The clinical use of cellular immunotherapies is gaining momentum and the number of approved indications is steadily increasing. One class of cellular therapies—chimeric antigen receptor (CAR)-modified T cells—has achieved impressive results in distinct blood cancer indications. These existing cellular therapies treating blood cancers face significant relapse rates, and their application beyond hematology has been underwhelming, especially in solid oncology. Major reasons for resistance source largely in the tumor microenvironment (TME). The TME in fact functionally suppresses, restricts, and excludes adoptive immune cells, which limits the efficacy of cellular immunotherapies from the onset. Many promising efforts are ongoing to adapt cellular immunotherapies to address these obstacles, with the aim of reshaping the tumor microenvironment to ameliorate function and to achieve superior efficacy against both hematological and solid malignancies. Cellular immunotherapies, encompassing the use of modified autologous or allogeneic immune cells as treatment against disease, have recently advanced to become part of the standard of care in a few types of relapsed and refractory hematological malignancies. Recent evidence suggests that they might even progress to earlier lines of treatment at least in some indications, highlighting the untapped potential of these approaches.Overall, cellular immunotherapies have so far employed dendritic cell (DC), T cells, or natural killer cells (NK) into patients for treatment of disease. DC vaccines, which utilize mature dendritic cells or monocyte-derived dendritic cells derived from patient blood, harness the natural role of the dendritic cell in antigen presentation and T cell licensing to target cancer. Dendritic cells are pulsed with tumor-associated antigens and neoantigens that would then be presented to T cells in lymph nodes to induce cytotoxic lymphocyte priming and polarization to mount a specific immune response. Various DC vaccines have shown promising safety and efficacy in clinical trials against pediatric solid tumors and other forms of solid tumors –3. TheseMeanwhile, TCRs and CARs are receptors genetically engineered into T cells isolated from patient blood and reintroduced into the patient to target cancers. TCRs used are derived from natural sequences that bind the desired antigen and behave similarly to normal TCRs . In contThe tumor microenvironment—comprises malignant cells together with their immediate environment consisting of immune cells, fibroblasts, extracellular matrix (ECM), blood vessels, and secreted factors. The TME can support the survival and proliferation of tumor cells and tumor-associated cell populations and thus contributes a major share to cancer hallmarks Fig. . Crucial. Along these lines, the TME profoundly regulates and suppresses immune responses and appears as the aspect to beat to enable cell therapy efficacy.Chemokines released by tumor cells recruit and retain other populations of immunosuppressive cells into the tumor microenvironment Fig. . T-regulMany insights have already been gained into improving existing cellular therapy. For instance, application via intratumoral injection leads to increased efficacy of adoptive CAR-T cells in certain tumor indications by physically circumventing the issue of TME exclusion and adoptive cell infiltration , 43. To Chemokines are mediators signaling for directed migration towards the source they originate from . Chemokines orchestrate the localization of cells within the body and accordingly play a crucial role in the trafficking of immunosuppressive cells to the TME , 50. HowChemokine engineering into therapeutic immune cells has been incorporated into cellular therapies with the goal of increasing the migration of both endogenous inflammatory cells and also adoptively transferred cells into the tumor Fig. . The cheAnother related strategy to increase immune infiltration is endogenous activation and proliferation, ultimately leading to higher anti-tumor effector cell numbers at the tumor site. In this sense, T cells can be genetically engineered to express immune checkpoint inhibitors, with anti-PD-1 or anti-PD-L1 antibodies being the most utilized avenue –61. AntiThe TME is typically rich in cytokines such as IL-1, favoring expansion and polarization of immune suppressive cell populations of myeloid and lymphoid origin . In contThe aforementioned strategies remodeling the cytokine environment in the TME indirectly affect TAMs, MDSCs, and T-regs by antagonizing their suppressiveness or reversing their suppression program. However, other cellular therapy approaches aim to directly target these immunosuppressive populations for elimination or remodeling Fig. . For exaSignificant obstacles of cellular immunotherapy in solid tumors do not only arise from immunosuppressive cell populations and a lack of immune cell activation within the TME but are additionally characterized by the establishment of CAF-mediated tumor stroma as a physical barrier, diminishing cellular therapy effectiveness. Along these lines, therapy can be enhanced if either the cellular components creating stroma are depleted or acellular stromal components are digested Fig. . FibroblA different strategy to surmount the desmoplastic stroma of the TME and enable superior immune cell infiltration is the direct targeting of fibrous proteins, glycosaminoglycans, and proteoglycans composing the ECM via matrix-degrading components. Heparanase (HPSE) is an enzyme that decomposes heparan sulfate proteoglycans and has been found to be insufficiently expressed in CAR-T cells, thereby limiting their capacity to infiltrate stroma-rich tumors . EquippiVarious strategies have also been developed to address the secondary issue of physical tumor-exclusion—aberrant and dysfunctional vasculature that leads to poor T cell infiltration Fig. . One strRecent efforts to remodel the tumor microenvironment with cellular therapies have advanced with the advent of engineering CARs or CAR-like receptors on myeloid lineage cells, notably on macrophages and in some instances dendritic cells Fig. . TraditiWhile cellular therapies have come a long way to become an established method of cancer treatment, their future potential for increased efficacy in hematological malignancies and even meaningful efficacy in solid tumor indications largely relies on their ability to address the obstacles posed by the TME. This review highlights the current considerable efforts that have been made to improve various aspects of cellular therapies to reshape the TME to become more permissible for treatment: novel concepts that target immunosuppressive cell populations, inflame an immune-restricted tumor, and address chemotactic signaling and physical barriers excluding immune infiltration. The improvements made on these therapies have been shown to lead to superior anti-tumor efficacy compared to more standard cellular therapies. Moreover, many cellular therapies covered here that target the TME as an entity have been combined with other treatments that primarily target the tumor, forming a dual-pronged targeting approach that in many cases shows synergistic efficacy. Additionally, concepts incorporating combinatorial improvements that address multiple TME obstructions show further enhanced function, demonstrating additionally the promising and synergistic nature of reshaping the tumor microenvironment, and hints at robust effects for combinatorial treatments with existing therapies such as ICB. Promising pre-clinical and clinical results of many of the therapies listed bode well for the application of cellular immunotherapies for the treatment of both hematological and solid tumors in the future.


