplitude, Dr Eide monitored and analysed overnight ICP prior to shunt surgery in IIH patients who were refractory to medical management. He found that the mean wave amplitude was abnormal despite a normalized mean ICP. As he suggested these recordings were taken in people with established disease and this may reflect reduced brain compliance, with a proposed alteration in the glia–neurovascular interface that may impair the astrocytic pulsation absorber mechanisms . FurtherManagement remains a challenge with no class one evidence for surgery for sight threatening IIH. A number of groups tackled this topic and provided their insights into the various surgical techniques deployed currently for IIH. These included neurosurgical shunting ,6, opticDisease remission from weight management remains a medical and social challenge in many healthcare systems. The IIH:Weight Trial was the first to compare the efficacy and cost-effectiveness of bariatric surgery with a dietary intervention in the setting of a randomised control trial ,22. The In conclusion, this Special Issue has advanced the field of IIH. It has provided novel insights into how the disease can be stratified, it has carefully unpicked the patient pathways that exist across specialties and importantly analysed how we treat sight threatening disease. The expert authors collected here have a wealth of knowledge working in this rare condition and know that the field needs to propel itself forward to further understand the pathophysiology, validate its models and above all improve the path for all patients from disease to remission.


In the Covid-19 pandemic, media stories and government reports have emphasized the heightened risk of being “old” and placed a spotlight on the way we think and talk about older adults and aging. In this symposium we investigate how the pandemic and the public discourse about older adults has shaped views of aging in different countries. Bellingtier et al. report on German children’s views of older adults before and during the pandemic. Children placed greater distance between themselves and older adults both before and after the pandemic, suggesting early ageism in children that predates the pandemic. Levy et al. provide experimental evidence that media stereotypes about aging and Covid-19 influence the mental health of older American adults, both in positive and negative. Schwartz and Ayalon found that greater perceptions of age-based discrimination in the healthcare system by Israeli adults 50+ were significantly related to greater Covid-19 worries. Greater worry can motivate older adults to take precautions, but be detrimental if it becomes too high. In line with this finding, Tingvold et al. found in a study with older adults from Luxembourg that more Covid-19 worry predicted feeling older four months later, but only for those in worse health. Finally, Terracciano examined longitudinal change in subjective age and found that American adults reported feeling younger after the emergence of Covid-19 than before, suggesting that perceptions of aging partly reflect a coping process to counter the negativity in the media.


Xylazine, an alpha-2 receptor agonist, is used in veterinary medicine as a sedative and muscle relaxant; it is not approved for use in humans. However, reports of adulteration of illicit opioids with xylazine have been increasing in the United States (A xylazine-associated death was defined as a positive postmortem xylazine serum toxicology test result in an unintentional, undetermined, or pending intent substance-related death during January 2017–October 2021. Routine postmortem tests were conducted for other substances including fentanyl, fentanyl analogs, cocaine, and naloxone. Xylazine testing is standard in Cook County for suspected drug overdose deaths. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.*A total of 236 xylazine-associated deaths were reported during the study period. Xylazine-associated deaths increased throughout the study period; incidence peaked during July 2021 . The perThese findings highlight a concerning trend in xylazine-involved deaths in Cook County, Illinois. Increased monitoring and public education within Cook County are warranted along with expanded surveillance in other jurisdictions, particularly those in which fentanyl use is highly prevalent. These findings can be helpful in guiding overdose prevention and response efforts because naloxone has not been shown to reverse the effects of xylazine. Although a specific antidote is not available for xylazine, naloxone should still be administered in suspected cases of potentially fatal overdose because most cases co-occur with opioids. Cardiovascular and respiratory support are critical to the management of serious xylazine toxicity; health care providers should be made aware that cases of suspected fentanyl overdose that are refractory to naloxone administration might involve xylazine toxicity. Designation of xylazine as a controlled substance has occurred in some states and would be an important policy to be considered more broadly.


