Mormopterus francoismoutoui) are associated with major increase in the prevalence of bats shedding RNA viruses. The synchronicity of such shedding pulses, however, is yet to be assessed between viruses but also maternity colonies. Based on 3422 fresh faeces collected every 2–5 weeks during four consecutive birthing seasons, we report the prevalence of bats shedding astroviruses (AstVs), coronaviruses (CoVs) and paramyxoviruses (PMVs) in two maternity colonies on Reunion Island. We found that the proportion of bats shedding viruses is highly influenced by sampling collection periods, and therefore by the evolution of the population age structure. We highlight that virus shedding patterns are consistent among years and colonies for CoVs and to a lesser extent for PMVs, but not for AstVs. We also report that 1% of bats harbour co-infections, with two but not three of the viruses, and most co-infections were due to CoVs and PMVs.Infection dynamics in vertebrates are driven by biological and ecological processes. For bats, population structure and reproductive cycles have major effects on RNA virus transmission. On Reunion Island, previous studies have shown that parturition of pregnant females and aggregation of juvenile Reunion free-tailed bats ( Seasonal infection dynamics in vertebrates are driven by a large set of biological and ecological factors, including social behaviours and changes in host population structure . For insAlthough many studies have reported viruses, bacteria and blood parasites in bats –13, a prIn this study, we investigated the effect of population size, occupation length and age structure on virus shedding, in molossid bat maternity colonies. Because reproductive cycles are highly synchronised, we hypothesised that viral shedding patterns could be similar and predictable between years. However, differences may be expected between viral families, and associated to either epidemiological or ecological factors such as herd immunity or the maintenance of viral particles in the environment. We also assumed that viral co-circulation in bat populations may generate positive or negative interactions between viruses, with cascade effects on their transmission dynamics.Mormopterus francoismoutoui), a molossid species endemic to Reunion Island. We collected 3422 fresh faeces simultaneously in two maternity colonies, during four consecutive years, and estimate the prevalence of astroviruses (AstVs), coronaviruses (CoVs) and paramyxoviruses (PMVs). More precisely, (i) we assessed temporal variations in the prevalence of bats shedding viruses, (ii) estimated the proportion of co-infected bats and (iii) tested whether the detection of a given viral family was associated to the presence of another.To test these hypotheses, we focused on the Reunion free-tailed bat . This colony contains the highest number of bats on the island, and is occupied only during the birthing season, from October to June [The study was conducted in two monospecific RFTB colonies on Reunion Island, a 2500 km to June . During  to June . These f to June , 22, pop3 building housing a power transformer, located in the North coast of the island (referred to hereafter as ‘building’). In this colony, adults are reported all year long but newborns are present in mid-December, and juveniles between January and May, as for the cave colony. The building remains occupied between June and September corresponding to the austral winter, although it is not possible to visually assess the population age structure at this stage of the season. Juveniles’ fur coloration starts to change and differences between juveniles and adults cannot be discriminated based on fur coloration only.A smaller colony (up to 1200 flying bats) was also monitored, in a ~5 mThe cave colony was monitored during four consecutive years (i.e. each year corresponding to a birthing season), from October 2016 to March 2020. The building colony was monitored during three consecutive years, from November 2017 to October 2020. Because of the lockdown associated with the COVID19 pandemic, sampling was not done in March and April 2020.Fresh bat faecal pellets were collected every 2–5 weeks, and during the same day in both colonies . For the cave colony, samples were collected in the morning, by placing Benchguard® sheets (60 cm × 49 cm)  under roosting bats . For then = 499; building: n = 465) between November 2017 and October 2018, during 17 sampling sessions. Nine hundred and eighty faeces were collected  between November 2018 and September 2019 during 17 sampling sessions. Finally, 898 samples were collected  between October 2019 and October 2020 during 16 sampling sessions.In total, 3422 fresh faeces were collected from the two colonies during 64 sampling sessions (Supplementary Table S1). In summary, 580 samples were collected in the cave between October 2016 and June 2017 for the first season, during 14 sampling sessions. For the second season, a total of 964 faeces were collected