Iron deficiency presents a major public health concern in many malaria-endemic regions, and both conditions affect young children most severely. Daily iron supplementation is the standard public health intervention recommended to alleviate rates of iron deficiency in children, but there is controversy over whether universal supplementation could increase the incidence and severity of malaria infection. Current evidence suggests that iron supplementation of deficient individuals is safe and effective in high-transmission settings when accompanied by malaria prevention strategies. However, low-resource settings often struggle to effectively control the spread of malaria, and it remains unclear whether supplementation of iron replete individuals could increase their risk of malaria and other infections. This review explores the evidence for and against universal iron supplementation programmes, and alternative strategies that could be used to alleviate iron deficiency in malaria-endemic areas, while minimising potential harm. It is the most common cause of anaemia and can cause severe and irreversible impairment of neurodevelopment in children. ID anaemia and malaria have significant geographical overlap, and both affect infants and preschool children most severely. Recent estimates suggest 64.1% of children aged 6–59 months in sub-Saharan Africa are anaemic, with over 60% of anaemia globally being caused by iron deficiency. Current World Health Organization (WHO) guidelines recommend that daily iron supplementation should be given to all infants and young children aged 6–24 months in settings where the prevalence of anaemia is 40% or higher in that age group. However, these guidelines are rarely implemented, partially due to controversy over whether iron supplementation may increase infection and severity of malaria, particularly in iron replete children. Untangling the complex and controversial relationship between iron and malaria is vital to evaluate the safety and effectiveness of universal iron supplementation in malaria-endemic regions.Iron deficiency (ID) is the most prevalent micronutrient deficiency worldwide, affecting over 1.2 billion people globally. As animal (heme) sources of iron have higher bioavailability than vegetable sources, invariable plant-based diets prevalent in low-resource settings can predispose populations to ID anaemia. For example, a cross-sectional study of 6 to 10-month-old infants in southern Kenya found that 52.2% consumed only maize porridge as their main complementary food, with only 9% consuming any meat. Diets are often also low in fruit intake (which can enhance iron absorption) and high in cereals (many of which contain phytate that hinders absorption).The main driver of iron deficiency in low-resource settings is a lack of bioavailable iron in staple foodsvia hepcidin, high rates of respiratory and malaria infections can also contribute towards ID rates. Parasitic infection with whipworm and hookworm can cause chronic intestinal blood loss, increasing iron demand. A meta-analysis of hookworm infection found that both low-intensity and high-intensity infection were significantly associated with a reduction in haemoglobin levels in school-age children. The burden of infection is an important contributor to childhood iron deficiency in low-resource settings.Hepcidin is a hormone that reduces absorption of iron from the gut lumen and serves as the primary mechanism by which the body regulates iron levels. Hepcidin is secreted by the liver as an innate response to infection and works to restrict iron supply to pathogens. As infection reduces absorption of dietary iron. Longitudinal studies have demonstrated that hepcidin levels are highest in young infants, reducing their ability to effectively absorb iron from the diet, and so they are dependent on iron stores from pregnancy. The high prevalence of maternal ID in low-resource settings reduces the size of these neonatal iron stores, further exacerbating the problem of childhood ID. Nevertheless, a longitudinal analysis in Gambian infants found that weight gain correlated with decreasing hepcidin alongside decreasing ferritin levels , suggesting that while rapidly growing infants are the most susceptible population to iron deficiency, they are also the group most likely to be responsive to oral iron supplementation. High iron demand combined with poor iron availability in the diet makes early childhood the highest risk period for iron deficiency and iron deficiency anaemia, and it can be almost impossible for resource-constrained households to provide adequate iron without supplementation.Young children are particularly susceptible to ID anaemia, due to their high iron requirements during growth and development. From around 4–12 months of age, children are in a period of ‘iron famine’ as their blood volume rapidly expands with growth, and high rates of erythropoiesis are required to maintain haemoglobin concentration.The causes of iron deficiency in low-resource settings are summarised in. The most used iron markers include haemoglobin and serum ferritin levels, but each of these has its own caveats.There is significant controversy over the effectiveness of current iron markers and established thresholds for the diagnosis of ID, as many iron markers are confounded by infection or inflammation and cannot be easily normalised by comparison with markers of inflammation is not specific to iron deficiency. As malaria itself can cause anaemia, haemoglobin is generally unsuitable to measure iron status in malaria-endemic areas unless used in conjunction with other iron markers. In addition, evidence from human studies and animal modelsshows that the brain’s iron status is compromised before that of red blood cells, suggesting that children who are iron deficient without anaemia may still experience the neurodevelopmental defects associated with iron deficiency.While haemoglobin levels are very easy to measure, anaemia (defined by WHO as a haemoglobin level of less than 110 g/L)i.e., malaria-endemic regions). The cut-offs used by WHO to define ID have been updated to include increased cut-offs in the presence of infection  between the current WHO guidelines and a proposed internal regression definition found that the WHO guidelines significantly underestimated the prevalence of ID in African children across four countries . Nevertheless, Castberget al., measured conventional iron markers in children recovering from acute malaria episodes and found that inflammatory markers normalise at least two weeks earlier than serum ferritin. This means that techniques used to correct serum ferritin and other iron markers for inflammation may still be insufficient to eliminate bias in studies carried out in malaria-endemic areas. This also suggests that targeted supplementation strategies  risk underestimating the prevalence of ID in malaria-endemic areas, leading to higher rates of anaemia.Rather than the use of an arbitrarily raised cut-off for serum ferritin in the presence of inflammation, it has been suggested to use an internal linear regression to correct iron marker levels for malaria parasitemia and for inflammation using C-reactive protein (CRP) or α1-acid glycoprotein (AGP) measurementse.g., serum ferritin or serum transferrin). They found that subclinical inflammation (as indicated by acute phase reactant measurements) is prevalent even in low-infection-burden countries such as the United States, and that low levels of inflammation can bias iron status indicators. Therefore, the problem of estimating the ‘true’ burden of iron deficiency and iron deficiency anaemia rates is not restricted to high-infection-burden countries.The Biomarkers Reflecting Inflammation and Nutrition Determinants of Anemia (BRINDA) project was set up in 2012 with the aim of improving micronutrient assessment and anaemia characterisation globally. The BRINDA project pooled national and regional nutritional surveys over the previous 10 years representing ~30,000 preschool children and 21,000 school age children from all six WHO geographic regions, and measured haemoglobin and CRP levels alongside at least one other indicator of iron status  and was found to most closely match the current gold standard for iron deficiency measurement (regression corrected ferritin levels). However, despite this, the area under the curve for transferrin saturation was only 0.77, suggesting limited sensitivity as a diagnostic tool.Transferrin saturation has been found to be less affected than serum ferritin by inflammation and malaria parasitaemia when tested against other iron markerset al., used a univariate statistical model to compare multiple iron markers as predictors of iron incorporation into erythrocytes after supplementation, and found that hepcidin was the most accurate determinant of iron incorporation over 30 days, providing further evidence that the development of cost-effective assays for hepcidin could prove valuable in iron supplementation trials.Potential solutions to this problem may include combining multiple iron biomarkers or switching the focus from biomarkers of iron levels to biomarkers of iron need. Recently, hepcidin itself has attracted attention as a clinically useful indicator for iron supplementation. Hepcidin is the key iron regulator in the body and is downregulated in iron deficient populations to promote iron absorption but upregulated during infection in order to restrict iron supply to pathogens. Therefore, high hepcidin levels indicate either that the child is iron replete, or that they currently have low iron absorption rates due to infection or inflammation—both of which would indicate that iron supplementation would be ineffective. Prentice, and indirectly through ID anaemia, which can cause impaired cognitive and motor development, reduced growth velocity, and anorexia. Of particular concern are studies that indicate that these changes may lead to long-term deficits in executive function and recognition memory. Even iron deficiency that is not severe enough to cause anaemia (and therefore not detected by common screening procedures), has been found to adversely affect infant social-emotional behaviour at 12 months. Iron supplementation in at-risk populations during the first year of life has been shown to improve motor outcomes, neurocognitive and language outcomes, and social development, and the opportunity to avoid these knock-on effects in development has made establishing iron sufficiency in children a key public health goal worldwide.Iron plays key roles in oxygen transport and cellular metabolism and is essential for immune and neural development. Iron deficiency may have deleterious effects on neurodevelopment in children: directly through effects on iron-dependent myelination and long lasting epigenetic alterations to metabolism. Indeed, a randomised controlled trial by Pasrichaet al., (2021) found that while both oral iron supplementation and iron-containing micronutrient powders decreased the prevalence of anaemia in Bangladeshi infants compared to a placebo, there was no difference in cognitive development, or on any other developmental or growth outcome between treatment groups and the placebo group, either immediately after the three month