Little is known about the potential health impact of police encounters despite a ubiquitous police presence in many disadvantaged urban environments. In this paper, we assess whether persistent or aggressive interactions with the police are associated with poor mental health outcomes in a sample of primarily low-income communities of colour in Chicago.Between March 2015 and September 2016, we surveyed 1543 adults in ten diverse Chicago communities using a multistage probability design. The survey had over 350 questions on health and social factors, including police exposure and mental health status. We use sex-stratified logistic regression to examine associations between persistent police exposure (defined as a high number of lifetime police stops) or aggressive police exposure (defined as threat or use of police force during the respondent's most recent police stop) and the presence of post-traumatic stress disorder (PTSD) or depressive symptoms.Men reporting a high number of lifetime police stops have three times greater odds of current PTSD symptoms compared with men who did not report high lifetime police stops , after adjusting for respondent age, race/ethnicity, education, history of homelessness, prior diagnosis of PTSD and neighbourhood violent crime rate. Women reporting a high number of lifetime police stops have two times greater odds of current PTSD symptoms, although the results are not statistically significant after adjustment . Neither persistent nor aggressive police exposure is significantly associated with current depressive symptoms in our sample.Our findings support existing preliminary evidence of an association between high lifetime police stops and PTSD symptoms. If future research can confirm as causal, these results have considerable public health implications given the frequent interaction between police and residents in disadvantaged communities in large urban areas. Aggressive policing tactics, such as stop-and-frisk and excessive use of force, routinely occur in many urban environments, particularly disadvantaged communities of colour  and west-West Town (western portion only), each community's sample (ranging from n = 88–245) is representative of its respective community area population  was a cross-sectional, multistage probability health survey of selected Chicago community areas led by Sinai Urban Health Institute (SUHI), a member of Sinai Health System in Chicago. Community areas are a geographic designation unique to Chicago composed of contiguous census tracts. Under SUHI's direction, the University of Illinois at Chicago's Survey Research Laboratory (SRL) interviewed residents in ten Chicago community areas  from March 2015 through September 2016. As part of the original sampling structure, we selected community areas based on geographic location and racial/ethnic composition to include Puerto Rican, Mexican, Non-Hispanic (NH) black and NH white residents. Except for Lower West Side . Interviewers made at least ten in-person attempts to contact selected individuals. One or two adult respondents (aged 18 and over) were selected to complete the adult questionnaire based on a random selection algorithm. The survey instrument included over 350 questions on a number of health topics and took 84 min to complete on average. SRL interviewed 1543 respondents for the adult survey in both English and Spanish using Computer Assisted Personal Interviewing (CAPI).The response rate, calculated by dividing the number of completed interviews by the number of interviews, refusals, non-contacts of known eligible respondents and a proportion of households with unknown eligibility (per American Association for Public Opinion Research (AAPOR) response rate formula 3), was 28.4% .We classified respondents as exposed to police use of force if they answered yes to the following question: ‘Please tell me ONLY about the MOST RECENT time the police stopped you. During this stop, did the police use or threaten to use force against you for any reason?’ Respondents who had never been stopped by the police, and therefore never experienced threat or use of police force, were considered unexposed.et al., et al., et al., The survey included screenings for current PTSD and depressive symptoms. An abbreviated version of the Post-Traumatic Stress Disorder Checklist for Civilians (PCL-C) measured current PTSD symptoms   or empirical evidence of a strong association with both the exposures and outcomes (ever homeless). All confounders were pulled from Sinai Survey 2.0 apart from neighbourhood violence crime rate. We calculated violent crime rate per 1000 persons at the census tract level by dividing crime counts for the period of March 2016–March 2017 from the Chicago Police Department's CLEARMAP crime summary reporting tool  and over-adjusted model. Among women, there is a significant association between a high number of lifetime police stops (>3) and current PTSD symptoms in the unadjusted model . This association maintains its magnitude but loses statistical significance after adjusting for potential confounders .Logistic