in both sites . Reverse-transcription was performed on 10 μl of RNA, with the ProtoScript II Reverse Transcriptase and Random primers 6 , as previously described [Samples were thawed at 4°C overnight, briefly vortexed and centrifuged at 1500 escribed .cDNAs were tested for the presence of the AstVs RNA-dependent RNA-polymerase (RdRp) gene using a Pan-AstV semi-nested polymerase chain reaction (PCR), following a previously published protocol  routinelcDNAs were tested for the presence of the CoVs RdRp gene using a Pan-CoV multi-probe real-time (RT) PCR following a previously published protocol  routinelRespiroviruses, Morbilliviruses and Henipaviruses (RMH) using a semi-nested PCR following a previously published protocol [cDNAs were tested for the presence of the PMVs L-polymerase gene targeting protocol  routinelprotocol , 30, 31,2) [Analyses were made with the assumption that each faeces came from an individual bat. Based on the high number of bats (hundreds in the buildings to tens of thousands in the cave), together with the high bat density  , and the2)  providedχ2 tests were conducted to globally examine the effect of the colony and the year of collection on virus detection. Then, four generalised linear mixed models (GLMMs) with binomial error structures were used to explore the effect of the colony (different population sizes and occupation lengths) and the sampling collection period, respectively, on the detection of AstVs, CoVs and PMVs RNA, as well as co-infections, with the year (i.e. season of parturition) included as a random factor. Five sampling collection periods were defined based on the biology of the studied species, and the evolution of the population age structure. Period A ranged from the beginning of the birthing season to the parturition. Period B corresponded to the birth period. Period C represented weeks during which newborns become juveniles. Period D corresponded to the departure of adults after juveniles’ weaning. Finally, period E represented the austral winter, when only the building remains occupied. Analyses were conducted only when data were available for both sites . Three generalised linear models with binomial error and a logit link function were used to test if the presence/absence of each virus was influenced by those of the other viruses. Analyses were conducted in R version 4.1.0 [lme4’ [Anova’ function from the ‘car’ package [Pearson on 4.1.0  with the0 [lme4’ . The sig package .Adult bats were observed between October and December, in both the cave and the building colonies. Newborns were sighted in both colonies from mid-December to late January, suggesting that parturition was highly synchronised between the two maternity colonies . From February to May, both colonies were mainly composed of weaned juvenile bats, following the departure of adults approximately 1 month after parturition. No bats were observed in the cave between mid-June and September . These observations are consistent with previous studies , 22.χ2 = 11.79, df = 3, P < 0.01). The prevalence of bats shedding AstVs was lower in 2019–2020. However, no significant difference was observed between colonies . The GLMM did not reveal any significant variation between sampling collection periods , nor colonies .AstVs were detected in both colonies, every year . The global prevalence was lower in the building (13.8 ± 1.9%) as compared to the cave (18.7 ± 1.7%). However, no significant difference was observed between years . The GLMM highlighted major variations in the prevalence of bats shedding CoVs between the sampling collection periods , however no significant variations was detected between colonies . The proportion of bats shedding CoV RNA was significantly higher for the periods C (50.5 ± 5.0%), D (20.1 ± 2.9%) and A (12.2 ± 2.3%). For period A, a shedding pulse was recorded in December almost all years for both colonies (e.g. ranging from 8.0 ± 7.5% to 38.0 ± 13.5% in the cave), except in 2019–2020 in the building for which no samples tested positive during the period . The global prevalence was lower in the cave (5.4 ± 1.0%) as compared to the building (8.3 ± 1.5%). However, no significant difference was observed between years . The GLMM revealed major variations in the prevalence of bats shedding PMVs between the sampling collection periods , however no significant variations were detected between colonies . The proportion of bats shedding PMV RNA was significantly higher for the period A (10.7 ± 2.2%). A strong interaction between the sampling collection period and the colony was also identified . Interestingly, PMV RNA was also detected during the austral winter (period E) in the building (e.g. up to 50.0 ± 21.9% in June in 2018–2019)  .