Introduction: Chediak-Higashi syndrome (CHS) is rare autosomal recessive disorder caused by bi-allelic variants in the Lysosomal Trafficking Regulator (LYST) gene. Diagnosis is established by the detection of pathogenic variants in LYST in combination with clinical evidence of disease. Conventional molecular genetic testing of LYST by genomic DNA (gDNA) Sanger sequencing detects the majority of pathogenic variants, but some remain undetected for several individuals clinically diagnosed with CHS. In this study, cDNA Sanger sequencing was pursued as a complementary method to identify variant alleles that are undetected by gDNA Sanger sequencing and to increase molecular diagnostic yield.Methods: Six unrelated individuals with CHS were clinically evaluated and included in this study. gDNA Sanger sequencing and cDNA Sanger sequencing were performed to identify pathogenic LYST variants.Results: Ten novel LYST alleles were identified, including eight nonsense or frameshift variants and two in-frame deletions. Six of these were identified by conventional gDNA Sanger sequencing; cDNA Sanger sequencing was required to identify the remaining variant alleles.Conclusion: By utilizing cDNA sequencing as a complementary technique to identify LYST variants, a complete molecular diagnosis was obtained for all six CHS patients. In this small CHS cohort, the molecular diagnostic yield was increased, and canonical splice site variants identified from gDNA Sanger sequencing were validated by cDNA sequencing. The identification of novel LYST alleles will aid in diagnosing patients and these molecular diagnoses will also lead to genetic counseling, access to services and treatments and clinical trials in the future. Chediak-Higashi syndrome  is a rare autosomal recessive disorder characterized by partial oculocutaneous albinism, bleeding diathesis, recurrent infections, an increased risk of developing the hyperinflammatory condition called hemophagocytic lymphohistiocytosis (HLH), and neurologic impairment . The preCHS has significant clinical overlap with several other genetic disorders, emphasizing the importance of a molecular diagnosis. Other disorders that include gray or silvery hair as observed in CHS include Griscelli syndrome , Elejalde neuroectodermal melanolysosomal syndrome (MIM 256710), and oculocerebral syndrome with hypopigmentation (MIM 257800) . There aLYST) gene is the only known molecular cause of CHS and bi-allelic pathogenic variants in LYST establish a molecular diagnosis  detects the majority of pathogenic variants, but for some individuals clinically diagnosed with CHS, pathogenic variants remain undetected, likely due to large-scale indels and deep intronic variants or synonymous exonic variants that lead to aberrant splicing. Uniparental disomy leading to the inheritance of two copies of a pathogenic LYST variant from one parent has also been reported as a molecular mechanism for CHS  or the Diagnosis and Treatment of Patients with Inborn Errors of Metabolism or Other Genetic Disorders protocol 76-HG-0238  approved by the National Human Genome Research Institute’s Institutional Review Board. Written informed consent was obtained prior to the study. Clinical evaluation included collecting the medical and family history, physical examination, complete blood count (CBC) blood test. Peripheral blood smear analysis and microscopic hair examination were used to assess the presence of giant inclusions in leukocytes and pigment clumping in hair shafts, pathognomonic features of CHS.Six patients clinically diagnosed with classical or atypical CHS were included in this study. These patients were enrolled over the course of 10–20 years in the Investigation of Chediak-Higashi Syndrome and Related Disorders protocol 00-HG-0153 . Quantitative PCR was performed using TaqMan gene expression assays according to the manufacturer’s specifications. Further details are presented in the Supplementary Data.Total RNA was extracted from cultured primary dermal fibroblasts or melanocytes using the RNeasy Mini Kit (Qiagen). Genomic DNA was removed by on-column DNase I digestion (Qiagen) during total RNA extraction. Reverse transcription was performed using the Omniscript Reverse Transcription Kit (Qiagen) and Oligo (dT)LYST (NM_000081.3) coding sequence (exons 3–53), including intron-exon boundaries, were amplified by PCR using the primers listed in Genomic DNA (gDNA) was extracted from peripheral blood or cultured primary dermal fibroblasts using standard procedures. gDNA from cultured primary fibroblasts was used if the gDNA from peripheral blood was no longer available. Regions of the LYST coding sequence (exons 3–53) were amplified by PCR using the primers listed in Total RNA was extracted from cultured primary dermal fibroblasts or melanocytes using the RNeasy Mini Kit (Qiagen). cDNA was synthesized by reverse transcription with the High-Capacity RNA-to-cDNA Kit (Applied Biosystems). Regions of the PCR products were cloned into the pCR4-TOPO TA vector using the TOPO TA Cloning Kit (Invitrogen). Single clones were Sanger sequenced to individually analyze the cDNA alleles for which chromatograms obtained from the initial cDNA Sanger sequencing were difficult to interpret.Variant pathogenicity classification was performed according to the standards and guidelines presented by the ACMG-AMP and the ACGS . Furtherp-value of less than 0.05 was considered statistically significant.Statistics were performed using GraphPad Prism 8 version 8.4.3 . A two-tailed Mann-Whitney test was performed for experiments comparing two sets of data. A CHD3 presented with silvery hair, pale skin, and ocular albinism as well as a history of recurrent respiratory and skin infections and nose bleeds. He was clinically diagnosed with classical CHS at the age of 7 years. Abnormal pigment clumping was observed in his hair shafts . He receStaphylococcus aureus (MRSA). She also had learning difficulties and a mood disorder. Pathognomonic giant inclusions were observed in her leukocytes and abnormal pigment clumping in her hair shafts . These cellular findings substantiate prior cellular findings reported in human CHS and in the beige mouse model  (Pathogenic variants have been identified throughout the ication) . Eight oication) ; Table 1ication) . AlthougLYST-expressing cell types, including dermal fibroblasts, melanocytes, NK cells, and lymphoblastoid cell lines, for the preparation of total RNA. Archiving cells from each parent and all available family members would also be useful for variant phasing and segregation studies.cDNA Sanger sequencing in combination with conventional gDNA Sanger sequencing offers several advantages. First, cDNA Sanger sequencing can detect variant alleles that are not readily detectable by conventional gDNA Sanger sequencing. While establishing a clinical diagnosis is valuable, the confirmation of a molecular diagnosis is critical for optimal patient care, genetic counseling for the individual and their family members, and eligibility in future clinical trials. Second, cDNA Sanger sequencing is relatively easy to incorporate into the molecular genetic testing workflow, requiring only routine cell culture and total RNA extraction techniques. An important consideration is patient sample archiving of LYST. Furthermore, only cDNA from each of the six patients was analyzed in this study due to sample availability. While we were unable to assess cDNA from cells derived from family members due to sample availability, cDNA Sanger sequencing could be performed to segregate LYST alleles in a family even if the variant at the level of gDNA is unknown.A key limitation of this study was that we were unable to identify the cause of the full or partial exon skipping at the gDNA level for some alleles. While efforts were made to sequence nearby intronic regions and identify exonic synonymous variants that might lead to the aberrant splicing, proving the consequence of such variants requires further functional validation. With the decreasing costs of genome sequencing and targeted next-generation sequencing, these are becoming viable options for the identification of deep intronic variants leading to splicing changes in LYST gene in CHS. Because of the increasing access to next-generation sequencing and its rapid turnaround time, we recommend the utilization of clinical genome sequencing to include copy number variant analysis for patients in which CHS is suspected. When available, RNA sequencing using lymphoblastoid cell lines and melanocytes could help delineate the resulting splice site abnormalities from intronic variants. For standard clinical practice using exome sequencing and when clinical genome sequencing is not available, targeted gDNA Sanger sequencing and copy number detection is recommended for patients highly suspected to have clinical CHS, followed by RNA sequencing (as above) or cDNA Sanger sequencing if only one or no variants are detected by gDNA Sanger sequencing. It will also be interesting to pursue efforts on long-read sequencing technologies to identify deletions in these large genes and to phase variants in the absence of parental samples in the future. Overall, the identification of disease-causing variants will aid in the future diagnosis and care of individuals with CHS.In this study, the integration of thorough clinical phenotyping and conventional gDNA Sanger sequencing in combination with cDNA Sanger sequencing increased the mutational spectrum of CHS. Based on our experience from this study, we provide the following recommendations for molecular genetic testing of the


Inhaled medications, including beta-agonists, muscarinic antagonists, and corticosteroids, are the backbone of chronic obstructive pulmonary disease (COPD) treatment, and pharmacotherapy plans are frequently optimized during and following hospitalization. Clinical practice guidelines acknowledge that patients living with COPD may experience medication errors from inadequate inhaler technique or device faults, but inhaled medication errors within COPD pharmacotherapy plans remain unreported. This literature review aimed to collect and present studies describing medication errors occurring with inhaled medications in patients living with COPD during and following hospitalization. The databases searched included Ovid MEDLINE, Embase, and International Pharmaceutical Abstracts. One hundred forty-five unique studies were collected, and 10 studies were included. The rate of inhaled medication errors reported across the 10 studies ranged between 2.5% and 66% of patients living with COPD and who were hospitalized or discharged. The incidence and types of medication errors reported across the studies varied significantly. Standardization in categorizing and reporting inhaled medication errors is necessary for future studies to determine the true incidence of inhaled medication errors occurring in patients living with COPD who are hospitalized or discharged. Patients living with chronic obstructive pulmonary disease (COPD) may take medications to palliate symptoms, improve health status, tolerate exercise, and reduce the risk and severity of exacerbations of COPD (ECOPD) . InhaledHowever, the comprehensive formulary of inhaled medications may be overwhelming for both patients and prescribers and thus there is potential for medication errors. Hospitalization is a critical time wherein inhaled medication errors may occur and between 7% and 33% of patients living with COPD will experience at least one COPD-related hospitalization annually . PatientThe purpose of this review is to collect and present literature describing medication errors occurring with inhaled medications in patients living with COPD during and following hospitalization.Review methodsThis was a literature review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol . The resAn electronic literature search was performed using Ovid MEDLINE, Embase, and International Pharmaceutical Abstracts on February 14, 2023. Search strings for each database are included in Appendix A and adhered to the PRISMA-S extension for literature search reporting . Study rResults from each database search were exported as a Research Information Systems file and then imported into Covidence . During the initial file upload, Covidence automatically de-duplicated identical records retrieved across databases. Abstracts were independently screened by two authors (KH and MG) and screening conflicts were resolved by a third author (PB). Full texts were independently screened by two authors (KH and MG) and screening conflicts were resolved by a third author (PB). Data abstraction was independently performed by two authors (KH and MG). To minimize heterogeneity across the articles and among authors, extraction was performed using a template in Covidence. Data collected included study location, study design, characteristics of the cohort , characteristics of patients living with COPD , and medication errors. There are many frameworks for reporting medication errors, medication error research, and outcomes attributable to medication errors . BecauseFigure Ten studies were ultimately included and are charted in Table Medication-related problemsIn a pilot study conducted at an academic medical center, pharmacists performing admission and discharge medication reconciliation discovered a medication-related problem (MRP) in 96% of patients during admission and discharge transitions of care, with an average of six MRPs encountered per patient . These MOne Veterans Affairs health care center conducted a pre-post study and found an absolute decrease of greater than 10% in prescribing errors upon discharge in each of the categories of SABA, LABA/LAMA, and ICS upon implementing an order set for ECOPD . DecreasPrescribing errors and omissionsOne retrospective cohort study of older adults hospitalized in Palestine leveraged the Screening Tool of Older Persons’ Prescriptions and Screening Tool to Alert to Right Treatment (STOPP/START) to determine potentially inappropriate prescribing via inappropriate medications and omissions . The autIn one multisite retrospective cohort study conducted in Australia, 93.2% of hospitalized COPD patients received nebulized ipratropium, with 48% of these patients deemed as having received inappropriate nebulized ipratropium because they were ordered (duplicative) inhaled ipratropium concomitantly . At discDiscussionThe rate of inhaled medication errors was heterogeneous across the 10 studies in this review -16. BrowThis literature review is not without limitations. Although the authors utilized a systematic approach to searching, assessing, and presenting the included studies, this literature review did not meet the technical standards of either a systematic or scoping review. Future systematic reviews on the themes and topics raised within this literature review are necessary to answer patient-specific questions. The authors did not perform a bias assessment of each article and doing so would have qualified the methodologic rigor of the included studies; although six studies were retrospective designs ,13,14,16As few as 2.5% or as many as 66% of patients living with COPD who are hospitalized may experience an error in their inhaled medication pharmacotherapy plan. Pharmacologic classes with reported errors include short- and long-acting beta-agonists, muscarinic antagonists, and inhaled corticosteroids. Standardization in categorizing and reporting inhaled medication errors is necessary in subsequent studies; the Pharmacy Quality Alliance Frameworks or Medication Error Reporting and Prevention Index are validated and widely used instruments that may be considered in future studies. Future research should aim to clearly compare and contrast findings across clinical settings and investigations and determine the true incidence of inhaled medication errors.