regression results for associations between police encounters and current PTSD symptoms by sex are presented in p = 0.052). This odds ratio is reduced and not significant after adjusting for potential confounders . Age, which is inversely associated with reported threat or use of force during the most recent police stop and PTSD symptoms for men, and a history of homelessness appear to be important confounders of this relationship. Similarly, the association between perceived threat or use of force during the most recent police stop and current PTSD symptoms among women in the unadjusted model  is reduced and no longer significant in the adjusted model  and further reduced in the over-adjusted model. For women, a history of homelessness, race/ethnicity and a prior diagnosis of PTSD all positively confound this association.In the unadjusted model, men reporting threat or use of force during their most recent police stop have greater odds of current PTSD symptoms than men without perceived threat or use of force during their most recent police stop, although only marginally significant . However, this odds ratio is reduced and no longer statistically significant after adjusting for potential confounders. This is largely driven by joint confounding by a history of homelessness and prior diagnosis of depression. Among women, the relationship between high number of lifetime police stops and current depressive symptoms is not statistically significant in unadjusted or adjusted models . The relationship between high lifetime stops and current depressive symptoms in the over-adjusted models is comparable to adjusted model estimates.p = 0.045). The magnitude of this association decreases and is not statistically significant after adjusting for potential confounders . A history of homelessness, race/ethnicity, violent crime rate and prior diagnosis of depression appeared to be jointly responsible for reducing the magnitude and significance of this estimate. Over-adjusted models of perceived threat or use of force and current depressive symptoms do not vary substantially from adjusted models, although exposure point estimates are lower in magnitude. We were unable to accurately assess interactions between either police exposure and race/ethnicity or mental illness history as small cell sizes led to unstable estimates.Perceived threat or use of force during the respondent's most recent police stop is not associated with current depressive symptoms among men. However, women reporting threat or use of force during their most recent police stop have nearly four times greater odds of current depressive symptoms than women reporting no threat or use of force during their most recent police stop  and no longer significant after potential over-adjustment (p = 0.120). For women, the positive association between lifetime police stops and PTSD symptoms is only marginally significant in the unadjusted model when using the continuous exposure variable (p = 0.083).Apart from differences in point estimates from the dichotomised police stop variable, results did not differ in interpretation or significance for associations between continuous lifetime police stops and depression for men or women. For men, the significant positive association between continuous lifetime stops and PTSD symptoms in the unadjusted model becomes marginally significant after adjustment (Our findings suggest a potential association between persistent police exposure and current mental health status. High lifetime police stops are strongly and significantly associated with current PTSD symptoms among men, and marginally significantly associated among women. Yet perceived threat or use of force during the most recent police stop is not significantly associated with current PTSD symptoms for men or women after adjustment. It is somewhat unexpected that high lifetime police stops, but not perceived use of force during the most recent stop, is associated with current PTSD symptoms.et al. found a significant association between lifetime police stops and PTSD symptoms among young men in New York City, although their PTSD scale was specific to the respondent's most memorable police stop (Geller et al., et al., This finding, however, is consistent with another population-based study on this subject. Geller most recent police stop only. Therefore, we cannot interpret these results as lifetime exposure to aggressive policing. Individuals who have been repeatedly stopped by the police may be at greater risk for exposure to aggressive policing tactics over the course of their lifetime. In this instance, the trauma pathway may be operating, whereby exposure to police aggression or violence may traumatise the victim, leading to symptoms consistent with PTSD.Alternatively, persistent police stops may be serving as a proxy for lifetime exposure to aggressive policing tactics. In this study, perceived threat or use of force was measured in relation to the et al., et al., Reverse causality may also be at play, whereby individuals with existing PTSD may be more likely to be stopped by the police. This is