χ2 = 0.26, df = 1, P = 0.61), nor between years . Only bi-infections were observed. Co-infections with CoVs and PMVs (0.7 ± 0.3%) were more common than those with AstVs and PMVs (0.1 ± 0.1%) or AstVs and CoVs (0.3 ± 0.2%) . GLMM did not reveal any significant variation in the prevalence of bats shedding co-infections between sampling collection periods , nor between colonies . Additionally, there was no statistical association between viruses indicating that the presence of one virus may not be determined by the presence of another (Supplementary Table S2).Co-infections were detected in both colonies and every year. In total, 36 of the 3422 samples tested positive for more than one virus , and occupation length (maternity period vs. permanent colony), a similar shedding pattern was observed between colonies for CoVs and, to a lesser extent, for PMVs. Strong variations were observed among sampling collection periods and could be related to the evolution of the population age structure and the presence of naive individuals throughout the birthing season, or to broader environmental and/or biological factors affecting herd immunity. We also detected a slight proportion of co-infected bats, with CoVs and PMVs co-infections more commonly detected than AstVs and CoVs, or AstVs and PMVs.Based on the molecular detection of AstVs, CoVs and PMVs, we precisely assessed temporal variations in virus shedding dynamics in two RFTB colonies during four consecutive years. In spite of differences between colonies, notably population size (up to 50 000 Myotis myotis) in Germany [A major shedding pulse was consistently observed a few weeks after parturition in both colonies for CoVs. It was detected in February for the first 3 years of the follow-up, and in March for the last year. The similarities among colonies suggest that population size may not affect CoVs transmission in RFTB. However, age structure and the presence of naive individuals could be one of the drivers of the epidemiological process . This ma Germany . The tra Germany , 37, but Germany . Interes Germany , 8, 22. Repeated shedding pulses were also detected for PMVs, although with a lower amplitude than for CoVs. Synchronised increases were observed between colonies, at the beginning of the birthing season in November and could be associated to the presence of immune depressed pregnant females as for CoVs, and as previously already suggested in another study investigating PMV infection dynamics in the cave . AlthougIn addition to the variations in the prevalence of bats shedding PMVs and CoVs, we also highlighted a major difference among the two viruses after the birthing season, between June and October. Indeed, PMVs were detected in the building, every year, during the austral winter, but not CoVs. This discrepancy raises questions about their maintenance in bat populations. PMVs may be maintained in bat populations by circulating in roosting habitats mostly composed by juvenile bats during the austral winter, allowing immune-depressed pregnant females to be infected at the beginning of the following birthing season. For CoVs, the maintenance could be driven by an environmental persistence of viral particles during the austral winter within the colonies, leading to yearly exposure of susceptible individuals at the beginning of the birthing season. This assumption could be supported by the detection of CoV RNA in dry guano samples up to 3 months after the bats’ departure in the cave in our previous study . HoweverMyotis myotis) maternity colony, reporting a higher prevalence and AstV shedding pulses early in the birthing season [For AstVs, no significant variation was observed in the detection of RNA throughout the birthing season. Additionally, the global prevalence was lower than for CoVs and PMVs. These results contrast with a previous longitudinal study conducted in Germany, in a Greater Mouse-eared bat (g season . These dg season .Hipposideros cervinus) [Leptospira sp. bacteria whose presence is positively associated with the presence of PMVs [Of the few co-infections detected, most involved CoVs and PMVs, and may be explained by the higher proportions of bats shedding these two viruses, as compared to AstVs. We did not report any interaction among viruses. In Borneo, a study conducted in eight tropical species reported co-infections and interactions between AstVs and CoVs in Fawn Leaf-nosed bats (ervinus) . We focuervinus) , 40. The of PMVs . Experim of PMVs , 19, andOverall, this study depicts a strong seasonality of the infection dynamics in a tropical bat population for CoVs and PMVs, but not for AstVs. Different shedding patterns between viral families were found, with predictable infection patterns among years for CoVs. We suggest that these patterns could be driven by the evolution of the population age structure and to the presence of immunologically naive individuals. These findings further underline the need to assess the drivers involved in virus transmission dynamics in bats, beyond host-related factors, by focusing on the interactions with the environment and other infectious agents. Such a global assessment is needed to explore spill-over risk associated with major shedding pulses in bat populations , 19.