Maiato and Silva discuss the origin and fate of chromosome segregation errors that satisfy the spindle assembly checkpoint, focusing on anaphase surveillance/correction mechanisms and post-mitotic clearance pathways. Enduring chromosome segregation errors represent potential threats to genomic stability due to eventual chromosome copy number alterations (aneuploidy) and formation of micronuclei—key intermediates of a rapid mutational process known as chromothripsis that is found in cancer and congenital disorders. The spindle assembly checkpoint (SAC) has been viewed as the sole surveillance mechanism that prevents chromosome segregation errors during mitosis and meiosis. However, different types of chromosome segregation errors stemming from incorrect kinetochore–microtubule attachments satisfy the SAC and are more frequent than previously anticipated. Remarkably, recent works have unveiled that most of these errors are corrected during anaphase and only rarely result in aneuploidy or formation of micronuclei. Here, we discuss recent progress in our understanding of the origin and fate of chromosome segregation errors that satisfy the SAC and shed light on the surveillance, correction, and clearance mechanisms that prevent their transmission, to preserve genomic stability. Saccharomyces cerevisiae [300 billion cell divisions must take place every day in the human body to ensure tissue homeostasis and function . In vitrrevisiae ), these Somatic cell aneuploidy is implicated in tumorigenesis, genomic instability, tumor evolution, metastasis, drug resistance, and reduced cancer patient survival, whereas germline aneuploidy directly accounts for infertility, pregnancy loss, and developmental disorders . HoweverCell cycle checkpoints are constitutive feedback control mechanisms that delay cell cycle progression until completion of a critical event, providing time for the correction of potential errors . EliminaRecent high-resolution live-cell studies tracking kinetochore or chromosome behavior through metaphase and anaphase in human somatic cells in culture have revealed that many more chromosomes tend to lag behind in anaphase than previously anticipated . This beThe role of anaphase spindle mechanics was first established through the observation that merotelic kinetochores with uneven microtubules facing the poles experience a significant stretch and elongate under tension, eventually favoring segregation to the correct daughter cell. Only a small fraction (<10%) of the merotelic kinetochores that persist through anaphase show an even microtubule ratio facing the poles and result in long-lasting lagging chromosomes that missegregate . Live imMore recently, it was demonstrated that spindle elongation is directly required for anaphase error correction . The acuAurora B kinase activity at centromeres plays a key role in error correction during early mitosis . HoweverTwo possible models have been proposed to explain how a midzone-based Aurora B activity gradient mediates error correction during anaphase . One is An alternative model favors the idea that midzone Aurora B activity mediates anaphase error correction of merotelic kinetochores by assisting the mechanical transmission of spindle forces to a stable kinetochore–microtubule interface on lagging chromosomes . Live-ceDirect measurements of kinetochore–microtubule half-life during anaphase revealed a low kinetochore–microtubule turnover , which wThe finding of a distinct phosphorylation state on Aurora B substrates at kinetochores of anaphase lagging chromosomes  suggestsBut why is the spatiotemporal control of NER important? On one hand, preventing premature NER on incompletely separated chromosomes during normal anaphase protects against polyploidy. Whole-genome duplication is a common evolutionary event that is also frequent in >30% of human tumors early in tumorigenesis and is thought to promote chromosomal instability and metastasis by providing a selective advantage in certain contexts . On the One may argue that a delay of just a few minutes in a process that is normally completed within 5–10 min in human somatic cells cannot be explained by a robust checkpoint mediated by Aurora B at the spindle midzone. Instead, midzone microtubules may act independently of Aurora B activity by forming a physical barrier that selectively prevents the recruitment of non-core nuclear envelope proteins , includIn an attempt to separate the role of microtubules from that of Aurora B at the spindle midzone in the spatiotemporal control of NER, high-resolution live-cell microscopy was used to simultaneously monitor Aurora B activity on chromosomes, the recruitment of NPC proteins, and the distribution of spindle midzone microtubules throughout anaphase, upon manipulation of Aurora B midzone localization . These eQuantitative microscopy analyses further revealed that even just a small but significant delay in the completion of NER relative to the main segregating chromosome masses allows most anaphase lagging chromosomes in human cells to gradually correct and move away from the spindle midzone. Moreover, this delay depended on the establishment of a midzone-based Aurora B phosphorylation gradient that prevented formation of micronuclei . TherefoConcerning potential targets involved in the spatiotemporal regulation of NER, Aurora B may regulate Condensin I removal and/or recruitment of HP1 and LBR as chromosomes separate during anaphase  or may mAnaphase lagging chromosomes that escape surveillance and correction mechanisms operating in anaphase rarely missegregate to give rise to aneuploidy, but they may lead to the formation of micronuclei . ImportaMicronuclei derived from chromosome segregation errors have four possible outcomes upon mitotic exit: (1) persistence as independent structures; (2) reincorporation into the main nucleus; (3) degradation; or (4) extrusion  sensor that mounts a type-I IFN innate immune response through its adaptor protein STING, referred to as the cGAS-STING pathway . The actGiven the possible role of p53 in limiting the proliferation of aneuploid and micronucleated cells, an outstanding question is whether the cGAS-STING pathway somehow crosstalks with p53. Recently, a mutant form of p53 was shown to suppress innate immune signaling through the cGAS-STING pathway, resulting in immune evasion and tumor progression . In thisWhile a lot remains to be known regarding the mechanisms underlying cGAS-STING–mediated immunosurveillance of mitotic errors and their respective implications for tumor evolution, defective micronuclei are now well established as potential hubs for chromothripsis . ChromotWhile the high rates of aneuploidy during female meiosis have been linked to a weakened SAC and intrinsically unstable kinetochore–microtubule attachments , aneuploIn addition to direct missegregation from misaligned chromosomes, late-aligning chromosomes associated with peripheral nuclear positioning during interphase are also more prone to lag behind in anaphase and missegregate at higher frequencies . LikewisOverall, these recent findings instigate future studies to determine the underlying mechanisms that normally prevent aneuploidy during mitosis and meiosis, while continuing to evaluate the contribution of aneuploidy-inducing events of different origin and how cells deal with them in health and disease contexts.