a concern because individuals with mental disorders may be at increased risk of police contact (Hartford There is not strong evidence of an association between police exposure and depressive symptoms in our sample. High lifetime police stops are associated with current depressive symptoms among men in the unadjusted model, but the odds ratio is diminished and no longer significant after adjustment. Similarly, among women, there is a strong but partially confounded relationship between perceived threat or use of force during the most recent police stop and current depressive symptoms.This study advances our knowledge of potential associations between persistent police exposure and current mental health status using a representative population-based survey of several Chicago communities. The Sinai Survey is a unique, comprehensive survey of hard-to-reach populations in Chicago. In addition to collecting information on both police exposures and mental health, Sinai Survey included a large number of related social and demographic factors, allowing for the measurement and control of a number of potentially confounding variables. Given the importance and nature of conducting research in disadvantaged communities, we were pleased to successfully complete interviews over 50% of the time when a household resident was reached.Precision of our findings is limited by lack of detailed information on the timing of the respondent's most recent police stop, no measure of exposure to aggressive policing tactics beyond the most recent stop, and the inability to distinguish between threat and use of force. Although we asked whether the respondent had been stopped in the past year, we did not restrict the analysis to respondents who reported threat or use of force in the past year as it diminished the proportion exposed considerably. We attempted to alleviate potential recall issues related to reporting lifetime police stops by categorising number of police stops as either high or low using sex-specific percentile cut-points. Additionally, we did not collect information on when depressive or PTSD symptoms first occurred. As a cross-sectional study, we cannot clearly establish temporality.Additional population-based studies in urban environments are needed to confirm our findings and further knowledge on associations between police encounters and mental health status. Future studies should differentiate between threat and use of force and include a large enough sample size to examine associations by race/ethnic group across different neighbourhood environments. Longitudinal studies are needed to establish temporality and address reverse causality issues, as well as collect detailed information on the timing, nature and type of police encounters experienced. Finally, in addition to studying the impact of police exposure at the individual level, future research should attempt to quantify and assess the impact of police discrimination at the institutional level as an important risk factor for poor mental health outcomes.Despite recent interest, the field of public health has not developed a coordinated strategy to quantify and study law enforcement overexposure and violence as a public health issue. Our findings support preliminary evidence of an association between persistent police exposure and poor mental health status. This is a salient finding given the apparent pressure the Chicago Police Department is under to increase the number of street stops WBEZ, . In 2014


Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder affecting up to 13 % of women. Lifestyle interventions are first-line treatments, however attrition in women with PCOS is high. This review summarises current evidence on barriers to lifestyle management in PCOS and suggested strategies for overcoming these challenges, mapped to the Capability, Opportunity, Motivation and Behaviour model.Physical capability for lifestyle changes may be impacted by altered gut hormone regulation and energy expenditure in PCOS. This may contribute to difficulties with weight management. The higher prevalence of eating disorders, disordered eating, fatigue and sleep disturbances are further barriers. Psychological capability may be reduced due psychological symptoms and lack of critical health literacy. Women with PCOS face similar challenges in terms of Opportunity to make lifestyle changes as other women of reproductive age. However, these are complicated by features more common in PCOS including body dissatisfaction. Motivation to adopt healthy lifestyles may be impacted by suboptimal risk perception and intrinsic motivation.To address these barriers, screening for and management of eating disorders, disordered eating, depression, and Obstructive Sleep Apnoea should be undertaken as per international evidence-based guidelines. A weight-neutral approach may be appropriate with disordered eating. Building capability among health professionals to better partner with women with PCOS on their management is essential in addressing health literacy gaps. Behavioural strategies that target risk perception and