Drs. Shields authored 38% of the papers. The number of citations per year was positively correlated with the number of authors, r = 0.26 (p = 0.008). The number of patients was significantly associated with the number of citations per year (p = 0.012). Although papers on radiotherapy were the most common, publications about intra-arterial chemotherapy (IAC) were associated with 88.3% more citations per year (p = 0.031) and papers on intravenous chemotherapy (IVC) were associated with 40.3% more citations per year (p= 0.04). Review and meta-analysis studies had a higher median of citations (10.5) than interventional (6.4) or observational (5.2) studies. Conclusions: This study compiles a comprehensive analysis of the most-cited articles on Rb. Studies with a higher number of citations per year were associated with IAC, which emphasizes the significance of the advances in Rb treatments that allow for the saving of eyes and vision as well as lives. Review studies had more citations than observational or interventional studies. More citations were associated with a larger number of authors or more reported patients per paper. These findings highlight the importance of collaborations to achieve relevant, high-quality research of Rb.Purpose: To summarize the characteristics and trends of interest in retinoblastoma (Rb) in the last 50 years. Methods: The Web of Science Database was used to find all studies focused on Rb published from 1970 to 2018. The term “retinoblastoma” was used to search for the 100 most cited records. Results: The mean number of citations was 153.55 ± 88.9. The majority were from the United States (US) ( Retinoblastoma (Rb) is an aggressive eye cancer of the infant retina . It is tThe purpose of this study was to identify the 100 most-cited publications on Rb throughout five decades and analyze the trends of interest in this field, providing a historical overview of the developments in the diagnosis, treatment, and follow-up of Rb patients.The Web of Science Database was searched by an experienced medical librarian (SD) for the keyword “retinoblastoma” in the title, excluding the terms “protein” and “gene,” when searching for publications in peer-reviewed journals to create the list of the 100 most frequently cited clinical articles on Rb. The search included papers in all languages published between 1970 and 2018. This search was conducted in December 2021. We chose 1970 as the first year to provide a retrospective overview of the last 48 years, and 2018 was selected as the last year to allow enough time from when the article was published until it was cited. The papers were reviewed by 5 authors . Data parameters recorded from each paper are presented in p < 0.05 was considered statistically significant. The SPSS software was used .Categorical variables were summarized as frequency and percentage. Continuous variables were summarized or reported as medians and interquartile ranges. The association between the number of citations per year and other continuous variables was evaluated using Spearman’s correlation coefficient. While the number of citations per year was compared between categories using the Kruskal–Wallis test or the Mann–Whitney test. The multivariable analysis included all variables that were significantly associated in the univariable analysis. The dependent variables and the number of participants were transformed using natural logs before applying linear regression. The linear regression was performed using the backward method. All statistical tests were two-sided, and To account for the age of the article and number of citations, the number of citations of each article was divided by the number of years since publication to solve for “number of citations per year”.n  =  29). The papers were published in 38 different journals. Twenty-seven were American, seven British, four European, and two Asian journals. The leading journals were Ophthalmology (n = 14), the British Journal of Ophthalmology (n = 11), JAMA Ophthalmology (n = 10), the Journal of Clinical Oncology (n = 7), the American Journal of Ophthalmology (n = 5), Cancer (n = 4), the American Journal of Diseases in Children (n = 3), the Proceedings of the National Academy of Sciences (n = 3), and the Current Opinion in Ophthalmology (n = 3). Eleven other journals had two publications, and all other journals had one publication. All articles were published in a Q1 journal except for six and all were written in English. The papers’ mean impact factor was 10.95± 17.14 .The 100 most cited papers on Rb from the years 1970 to 2018 were compiled . The mean = 68), the United Kingdom (n = 7), and the Netherlands (n = 7). In all parameters, the last author affiliations were similar to the first author affiliations but varied with a total of 16 different country affiliations. Most of the last authors were from the United States (US) (n = 61), the Netherlands (n = 7), and the United Kingdom (n = 6). The Wills Eye Hospital and Thomas Jefferson University were the origins of the greatest number of articles on the list (n = 21), the New York Hospital-Cornell Medical Center, New York, NY, was second (n = 7), and four or fewer papers originated in the rest of the medical institutions (n = 19 each), followed by Dr. D.H. Abramson from the Memorial Sloan Kettering Cancer Center, USA (n = 14), while all others authored eight or fewer papers (n = 6), interventional (n = 7), and review/meta-analysis (n = 7).The first authors of the papers were affiliated with institutions in 13 different countries. The majority were from the United States (US) . The mean number of citations per year was greatest when the first author was from North America  or Europe . The