Idiopathic subglottic stenosis (iSGS) is a rare fibrotic disease of the proximal airway affecting adult Caucasian women nearly exclusively. Life-threatening ventilatory obstruction occurs secondary to pernicious subglottic mucosal scar. Disease rarity and wide geographic patient distribution has previously limited substantive mechanistic investigation into iSGS pathogenesis.By harnessing pathogenic mucosa from an international iSGS patient cohort and single-cell RNA sequencing, we unbiasedly characterize the cell subsets in the proximal airway scar and detail their molecular phenotypes. Results show that the airway epithelium in iSGS patients is depleted of basal progenitor cells, and the residual epithelial cells acquire a mesenchymal phenotype. Observed displacement of bacteria beneath the lamina propria provides functional support for the molecular evidence of epithelial dysfunction. Matched tissue microbiomes support displacement of the native microbiome into the lamina propria of iSGS patients rather than disrupted bacterial community structure. However, animal models confirm that bacteria are necessary for pathologic proximal airway fibrosis and suggest an equally essential role for host adaptive immunity. Human samples from iSGS airway scar demonstrate adaptive immune activation in response to the proximal airway microbiome of both matched iSGS patients and healthy controls. Clinical outcome data from iSGS patients suggests surgical extirpation of airway scar and reconstitution with unaffected tracheal mucosa halts the progressive fibrosis.Our data support an iSGS disease model where epithelial alterations facilitate microbiome displacement, dysregulated immune activation, and localized fibrosis. These results refine our understanding of iSGS and implicate shared pathogenic mechanisms with distal airway fibrotic diseases. Idiopathic subglottic stenosis (iSGS) is a rare  but devaHistologically, iSGS cases show pronounced fibrosis restricted to the proximal airway mucosa . DiverseIn iSGS the functional alterations underlying airway remodeling remain poorly understood. In this study, we harnessed tissue samples from an international iSGS patient cohort and cutting-edge molecular tools to define the molecular phenotype of the proximal airway mucosa at single-cell resolution. Our results provide an unbiased assessment of the cell types within the normal human subglottis and illuminate the changes accompanying iSGS. The results suggest epithelial barrier dysfunction and immune infiltration are key components of iSGS pathogenesis. Matched superficial and deep tissue microbiomes support displacement of the native microbiome into the lamina propria of iSGS patients rather than disruption of bacterial community structure. However, animal models confirm that bacteria are necessary for pathologic proximal airway fibrosis and suggest an equally essential role for host adaptive immunity in remodeling after mucosal injury. Clinical data support the role of epithelial dysfunction in treatment response. Our data suggests that in iSGS the native microbiome is displaced across a dysfunctional epithelial barrier leading to an adaptive immune response which drives obstructive airway fibrosis. These novel results reshape our understanding of iSGS, implicate shared pathogenic mechanisms with distal airway fibrotic diseases, and open new avenues for therapy.Supplemental Table T1) and performed scRNAseq using the 10x Genomics Chromium platform . The samples were collected and processed at two different sites ; however, both sites collected cases and controls. To maximize our ability to identify rare cell populations, we jointly analyzed data from all samples. We defined inclusion criteria for cells based on observations from the entire dataset, removed low-quality cells accordingly, applied normalization and variance stabilization of the 25,974 recovered cells using Seurat. Initially one small CD8 effector T cell population was grouped together with a larger CD8 T effector population due to observations that cell cycle activity was driving distinct cluster identity. All cell types were identified both in airway scar and healthy mucosa. Notably, we did not observe overt batch effects driven by processing site or sequencing batch in our dimensionality reduction and visualization . Cell types/states were also manually grouped into 4 broad tissue classes  based on their identity . Quantification of cell types demonstrated significant differences between iSGS airway scar and matched healthy mucosa controls. Airway scar showed significantly more Immune cells  and significantly fewer epithelial cells  . When grouping cells into their tissue layer, the epithelium demonstrated significantly more DEG than immune cells   . In addi< 0.001)  (DEG: P = 0.007) . The dif= 0.007) .Supplemental Figure S4). Gene ontology (GO) pathway analysis supported the Hallmark geneset EMT findings; iSGS airway scar showed enrichment for mitochondrial matrix genes . In parallel, proliferating epithelial cells in iSGS airway scar showed down-regulated glycosylation and junctional protein complexes . Both aerobic respiration and loss of cell-cell adhesion are consistent with EMT.Molecular and functional evidence of epithelial dysfunction in iSGS scar. We further analyzed the epithelial clusters  and idenTo provide functional evidence of epithelial barrier dysfunction, we investigated if native bacterial displacement into the deeper lamina propria was a unique feature of iSGS. Employing fluorescence in situ hybridization (FISH) with the pan-bacterial probe, Eub338, we investigated if mucosal biopsies from iSGS and healthy controls evidenced bacteria in the deep layers of the proximal airway mucosa. Representative FISH stains show iSGS mucosa possessed signal for bacteria in the deeper lamina propria while healthy control did not . In a seCharacterization of the mucosal microbiome in iSGS. Given the observed bacterial displacement into the lamina propria of the airway mucosa, we investigated if alterations in microbiome community structure were also observed in iSGS. We first quantified the number of 16S rRNA gene copies in deep tissue biopsies via qPCR . We deteSupplemental Figure S6). The majority of bacterial species present in healthy subglottis were consistent with the established healthy lung microbiome composed of supraglottic predominant taxa . Using ptococcus).Supplemental Fig. 7A) nor between disease severity and alpha diversity  or richness .Additional microbial community structure testing using established diversity and richness indices confirmed no detectable differences between iSGS, iLTS and healthy controls. ANOVA testing of alpha diversity  and richness .Anatomic location of bacterial species in iSGS mucosal scar. To validate our findings and explore if superficial and deep tissue sampling methods produced unique bacterial communities, we next compared published 16S rRNA sequencing data of superficial swabs of iSGS scar (n = 5) with ourSupplemental Fig. 8). As expected, wild-type mice developed mucosal inflammation and significant thickening of the lamina propria 14 days after injury . Interestingly however, no significant thickening of the lamina propria was observed when using either germ-free mice , or severe combined immunodeficient mice (SCID) lacking ce (SCID) & B.eff cells in scar , along with more CD4 + Treg  and more NK cluster 2 cells . In contrast, the NK cluster 1 population was significantly reduced in scar   .The native proximal airway microbiome generates an antigen-specific immune response in infiltrating CD4 + and CD8 + T cells. In order to probe the function of the observed immune infiltrate, tissue biopsies acquired during the operative endoscopy of 5 unique iSGS patients were used to create fresh single-cell suspensions as described. Suspensions were rested for 6 hours, then cultured in the presence of a matched iSGS airway microbiome, the microbiome from an unrelated healthy subject, or left untreated.After 24 hours of stimulation, cells were washed and stained for markers of T cell activation (CD154) and analyzed via flow cytometry . For CD4Clinical data suggest that restoring epithelial barrier function is associated with a more durable treatment response. Treatment outcomes of iSGS patients in an ongoing cohort study  demonstrIdiopathic subglottic stenosis (iSGS) is a debilitating localized fibrosis of the proximal airway. Affected patients possess tightly conserved clinical demographics, histopathology, and physiologic impairment . Our humThe pseudostratified epithelium lining the human airway comprises several distinct populations of cells with specialized effector functions. Airway epithelium and the overlying mucociliary layer maintain a physical barrier against environmental insults . Many primary respiratory diseases, including chronic obstructive pulmonary disease (COPD), asthma, and idiopathic pulmonary fibrosis (IPF), display substantial pathological alterations in the airway epithelium. Evidence suggests that impairment of the epithelial barrier allows bacteria to penetrate the overlying mucociliary layer, intercalate within the epithelium, and activate host immunity. When sustained inappropriately, this inflammation can culminate in fibrotic tissue remodeling and physiologic impairment.in vitro human data and genetic evidence suggest that the airway epithelium plays a central role in disease susceptibility  of the residual epithelial cells showed a mechanistic target of rapamycin (mTORC1) pathway activation and enhanced aerobic metabolism. mTOR is a master sensor that integrates environmental factors to regulate cell growth. In general, activation of mTOR stimulates proliferation, mitochondrial biogenesis, and oxidative phosphorylation . The GESAlthough an often-overlooked anatomic subsite, the subglottis is uniquely enriched in antigen-presenting dendritic cells and T lymphocytes . AdditioPrior small case series examining environmental factors contributing to iSGS have implicated disruption of the proximal airway microbiome, one using pathogen-specific molecular approaches, and anoHowever, the displaced microbiome may not be the sole target of the adaptive immune response observed in iSGS mucosal scar. A feed-forward inflammatory loop may become established when peptides from microbial proteins share suffi cient structural similarity with self-peptides and activate autoreactive T cells, termed “molecular mimicry”. InflammAlthough we acknowledge the limited ability to assign causality in pathologic studies involving human tissue, single-cell transcriptional profiling provides an unbiased assessment of the cell types within the human subglottis and illuminates the epithelial and immune alterations accompanying disease. Histologic localization of pathogens deep in the lamina propria and bacterial community profiling support the functional impact of the observed epithelial dysfunction rather than suggest microbiome disruption is a primary driver of disease. Animal models confirm the importance of both bacteria and host immunity in the pathogenesis of airway fibrosis after epithelial injury and robust clinical data suggests restoring the epithelial barrier with healthy mucosa minimizes disease recurrence.Despite the inherent limits involved in rare disease research, our findings dramatically shift our concept of iSGS disease pathogenesis . UnbiaseDetailed experimental methods are included in the Supplemental Material.