regimen or at follow-up nine months later.However, while meta-analyses have shown that iron supplementation programmes are effective at reducing rates of anaemia, they are equivocal about impact on functional outcomes, however children who had a high 6-month haemoglobin (>128 g/L) and were given high-iron feed had poorer neurodevelopmental scores at 10 years old when compared to the low-iron group. A potential explanation for this could be that children who have high iron levels at baseline  may be adversely affected by iron fortification during early life, which would suggest caution when it comes to universal supplementation programmes. Nevertheless, the authors also note that high Hb levels do not necessarily reflect iron status and could instead be a marker of chronic hypoxia due to another factor, such as maternal smoking, which itself is linked to poor neurodevelopment in children. Indeed, a later study by Aminet al., (2012) found no increase in neurodevelopmental impairment at 8–12 months in premature infants with iron overload compared to premature infants with normal iron status, after controlling for confounders. While more research is needed in this area, there is very little evidence to suggest a major risk of iron overload due to universal iron supplementation programmes.There is also some concern that iron supplementation in children who are iron replete may cause harm to development. A Chilean study found a neurodevelopmental benefit at 12 months in infants given high-iron formula feed. Iron acts as a co-factor for the production of enzymes such as myeloperoxidase and nitric oxide synthase that are required for the killing of intracellular pathogens, with iron deficiency being shown to both blunt neutrophil production and suppress antibacterial mechanisms in neutrophils. Iron deficiency has been linked to a reduced immune response against specific pathogens, including bacterial infections and malaria. A prospective study into the effect of ID anaemia on infection amongst Bedouin infants found that anaemia at six months old was an independent risk factor for diarrhoea and respiratory disease from 7–18 months of age, even after controlling for environmental and socio-economic factors. Iron deficiency can therefore be both a cause and consequence of infection. This positive feedback effect creates a vicious cycle that results in high healthcare burdens for low-income countries.Iron is essential to maintaining immunity, with ID anaemia associated with significantly lower baseline IgG levels, reduced IL-2 and IL-6 production, and reduced phagocytic activityvs. 40 age-matched healthy children found that the ID anaemia group had significantly lower CD4+ T cell counts and decreased CD4:CD8 ratios. Oral iron supplementation was found to significantly improve CD4+ T cell counts and CD4:CD8 ratios in the ID anaemia group. A recent cohort study in Kenyan infants also suggests that ID anaemia may reduce antibody responses to vaccines, with a follow-up randomised controlled trial (RCT) specifically investigating the response to the measles vaccine showing that iron supplementation prior to vaccination helps to restore the humoral response. These findings have significant impact for public health and policy, as they indicate that correcting childhood iron deficiency may be a cost effective and clinically efficacious method of combating infectious disease.Studies into the effect of iron on adaptive immunity show similar trends. A case control study of 40 children with ID anaemia. A similar trial conducted in Nepal , however, found no evidence of increased mortality in the iron arm compared to controls. The results of these trials raised concerns over whether universal iron supplementation was safe in malaria-endemic regions.In 2006, a large prospective randomised control trial (RCT) conducted on Pemba Island, Zanzibar  was stopped prematurely because both arms receiving iron and folate supplementation had a higher rate of adverse events. In particular, malaria-related hospital admissions were significantly higher in the iron arms than in the placebo arm Plasmodium, the group of parasites that cause malaria, are dependent on iron both in the clinically silent hepatocyte stage and disease associated erythrocyte stage to proliferate. Clarket al., (2015) established a potential causal mechanism for the effects of iron on malaria risk, showing that malaria growth is reduced in red blood cells (RBCs) from individuals with ID anaemia and increased in RBCs from iron-supplemented donors. Iron supplementation may also increase the amount of non-transferrin-bound iron (NTBI), which promotes free radical formation and is more bioavailable toPlasmodium. Alternatively, iron’s effect on malaria may be mediatedvia the immune system, rather than directly through effects onPlasmodium. For example, infected RBCs are easier to phagocytose in iron-deficient hosts, increasing the ability of the immune system to control and neutralise infections. It is likely that all these mechanisms contribute to the effect of host iron status on malaria.Several mechanisms have been proposed to explain this association.. For example, a prospective cohort study by Muriukiet al., (2019) found that iron deficient children had a malaria incidence rate ratio of 0.7 compared to iron replete children  over a six month period. Similarly, high iron levels have been associated with an increased risk of malaria, with Moya-Alvarezet al., (2017) finding that infant iron levels were significantly associated with risk of a positive blood smear  andPlasmodium falciparum parasite density during the first year of life.Iron has complex effects on immunity and host-pathogen interactions, and iron supplementation may increase the risk of infectious disease. Several observational studies have demonstrated that iron deficient children have a reduced risk of malaria, even accounting for misclassification and other potential causes of bias) have not detected any additional risk when used in conjunction with appropriate malaria management and prevention strategies. The most recent Cochrane review into the safety of iron supplementation in malaria-endemic areas analysed 35 individually and cluster RCTs conducted in areas where malaria was hyper- or holo-endemic , with evidence from 31,955 children aged 0–18 years. It found that overall, iron does not cause an excess of clinical malaria in the presence of effective malaria control (risk ratio (RR), 0.93; 95% CI ). In areas without prevention and management programmes for malaria, iron may increase malaria risk . Based on this evidence, WHO changed their guidelines in 2016 to recommend universal iron supplementation in malaria-endemic settings “in conjunction with public health measures to prevent, diagnose, and treat malaria”.Although observational studies have associated host iron status with increased risk of malaria, RCTs into the safety of oral iron supplementation , but may have harmed iron replete children, increasing rate of adverse events by 63% (p=0.24). While this effect was not significant in the Pemba sub study, the lack of baseline iron status measurement in studies used in the Neuberger meta-analysis means it is impossible to tell if harm done to iron replete children was masked by the benefit to iron deficient children.However, the 2016 NeubergerIt is also important to consider whether the trials included in the 2016 Cochrane Review had an appropriate trial outcome. For example, the Pemba trial only reported on malaria that resulted in hospital admission, and therefore there is a risk that it underestimated the total incidence of malaria in the trial population. All other trials used clinical malaria as an endpoint (defined as fever accompanied by parasitaemia). However, this endpoint excludes asymptomatic parasitaemia, which is common in areas with high rates of malaria transmission. Therefore, it is possible that the trials included in the meta-analysis systematically underestimated the prevalence of malaria infection, reducing the strength of the association between iron supplementation and malaria.The authors also note that results from cluster RCTs may not have been appropriately adjusted, which may have had a significant impact on the results of the meta-analysis. Nine out of the 35 trials included were cluster RCTs, and as the largest trials they carried significant weight in the meta-analysis. Six out of nine of these cluster RCTs failed to report on the intracluster correlation coefficient (denoting degree of similarity in variables such as iron status for children in the cluster). The authors had to estimate intracluster correlation coefficients to adjust the weight of the cluster RCTs in meta-analysis, which reduces the quality of the conclusions reached.While RCTs are treated as the gold standard in epidemiology, they are not without their flaws. Individuals in RCTs are subject to active surveillance and are therefore more likely to receive prompt treatment in the case of adverse events. In addition, RCTs measure only a limited duration of iron supplementation and may not be representative of the child population in need of iron supplementation. While efforts can be made to make RCTs more realistic, they will never be able to replicate the epidemiological reality of malaria-endemic settings as observational studies do.Overall, while the evidence suggests that iron supplementation is safe in malaria-endemic settings when accompanied by malaria prevention and management strategies, areas of uncertainty remain. These include whether iron supplementation increases malaria risk in iron replete children, or in low-transmission areas, and what levels of malaria prevention and management are sufficient to justify the safe use of universal iron supplementation strategies.et al., (2013) examined the safety of micronutrient powders (MNPs) in fortifying the iron content of home meals over 12 months and found that both micronutrient groups had higher rates of bloody diarrhoea and higher overall morbidity than the unfortified group. This study was limited by its lack of a placebo control group, and it is unclear how translatable this trend is to other oral iron supplementation programmes. However, a range ofin vitro andin vivo studies suggest that both MNP fortification and other forms of oral iron supplementation significantly increase colonic iron levels, and adversely alter the gut microbiome by decreasing the balance of commensals to enteropathogenic pathogens, resulting in gut inflammation and increased risk of diarrhoea. This is an important side effect to note, as diarrhoea is a significant contributor to infant mortality in low-resource settings and is estimated to contribute to the deaths of approximately one in nine children less than five years old in sub-Saharan Africa.Iron supplementation may also alter the gut microbiome, increasing the risk of gram-negative bacterial infection and bloody diarrhoea in children. A cluster RCT by Soofi. It is therefore possible that iron supplementation in malnourished paediatric populations may carry increased risk. Nevertheless, at present, there is very little clinical evidence of iron supplementation causing increased oxidative stress in children. Indeed, a prospective