papers from Asia, Africa, and South America had the least citations and were grouped together for statistical analysis . When the affiliations of the first and last authors of the 100 most cited papers were compared by continent, most authors were affiliated with a North American institute (p = 0.008). Using the multivariate with backwards method, it was discovered that adding one author to each study increased the number of citations per year by 4.6% (p = 0.067).The mean number of authors for each paper was 5.7 ± 5.3 . Using univariable analysis, there was a positive correlation between the number of citations per year and the number of authors, r = 0.26 (p = 0.048). When the multivariate with backwards method was performed, the number of patients was significantly associated with the number of citations per year (p = 0.012), and an increase of 1% in the number of patients in each study was found to increase the number of citations per year by 0.1% (p = 0.012).In 75 clinical papers, the number of patients analyzed varied, with a mean of 462.2 ± 732.4 patients . When univariable analysis was performed, there was a positive correlation between the number of patients in the study and the number of citations per year, r = 0.23, (p = 0.001) and interventional studies , (p = 0.016). Fifty-eight papers were funded, and eight of those were multicenter studies.The articles were divided into three categories: observational, interventional, and review/meta-analysis. In total, 71% of the published papers were observational studies, 15% were interventional, and 14% were reviews. When comparing the article types, the review and meta-analysis studies had significantly higher citations per year  in comparison to the observational studies , (n = 67), incidence (n = 40), genetics (n = 35), pathology (n = 33), metastasis (n = 33), secondary tumors (n = 31), classification system (n = 19), diagnosis/screening (n = 13), and trilateral Rb (n = 7). The topic of treatment was further divided into methods of treatment, including radiation (n = 59), surgery (n = 50), intravenous chemotherapy (n= 48), chemoreduction with focal consolidation (n = 16), intra-arterial chemotherapy (n = 9), and vitreous body injections (n = 7). When using the multivariate with backwards method, the papers about intravenous chemotherapy were associated with 40.3% more citations per year in comparison to the papers that did not include this topic (p = 0.04). In addition, the papers on the topic of intra-arterial chemotherapy were associated with 88.3% more citations per year in comparison to the papers that did not include this topic (p = 0.031). Yet, the papers on the topic of surgical treatment were associated with 34.5% fewer citations per year in comparison to the papers that did not include this topic (p = 0.009).The topics assessed in the papers were on the following subjects: treatment . Eight of the top ten papers were affiliated with universities, nine were affiliated with hospitals, and four were funded. The type of study varied, with eight observational studies, one interventional study, and one review and data analysis. The number of authors varied from one to nine on these papers. Six of the papers discussed incidence; five papers discussed genetics; two papers discussed the classification system for Rb; seven papers discussed treatment options; and four papers discussed secondary tumors. Of the papers that discussed treatment options, six included radiation, five included intravenous chemotherapy, one discussed chemoreduction with focal consolidation, and two discussed surgery treatment. The two most cited papers on the list were on the prevention of secondary tumors.In recent years, new therapies have emerged as promising methods to salvage lives, eyes, and vision. With the constant development of imaging and surgical techniques, an abundant literature has emerged, helping to improve the diagnosis, follow-up, and treatment of Rb patients. However, the volume of literature makes it difficult to identify the papers with significant contributions. The purpose of this study was to conduct the first bibliographic study that covered the top 100 cited articles on Rb and to gain insight into the trends, novelty, and quality of the published work in the last 50 years.Two hundred and fifty to three hundred and fifty Rb cases are diagnosed each year in the USA  and the The study of Girdler et al. has identified many global collaborations involving patient referrals, consultations, and twinning/capacity building, demonstrating an extensive effort to reduce retinoblastoma mortality . Such inn = 6), 2000s (n = 7), and 2010s (n = 6). This indicates the constant contribution and relevance the Shields have had in the field of Rb research. The type of study varied with six observational, seven interventional, and seven review articles, showing the array of study methods that the Shields implement. All 19 of the respected publications by Dr. Carol and Dr. Jerry Shields included the topic of treatment interventions and covered every treatment option. This aligns with the general trend in our list of treatment intervention being the most recurring topic (n = 67), possibly due to the recent advances made in Rb treatment. The paper authored by the Shields in the top ten publications discussed Rb classification and intravenous chemotherapy, following the trend in our list: the papers that discuss intravenous chemotherapy were associated with 40.3% more citations a year. Lastly, another main topic discussed in many of the Shields’ publications was metastases (n = 11). Like the increase in publications on secondary tumors from radiotherapy, as survival rates for Rb patients increase, more