Integrating robotics into orthopedic healthcare represents a transformative paradigm shift driven by technological advancements. This editorial explores the profound impact of robotics on the diagnosis, treatment, and rehabilitation of musculoskeletal conditions. Robotics redefines precision in orthopedic surgery through advanced imaging and real-time feedback, resulting in minimized disruption to tissues and faster recovery. Personalized treatment plans leverage robotics' capabilities to tailor procedures to individual anatomical characteristics, enhancing outcomes and reducing complications. Minimally invasive procedures, facilitated by robotics, mitigate trauma and expedite patient recovery. This collaboration between surgeons and robotic systems enhances precision without supplanting human expertise. Moreover, robotics extends to postoperative rehabilitation, utilizing exoskeletons and motion-capture systems to optimize mobility and strength recovery. While challenges of cost and training exist, proactive collaborations are shaping the future of robotics in orthopedic care. Ethical considerations underline the importance of balancing human intervention with robotic assistance. As robotics evolves, orthopedic healthcare embraces a future where technology and human expertise synergize, ultimately conquering musculoskeletal conditions. In recent years, the realm of healthcare has been undergoing a transformative journey fueled by remarkable technological advancements. Among the most impactful areas experiencing this revolution is orthopedic healthcare, where robotics catalyzes a paradigm shift in approaching the diagnosis, treatment, and rehabilitation of musculoskeletal conditions. As the symbiotic relationship between robotics and orthopedic care continues to evolve, a future brimming with the potential for enhanced precision, swifter recovery times, and overall improved outcomes comes into view.Orthopedic conditions, an extensive array of musculoskeletal disorders, have long posed challenges due to the intricate complexity of human anatomy and the delicate nature of bone and joint structures. Robotics' assimilation into orthopedic care has introduced a new dimension, addressing these challenges with unprecedented precision and efficacy.Robotic systems revolutionizing orthopedicsSeveral robotic systems have emerged as game-changers in orthopedic surgery, each offering unique features and benefits.MAKO Surgical SystemThe MAKO system  is renowned for its application in joint replacement surgeries. Advanced imaging and real-time feedback assist surgeons in precise bone preparation and implant positioning, resulting in improved alignment and joint function. Its haptic feedback mechanism aids in accurate bone resection. MAKO utilizes computed tomography (CT) scans to create patient-specific 3D models. Surgeons plan implant placement virtually, ensuring optimal alignment. The robotic arm is guided by the surgical plan in the operating room and provides haptic feedback to prevent excessive bone resection. Surgeons retain control while benefiting from enhanced accuracy.ROSA ROSA  is widely utilized in neurosurgery and spine procedures. Its features include real-time intraoperative data, image guidance, and robotic arms for enhanced surgical precision. ROSA facilitates minimally invasive surgeries and assists in complex spinal deformity corrections. ROSA integrates with various imaging modalities like CT and X-ray, to create a comprehensive surgical plan. It assists in cranial and spinal surgeries by providing real-time data, enabling precise targeting and trajectory planning. The system's robotic arms are guided by the surgeon's commands, enhancing procedural accuracy.NAVIO Surgical SystemNAVIO  offers robotics-assisted procedures in orthopedics, focusing on knee surgeries. It employs intraoperative planning and a handheld robotic-assisted tool for precise bone resurfacing. NAVIO's image-free registration enhances accuracy and outcomes in knee arthroplasty. NAVIO operates without preoperative imaging, utilizing a computer-assisted tool for intraoperative planning. Surgeons use tactile guidance to create a patient-specific plan and execute bone resurfacing accurately. This system enhances implant alignment, potentially improving implant longevity and patient satisfaction.Stryker Mako Total Hip Arthroplasty SystemThe Stryker Mako total hip arthroplasty system (Stryker) is tailored specifically for total hip arthroplasty. It provides a combination of 3D preoperative planning and robotic arm assistance during surgery. Surgeons benefit from real-time feedback, facilitating accurate acetabular cup positioning and leg length restoration. This system combines preoperative planning with intraoperative robotic assistance. Surgeons use a handheld robotic arm to prepare the acetabulum and place the cup precisely. Real-time feedback ensures accurate leg length restoration and hip offset, minimizing complications.RAS (Robotic Arm System) in Spine SurgeryRAS systems  are designed to enhance the accuracy of pedicle screw placement in spine surgeries. They utilize advanced imaging and robotic arms to guide surgeons in complex procedures, reducing the risk of nerve injury and revision surgeries. RAS employs advanced imaging and navigation to guide robotic arms for pedicle screw placement. Surgeons create a preoperative plan, and the robotic arm assists in accurate trajectory execution. This reduces radiation exposure, enhances accuracy, and potentially reduces revision surgeries.TM Robotic Guidance SystemMAZOR X Stealth EditionThe MAZOR X Stealth™ Edition robotic guidance system  offers both preoperative and intraoperative planning capabilities. With features like customizable implant options, optimal trajectories for implants, and advanced 3D analytics, this planning functionality empowers surgeons to enhance construct optimization and achieve a more predictable surgical procedure. The foundation of robotic precision lies in cutting-edge registration and mechanical stability. The MAZOR X™ platform establishes a closed-loop connection between the robotic arm mounted on the operating table, the securely positioned patient, and a rigid link between the robot and the patient's skeletal structure. This robotic system is table-mounted, optimizing the operating room space while ensuring unparalleled precision. The Stealth™ Navigation technology provides real-time visualization of implant placement within the patient's anatomy, aligning with the pre-operative plan. By seamlessly integrating two guidance technologies into a comprehensive platform, surgeons can confidently execute procedures during surgery, effectively bridging the gap between planning and execution. The navigation feature offers the visibility required to complete the surgical plan. With an accuracy rate of up to 100%, the MAZOR X Stealth™ Edition ensures precise screw placement.Precision redefinedAmong the most compelling contributions of robotics to orthopedics is its capacity to elevate surgical precision. Conventional surgical techniques often hinge on the surgeon's manual dexterity, leaving room for inadvertent errors. Robotic systems, fortified with advanced imaging and real-time feedback mechanisms, empower surgeons to meticulously plan and execute procedures with a degree of accuracy measured in sub-millimeters . This lePersonalized treatment plansIntroducing robotics in orthopedic surgery marks a revolutionary phase in tailored treatment plans. Robotic systems enable surgeons to intricately strategize procedures that cater to each patient's unique anatomical characteristics . This hiMinimally invasive proceduresRobotics has been instrumental in fostering the proliferation of minimally invasive procedures within orthopedics . ConventAdvantages of robotic systems in orthopedicsThe following are the advantages of robotic systems in orthopedics.Enhanced precision: Robotic systems offer unmatched precision and accuracy in executing surgical tasks, leading to improved implant alignment and surgical outcomes.Personalized treatment: Robotic platforms allow for the customization of surgical procedures based on each patient's unique anatomy, potentially reducing complications and improving long-term outcomes.Minimized tissue trauma: Robotic-assisted procedures often require smaller incisions and result in less disruption to surrounding tissues, leading to reduced postoperative pain and faster recovery times.Improved implant placement: Robotic systems enable precise implant positioning, potentially increasing implant longevity and patient satisfaction.Real-time feedback: Many robotic platforms provide real-time feedback to surgeons during procedures, allowing for adjustments and ensuring optimal outcomes.Complex maneuvers: Robotic arms can execute complex maneuvers that might be challenging for a human hand, enhancing the surgeon's capabilities.Reduced radiation exposure: In procedures such as spine surgery, robotics can reduce the need for fluoroscopy, leading to lower radiation exposure for both patients and surgical staff.Disadvantages of robotic systems in orthopedicsThe following are the disadvantages of robotic systems in orthopedics.High initial costs: Robotic systems require substantial investments in terms of equipment and training, potentially increasing the overall cost of procedures.Learning curve: Surgeons need to undergo specialized training to operate robotic systems effectively, and the learning curve can initially extend procedure times.Limited flexibility: Robotic systems follow preplanned trajectories, which might limit the surgeon's ability to make spontaneous adjustments during the procedure.Dependency on technology: Technical malfunctions or software glitches could interrupt surgeries or lead to suboptimal outcomes, highlighting the system's reliance on technology.Time-consuming setup: Setting up the robotic system and registering patient data can add time to the overall surgical process, especially during the learning phase.Complexity of integration: Integrating robotic systems into existing surgical workflows might be challenging and require adjustments in hospital processes.Ongoing maintenance and costs: Beyond the initial investment, robotic systems require maintenance, software updates, and potential hardware upgrades, leading to ongoing costs.Surgeon-support collaborationA fundamental tenet of understanding robotics in orthopedics is that it augments, rather than supplants, the role of surgeons. Robotic systems are invaluable tools, furnishing real-time insights, haptic feedback, and unparalleled visualization during procedures. Surgeons retain complete control while benefiting from the precision and data-driven guidance offered by the robotic platform . This coPostoperative rehabilitationThe impact of robotics resonates beyond the confines of the operating room, extending to the rehabilitation phase. Robotics-assisted rehabilitation devices, including exoskeletons and motion-capture systems, are revolutionizing how patients regain mobility and strength after orthopedic procedures . These dChallenges and ethical considerationsWhile integrating robotics into orthopedic healthcare holds great promise, it concurrently presents challenges and ethical considerations. The initial expenses associated with procuring and implementing robotic systems can be substantial, engendering concerns about accessibility and healthcare inequities. Furthermore, specialized training to proficiently operate these systems necessitates ongoing education and skill development investments. Ethical dilemmas arise in cases where the equilibrium between human expertise and robotic assistance is at issue. Striking the right balance between surgeon intervention and robotic autonomy necessitates meticulous deliberation. The focus should invariably remain on safeguarding patients’ well-being and ensuring that the benefits of automated technologies outweigh any potential risks.The path aheadAs the realm of robotics in orthopedic healthcare continues its expansion, a proactive and visionary approach is indispensable. Collaborative endeavors involving engineers, medical practitioners, and regulatory authorities are pivotal in refining existing technologies and conceiving novel solutions that cater to the evolving needs of patients. Investments in research and development will be instrumental in fostering innovation, thereby propelling the creation of even more sophisticated robotic systems capable of redefining the boundaries of orthopedic care.Integrating robotics into orthopedic healthcare marks a watershed moment in the medical arena. Its precision, personalization, and minimally invasive approach reshape the landscape of orthopedic procedures, offering patients renewed hope and an enhanced quality of life. As the medical community, policymakers, and technology innovators navigate the challenges and ethical considerations, the collective responsibility lies in shaping a future where robotics and human expertise harmoniously converge, redefining the horizons of orthopedic healthcare. With each surgical procedure and rehabilitation session, robotics propels us closer to a world where musculoskeletal conditions are not merely treated but unequivocally conquered.


To describe clinical features and the course of a case of non-necrotizing herpetic retinitis secondary to Varicella zoster virus (VZV).A single case report documented with multimodal imaging.A 52-year-old female patient with a past medical history of diabetes mellitus who presented with painful red right eye (OD). Ophthalmic examination showed perilimbal conjunctival nodule, granulomatous anterior uveitis, sectoral iris atrophy and increased intraocular pressure. Fundus examination in OD revealed posterior multifocal retinitis. Left eye examination was unremarkable. Polymerase chain reaction (PCR) of aqueous humor sample confirmed the presence of VZV DNA. Systemic antiviral therapy allowed the improvement of intraocular inflammation and disappearance of the retinal non necrotizing retinitis after one year of regular follow-up.Non-necrotizing retinitis is an underdiagnosed form of VZV ocular infection. Herpesviridae are common worldwide. Among the spectrum of viral retinitis, acute retinal necrosis (ARN), progressive outer retinal necrosis (PORN), and Cytomegalovirus (CMV) retinitis are the most severe and sight threatening viral infections [Viral infections due to fections . Besidesfections . The purA 52-year-old female with a past medical history of diabetes mellitus, presented with progressive pain, redness and vision loss of the right eye (OD). Her best corrected visual acuity (BCVA) in OD was 20/200 and 20/20 in the left eye (OS). Anterior segment examination of OD showed a perilimbal nodular conjunctival lesion, granulomatous anterior uveitis with sectoral iris atrophy Fig. . IntraocCase reports of NNHR have been described in five patients with positive test results for HSV or VZV in AH who had non-necrotizing retinitis consisting mainly of vasculitis, papillitis, or vitritis . Other cPCR was shown to be a powerful technique that allows detection of small quantities of DNA and RNA in ocular fluids. Various infectious agents can be detected with high specificity and sensitivity, including viruses. Results of PCR analysis of ocular fluids, being available within 24 to 48 h, have greatly improved the diagnosis of ocular viral infections, particularly those caused by human herpesviruses. AH analysis was contributory in 86.4% of patients with necrotizing viral retinopathies . BodaghiThe viral retinitis described in our patient is different from most cases of atypical viral retinitis reported in the literature, but resembles the cases reported by Hazirolan et al., with retinal lesions that are smaller and focally situated at the posterior pole without progression with antiviral treatment .The underlying reason for the variable clinical manifestations and severity of herpetic posterior uveitis is unknown but could be, in addition to pathogen-related factors, influenced by the variation in patients’ immune capacity. Bodaghi et al. hypothesized that necrotizing herpetic retinitis were due to an intracellular presence of the virus with subsequent cytopathic damage, whereas the NNHR were assumed to be associated with tissue damage based on immunological processes . WensingHazirolan et al. suggested that viral retinopathies might constitute a continuous spectrum of diseases, which clinical presentations depend on the patient’s immune status. Our patient, as well as theirs, with focal posterior non-necrotizing viral retinitis may be located at the starting point of the spectrum of herpetic retinopathies and constitute the mildest form of the disease . HoweverA remission was obtained in all cases after reaching the proper etiological diagnosis and initiating antiviral treatment. Oral acyclovir is mostly used for 6 weeks , but thiAlbert et al. reported several recurrences after arrest of antiviral treatment, it was the first case of anterior uveitis recurrence after NNHR described in the literature . Long-stFuture studies including a larger number of NNHR patients could reveal characteristics we were unable to identify here. The differential diagnosis of atypical viral retinitis is difficult clinically as it can mimic various other retinal conditions. In agreement with the previous studies, we propose viral analysis of ocular fluids in patients with retinitis, even in the absence of retinal necrosis, before initiation of immunomodulatory therapy and/or in those patients whose symptoms worsen while undergoing immunomodulatory treatments.Varicella zoster virus can cause a wide spectrum of clinical manifestations ranging from severe ARN to slow-progressing necrotizing and non-necrotizing types of inflammation. Non-necrotizing herpetic retinitis are currently underdiagnosed. PCR analysis of ocular fluids along with multimodal imaging could contribute to the confirmation and thus an earlier recognition of the diagnosis and the initiation of appropriate therapy.