observational study in which 21 healthy six-week infants with very low birth weight were given high dose iron (18 mg daily) found no significant change in markers of oxidative stress in the urine. This suggests that any additional ROS production caused by iron supplementation is clinically insignificant. However, the major caveat to this study is that iron supplementation was only given for one week, which may not have been a long enough period for markers of oxidative stress to increase significantly. Additionally, the study only observed a small sample of healthy premature infants, and so it is unknown how well these findings translate to a larger population of children from a wide age range who may suffer from infection or malnutrition.Non-transferrin bound iron has the potential to react with oxygen to create reactive oxygen species (ROS) that can damage lipid membranes within the body. This is a risk primarily in children with low concentrations of iron-binding proteins whose systems are overwhelmed by high dose iron supplementation therapies. For example, malnourished children with kwashiorkor have lower concentrations of transferrin, and this is associated with increased mortalityCurrent evidence suggests that iron supplementation may still carry risks in low-income areas where malaria control is ineffective and the burden of infectious disease is high. Given this, what practical strategies are there to balance the safety and efficacy of iron supplementation strategies in children?et al., (2014) analysed iron status and hepcidin levels over the course of a malaria season in The Gambia and Kenya and found that ID increased and hepcidin levels decreased over the course of the malaria season. A more recent study by Roberts SAet al., (2021) found the same association in adolescents in Burkina Faso, with higher hepcidin concentrations in the wet season corresponding with rising malaria prevalence. Therefore, targeting iron supplementation programmes at the end of the malaria or wet season could maximise their effectiveness (as low hepcidin levels mean iron absorption is at its peak), target the populations that need it the most , and increase their safety .Atkinsoni.e., fortification of staple foods at the point of manufacture, such as fortified wheat), and point-of-use fortification . These strategies enable the delivery of small doses of iron several times a day, which, while slower to raise iron levels, may prove safer than oral supplementation. Biofortification and industrial fortification are effective in malaria-endemic countries and have several practical advantages over supplementation, in that they reach all sections of society, are not dependent on patient compliance, and have lower costs than oral iron supplementation programmes. Point of care fortification with MNPs and SQ-LNSs still require uptake by the population but could prove safer and milder in side-effect profile than oral iron supplementation. However, the effectiveness of food fortification strategies in reducing rates of ID anaemia is dependent on a host of contextual factors, including cooking techniques, staple foods (and whether they aid or counter iron absorption) and the chemical composition of MNPs/SQ-LNSs, leading to variability in outcomes between countries. For example, a MNP intervention in Uganda by Fordet al., 2020 found no change in anaemia status despite high programme fidelity, and theorised that cooking with soda ash, which reduces micronutrient bioavailability and absorption, may explain the lack of effectiveness.An alternative strategy to boost iron intake at a population level is food fortification. Several methods can be used to fortify food with iron, including biofortification of staple food crops, industrial fortification  demonstrating that deworming using albendazole is associated with significantly raised haemoglobin levels in children. A growing evidence base suggests that malaria contributes to the burden of iron deficiency, with a recent paper by Ntendaet al., (2022) concluding that both asymptomatic and clinical malaria were independent risk factors for anaemia and functional iron deficiency (FID). Therefore, malaria elimination programmes themselves may be an effective strategy to address ID in malaria-endemic areas. For example, Froschet al., noted significant increases in haemoglobin and serum ferritin levels in children <5 years old after a 12-month period of interrupted malaria transmission in highland Kenya.Other approaches involve tackling the causal factors of iron deficiency at a population level. As infants in low-resource settings often have insufficient iron stores from pregnancy, delayed umbilical cord clamping after birth has been suggested as a method to increase fetoplacental blood transfusion and infant blood volume. This strategy has been shown to increase infant iron stores and prevent ID in early infancy, with an RCT demonstrating that delayed clamping for >3 minutes after birth reduces the relative risk of anaemia for up to 12 months Current evidence suggests that universal iron supplementation is safe in malaria-endemic areas when accompanied by appropriate malaria prevention and diagnosis. In low-resource settings where malaria control is inadequate, there is some evidence that iron supplementation may increase the risk of malaria and gram-negative bacterial infection in children. On the balance of risks, it is likely that the benefits of universal iron supplementation in reducing population levels of iron deficiency and anaemia outweigh any potential increases in the risk of infection.The current literature base is limited by a lack of accurate iron markers that are unbiased by the high rate of infection in malaria-endemic areas, and so new markers must be developed to investigate the effects of host iron status on the safety of iron supplementation. From a health policy perspective, addressing the causal factors of iron deficiency could reduce the need for iron supplementation, while in the meantime, small changes to iron supplementation programmes (such as aiming them at the end of the wet season) could increase their efficacy and limit any potential risks.. Therefore, sufficient attention must be given to ensure that childhood obesity and the chronic inflammation associated with it does not exacerbate the challenges associated with treating iron deficiency in malaria-endemic areas.Looking to the future, thought must also be given to the changing public health landscape of malaria endemic areas. Many people living in malaria-endemic areas are currently undergoing rapid dietary and lifestyle changes associated with increased urbanisation. While lifestyle diseases are often seen as solely the problem of high-income countries, urban settings in Sub-Saharan Africa and South America are increasingly facing ‘the dual burden of disease’, in which conditions such as iron deficiency anaemia and obesity present in the same children. A recent study of children in Lima, Peru, showed that both adiposity and CRP were associated with a lack of response to iron supplementation after one month of treatment In this article, Abuga K.M. et al describe the impact of severe anemia on bacterial infections, a scenario that is recurrent in Saharan Africa, where this association constitutes a major health concern. Prevalent pathogens and risk factors for specific comorbidities are reported, as the importance of iron metabolism in activating the innate and adaptive immunity by discriminating its function between different immune cells. This comprehensive review also highlights the role of this metal in ensuring the survival of both pathogen and host, emphasizing the need for additional studies to better address the effects of severe anemia on vaccine efficacy. The article is well written and the authors provide an interesting overview on the current knowledge on this field.Is the review written in accessible language?YesAre all factual statements correct and adequately supported by citations?YesAre the conclusions drawn appropriate in the context of the current research literature?YesIs the topic of the review discussed comprehensively in the context of the current literature?YesReviewer Expertise:Immunology, infectious diseases, malaria, neurodegeneration, neurodegenerative diseases, African countriesI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Universal iron supplementation: the best strategy to tackle childhood anaemia in malaria-endemic countries?”byKarthikappallil and Atkinson is a well-written and adequately referenced review of universal iron supplementation strategies in malaria-endemic countries to combat iron deficiency anemia. I would only expand on recent knowledge regarding the risks of using iron supplements for improving iron deficiency in infants :471-477). Although iron repletion increases anti-measles immunoglobulin G seroconversion, a very useful effect in low-income settings, unabsorbed iron reaching the colon adversely affects the gut microbiome causing gut inflammation and diarrhea. To this extent, galactoligosaccharides and apolactoferrin may prove useful in malaria-endemic areas by increasing the absorption of iron and simultaneously lessening the adverse effects of unabsorbed iron on the infant’s gut.The manuscript “Is the review written in accessible language?YesAre all factual statements correct and adequately supported by citations?YesAre the conclusions drawn appropriate in the context of the current research literature?YesIs the topic of the review discussed comprehensively in the context of the current literature?YesReviewer Expertise:Benign Pediatric Hematology Oncology, iron deficiency prevention and treatment, parenteral iron therapyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Ultra-rapid genomic sequencing (urGS) is increasingly used in neonatal and pediatric intensive care settings (NICU/PICU), demonstrating high diagnostic and clinical utility. This study aimed to explore the perspectives of healthcare professionals (HPs) and the challenges raised by urGS, particularly when making treatment decisions. Four focus groups and two interviews were conducted with HPs who had experience using urGS in NICU/PICU. Inductive content analysis was used to analyze the data. Nineteen HPs participated overall . One challenging area of practice identified by HPs was setting realistic expectations for outcomes of urGS among HPs and families. HPs reported modifying pre-test counseling to include life-limiting diagnoses as a possible test outcome and felt concerned about the timing of the test and its impact on parent–child bonding. UrGS results of uncertain prognostic significance posed considerable challenges. Moral distress arose when families and HPs were misaligned regarding treatment goals following the urGS diagnosis. We identified areas of practice that remain ethically challenging for HPs using urGS in the NICU/PICU. HPs experiences of using urGS in the NICU/PICU could inform specialized training in withdrawal of treatment decision making for the genomics workforce. Ultra-rapid genomic sequencing (urGS) (whole exome or whole genome sequencing completed in <5 days) was specifically developed for use in the neonatal and pediatric intensive care (NICU/PICU) settings to enable