metastases are being observed.All the papers on our list authored by the Shields were published between the years of 1981 and 2015. A nearly equal distribution was found between the number of papers published in the 1990s , incidence (n = 40), genetics (n = 35), pathology (n = 33), metastasis (n = 33), secondary tumors (n = 31), classification system (n = 19), diagnosis/screening (n = 13), and trilateral Rb (n = 7). Majority of the papers were on the topic of treatment. This could be explained by the advances made in Rb treatments in recent years. Intra-arterial chemotherapy is one of these advances. This method involves a single-agent injection into the ophthalmic artery under careful neuro-interventional guidance [p = 0.031). This finding emphasizes the great impact of this treatment on the Rb medical field, offering a promising new treatment associated with high rates of globe salvage. The primary goals of Rb treatment are patient survival, eye protection, and, lastly, visual function. As a result, primary enucleation is still used in some cases. In our study, the papers on the topic of surgical treatment were associated with 34.5% fewer citations per year, demonstrating this trend. Nevertheless, the papers about intravenous chemotherapy were associated with 40.3% more citations per year. This may be because many times a combination of treatments is used, including intravenous chemotherapy as induction or adjuvant therapy, explaining the abundance of citations on the subject [In our study, we found that the articles on the top of the list were published on a variety of topics, consisting of treatment . The majority were observational studies (80%) and the number of authors varied from one to nine on these papers. Treatment options were discussed in 70% of these papers, including radiation (60%) and intravenous chemotherapy (50%). This could be explained by the high concern of secondary tumors post radiation treatment in Rb patients ,21. The It may be assumed that the true impact of a study cannot be evaluated for at least two decades from its publication . In our The present study has several limitations. First, the number of citations provided by the Web of Science might not be inclusive of published publications. Other search means may have produced a different list of the most cited articles on Rb. Although the Web of Science is known to be a trusted publisher-independent global citation database, using a few search engines could enable a better validation of the 100 most-cited papers list. Second, examining the number of citations of an article is a limited and objective measure of the relevance of a study. Third, recently published studies were not included in our analysis. These studies may have greatly influenced the field of Rb but have not yet generated many citations as they have only recently been published. In this study, 2018 was determined to be the last year of publications to allow enough time from when the article was published until it was cited.In conclusion, this study demonstrated that most papers published in the US were by authors who were affiliated with US hospitals. The importance of conducting novel and significant research in the field of Rb can be seen as the improvement in the survival of Rb patients in the US has been faster than any other cancer in children or adults in the USA and can be at least partially attributed to the pioneering research work conducted in North America. The Shields, who are experts in the field of Rb, authored a remarkable 19% of the papers. Although most citations were observational, review and meta-analysis papers had more citations on average. This is likely because these study methods involved distributing large quantities of data from many papers to allow for a new understanding of the evolution of Rb treatment and follow-up, which have undergone considerable changes during the last few years. The treatment of Rb was the focus of the most cited papers. The treatment of Rb was the focus of the most cited papers on Rb. While most papers on the list dealt with radiotherapy, the papers on intravenous and intra-arterial chemotherapy were associated with more citations per year, had the greatest impact on citation rank, and were associated with the most citations per year. This emphasizes the significance of recent advances in RB treatments, which allow for the saving of eyes and vision as well as lives. Additionally, the papers with more authors or a larger number of subjects were also associated with more citations, as these papers were collaborations among many centers and even many countries, with higher external and internal validity studies. The two most cited articles on the list, with more than 400 citations each, were on secondary tumors in Rb patients, emphasizing the importance of reducing radiation exposure in these patients and a lifelong follow-up. In conclusion, the current study analyzed the 100 most cited articles on Rb in the last 50 years according to their authors, institutions, countries, and journals, to outline the cause of their important contributions to this field.