A review exploring biological, chemical, and physiological processes that occur between aboveground plant components and belowground (rhizosphere) networks that may be altered due to waterlogged conditions. Above- and belowground linkages are responsible for some of the most important ecosystem processes in unmanaged terrestrial systems including net primary production, decomposition, and carbon sequestration. Global change biology is currently altering above- and belowground interactions, reducing ecosystem services provided by natural systems. Less is known regarding how above- and belowground linkages impact climate resilience, especially in intentionally managed cropping systems. Waterlogged or flooded conditions will continue to increase across the Midwestern USA due to climate change. The objective of this paper is to explore what is currently known regarding above- and belowground linkages and how they impact biological, biochemical, and physiological processes in systems experiencing waterlogged conditions. We also identify key above- and belowground processes that are critical for climate resilience in Midwestern cropping systems by exploring various interactions that occur within unmanaged landscapes. Above- and belowground interactions that support plant growth and development, foster multi-trophic-level interactions, and stimulate balanced nutrient cycling are critical for crops experiencing waterlogged conditions. Moreover, incorporating ecological principles such as increasing plant diversity by incorporating crop rotations and adaptive management via delayed planting dates and adjustments in nutrient management will be critical for fostering climate resilience in row-crop agriculture moving forward. Above- and belowground linkages have long been identified as critical for numerous ecological processes in both natural and managed systems . The mosGlobal change biology influences above- and belowground interactions, altering chemical, biological, and physiological processes and overall plant survival in natural landscapes. Climate stress can drastically alter biogeochemical cycles due to shifts in biomass allocation, whereby plants often allocate more resources belowground . From a 2 of land globally  had a greater rate of mycorrhizal colonization, greater alkaline phosphomonoesterase-producing bacteria, and greater overall abundance of bacterivorous nematodes relative to the native species in a mixed polyculture community. This demonstrates that invasives are able to exploit available nutrients by fostering bacteria–nematode interactions more efficiently than their counterpart native species. As climatic extremes such as flooding and drought increase, exploitation of resources and alteration of chemical and biological processes by invasive species will only continue , though the degree of the flooding effect was greater for some taxa than others suggesting variability in their tolerance levels  . Successful weed control in corn was determined to need 5–10 cm precipitation within 15 d of application to effectively incorporate herbicides and facilitate uptake by weeds  or winter barley (Hordeum vulgare) should be considered. These crops will all be in the ground with living roots during the winter months prior to any extreme precipitation that might impact the growing season. Small-seeded brassica species such as camelina, carinata, and most recently oilseed pennycress may also have utility as a winter annual option. Inclusion of these species into rotations with altered growth habits, nutritional content, and low C:N components may further influence above- and belowground cycling dynamics. Extending crop rotations and including three or more species often enhances soil C accumulation  has been developed and marketed as Perennial Kernza®. Kernza has been shown to drastically reduce nitrate leaching and improve soil health . The goal of perennial grain production is to develop a crop that can compete with annual crops but delivers ecosystem services like perennials found in nature due to deep and extensive root systems. For example, intermediate wheatgrass , though it is unclear ultimately how or when these webs will begin to stabilize and what the ultimate influence will be on the ecosystem. Species shifts in weed populations are anticipated, and existing methods for control may be less effective under extreme weather conditions. Adaptive management in row-crop agriculture, including increased biodiversity and perenniality that bolsters trophic interactions and nutrient balance, will be critical within flooded agroecosystems to mitigate the level of destabilization that is anticipated. Furthermore, we have demonstrated major areas in research especially in regard to rhizosphere processes, including plant–microbe interactions that may foster climate resilience within cropping systems. More research addressing both above- and belowground responses to flooded conditions and how these influences crop productivity and ecosystem function within agroecosystems is needed. Lastly, breeders should consider above- and belowground linkages when identifying key traits for flood-tolerant cultivars.


Nature depicted the genomic differences between late-stage treated metastatic cancers and early-stage untreated primary cancers via a pan-cancer whole-genome sequencing (WGS) analysis.1 This study characterizes unique features of metastatic solid tumors and provides a valuable resource for further investigating tumor evolution and treatment resistance.Recently, a study by Edwin Cuppen’s group published in 2 about 90% of cancer-related death can be attributed to advanced metastatic diseases, and unfortunately, most are incurable by aggressive treatment regimes.3 Therefore, it is important to identify genome differences between metastatic and primary tumors and evaluate their influence on treatment resistance. This may help in understanding and leveraging therapeutic interventions, thus to create more effective therapeutic regimens. The study by Edwin Cuppen and colleagues established a harmonized WGS dataset of 7108 tumor samples from 71 cancer types, including more than 4700 metastatic cancer samples from Hartwig Medical Foundation (Hartwig) dataset and more than 2300 untreated primary cancer samples from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium , including single-base substitutions (SBSs), double-base substitutions (DBSs) and indels (IDs). This result indicates that TMB does not inevitably reflect the status of cancer progression, and the entire mutation spectrums are formed before or during primary cancer progression. Further comparison of mutational process activity revealed the existence of exogenous (such as exposure to platinum or radiation-based treatments) and endogenous (such as increase in APOBEC and SBS1 mutation burden) mutational processes that generate TMB differences. By investigating the divergence of SBS1 mutation burden in detail, the authors revealed a highly cancer type-specific SBS1 mutation burden per age. The majority of tumor types showed a prominent enrichment of SBS1 mutations along with age in both primary and metastatic lesions, however, 4 cancer types  only displayed increased SBS1 mutation burdens in metastatic cohorts in an age-independent manner.Compared with TMB, an elevated frequency of structural variants (SVs) was noticed in most tumor types included in metastatic cohorts. The underlying genomic instability signatures linked to this phenomenon are TP53 alterations and genome ploidy, which exhibited significant pan-tumor correlations with duplications and deletions, thus likely to play an essential role in SV increase in metastatic cancers. In addition, the researchers found a modest overall increase of driver gene alterations in patients with metastatic cancers. The majority of genetic drivers enriched by cancer metastasis were tumor-type specific, including some well-known driver genes related to resistance to anticancer treatments, whereas 3 genetic drivers  exhibited significant enrichment in metastatic cohorts across various cancer types, suggesting that changes in such genes may promote invasiveness via interfering with tumorigenesis hallmarks of pan-cancer. When comparing therapeutically actionable variants for each type of cancer, the authors found that the metastatic cohort had an overall higher proportion of patients with such variants, although the distribution was highly cancer type specific.The presence of treatment-resistant genetic drivers in advanced cancers led the authors to identify therapeutically enriched drivers (TEDs) that were either treatment enriched or exclusively found in a treatment-specific and cancer type-specific manner. Ultimately, 61 TEDs related to 33 therapeutic groups were identified, and most top hits were well-established resistant drivers to anticancer treatments. Notably, TP53 alterations were found to be frequently relevant with multiple treatment resistances, indicating such variants are potential predictive markers for augmented cancer plasticity and aggressiveness instead of the resistance mechanism for a specific tumor type. Overall, TEDs could be found in 53% of patients in metastatic cohort. After excluding TEDs, the raw difference between primary and metastatic tumors will be reduced by 36% in the number of drivers per sample, suggesting that a significant portion of the metastatic-enriched drivers are very likely linked to anticancer treatment resistance.5 Despite the aforementioned contributions, this study was also limited by the usage of distinct laboratory workups and sequencing procedures for the tumor samples from different datasets and the finite sample sizes of some cancer cohorts. Therefore, it is important to enlarge cancer cohorts and further uniform sample collation and sequencing processes to facilitate and validate the present understanding of cancer development. Moreover, genomic alterations are unable to fully elucidate cancer metastasis and resistance, and using the information from tumor microenvironment and additional cancer omics will also be essential for further anatomizing and better understanding the underlying mechanisms.Taken together, this study confirmed previous findings observed in certain cancer types and provided novel biological insights into the unique characteristics of metastatic cancers and their genomic differences with primary tumors, such as low intratumor heterogeneity, high genomic instability and elevated SVs. Nevertheless, the extent of genetic differences between metastatic and primary cancers varied significantly across cancer types and was affected by anticancer treatment exposure. Among the 23 tumor types, breast, clear cell renal cell, thyroid, prostate and pancreatic neuroendocrine cancers showed strong transformation in genomic landscape in advanced stages. In addition, this study provides a valuable resource for further investigating other aspects of cancer progression, such as the study on genetic immune escape alterations between metastatic and primary cancers conducted also by Edwin Cuppen’s group recently.