build intrinsic motivation should be utilised. More research is required to understand optimal self-management strategies, risk perception, energy homeostasis and overcoming attrition in women with PCOS. Polycystic Ovary Syndrome (PCOS) is a multisystem disorder with reproductive, metabolic, and psychological manifestations  affectinIn addition to the reproductive features, PCOS is also associated with psychological and metabolic complications including decreased health-related quality of life  and incrcapability), the enabling circumstance (opportunity), and the willingness to engage (motivation) all need to be present for a particular behaviour to occur [Capability, opportunity and motivation/COM) and a ‘Behaviour Change Wheel’, around which nine intervention functions are positioned, which inform strategies to behaviour change corresponding to the COM domains [While effective lifestyle modification is a key component of PCOS management, the evidence of higher obesity prevalence and longitudinal weight gain in community-recruited populations , combineto occur . Develop domains .There are a number of potential physiological reasons unique to women with PCOS that may explain difficulties with weight management. Insulin resistance and hyperinsulinaemia may predispose women with PCOS to gain weight, supported by insulin therapy-inducing weight gain  through There may also be abnormalities in energy homeostasis in women with PCOS. The limited literature in this area has reported decreases in basal metabolic rate  or postpAppetite regulation has also been reported to be impaired in women with PCOS, with alterations in hunger and gut hormones. A systematic review of 20 studies involving 894 women with and 574 women without PCOS reported lower ghrelin in PCOS  , relatedWomen with PCOS are reported to have a higher prevalence of both disordered eating behaviours –48 and eFatigue has been reported by women with PCOS as a barrier to adopting lifestyle changes , which mFatigue and sleep disturbances may also indicate depression, and are the most commonly reported depressive symptoms in women with PCOS . The preWomen with PCOS are more likely to report a lack of confidence about maintaining physical activity  which maSelf-management is a continuous process of self-directed behaviour change known to improve one’s personal emotional, behavioural and medical management, aiming to avoid disease-related complications, regulate symptoms and reduce the severity of disease –79. ThesHealth literacy provides a comprehensive lens on self-management among women with PCOS. Health literacy is an important determinant of health equity and comprises a multi-dimensional concept described by the World Health Organisation as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” . ResearcThere are three main categories of health literacy: functional, interactive and critical health literacy . While eFunctional health literacy describes the basic knowledge and skills in health including literacy and numeracy skills to process health information such as reading food labels [d labels . Higher d labels . Past std labels –95. Thisd labels , 96. Thed labels .Interactive health literacy describes the ability to apply the knowledge through supportive relationships, which could include accessing health services and support, the ability to engage healthcare professionals to manage health and having social support for health [r health , 97. In r health –100. Thir health . Howeverr health .Critical health literacy builds on functional and interactive health literacies to advocate for individual and social health, such as making shared decisions on one’s health with health professionals [ssionals , 104. Inssionals , which issionals , 104. Asssionals .Women with PCOS report similar barriers to lifestyle and weight management as those generally faced by women of reproductive age without PCOS, including conflict with work and family commitments, or disliking the “mundaneness” of a restricted diet , 106. ThRisk perception is one’s subjective judgement about the likelihood that an adverse event will occur and the severity of consequences should it occur . Risk peNotwithstanding their own perceptions of risk, evidence suggests that PCOS is associated with greater risk of metabolic diseases such as type 2 diabetes in the long term , 118. MoWomen with PCOS also appear to lack intrinsic motivation to undertake lifestyle change, such as enjoyment of physical activity, instead viewing physical activity only as a means to weight loss. This is evidenced by previous research reporting that a major barrier to physical activity adoption among women with PCOS is the perceived barrier that exercise is tiring and hard work , and feaCapability, Opportunity and Motivation contribute to the key behavioural issue underlying lifestyle management in PCOS—attrition. Attrition is a common barrier to successful weight management, reported across all weight management interventions targeting women of reproductive age with or without PCOS [All the barriers in out PCOS . Women wout PCOS  in this out PCOS , 124–126It is known that individuals who prematurely terminate weight loss interventions do not attain the required skills and strategies to effectively overcome barriers to lifestyle change. This impacts long term weight management, with intervention completion positively correlated with weight loss . Other hTo date, literature has identified participant characteristics   and predWhen communicating to women with PCOS, it is important to be aware of these mechanisms as to best acknowledge the potential pathophysiology of challenges they may experience when trying to manage weight. Further research is needed both in women with PCOS and the general population on strategies to aid weight management through modulating energy expenditure or appetite regulation.If fatigue, sleepiness and non-restorative sleep are identified, screening for OSA should be considered, followed by a referral to a sleep specialist if required. The tool recommended by international evidence-based guidelines on PCOS is the Berlin Questionnaire , althougLifestyle recommendations may need to be sensitive to disordered eating or eating disorders so as to not perpetuate disordered eating psychopathologies . Eating As lifestyle interventions and weight management are key recommendations for the management of PCOS, identifying the most effective and acceptable lifestyle-related self-management strategies in this population may help support them in achieving lifestyle change and meeting the nutrition and physical activity recommendations as outlined in the 2018 evidence-based clinical guidelines for optimal PCOS management . This wiEvidence-based guidelines recommend that all women with PCOS should be routinely screened for anxiety and depression symptoms at diagnosis and referred for psychological therapy if required. Initial screening questions and follow-up screening are provided in Table Involving women with PCOS in the co-development of health interventions or decisions is key to addressing the gap in critical health literacy, as demonstrated in recent research . Better Wider adoption of evidence-based tool such as the AskPCOS smartphone application could improve communication between women with PCOS and health professionals , since it includes a question prompt list that enables women with PCOS to discuss targeted health concerns with their healthcare providers , 144. AdConsidering the barriers of lack of time, childcare responsibilities and work commitment in women of reproductive age , 106, inDespite limited evidence, there is a clear need for increased education, awareness, and accuracy of risk perception among women with PCOS. Shared decision-making and an improved understanding of the features of risk  are important considerations for successfully implementing lifestyle change . HoweverWomen should be encouraged to choose physical activities that they find enjoyable, rather than the ones they think they are expected to engage in (such as going to the gym). The use of mindfulness-based therapies is a potentially novel intervention that may help to enhance intrinsic motivation to exercise, and may have additional benefits for mental health .Our recent meta-analysis on strategies to reduce attrition in weight loss interventions for the general population included 57 studies and 7581 participants and reported that intervention strategies such as multi-component interventions , monetary incentives , and self-monitoring significantly reduce the risk of attrition in weight loss interventions. Multi-cWithin a clinical setting, financial incentives could be small cash payments, lottery tickets, grocery vouchers, or reduced-fee follow-up appointments to reward clinical attendance , 150–152Our systematic review highlighted a current lack of studies reporting attrition in female-only weight loss lifestyle interventions and we were unable to conduct subgroup analyses to determine the most effective attrition reducing strategies in females. In anotThere are a number of barriers to successful lifestyle change among women with PCOS. Emerging research suggests that a range of intrinsic factors for weight management may be altered in PCOS affecting the capability of women with PCOS to manage their weight, although this evidence is limited and currently inconsistent. Opportunity may be reduced due to systemic and general barriers which are compounded by PCOS-specific factors such as negative body image. Altered risk perception and a lack of intrinsic motivation (i.e. enjoyment) may affect motivation in women with PCOS. In assisting women to achieve their lifestyle goals, a multidisciplinary and multicomponent approach is required, incorporating self-management, behaviour change techniques to overcome barriers, screening and referral as appropriate for depression, negative body image, and eating disorders as per evidence-based guidelines, and overcoming health literacy gaps. More research needs to be conducted on overcoming attrition, gaps in risk perception, use of financial incentives and on tailoring recommendations for lifestyle change to be specific to women with PCOS.