The frequency-dependent signal to noise ratio of cryo-electron microscopy data varies dramatically with the frequency and with the type of the data. During different steps of data processing, data with distinct SNR are used for calculations. Thus, specific weighting function based on the particular SNR should be designed to optimize the corresponding calculation. Here, we deduced these weighting functions by maximizing the signal to noise ratio of cross correlated coefficients. Some of our weighting functions for refinement resemble that used in the existing software packages. However, weighting functions we deduced for motion correction, particle picking and the refinement with overlapping densities differ from those employed by existing programs. Our new weighting functions may improve the calculation in these steps. Low-dose imaging however produces images with low signal-to-noise ratios (SNRs) that become a major problem in subsequent cryo-EM data processing steps.During the imaging of cryo-electron microscopy (cryo-EM) biological samples with a transmission electron microscope (TEM), proteins may undergo irreversible radiation damage  further decreases the signals exponentially with increasing frequency , other protein densities apart from that of the target protein are involved in the calculation of CCCs. These protein densities can be treated as noise but this changes the SNRs. Thus, different weighting functions need to be developed and used in the different stages of data processing. Calculating or optimizing the frequency-dependent weighting functions at different stages of cryo-EM data processing remains unresolved.In different cryo-EM data processing stages, such as motion correction, particle selection, and alignments of 2D images with a reference, cross correlation coefficients (CCCs) are usually calculated to compare two images. An accurate calculation of the CCCs has to take the frequency-dependence of SNRs into account. For instance, data with low SNRs should be multiplied by a weighting lower than those with high SNRs. Programs such as Frealign and Jalign use CTF and SNR-dominated weighting to calculate the CCCs during refinement  of a cryo-EM image and derive different weighting functions according to the different types of SSNR , an We partitioned the frequency range into three intervals of resolution depending on the value of the frequency-dependent SSNR, specifically (1) the low-resolution interval in which the SSNR is larger than 10, (2) the medium-resolution interval in which the SSNR is between 0.1 and 10, and (3) the high-resolution interval in which the SSNR is below 0.1. The assumption that SSNR et al. et al. et al. The ice-embedded proteins move during imaging as a consequence of either the irradiation of the electron beam . Thus, we assume SNR The high-resolution reconstruction of protein structures by a single-particle analysis often requires a selection of particles from micrographs. Template-based particle selection with CCC is widely used in single-particle analysis (Chen and Grigorieff k) denotes the micrograph, which contains particles in various views and noise, and M(k) isHere, n-th particle, and hence the CCC becomeswith By applying condition CTF(k)·F(k). The final optimized weighting approximates a whitening of the power spectrum of the micrograph  between two independent aligned data sets (Sindelar and Grigorieff FRC(k) denotes the 2D analog of the Fourier shell correlation, i and j index the location of the grid component in Fourier space, and the black dot "·" signifies the dot-product operation for the corresponding points on the ring of Fourier pixels.where We calculated the FRC between projections of the two half cryo-EM reconstruction of apoferritin. The images have a defocus variation from 0.4 to 2.1 μm to remove the CTF oscillations. After converting the FRC to SSNR using Eq. 23, we achieved the final estimate of the SSNR.Jing Cheng and Xinzheng Zhang declare that they have no conflict of interest.


Tumor Necrosis Factor-alpha (TNF-α) is ubiquitous in the human body and plays a significant role in various physiological and pathological processes. However, TNF-α-induced diseases remain poorly understood with limited efficacy due to the intricate nature of their mechanisms. N6-methyladenosine (m6A) methylation, a prevalent type of epigenetic modification of mRNA, primarily occurs at the post-transcriptional level and is involved in intranuclear and extranuclear mRNA metabolism. Evidence suggests that m6A methylation participates in TNF-α-induced diseases and signaling pathways associated with TNF-α. This review summarizes the involvement of TNF-α and m6A methylation regulators in various diseases, investigates the impact of m6A methylation on TNF-α-induced diseases, and puts forth potential therapeutic targets for treating TNF-α-induced diseases. Tumor Necrosis Factor-alpha (TNF-α), a cytokine ubiquitous in the human body, is pivotal in the pathogenesis of various diseases, particularly immune and inflammatory disorders. The intricate mechanisms and aggressive therapeutic interventions necessitate a further investigation of the underlying pathogenesis and potential therapeutic targets. The widespread involvement of m6A methylation in physiopathological processes is a well-established phenomenon. Recent studies have demonstrated the existence of m6A-induced gene expression regulation in various TNF-α-induced diseases. This regulation involves the participation of the writer, eraser, and reader and plays a crucial role in multiple biological processes, including RNA stability, degradation, and variable cleavage. This study aims to summarize the TNF-α-induced diseases and elucidate the relationship between signaling pathways and m6A methylation. This endeavor provides a promising opportunity to gain further insights into the role of m6A methylation in TNF-α-induced diseases and identify potential therapeutic targets.