Biomaterials offer numerous opportunities to preserve spheroid function and guide spheroid behavior by tailoring the local microenvironment.Spheroids are three-dimensional cell aggregates that mimic fundamental aspects of the native tissue microenvironment better than single cells, making them a promising platform for the study of tissue development and therapeutics. Spheroids have been investigated for decades as models in cancer research, yet we have only just scratched the surface of their potential clinical utility in cell-based therapies. Like many cells, spheroids commonly exhibit a loss of key attributes upon implantation, motivating the need for strategies to regulate their function  Systemic or localized injection of cells results in poor survival and inconsistent behavior due to the lack of instructional cues or aberrant signaling from the diseased microenvironment. As an alternative to monodisperse cells, spheroids are three-dimensional cell aggregates that retain key aspects of the cellular microenvironment including cell-cell interactions, engagement with an endogenous cell-secreted extracellular matrix (ECM), and gradients in signaling that result in heterogeneous nutrient distribution that better recapitulate native tissues. Furthermore, spheroids secrete substantially more endogenous trophic factors that promote neovascularization and influence the inflammatory microenvironment Biomaterials have an essential role in the development and application of spheroid-based technologies. Beyond materials-based approaches for spheroid formation, entrapment of spheroids in tunable biomaterials has emerged as a promising strategy to instruct spheroid function and differentiation and regulate cell migration from the spheroid into the surrounding tissues. The synergistic effects of biomaterial properties and spheroid signaling, although not fully understood, directly influence cytokine production, cell spreading and migration, viability, and differentiation. Thus, intelligent selection of a biomaterial is required and should be taken into consideration to instruct spheroid behavior and achieve the desired therapeutic effect.2Our group has predominantly studied spheroids formed of mesenchymal stromal cells (MSCs) to potentiate their secretion of regenerative trophic factors and guide their direct contributions to tissue formation. Spheroids of other cell types are under investigation, and key factors such as cell type and spheroid diameter are intrinsically related to their desired application. Nonetheless, the interplay of additional environmental cues can affect spheroid function and instruct behavior for specific applications. Spheroid function is regulated by the biophysical properties of the spheroid carrier material or entrapment of other components within the spheroid to guide cell function and differentiation.Spheroid function has been widely controlled by encapsulation in engineered hydrogels and controlling biophysical properties such as adhesivity, stiffness, and viscoelasticity. Alginate hydrogels covalently modified with cell-adhesive RGD (Arg-Gly-Asp) peptides are widely used as model systems and vehicles for cell transplantation. RGD-modification regulated cell adhesion, outgrowth, and tissue formation using MSC spheroids e.g., Yes-associated protein, YAP). These findings demonstrate the potential of cell-based materials to increase biomineralization without the need for exogenous osteoinductive cues or growth factors. Recent advances in macromolecular crowding approaches may open the door to improve growth factor retention and influence other relevant ECM properties such as protein content or fiber alignment Instructive materials can also be incorporated within the spheroid itself to guide cell function. As spheroids initially lack an endogenous ECM, our group formed spheroids with an engineered, MSC-secreted ECM to activate integrin signaling In many applications, it may be necessary to leverage biomaterials that provide structure or regulate spatial patterning to achieve desired tissue formation using spheroids. For example, silicon nanowires were applied to promote differentiation of human induced pluripotent stem cell spheroids (hiPSC) into hiPSC-derived cardiomyocytes for cardiac repair 32) that promote angiogenesis, modulate the inflammatory microenvironment, and stimulate wound repair, and MSC spheroids secrete more trophic factors than monodisperse MSCs. MSC spheroids entrapped in fibrin hydrogels with higher elastic moduli (∼45 kPa) secreted significantly more VEGF, while PGE2 secretion was greater for spheroids in softer gels (∼5 kPa) The MSC secretome is a potent collection of bioactive factors that stimulates host cell migration and tissue repair. MSCs secrete endogenous factors such as vascular endothelial growth factor (VEGF) and prostaglandin E2 (PGE4Spheroids have enormous promise for use as building blocks for tissue regeneration. Although initial applications injected spheroids into diseased tissues without supportive biomaterials, substantial evidence confirms the capacity for material-driven approaches to potentiate spheroid function. However, we have yet to create materials that accurately model the complex characteristics and behavior exhibited by many human tissues. The use of biomaterials that mimic the biophysical properties of native tissues will increase the therapeutic potential of spheroids in clinical applications.via ultrasound, light, or delivery of fast-reacting small molecules that rapidly stiffen or weaken the biomaterial. Just as spheroids better recapitulate native tissues by increasing complexity from conventional 2D culture systems, we must embrace the same logic of increased complexity and multilayer design when developing biomaterials. This is made more challenging by the need to maintain biocompatibility. Nonetheless, new materials will propel the effective instruction of cell spheroids and establish them as a powerful tool for regenerative medicine, drug discovery, and disease modeling (The development of biomaterials possessing gradients in stiffness, composition, and soluble cues that imitate the heterogeneity of native tissues is a step in the right direction. These attributes can be enabled by chemistries that facilitate non-invasive tunability modeling .Fig. 1BiThe authors declare the following financial interests/personal relationships which may be considered as potential competing interests:J. Kent Leach reports financial support was provided by UC Davis Health System. David H. Ramos Rodriguez reports financial support was provided by UC Davis Health System.


Neuroinflammation is a key secondary event after spinal cord injury (SCI) and can increase barriers to regeneration, leading to various neurological disorders. Infiltrated hematogenous innate immune cells into the injured site are considered the main effector cells of the inflammatory responses after SCI. Glucocorticoids were the standard of care for spinal cord trauma for years due to their anti-inflammatory properties yet were also associated with unwanted side effects. While the administration of glucocorticoids is controversial, immunomodulatory strategies that limit inflammatory responses provide the potential therapeutic approaches to promote functional regeneration following SCI. Herein, we will discuss emerging therapeutic strategies to modulate inflammatory responses to enhance nerve recovery after spinal cord trauma. Traumatic Spinal Cord Injury (SCI) results in an initial primary injury, followed by secondary events including ischemia, anoxia, and excitotoxicity for the first minutes, hours, and days after injury –4. As a Various gene therapy-based approaches have been introduced in the last twenty years and continue to be utilized as a powerful therapeutic approach to alter or correct defective genes for the treatment of multiple diseases ,13. WhilNanomedicine employing polymeric nanoparticle (NP) has received significant attention due to its inherent therapeutic potential to modulate immune responses to cure inflammatory responses-mediated disorders including SCI –22. PrevStem cells can proliferate and differentiate into any cell type present in the body. Considering their therapeutic potential and abilities of self-renewal and differentiation, stem cells are widely used following SCI ,32. In aImmunotherapeutic approaches for the treatment of SCI have the capacity to indirectly and/or directly enhance functional recovery. Although many preclinical studies have demonstrated therapeutic effects of immunomodulatory factors on SCI, the introduction of these strategies in the clinic faces various limitations for SCI victims. Further investigations will be required to assess how each of the immunomodulatory factors can be employed synergistically to reprogram the immune system to promote functional recovery after SCI while limiting life-threatening side effects.


Background: Overall, ~12% of outpatient visits result in an antibiotic prescription, and 30% of those prescriptions are inappropriate. Behavioral nudges help influence practitioner behavior. We hypothesized that peer comparison combined with a behavioral nudge  would influence prescribers to reduce antibiotic prescriptions and improve antimicrobial stewardship in the outpatient setting. We pilot-tested this intervention in outpatient primary care clinics associated with a large Veterans Affairs (VA) medical center. Methods: We conducted a clustered randomized controlled trial of 12 community-based outpatient clinics. All practitioners in the intervention arm received quarterly comparative feedback reports and, when indicated, quarterly patient alert letters. Comparative feedback reports gave personalized feedback about antibiotic prescriptions for upper respiratory tract infections, comparing the recipient’s antibiotic prescriptions to the average for all practitioners at the primary care clinics included in our study. Patient alert letters notified practitioners to patients in their panel with recently detected Clostridioides difficile or resistant organism and their antibiotic exposures. We assessed outpatient visits during the preintervention period (April–September 2020), the intervention period (October 2020–September 2021), and the postintervention period (October 2021–September 2022). A mixed-effects logistic regression model predicting antibiotic prescriptions compared the arms across these periods. Results: The outpatient populations observed in the intervention and control arms were similar during each phase of the study. Prior to the intervention, the average proportion of visits with an antibiotic prescription was lower among clinics in the intervention arm . This difference broadened slightly during the intervention period  and the postintervention period  . Throughout the study, clinics in the intervention arm typically used more doxycycline and azithromycin and less amoxicillin-clavulanate and sulfamethoxazole-trimethoprim compared to clinics in the control arm. . In the 6-month preintervention period, which coincided with the early phase of the COVID-19 pandemic, antibiotic prescriptions in the intervention compared to control clinics were similar. During the intervention and postintervention periods, the proportion of visits with an antibiotic prescription remained steady for clinics in the intervention arm and increased for those in the control arm. These results suggest that this pilot study using a low-intensity intervention consisting of comparative feedback reports and patient alert letters was successful in influencing the antibiotic prescribing behavior of primary care clinicians practicing in community-based outpatient clinics affiliated with a VA medical center.Financial support: This study was funded by Merck.Disclosures: None


Cervical cancer is the fourth-leading cause of cancer incidence and death among females according to Global Cancer Statistics 2018.This video demonstrates the fertility-sparing surgery procedure containing radical trachelectomy and pelvic lymphadenectomy with bilateral ascending branches of uterine arteries preservation. The patient was a 34-year-old woman diagnosed with International Federation of Gynecology and Obstetrics stage IB1 moderately differentiated squamous cervical cancer who expressed a strong desire for reproduction. After sufficient consultation, she decided to receive a fertility-sparing treatment protocol. This video highlights the feasibility of sufficiently dissecting paracervical structures and exposing uterine artery branches with complex procedures and no assistance via TU-LESS. We adopted a simplified uterine manipulator, which minimized the squeezing and injury to the cervix, to assist exposure of the surgical field. Resection of the cervix was accomplished transvaginally with a cold knife to ensure sufficient margin. Pathology examination of surgical margin, lymph node specimens, and lymphovascular invasion were negative. The umbilical incision was closed by Zheng’s anchor suturing technique to prevent incisional complications and improve cosmetics.Minimally invasive surgery is safe and effective for fertility-sparing without compromising oncologic outcomes, especially in patients with a tumor size <2 cm.