swift diagnosis for critically ill patients with underlying genetic conditions. Diagnoses achieved through urGS can be used to guide the clinical management of serious conditions, enable access to life-saving treatment (in some cases within a matter of hours), and provide informed reproductive options for families ,2,3,4,5.When considering if urGS exacerbates moral dilemmas regarding treatment decisions, several studies have examined the perceptions and experiences of health professionals (HPs) using urGS in the NICU/PICU. While HPs consistently report perceived clinical utility and low perceived harms, both for diagnostic and uninformative results, ,2,11 stuAssistance and training in the interpretation of data from new technology to support clinical decision making for the treatment of critically ill infants is not novel; Wilkinson discussed the impact on clinical decision making due to the introduction of magnetic resonance imaging scans (MRIs) . As a neThis study utilized a qualitative methodology with focus groups as the primary method of data collection. Purposive sampling was used to approach potential participants within the Australian Genomics Acute Care Genomics (ACG) program, which is evaluating urGS as a first-tier test for diagnosis of critically ill neonatal and pediatric patients with rare disease . EligiblThe focus group format was chosen to enable participants to convey their experiences freely to their peers and allow sensitive subject matter to be discussed in depth ,20. As rInductive content analysis was used to analyze the transcripts, in which codes were developed from the data, rather than deductively . SectionOverall, 19 HPs participated in the study , from six different Australian health services. Our analysis identified five categories relating to how urGS impacted HP decision making: (1) prioritization of urGS results; (2) timing of urGS; (3) adaptation of pre-test counseling; (4) differences between HP and family decisions; (5) prognostic uncertainty. Illustrative quotes are presented in tables. Pseudonyms are provided to maintain participants’ anonymity in the following style: session type (focus group (FG) or interview (I)), profession, and participant number. Professions are abbreviated as clinical geneticists (ClinG), pediatric specialists (P), genetic counselors (GC), and intensivists (Int).HPs observed that the introduction of urGS has created situations where priority is given to obtaining a result from the urGS over other tests. They explained witnessing colleagues wait for the urGS result to be returned before making treatment decisions and expressed concern that this reliance on urGS means clinicians are giving insufficient consideration to the entire clinical picture for each patient when making treatment decisions : Quote 1HPs discussed how the timing of the urGS test in the NICU creates unique challenges. They described situations where they felt providing a diagnosis so early after birth had negatively impacted the parent–child bonding process : Quote 1HPs described the ways in which using urGS in the NICU/PICU setting had changed how they speak to families about the outcomes of the urGS test during pre-test counseling : Quote 3HPs explained that the diagnosis of a condition that impacts quality of life via urGS can create a misalignment between families and treating teams regarding the decision to redirect care towards palliation. HPs described scenarios where the patient’s family did not accept the treatment recommendation of the medical team based on the urGS diagnosis. HPs found it particularly distressing when parents elected to redirect care towards palliation, despite treatment options being available. They discussed experiencing discomfort at ending a life that was potentially worth living : Quote 1In some cases, urGS will identify variants for which there is only a handful of previously documented cases; there is no roadmap for predicting likely outcomes and possible treatment options for patients. As described by HPs in our study, obtaining detailed prognostic information assists in predicting outcomes : Quote 1When exploring this view in the focus groups, HPs discussed that despite having extensive experience in caring for critically ill newborns, medical teams from the NICU/PICU have little experience managing older patients with the same diagnosis and emphasized how urGS testing can bridge the gap between HPs from pediatrics and adult populations, as well as across departments : Quote 4Utilization of urGS in the NICU/PICU setting is challenging because it occurs at a time when new parents are overwhelmed, and the implications of the genomic information provided may be unclear. The short timeframe in which testing takes place means any diagnosis, especially where palliative care for an infant is considered, needs to be processed fairly quickly by both the HPs and the infant’s family. Our findings are important, timely, and reveal the complex nature of using urGS in the NICU/PICU. Our findings revealed that some HPs prioritize urGS over other tests when trying to diagnose a condition, and this contrasts with earlier research by Lynch et al. who reported that HPs in the NICU/PICU focused on other tests rather than urGS . This diObtaining the urGS test result in the NICU/PICU means that the decision of whether to redirect care towards palliation may happen earlier in the treatment pathway. There were two important elements related to the unique timing of the decision. First, the rapid nature of the test means that families receiving testing do not have time to reflect on the potential scope of results. Second, the predictive nature of the results can be even more devastating for families in NICU/PICU than in other settings because they are being disclosed so early, not only in the diagnostic journey but also in the parenting journey. A survey of parents whose children had urGS testing in the NICU/PICU also highlighted the convergence of these two elements as unique, explaining that it is important for HPs offering urGS to families to weigh the likely benefit of the test against the family’s ability to cope with the result at that point in time . Our HPsHPs in our study felt parents had insufficient understanding to provide informed consent to the urGS test, a concern supported by parents who were often confused by the words “screening” and “diagnostic” tests . HoweverBoth genetically and non-genetically trained participants using urGS within the NICU/PICU explained that they have adapted their genetic counseling to alert parents more explicitly that redirection of care towards palliation may be presented to them post-urGS testing. Our findings support those of Lynch et al., who found that GCs modulate their pre-test counseling to prepare families to make difficult decisions . This haSome HPs in our study expressed that the timing of the urGS test and delivery of the result may impact parent–child bonding, simply by conducting it so early in the parenting journey; parents seem to emotionally disconnect themselves from their child and avoid discussions about the next treatment steps once a diagnosis of a severe/life-limiting condition is delivered. Emotional disconnection of parents from their children, and the parents’ subsequent ability to make decisions, has been observed in other settings, such as prenatal diagnosis . BabySeqUsing urGS in the NICU/PICU can exacerbate conflicts between HPs and families about how to proceed with treatment options for a sick child. HPs cited examples where a diagnosis via urGS provided a viable treatment pathway but there was a chance the child would still have moderate intellectual disability. Parents’ decisions did not always align with the treating team: the parents requested redirection of care towards palliation despite HP’s advice that a treatment option was available . While families appeared to make decisions based on their concepts of intellectual disability, support structures, and expected quality of life, the HPs were perhaps more focused on survival and less on the challenges of raising a child with an intellectual disability. Our findings support those of Mills and Cortezzo, who found that misalignment in value judgment, coupled with the pressure of abiding by parental wishes, makes the decision process profoundly distressing for HPs in this setting . The conIn theory, identifying rare conditions is no different with urGS compared to other means. In many cases, a diagnosis of a rare condition provides closure and helpful guidance regarding treatment options. However, when a rare disease is diagnosed rapidly in infancy, as is the case with urGS, it can create uncertainty about the future due to a lack of knowledge about the disease . Our resThis study has several limitations. Although we attempted to recruit widely across the ACG program, no nurses and only two intensivists participated. As such, our findings may not be representative of all HPs working in this setting. However, it is important to note that genetic services work across departments and the clinical geneticists and counselors interviewed for this study were recruited because of their role as part of the multi-disciplinary NICU/PICU teams within their health service. Our study sought to include HPs from the ACG program to ensure participants were experienced in using urGS in the NICU/PICU setting but this resulted in a geographical bias which reflects the composition of the genomics workforce and the number of state-based referrals . TherefoOur findings have several important implications for the use of urGS in clinical practice. Despite urGS raising ethical questions, it has previously been shown to be invaluable to families. Our study highlights a need for more education for non-genetic HPs, especially in the NICU/PICU about the limitations of urGS and the importance of multi-disciplinary input and intentional communication and cross-pollination of knowledge between non-intensive and NICU/PICU medical teams when making treatment decisions. Our findings also suggest the optimal time for offering urGS and assessment of each family’s ability to cope with a life-limiting diagnosis should be routinely considered, allowing parents the chance to adjust and make sense of the possible outcomes for their child and minimize the impact of urGS on parent–child bonding. Participants described how they adapt their pre-test counseling in order to discuss redirection of care towards palliation more readily with families. As a result, guidelines for HPs conducting pre-test counseling in this setting may need to be developed to ensure parents are well prepared to receive results with poor outcomes and are adequately warned that redirection of care towards palliation may be actively considered. Finally, our findings suggest that conflict between families and HPs is even more pronounced when using urGS in the NICU/PICU because of the limited time available for parents to become accustomed to the idea that their child is critically ill. Further development of ways to manage individual families, perhaps on a case-by-case basis, and the use of formal workplace support structures, such as ethics committees, may assist and support HPs through the decision-making process in this setting.