Given that neurons cannot divide to regenerate themselves, together with the fact that only a small number of new neurons derived from external cell transplantation can survive Goldman, , few neuGoldman, , there ain situ neuronal regeneration approach using AAV NeuroD1-based gene therapy could repair damaged brains in adult non-human primates (NHPs) with ischemic stroke  conversion displayed Tbr1Moreover, it was extremely attractive that the NeuroD1-mediated AtN conversion not only significantly increased the cortical neuronal density, dendritic marker, and synaptic marker levels in the ischemic injured areas of the monkey cortex but also improved the microenvironment, including reducing the number of reactive microglia and macrophages (Ge et al., in vivo astrocyte conversion in human clinical trials, it is very important and necessary to first test such findings in adult NHP models, such as in monkeys. Previously, acute NHP stroke models often were used to test drug effects, and the drug administration time was typically within a few hours after stroke (Takamatsu et al., in situ NeuroD1-mediated AtN conversion therapy had a broad time window from 10 to 30 days following ischemic stroke (Ge et al., Many clinical trials of treatment for cerebral ischemia based on preclinical parameters obtained from rodent animal models have failed in the past (Turner et al., Nevertheless, in this study, some neuronal functions of converted neurons were not investigated, such as neuronal excitability, production, and release neurotransmitter. Furthermore, there is a question as to why and how NeuroD1-mediated AtN conversion could reduce the number of microglia and macrophages; unfortunately, the mechanisms were not investigated, and further studies will be required. However, there is mounting evidence that the expression of NeuroD1 is often high during early brain development and is lower in the adult brain (Pataskar et al., in vivo rodent models and in vitro human astrocyte culture models, as well as take an important step toward future clinical trials using such technology for nervous system diseases with neuronal loss.Taken together, this is the first report about successful application of NeuroD1-mediated AtN conversion technology in NHP models, which might fill some gaps between XZ and FC wrote the first draft. YW reviewed and critiqued the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Individuals who use opioids have higher rates of hospitalization compared to the general population. Insufficiently treated withdrawal and pain are major factors contributing to high rates of self-initiated hospital discharges  in this population. While injectable opioid agonist therapy is limited or unavailable in the majority of Canadian communities, intravenous hydromorphone (IV HM) is widely available in the hospital setting and high-dose IV HM may be a useful treatment adjunct to improve comfort and engagement in inpatient care for some individuals who use opioids. However, major barriers to its use exist including lack of comfort amongst healthcare providers and hospital policies restricting administration. In this commentary, we highlight the potential usefulness of high-dose IV HM as a treatment adjunct for individuals who use opioids in the hospital setting and advocate for expanded hospital policies to facilitate its use. The overdose crisis is one of the most significant and devastating public health challenges in recent memory. The 2019 novel coronavirus (COVID-19) pandemic has generated an additional public health crisis, with growing evidence that COVID-19 has exacerbated the overdose crisis and contributed to increased mortality among people who use drugs .In select places in Canada and many places in Europe, injectable opioid agonist treatment (iOAT) is available as part of the spectrum of treatment for opioid use disorder (OUD) . It is rInjectable opioid agonist treatment (iOAT) with pharmaceutical-grade heroin (diacetylmorphine) or high-dose IV HM has emerged as an evidence-based treatment for select individuals with OUD, shown to reduce non-prescribed opioid use and associated crime, overdose risk, and medical consequences of unsafe injection practices . While iInadequate pain and withdrawal management, in addition to perceived stigma from healthcare providers, are significant factors cited by people who use drugs  who choose to self-initiate discharge , 3. PainFor individuals in community iOAT programs, ongoing prescribing of high-dose IV HM would be facilitated in hospital, once stable, to prevent loss of tolerance as detoxification carries significant risk of mortality . HoweverThe use of high-dose IV HM in hospital does warrant careful consideration and appreciation of potential associated risks. While there are published iOAT guidelines for the outpatient setting, there are no guidelines to support the management of inpatient IV HM, which makes implementation more challenging for providers unfamiliar with this treatment . There iDespite national recommendations to consider escalation to IV opioids in the inpatient setting for select individuals who use opioids, some hospitals’ currently established policies may present a major barrier to the practical implementation of high-dose IV HM. These include restrictive limitations on the maximum dose of IV HM that can be administered on medical wards, where the majority of people who use opioids in hospital would be located. While additional training of pharmacy and nursing staff may be needed to facilitate safe implementation, protocolization of high-dose IV HM such as through the use of standardized order sets can provide safeguards for prescribing and administration . As inpaWhile suboptimal symptom management and stigma from healthcare providers have negatively impacted the inpatient care of people who use drugs  for many years, the current landscape of the overdose crisis, ubiquity of fentanyl within the illicit drug supply, and the occurrence of COVID-19 are all factors generating a pressing need to expand inpatient opioid management strategies. For certain individuals who use opioids, the use of IV HM may help to enhance patient engagement and comfort while in hospital and reduce self-initiated discharge. In consultation with prescribers with expertise in this area, hospitals must revise their policies in order to facilitate administration of high-dose IV HM if felt to be indicated. Widespread expansion of iOAT as a community treatment modality and other alternatives to the toxic drug supply are also urgently needed.