Bipolar patients (BP) frequently have cognitive deficits, that impact on prognosis and quality of life. Finding biomarkers for this condition is essential to improve patients’ healthcare. Given the association between cognitive dysfunctions and structural brain abnormalities, we used a machine learning approach to identify patients with cognitive deficits.The aim of this study was to assess if structural neuroimaging data could identify patients with cognitive impairments in several domains using a machine learning framework.Diffusion tensor imaging and T1-weighted images of 150 BP were acquired and both grey matter voxel-based morphometry (VBM) and tract-based white matter fractional anisotropy (FA) measures were extracted. Support vector machine (SVM) models were trained through a 10-fold nested cross-validation with subsampling. VBM and FA maps were entered separately and in combination as input features to discriminate BP with and without deficits in six cognitive domains, assessed through the Brief Assessment of Cognition in Schizophrenia.The best classification performance for each cognitive domain is illustrated in Table 1. FA was the most relevant neuroimaging modality for the prediction of verbal memory, verbal fluency, and executive functions deficits, whereas VBM was more predictive for working memory and motor speed domains.Overall, the tested SVM models showed a good predictive performance. Although only partially, our results suggest that different structural neuroimaging data can predict cognitive deficits in BP with accuracy higher than chance level. Unexpectedly, only for the attention and processing speed domain the best model was obtained combining the structural features. Future research may promote data fusion methods to develop better predictive models.None Declared


Sickle cell disease (SCD) is a prevalent inherited hemoglobin disorder encompassing a cluster of congenital hemolytic anemias, each distinguished by the prevalence of sickle hemoglobin (HbS) . Anemia,Numerous novel agents are currently undergoing clinical development or have been introduced into clinical practice. In addition, the attempts to reduce long-term complications and enhance quality of life continue. This Special Issue aims to delineate both our current understanding and future options in SCD. All articles submitted to this Special Issue underwent a meticulous peer review process. Ultimately, two articles, two brief reports and one review were published. These five manuscripts are discussed below.(i)Forte and colleagues provided important data on the timely issue of COVID-19 and SCD, updating outcomes after two years of the pandemic .(ii)Tsitsikas and colleagues presented the rate of dental extractions in SCD, providing up-to-date knowledge on an understudied complication .(iii)Biswas and colleagues reviewed the role of mitochondria as an emerging consequential in SCD, highlighting pathophysiological and therapeutic challenges .(iv)Kuo and colleagues reported that thromboprophylaxis reduced venous thromboembolism in SCD patients with central venous access devices, studying a large retrospective cohort .(v)Gavriilaki and colleagues studied the immune response of adult SCD patients after their vaccination against COVID-19, providing the experience of a Greek center.Considering the multi-faceted challenges of SCD, we hope that this Special Issue will inspire researchers and clinicians to continue their explorations into novel advances in this field .


Artificial intelligence (AI) algorithms have been applied in abundant medical tasks with high accuracy and efficiency. Physicians can improve their diagnostic efficiency with the assistance of AI techniques for improving the subsequent personalized treatment and surveillance. AI algorithms fundamentally capture data, identify underlying patterns, achieve preset endpoints, and provide decisions and predictions about real-world events with working principles of machine learning and deep learning. AI algorithms with sufficient graphic processing unit power have been demonstrated to provide timely diagnostic references based on preliminary training of large amounts of clinical and imaging data. The sample size issue is an inevitable challenge for pediatric oncology considering its low morbidity and individual heterogeneity. However, this problem may be solved in the near future considering the exponential advancements of AI algorithms technically to decrease the dependence of AI operation on the amount of data sets and the efficiency of computing power. For instance, it could be a feasible solution by shifting convolutional neural networks (CNNs) from adults and sharing CNN algorithms across multiple institutions besides original data. The present review provides important insights into emerging AI applications for the diagnosis of pediatric oncology by systematically overviewing of up-to-date literature. The exponentially growing knowledge and techniques have explored innovative perspectives for multi-layered diagnoses in pediatric oncology that the expectation of patients and their families have been developed for their specific situation to receive optimized care instantly and comprehensively. Artificial intelligence (AI) strategies can tackle enormous amounts of original data in a short time to solve complex tasks with high accuracy , 2. PhysAI has developed into various computer-assisted theories and is mainly implemented with working principles of machine learning (ML) and deep learning (DL). AI algorithms fundamentally capture data, identify underlying patterns, achieve preset endpoints, and provide decisions and predictions about real-world events. ML, as a main subset of AI, indicates a different flowchart compared with traditional hard-coded software programs which apply algorithms to construct predictive models dynamically by training large amounts of historical data. DL, as a growing aspect of AI, represents benefits in learnable weights and high efficiency with minimal pre-processing based on the structure of convolutional neural networks (CNNs) with multiple inter-connected layers. DL-CNNs composed of multiple stacked CNN layers have advantages in accurate, faster, vendor-independent processing compared with ML algorithms applied previously . NotablyThe application of AI not only makes full use of the various aspects of clinical diversity but also helps to address the current lack of objectivity and universality in expert systems . The appDespite the current AI advancements, the sustainable development of health AI tools relies on the availability of large datasets with strict quality control . SeveralThe prosperous development of AI techniques promotes numerous potential applications in pediatric oncology with two main bottlenecks for successful utilities, including the need for large data entry and a strong graphic processing unit (GPU) with appropriate computer and memory power. AI algorithms provide timely references based on large amounts of clinical and imaging data and sufficient GPU power . MeanwhiClinicians make clinical diagnoses depending on their professional knowledge and clinical experience through signs, symptoms, laboratory, and imaging examinations. It seems hard to guarantee diagnostic accuracy and consistency by dealing with abundant and multidimensional data from the human brain. The AI algorithms have advantages in learning and training vast amounts of data and integrating it into a certain outcome in a very short time, which allows efficiency and effectiveness of computer-aided diagnosis (CAD) in clinical practices. DL algorithms have recently made significant progress in extracting and processing information from medical images, which have been applied in various medical tasks extensively not only in radiology and pathology with satisfactory performance comparable to or even superior to that of human experts. Notably, DL algorithms could identify underlying information from medical images associated with tumor diagnosis . The AI A performance comparison of diagnosis in pediatric hematological malignancies using AI strategies is shown in A performance comparison of diagnosis in pediatric intracranial tumors using AI strategies is shown in versus non-tumor/hemorrhagic and classify subtypes of brain tumors.Attallah , 43 propversus benign diseases [AI techniques have been applied in the diagnosis of pediatric extracranial tumors, mainly including soft-tissue and bone tumors . For bondiseases , 54. TheZhang et al.  and FranAI-based principles have been used for the detection and segmentation of pediatric malignant tumors. For example, Wu et al.  used a rH3 K27M amplification status in children with midline glioma with significantly greater accuracy ranging from 0.788 to 0.867 than prediction by chance. Giwa et al. [The AI algorithms have represented strengths in detecting tumor patterns by identifying underlying genetic and molecular characteristics associated with specific macroscopic tumor features based on medical images and/or high-throughput data. Zhao et al.  reporteda et al.  applied The application of AI technology faces some important challenges that must be resolved to ensure its use in pediatric cancer diagnosis . For exaAI techniques have revolutionized the diagnostic field of oncology. Although AI approaches have been widely implemented in adult tumors, specialized applications of AI algorithms in childhood cancer are still limited probably attributed to the insufficient amounts of available data sets. There are limited opportunities to transfer well-trained CNN architectures built on adults into pediatric oncology few CNNs are directly generalizable from adults to children. Therefore, it’s warranted urgently to develop dedicated AI algorithms applied in pediatric oncology. Although the data sets of pediatric oncology are not large enough to perform standardized DL analysis in medical imaging , the int


The purpose of this report is to provide a comprehensive account of an exceptional case involving the presentation of congenital rubella syndrome (CRS) in a newborn. Furthermore, it aims to document the successful regression of CRS through medical treatment alone. We present the case of a five-day-old infant who was referred to our facility as a CRS case. The patient presented with bilateral white corneal opacity, which was observed shortly after birth. The mother was diagnosed as rubella-positive during pregnancy. Upon the initial examination under anesthesia, both eyes exhibited central white corneal opacity accompanied by large intrastromal cysts. Although a few breaks in Descemet's membrane were observed in both eyes, there were no signs of vascularization or the presence of iridocorneal or lenticular-corneal adhesions. After undergoing medical treatment consisting of topical sodium chloride and steroids, the cysts in both eyes completely regressed. Subsequently, the patient underwent penetrating keratoplasty to further address the dense scar. This case enhances our comprehension of ophthalmological complications associated with CRS and provides valuable insights into alternative therapeutic approaches for corneal stromal cysts. Congenital rubella syndrome (CRS) is a prevalent congenital infection known for its wide range of severe ophthalmic and systemic complications . It typiA five-day-old male infant with a confirmed diagnosis of CRS was referred to our facility for examination due to the presence of white corneal opacification in both eyes. The patient's mother also had a confirmed diagnosis of reactive rubella during pregnancy. Upon the initial examination under anesthesia, both eyes exhibited central white corneal opacity along with large intrastromal cysts. Although a few breaks in the Descemet membrane were identified in both eyes, no signs of neovascularization or iridocorneal or lenticular-corneal adhesions were observed Figure . UltrasoCRS is a prevalent congenital infection characterized by various clinical manifestations, including heart defects, hearing impairments, and ophthalmological abnormalities . The mosIn conclusion, this case study brings attention to the infrequent presentation of corneal stromal cysts in a newborn with CRS, emphasizing the importance of identifying uncommon ophthalmological manifestations associated with CRS. The effective nonsurgical management of corneal stromal cysts demonstrates a noninvasive treatment option. This case contributes to a broader understanding of ophthalmological complications and provides valuable insights into alternative therapeutic approaches for corneal stromal cysts.