The sustained increase in lifespan expectancy achieved during the last years has critically increased the interest in understanding the molecular and cellular mechanisms triggering age-related diseases. Aging is a natural biological process that leads to a progressive decline in physiological functions, making individuals more susceptible to various age-related diseases.Lee et al. review and emphasize the contribution of immunosenescence to the functional decline of the immune system during aging. Among other features, senescent cells typically accumulated in the tissues during aging are characterized by the pro-inflammatory senescence associated secretory phenotype (SASP), contributing to drive local and systemic chronic sterile inflammation through the secretion of multiple cytokines and chemokines. Among the senescent signatures that appear in the major populations of immune cells, previous reports uncovered the decreased extent of type I IFN responses driven by innate immune cells is highlighted as a risk factor for viral infections in aged individuals . One of the key challenges in diagnosing neurodegenerative diseases is the difficulty in distinguishing between physiological aging and pathological aging. Identifying biomarkers that flag this transition would provide an earlier detection and therapeutic options. In this regard, recent findings point to a prominent role of neuroinflammation in triggering neurodegenerative diseases. While the role of myeloid cells, and specially microglia, was well established, how the adaptive immune system contributes to neurodegenerative diseases is progressively acquiring more relevance in this research field. Indeed, recent findings have evidenced that cytotoxic T cells accumulate in the brain of mouse models and patients with pathologies like AD, Amyotrophic lateral sclerosis or Parkinson’s disease .Cox et al. reviewed the potential of glutamate, a crucial neurotransmitter in the brain, as a biomarker for identifying this pathological transition in AD. During healthy aging, has been reported a decrease in glutamatergic synapses and neurons mainly in the hippocampus, prefrontal cortex and motor sensory areas which in combination with grey matter thinning helps to explain the subsequent cognitive, motor and sensory decline in healthy aging  between AD and control samples in three different databases, and by CIBERSORT algorithm they correlated those genes with differentially infiltrated immune cells (DIICs) . They reported that, in line with recent literature data . This correlates with increased systemic levels of the pro-inflammatory cytokine interleukin-6 (IL-6) and increased levels of pro-inflammatory markers in their brains. Moreover, they found a significant correlation of certain bacterial species such as Lachnospiraceae NK4A136 and Clostridium sensu stricto 1 with the altered behaviour and the appearance of disease markers in the brain of these mice . These findings align with recent reports that found that altered gut microbiota composition may be an indicator of preclinical AD in patients . This highlights that research on this field may bring the identification of altered, potentially druggable, molecular pathways in these diseases and not only the characterization of the effects of these interventions that are unfortunately not always easy to implement in these kind of patients.Finally, in this topic Eric This topic includes original papers and review articles summarizing the contribution of different mechanisms ranging from exogenously ingested damaging agents, pro-inflammatory molecules or exacerbated neurotransmitter release to neurodegeneration and age-associated cognitive decline. Moreover, the topic provides with potential therapeutic options that could ameliorate the impaired neuronal performance, which is characteristic of these conditions. On top of that, the readers will also find research on new markers that will eventually help diagnosing these conditions at earlier stages. Future research must deepen into why common mechanisms are altered during the progression of diseases with different aetiology, what could definitely make an impact in patients’ weelbeing.


Electrophysiological characterization of live human tissue from epilepsy patients has been performed for many decades. Although initially these studies sought to understand the biophysical and synaptic changes associated with human epilepsy, recently, it has become the mainstay for exploring the distinctive biophysical and synaptic features of human cell-types. Both epochs of these human cellular electrophysiological explorations have faced criticism. Early studies revealed that cortical pyramidal neurons obtained from individuals with epilepsy appeared to function “normally” in comparison to neurons from non-epilepsy controls or neurons from other species and thus there was little to gain from the study of human neurons from epilepsy patients. On the other hand, contemporary studies are often questioned for the “normalcy” of the recorded neurons since they are derived from epilepsy patients. In this review, we discuss our current understanding of the distinct biophysical features of human cortical neurons and glia obtained from tissue removed from patients with epilepsy and tumors. We then explore the concept of within cell-type diversity and its loss . We introduce neural homogenization to help reconcile the epileptogenicity of seemingly “normal” human cortical cells and circuits. We propose that there should be continued efforts to study cortical tissue from epilepsy patients in the quest to understand what makes human cell-types “human”. For decades, neuroscientific investigations have pursued the question: “What properties of the human brain allow for the uniqueness of the human experience?” With contributions of modern neuroscience, it is now understood that the quality of being human emerges from the interactions between the brain's 80 billion neurons. As inspired by the single neuron doctrine, resources from all over the world have been put toward understanding the constituent parts of the brain including individual neurons and their supporting glia Yuste, . Some inThe scientific study of neurological conditions  have made significant advances with the valuable insight provided by preclinical models  fail to provide seizure freedom, resective surgery is recommended Engel, . This elin vitro recordings were performed on human cortical tissue resected from a patient with epilepsy , brain tissue from the middle temporal gyrus (MTG) is removed to access the epileptogenic zone  cortical neurons can also be subdivided with respect to their long-range axonal projection targets: extra-telencephalic (ET), which project to areas within and outside the telencephalon, or intra-telencephalic (IT) which have projections that are restricted to the telencephalon   electrogenesis  and patch-sequencing, have allowed researchers to quantify the RNA expression of hundreds to thousands of individual cells simultaneously , which plays a role in ion homeostasis, synaptic activity sensing, and its modulation  compared to their murine counterparts (8.6 μm/s)   compared to adult human astrocytes (Rao et al., Human cortical circuits demonstrate distinctive signatures of collective activity, arising not only from specific biophysical features of human cortical neurons, but also from their unique functional connectivity to one another. Some of the first evidence identifying the unique network properties of human cortical circuits came from quadruple patch recordings that revealed long lasting polysynaptic events in human cortical circuits could be elicited with a single presynaptic action potential, that were an order of magnitude longer than observed in other species (Molnár et al., in-vitro theta oscillations, which in general are not elicited in in-vitro rodent cortical slices, yet are the most ubiquitous oscillations in the human brain (Groppe et al., in-vivo (Rizzuto et al., in-vivo and in-vitro (Florez et al., These unique aspects of synaptic physiology coupled with human specific biophysical properties (Moradi Chameh et al., A critical question regarding the cellular electrophysiology of human neurons from epilepsy patients, is whether or not the measured means of the biophysical parameters reflect normality. Here, we reviewed that the proximity of pyramidal neurons to the epileptogenic focus demonstrates more morphological and synaptic changes as well as increased susceptibility to electrical and convulsant chemicals. However, when examining the intrinsic biophysical parameters derived from epilepsy vs. control conditions, where the control tissue consists of healthy, non-epileptogenic neurons from tumor patients, there is no appreciable difference. In turn, we here present another line of evidence to support the notion that means of biophysical parameters of human cortical neurons, particularly those from the MTG likely reflect normalcy. Below we introduce the concept of biophysical diversity as represented by the population variance of a or multiple within-cell type biophysical features. We argue that the decrease in variability can explain how in light of “normal” mean parameter values pathological dynamics arise for decreases in their standard deviation.An often-overlooked aspect of the biophysical features of neurons is their variance within a cell-type (Santhakumar and Soltesz, Our physiology data from the resected human neurosurgical tissue suggests that such epilepsy-driven neural homogenization might occur via intrinsic plasticity mechanisms (Zhang and Linden, An additional potential mechanism for neural homogenization is through ion channel degeneracy (Goaillard and Marder, This conclusion is further strengthened by orthogonal data obtained from studies in tumor patients without epilepsy, who show no difference in the mean values of biophysical parameters between epilepsy and control groups (Deitcher et al., in vitro search for the “epileptic neuron” failed (Ward, In summary, the above observations help to reconcile the original work in human cortical tissue where the ed Ward, . In lighThe advent of investigations using resected brain tissue from humans has advanced both neurosciences, and more specifically the study of human brain mechanisms. Through the characterization of human neuronal biophysical properties, the intra- and inter-species differences that exist relative to commonly employed preclinical animal models are being addressed. Furthermore, by reviewing various morphological, electrophysiological, and transcriptomic studies, we have emphasized the significant species-related differences that exist between neuronal structure and functioning which necessitate the importance of conducting research on the human brain in addition to preclinical animal models. Finally, we suggest that within-cell type heterogeneity in morphological, electrophysiological, and transcriptomic features of neurons is a design feature conserved across species, with losses of such diversity able to explain pathological brain activity despite unaltered mean values.HMC contributed to the content and structure, conducted a literature search to acquire relevant information, wrote the initial draft and graphic design. MF contributed to the manuscript by writing, editing, and graphic design. MM contributed to the graphic design and editing. KA and SJT contributed to data analysis and graphic design for


The transplant community has faced unprecedented challenges balancing risks of performing living donor transplants during the COVID-19 pandemic with harms of temporarily suspending these procedures. Decisions regarding postponement of living donation stem from its designation as an elective procedure, this despite that the Centers for Medicare and Medicaid Services categorise transplant procedures as tier 3b . In times of severe resource constraints, health systems may be operating under crisis or contingency standards of care. In this manuscript, the United Network for Organ Sharing Ethics Workgroup explores prioritisation of living donation where health systems operate under contingency standards of care and provide a framework with recommendations to the transplant community on how to approach living donation in these circumstances.To guide the transplant community in future decisions, this analysis suggests that: (1) living donor transplants represent an important option for individuals with end-stage liver and kidney disease and should not be suspended uniformly under contingency standards, (2) exposure risk to SARS-CoV-2 should be balanced with other risks, such as exposure risks at dialysis centres. Because many of these risks are not quantifiable, donors and recipients should be included in discussions on what constitutes acceptable risk, (3) transplant hospitals should strive to maintain a critical transplant workforce and avoid diverting expertise, which could negatively impact patient preparedness for transplant, (4) transplant hospitals should consider implementing protocols to ensure early detection of SARS-CoV-2 infections and discuss these measures with donors and recipients in a process of shared decision-making. Living donor kidney and liver transplantation represents the optimal treatment for individuals with end-stage kidney and end-stage liver disease. These life-saving therapies are often contextualised as elective procedures because the donor operation should be conducted in way as to not pressure participation in any manner, yet the transplant procedure in the recipient may have medical urgency based on patient need. The stress on hospital systems due to the COVID-19 2020 Spring surge was unprecedented and legitimate concerns regarding exposure risk, inadequate testing protocols, personal protective equipment and intensive care unit availability required rationing of resources and prioritisation in the types of care delivered.functionally equivalent to usual patient care.Immense demands of patients with COVID-19 continue to tax health systems, forcing them to transition to ‘contingency standards of care’ and plan for ‘crisis standards of care’. Crisis standards of care is defined as ‘a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive  or catastrophic  disaster’.This ethical analysis examines whether proceeding with the living donor transplantation is appropriate when the goal is to provide contingency standards of care—not crisis standards—as long as there are safeguards in place that minimise exposure risk, maintain staff expertise and incorporate engagement of donor/recipient pairs in decisions about their willingness to accept often unquantifiable exposure risks. The aim is not to question prior decisions made under extraordinary circumstances, rather to learn from previous experiences and develop comprehensive decision-making tools to guide actions during future circumstances where healthcare resources are stressed.instrumental value may have different applications in bioethics, but as used in times of rationing healthcare refers to prioritising those—such as living donors—who have the means to save others.manner in which healthcare ends are procured is typically better understood instrumentally .In determining what priority to assign living donor transplantation, particularly in times of rationing, both intrinsic and instrumental value considerations become relevant. An intrinsic value refers to a normative preference that is inherently appreciated for its own sake, while an instrumental value is prudential, or strategic, and, thus, seeks to achieve a further end. The term Living donor transplantation has obvious intrinsic value, both for the recipient waiting for transplant, and for the living donor who has resolved to donate his, her, or their organ for a recipient’s benefit. At the same time, there are instrumental values to consider in performing living donor transplantation in times of severe resource constraints, where the clear benefits to society of proceeding with a planned transplant must be balanced against critical resources being exigently distributed in other ways. In this case, there are a number of instrumental values to consider. For example, does our allocation of resources appropriately balance the interests of patients of specific disease state, like end-stage organ failure, with the needs of the population-at-large? For example, there were other clinical conditions, for example, cancer patients, who were also subjected to delays in treatment, supply chain disruptions that impacted care and postponement of operative procedures, particularly in situations where radiotherapy or chemotherapy were considered reasonable alternatives.In considering the prioritisation of living donation in such circumstances, the pragmatism of preserving existing relationships between healthcare providers must also be instrumentally evaluated, for example, between dialysis centres and transplantation centres. There are different levels of scarcity, capacity and expertise that need to be considered and which are likely to be fluid requiring constant re-evaluation. For example, a living donor recipient who is predicted to require an ICU bed may or may not be an appropriate candidate dependent on several health system factors that could change in a short amount of time.Ideally, we would pursue a policy that reconciles intrinsic values with our understanding of the greater good, and where instrumental considerations align and reinforce intrinsic goals. In considering how intrinsic values cohere with instrumental values, during times of crisis, it may be useful to identify critical thresholds beyond which we revisit standing policies in order to make sure that all of the relevant considerations are being taken into account. These types of value assessments require a determination of a given need and the social context of a donation. These can only be fully understood through a framework that supports an open dialogue with patients, their respective donors and considerations of the potential impact to non-transplant patients whose care may be affected.The rationing of healthcare in times of resource scarcity is both required and ethical.The ethical principles that govern organ transplantation should ideally balance considerations of utility, justice (equity) and respect for persons (autonomy).In Spring 2020, 81% of transplant centres in regions of the country with a high cumulative COVID-19 prevalence (≥500 cases/100k population) chose to internally suspend their living donor kidney programmes, although none formally inactivated their programmes with Organ Procurement and Transplantation Network/United Network for Organ Sharing.et al have analysed data from the Scientific Registry of Transplant Recipients on the early effect of COVID-19 on kidney transplant outcomes. They show that new listings, deceased donor transplants and living donor transplants declined by 18%, 24% and 87%, respectively (15 March 2020 to 30 April 2020). States with the highest rates of COVID-19 cases had the lowest rates of living kidney donor transplants than expected (IRR=0.000.010.05), while these same states had a 2.2-fold higher observed waitlist mortality (IRR=1.882.222.62).Boyarsky The first surge was associated with a decrease in total living donor kidney transplants performed compared with 2019, while deceased donor volume was largely unaffected . This coet al also make the point that cessation of living donor transplant is particularly relevant in areas where dialysis is not readily available or constrained due to local resources.It is now evident that both in the USA and internationally, risks of proceeding with living donor transplant with its potential impact on patients and healthcare resources need to be balanced with the risks of continued dialysis where challenges to social distancing, increased demand and worse outcomes related to COVID-19 exposure are increasingly understood.et al show that liver transplants from living and deceased donors were 49%, and 9% lower compared with historical trends, respectively.Although there was no appreciable difference between 2019 and 2020 in the number of living donor liver cases performed, subsequent surges of the ongoing COVID-19 pandemic may pose a threat to the volume of living liver donor transplants given local conditions. From 15 March 2020 to 31 August 2020, Strauss We posit that there are indeed harms to delaying living liver donor transplants because this subset of patients does not have options for sustaining survival other than transplantation and, as such, represent a patient population with a high level of medical urgency. From an ethical perspective, the rule of rescue supports continuance of these procedures as it suggests that it is an imperative to advocate on behalf of an individual patients’ need who face a clear fatal outcome, regardless of expense.In light of the ethical analysis above, we propose some modest conclusions intended to be used as resources of guidance. These recommendations apply to transplant hospitals experiencing contingency standards of care and may not be applicable in conditions guided by crisis standard of care.Living donor transplants represent an important option for individuals with end-stage liver and kidney disease and should not be suspended uniformly when the aim is to provide contingency standards of care. Decisions to delay living donation may be appropriate given local conditions. However, these decisions should have on-going evaluation, be communicated transparently and include timely dialogue with patients.Exposure risk to SARS-CoV-2 should be balanced with other risks, such as exposure risks at dialysis centres. Because many of these risks are not quantifiable and variable given local case rates, donors and recipients should be engaged in the process of documented shared decision-making, in order to understand their perspectives of what constitutes risk as well as to come to a mutual appreciation of the social context of donation which informs the willingness to undertake these risks.Transplant hospitals should strive to maintain a critical transplant workforce in order to avoid diverting this unique expertise in a manner, which could negatively impact patient preparedness for transplant. Under crisis standards, it is understandable that every available resource is optimised to provide prioritised care. However, under contingency standards, transplant centres continue to provide equivalent services and, as such, should do so with an optimised workforce familiar with the complexities of waitlist management, transplant organ offers and post-transplant management.As the understanding of COVID-19 outcomes in immunosuppressed patients continues to evolve,Many transplant hospitals designate living donor transplantation as an elective procedure, which makes these operations susceptible to temporary suspensions in favour of procedures categorised as emergent or urgent. Although CMS designates transplantation at a high level of medical urgency (tier 3b), the elective nature of living donor transplantation reflects the general agreement that a living donor undergo’s surgery mainly to benefit others and should so without pressure or urgency. It is understandable that under crisis standards, living donor transplant procedures should be delayed in favour of allocating crucial resources to the population-at-large. Under contingency standards, which offers functionally equivalent care delivery, additional considerations applicable to a specific environment are necessary. For example, to assure standards of contingency during an outbreak of COVID-19 hospitalisations, additional protocols to minimise infectious transmission and to assure an adequate transplant workforce are key elements that need to be discussed with patients. Given the uncertainty surrounding the risks and outcomes associated with hospital exposure to SARS-CoV-2, advocating for continuance of these procedures under contingency standards of care should be undertaken by engaging donor/recipient pairs in a process of shared decision-making and within a framework of comprehensive informed consent. Although this proposed ethical framework was developed in the context of the COVID-19 pandemic, it may also be applicable in situations where local healthcare resources are strained, where continency standards are in effect, and where critical decisions regarding healthcare priorities need to be made.


We investigated (concurrent and construct) validity, factor structure and internal consistency of the NPI and FTD Module. We performed group comparisons on item prevalence, mean item and total NPI and NPI with FTD Module scores, and multinomial logistic regression to determine its classification abilities. We extracted four components, together explaining 64.1% of the total variance, of which the largest indicated the underlying dimension ‘frontal-behavioural symptoms’. Whilst apathy  occurred most frequently in AD, logopenic and non-fluent variant PPA, the most common NPS in behavioural variant FTD and semantic variant PPA were loss of sympathy/empathy and poor response to social/emotional cues (part of FTD Module). Patients with primary psychiatric disorders and behavioural variant FTD showed the most severe behavioural problems on both the NPI as well as the NPI with FTD Module. The NPI with FTD Module correctly classified more FTD patients than the NPI alone. By quantifying common NPS in FTD the NPI with FTD Module has large diagnostic potential. Future studies should investigate whether it can also prove a useful addition to the NPI in therapeutic trials.Most neuropsychiatric symptoms (NPS) common in frontotemporal dementia (FTD) are currently not part of the Neuropsychiatric Inventory (NPI). We piloted an FTD Module that included eight extra items to be used in conjunction with the NPI. Caregivers of patients with behavioural variant FTD (The online version contains supplementary material available at 10.1007/s00415-023-11596-3. MAPT), chromosome 9 open reading frame 72 (C9orf72), and progranulin (GRN). The two main clinical manifestations—behavioural variant FTD and primary progressive aphasia (PPA)—are distinguished by their early and predominant symptoms of behavioural or language deterioration respectively )The model with the NPI with FTD Module overall led to better classification of patients. More specifically, the NPI items delusions, agitation, anxiety, apathy, irritability, night-time behaviour and appetite, as well as the FTD Module items poor response to social/emotional cues, hypersexuality, and responsiveness to pain and/or temperature were significant contributors, leading to the largest improvement in patients with behavioural variant FTD, presymptomatic FTD mutation carriers and patients with primary psychiatric disorders. Overall classification going from 47.4 to 58.8% with the inclusion of the FTD Module is an important improvement, but also shows that there is likely significant overlap in FTD spectrum disorders to have a ‘perfect’ classification between the different conditions. In comparison to a previous study , the claA key strength of this study is our large total sample of patients, covering different clinical subtypes in both the symptomatic as well as presymptomatic phase of FTD. Using the original NPI and adding the eight items still makes the NPI with FTD Module a fast, easy, and flexible instrument to be used in clinical practice and future clinical trials. It could be argued that a study of this type entails a certain degree of circularity, in that the FTD Module is comprised of NPS common in behavioural variant FTD and was used for its clinical diagnosis in this study, inevitably improving the differential diagnosis among this FTD subtype vs. other dementia types in comparison to the original NPI. Moreover, as most clinical diagnoses were not pathologically confirmed, there is a small possibility that patients were misdiagnosed , with lower classification accuracy between dementia subtypes as a result. A limitation of the study is the relatively small sample sizes per patient subgroup, and replication using larger samples is warranted. Future studies using the FTD Module in FTD mutation carriers within the last five to ten years prior to estimated symptom onset will be helpful in understanding whether more subtle presymptomatic NPS can be picked up with this questionnaire. Moreover, longitudinal studies and subanalyses in the different FTD gene mutations will shed light on the development of NPS with approaching disease onset and mutation-specific NPS profiles in genetic FTD. Repeated administration of the NPI with FTD Module in a short-time-interval will allow the monitoring of within-person variability—and investigation of intra-rater reliability—in NPS in FTD spectrum disorders, as a recent study showed strong fluctuations in NPI scores in a memory clinic population . MoreoveIn summary, the FTD Module offers the ability to detect and quantify a set of NPS that are not currently included in the NPI. Whilst previous attempts have been made to make completely new questionnaires, here we wanted to make use of the extensive knowledge about the NPI and make an FTD Module that might be used alongside the well-validated NPI rather than starting again. We hope that future studies can investigate its use further, and in particular, whether it might be used with the NPI as a clinical outcome measure in therapeutic trials for FTD.Supplementary file1 (DOCX 57 KB)Below is the link to the electronic supplementary material.


While flow cytometry is a critical single cell analytical technique in biomedical science, the technology of flow cytometry associated cell sorting is equally important. Physical separation of cells analyzed by flow cytometry was recognized as an important goal even in the field’s beginning, and many of the earliest cytometers were also cell sorters. Isolation of cells based on flow cytometric analysis has formed the foundation of immune cell differentiation and development and continues to grow importance as techniques for genomic and proteomic analysis expand. This brief review will describe both the historical development and current state of cell sorting. The multiple mechanisms for cell sorters will be covered, and critical aspects of cell sorting will be discussed. Newer technologies for cell sorting including microfluidic technologies will also be considered. Cell sorting . The electrostatic plates and collection tubes are visible. hybrid cuvette system, where the cells are first analyzed in a quartz cuvette similar to a non-sorting analyzer . The cells are then ejected into the open air for droplet formation. Cuvette systems have better fluorescence sensitivity than jet-in-air systems since the resulting fluorescent signals are more efficiently transmitted to the instrument optics and are now more common. hybrid cuvette system on a spectral cell sorter , which collects complete cell spectra rather than individual fluorescence bandwidths on conventional instruments. Spectral cytometry is rapidly gaining favor due to its ability to collect larger simultaneous numbers of fluorescent probe signals for high-precision cell analysis  are focusing on microfluidic based systems for their ability to use disposable closed cartridge-based systems  have appeared in a few commercial cell sorters, including the discontinued BD Biosciences FACSort and FACSCalibur analyzers, and the Partec/Sysmex systems. The ability for these systems to be fully enclosed  has made these systems attractive for analysis in biohazard environments. However, these systems sort at very low sort rates, and have been largely supplanted by microfluidic-based systems. The use of acoustic fields to generate single cell streams has been employed as an alternative to hydrodynamic focusing by some cytometers; objects of different sizes can be acoustically focused, potentially allowing downstream capture , 20. WhiWT: Conceptualization, Writing – original draft.


Eating disorders are serious mental health conditions that significantly impact the social and economic burden of mental ill health in Australia. Best practice treatment for eating disorders includes a multi-axial approach, including medical, psychiatric, and psychological approaches. More recently, complementary and alternative therapy approaches, such as yoga, are used to support eating disorder recovery.This scoping review identified and examined current research exploring the use of yoga alongside psychological approaches for the treatment and management of eating disorders across the lifespan.Results highlighted the lack of available research, with only four studies identified. Three of these studies piloted programs and identified promising results with a reduction of eating disorder symptomatology. However, these results remain tentative due to methodological limitations and the overall lack of available evidence. In the future, researchers are encouraged to clearly articulate the theoretical concepts that underpin their yoga programs and focus on adequately powered and designed trials, such as RCTs, to accurately compare treatment effects between interventions combining yoga with psychological interventions and standard psychological treatment. Qualitative enquiry is also recommended to provide further insights regarding what makes interventions successful.Current evidence suggests further guidance and pragmatic recommendations to guide researchers and clinicians alike are required, ultimately improving outcomes for people experiencing an eating disorder across the lifespan. Yoga is commonly used as an additional therapy in eating disorder services. This research review aimed to identify studies that reported on how yoga was added to psychology approaches in eating disorder services. Only four studies have been published where yoga was used with psychological approaches for the treatment of eating disorders. The four studies showed yoga was overall a helpful addition. Consistent with various yoga and psychological approaches, there were differences in how each study incorporated yoga into treatment and their rationale for its inclusion. This study highlights the gaps regarding what we understand about how yoga can be a helpful addition to psychological approaches and makes recommendations for how studies in the future should explain and report the use of yoga. Eating disorders are typically characterised by an unhealthy preoccupation with eating, exercise, body weight or shape and behaviours such as restricting food, excessive exercise, binge eating and purging , 51. IndBest practice treatment for eating disorders includes a multi-axial approach, including medical, psychiatric, and psychological approaches . ResearcYoga involves breathing practices, physical poses which calms the nervous system, and meditation which often includes kindness towards oneself . ResearcWithin the range of hypothesised psychological mechanisms linking yoga-based interventions to improvements in eating disorders symptoms, embodiment has received significant focus. Embodiment has been defined as "the lived experience of engagement of the body with the world" . SeveralA recently published mapping review examined how yoga might complement evidence-based psychological therapies for adults with various mental disorders, including eating disorders . A singlAs such, this study applied scoping review methods , 35, 49 What is the scope and characteristics of the existing evidence when yoga is integrated alongside psychological approaches in the treatment of eating disorders?Subsequently, a broad research question was proposed:This scoping review followed Arksey and O'Malley's  methodolthe Population-Intervention-Comparisons-Outcomes-Study design (PICOS) mnemonic and designed to identify the extant literature examining interventions of integrated yoga and psychological approaches for treating eating disorders. The population was any person diagnosed with an eating disorder using any recognised diagnostic criteria and/or a standardised diagnostic assessment/tool and engaged in psychological interventions/treatment as part of their eating disorder treatment. As this was a scoping review there were no comparisons or outcome variables specified for inclusion.The research question was developed through discussions with all members of the research team and was based on asana), breath regulation/exercises (pranayama), and relaxation or meditation (dhyana), typical of hatha yoga, being the most common style of yoga in the western context [Search terms for the population were developed from the eating disorder diagnoses published in the Diagnostic and Statistical Manual (DSMV) . There w context . We adop context  cross-re context  guidelinThe search was conducted in April 2022 through electronic database searches of CINAHL, Embase, MEDLINE, and PsycINFO. Hand searching including reviewing reference lists of included studies was also undertaken in an attempt to identify additional studies not identified through this search, but no further studies were identified. Table Duplicates were removed from the final search and titles and abstracts of all studies were screened according to the inclusion and exclusion criteria. A full-text review of studies that met the criteria was undertaken Table .Table 3TData relating to the included studies were extracted according to the PRISMA-ScR checklist  and a daFindings from the data charting form were presented in extraction tables. These were discussed among the research team and a narrative synthesis of the results was developed to address the central research question.The final search identified 86 relevant studies. Seventy-nine studies were excluded based on not addressing the research question, resulting in seven studies for full-text review  that aimed to reduce symptomatology associated with AN and BN  for 29 aIn the first included study, the AMBR program  was evalThe AMBR program  was baseIn the AMBR program, 50 min of body focussed yoga and 15 min of meditation were used in the first part of the session followed by group discussion with activities developed from CBT, DBT, and dissonance-based interventions. The authors describe selecting CBT, DBT and dissonance-based interventions given they are evidence-based therapies for eating disorders and use cognitive and behavioural exercises to improve thoughts, feelings, and emotions. Group discussion included mindfulness, emotion regulation and distress tolerance activities along with a focus on developing positive relationship skills and challenging society’s thin ideal represented in media. Weekly themes were based on the Attuned Theoretical Model and eating disorder recovery, starting with thoughts, feelings, and emotions  followed by the impact of culture, community, and relationships . Curriculum content (yoga practice and group discussion) was designed to align with the weekly theme with participants given related readings (selected poems and short readings) to review and were encouraged to reflect on these through journaling. The group component of this program was seen as an important aspect with members actively invited to contribute and support each other in their recovery.In the second study, the Yoga Body Image (YBI) program aimed to reduce negative body image in people diagnosed with an eating disorder. Quantitative pre-post surveys based on the Body Shape Questionnaire  found a The authors of the YBI program reported the program was based on the theory that yoga is a multidimensional tool that can promote embodiment. Weekly sessions involved 45 min of therapeutic yoga that had aspects of hatha, vinyasa and viniyoga with postures, breathe techniques and guided imagery selected to align with the theme. This was followed by 45 min of group discussion that was aimed at encouraging participants to verbally process their experience by describing their sensations, emotions, and overall experience. Each session focussed on a different theme related to body image, such as body awareness and appreciation, free movement, non-judgement, emotional connection, breathing, body-mind capabilities, resiliency, and neutrality. Similar, to the AMBR program, YBI was designed to be delivered as a group intervention as the authors considered participant peer discussion and support to be an important therapeutic component in enhancing eating disorder recovery.The third study an unpublished dissertation described the HIVE program  which ain = 6) and the other receiving yoga followed by group discussion (n = 7). Three participants dropped out of the yoga only group and subsequently, the study was underpowered to sufficiently compare data between groups. Results indicated that for both groups there was a reduction in objective binge episodes, with binge episodes decreasing from 4.75 to 1.98 per week. A comparison of means between groups showed binge episodes in the yoga only group decreasing from 4.66 to 2.17 per week and yoga and discussion group 4.8 to 1.86 per week. However, the low number of participants and high dropout rate meant the study was underpowered to adequately compare data between groups. The authors concluded that a yoga-based intervention alongside psychological approaches might effectively support reducing binge eating episodes, but that larger controlled trials were required to support this finding.The final included study, another unpublished dissertation, evaluated the impact of ‘Finding OM’  a prograThe Finding OM program was developed based on the theory that exercise is a missing key component in the treatment of BED . The program aimed to use yoga exercises to raise participants’ levels of mindfulness while moving, with the group discussion designed to improve participants’ distress tolerance. Weekly themes were specifically related to BED issues such as distress tolerance, self-image and binge/food-related behaviour with the yoga and group discussion designed to align with these. It was hypothesised that engagement in the program would improve the participants’ ability to regulate their emotions and this would subsequently lead to a decrease in binge eating episodes. Homework was set each week including journaling, along with asking participants to keep a yoga log which was developed as an adaptation to a similar ‘food log’. The program was designed as a group intervention as group factors such as feelings of universality and the sharing of information were seen to be therapeutic.This review examined current research involving interventions incorporating yoga with psychological approaches that report how such approaches have been used to promote eating disorder recovery. Despite growing interest in the use of yoga as a complementary intervention for the treatment of eating disorders, there is a lack of research in this area, with only two published studies and two unpublished dissertations identified. All were conducted in the USA, and all developed a novel therapeutic group program designed specifically for people with an eating disorder that used a yoga practice in conjunction with various psychological approaches. All four studies used weekly themes related to ED recovery, with the yoga practice and group discussion designed to align with these themes. One unpublished dissertation  was a deDespite all four studies providing a theoretical framework and rationale for why they incorporated yoga and psychological approaches, the differences between them suggest there are various perspectives on how yoga might complement or enhance psychological approaches. The most cited theoretical approach across the studies was the concept of ‘embodiment’ (used in the YBI program) which is, similar to attunement from the ‘Attuned Theoretical Framework’ (used in the AMBR program). Embodiment is commonly cited within the literature to explain how yoga can help with eating disorder recovery (through a mindful connection to self)  and aligNotably, the group design used by all four programs was considered an important factor in supporting therapeutic change. The group component was seen to offer opportunities for engaging in an interpersonal and social setting within which the individuals can engage in authentic discourse and begin self-exploration, providing social modelling and active practice in intra- and inter-personal integrative experiences . TherapeGroup programs are prominent within clinical guidelines for the treatment of eating disorders , demonstDespite positive results for studies that trialled the novel group programs , 15, 18 Although two unpublished dissertations were included in this study, there may be other grey literature publications that could have added more depth to the discussion. Further to this, given the lack of identified studies in this area conclusions are limited.This scoping review was the first to examine yoga alongside psychological approaches for the treatment of eating disorders. Findings highlight the paucity of available research with only four studies identified. The studies that piloted programs all identified promising results with a reduction of eating disorder symptomatology. However, these results remain tentative due to methodological limitations and the overall lack of available evidence. In the future, researchers are encouraged to clearly articulate the theoretical concepts that underpin their yoga programs and focus on adequately powered and designed trials, such as RCTs, to accurately compare treatment effects between interventions combining yoga with psychological interventions and standard psychological treatment. Qualitative enquiry is also recommended to provide further insights regarding what makes interventions successful. Current evidence suggests further guidance and pragmatic recommendations to guide researchers and clinicians alike are required; ultimately improving outcomes for people experiencing an eating disorder across the lifespan.