+ T cells, and Natural killer cells (NK cells), secrete TNF-α in response to endotoxin stimulation  adaptor proteins . ConversTNF-α plays an important role in physiology and pathology. Physiologically, TNF-α is a critical component of normal immune responses. TNF-α is regulated by immune system activation and has various biological activities, such as regulating inflammation, apoptosis, chemokine production, and metabolism . HoweverAutoimmune/inflammatory diseases are a series of tissue injuries caused by systemic or organ-specific inflammation . EpidemiMacrophages and Th1 cells secrete TNF-α in RA, activate synovial fibroblasts, and produce excessive cathepsins and MMPs, destroying cartilage and bone and causing joint erosion. TNF-α promotes osteoclast generation and induces synovial hyperplasia and angiogenesis. TNF-α can also produce other inflammatory cytokines and promote an inflammatory milieu in the synovium, manifesting clinically as pain and joint swelling .Stressed keratinocytes secret TNF-α and other cytokines in PS, activating DCs macrophages and neutrophil accumulation, which is pathologically characterized by parakeratosis, acanthosis, and Munro microabscesses. TNF-α also induces keratinocyte proliferation and anti-apoptosis via the NF-κB/MAPK signaling pathway .IBD primarily comprises Crohn’s disease (CD) and ulcerative colitis (UC). TNF-α induces pro-inflammatory effects, including macrophages and T cell activation, chemotaxis of neutrophils and monocytes, increased endothelial cell adhesion molecules (EcAMs) expression, and activation of coagulation and fibrinolytic responses, resulting in epithelial injury, endothelial activation, and vascular destruction. TNF-α also promotes intestinal fibrosis caused by intestinal fibroblasts, leading to intestinal strictures formation .TNF-α is a double-edged sword in cancer. When TNF-α is secreted in excess, it stimulates tumor cells to release pro-inflammatory mediators, inhibits the anti-tumor activity of immune cells, suppresses mucosal healing, and disrupts mucosal barrier function, inducing cancer cell proliferation, immune escape, invasion, angiogenesis, and metastasis . The mecm6A refers to the adenine methylation at position N6 and is a rich and extensive RNA modification, accounting for approximately 80% of all RNA methylation modifications . m6A modMammalian m6A methylation sites near the mRNA stop codon and in the 3′untranslated region (3′UTR) , non-codEnzymes involved in catalyzing and recognizing m6A modifications can be divided into writer, eraser, and reader based on their function. m6A demethylase catalyzes the reversible m6A modification process. Demethylases, primarily Fat mass and obesity-associated protein (FTO) and Alkylation repair homolog protein 5 (ALKBH5), play a role in catalyzing demethylation . FTO belThe “writer” and “eraser” of m6A act on intranuclear mRNAs, making m6A modifications dynamic and reversible. Furthermore, downstream regulation at the mRNA translation level by the “reader” is required to achieve biological function. Some m6A readers have biological roles in the nucleus. Nuclear m6A readers include nuclear ribonucleoprotein (HNRNP) A2B1/C/G, YT521-B homology (YTH) domain-containing heterogeneous proteins, such as YTHDC1 . HNRNPs Many studies have revealed that m6A methylation is involved in TNF-α-induced disease progression. It mainly involves changes in global m6A methylation, enzyme levels and activities, and TNF-α-induced pathways. in vivo and in vitro, ultimately aggravating the disease  change upon TNF-α stimulation, ultimately impacting the disease. These results suggest that m6A methylation regulators may be involved in TNF-α-induced disease progression.  disease . Zhu et  disease .in vivo. METTL3 knockdown mice significantly decreased the proportion of naive T cells differentiating into Th1 and Th17 cells and a significant increase in Th2 cells. METTL14 expression is significantly increased in diabetic nephropathy, and METTL14 overexpression leads to increased inflammatory factor secretion, such as TNF-α in serum. Mechanistically, METTL14 downregulated α-klotho expression in an m6A-dependent manner, leading to glomerular endothelial cell apoptosis in the kidneys of diabetic nephropathy (DN) patients , an FTO inhibitor, binds explicitly the pocket containing the regulatory sites of RNA methylation in LHD protein, leads to loss of FTO function, inhibits palmitate-induced cardiac inflammation, reduces CD36 expression by reducing the stability of CD36 mRNA, and inhibits inflammatory factor expressions, such as TNF-α and IL-6, thereby relieving hyperlipidemic cardiomyopathy . Emodin In summary, m6A methylation is widely involved in TNF-α-induced diseases involving various diseases and cells. TNF-α exerts its biological function primarily via nuclear factor-kappaB (NF-κB) and mitogen-activated protein kinases (MAPK) signaling pathways. Studies have revealed that the above signaling pathways are also involved in m6A methylation in other diseases.NF-κB is a eukaryotic transcription factor family with five subunits: p65 (RelA), RelB, c-Rel, p105/p50, and p100/p52. It involves various processes, such as immune response, inflammation, apoptosis, growth, and development . NF-κB sThe m6A methylation is involved in the NF-κB pathway in various diseases and impacts the disease. METTL3 has been overexpressed in RA, positively associated with disease activity. Furthermore, METTL3 inhibited LPS-induced macrophages in inflammation via NF-κB . SpecifiMAPK is a signal-regulated protein kinase important in cell proliferation, differentiation, autophagy, apoptosis, immune response, and other physiological and pathological conditions . MAPKs aThis study reviews TNF-α and TNF-α-induced diseases and summarizes the role of m6A methylation in TNF-α-induced diseases and the main signaling pathways involved in TNF-α. Moreover, an in-depth study of m6A methylation may elucidate the pathogenesis of TNF-α-induced diseases and provide more possibilities to identify potential therapeutic targets.If an m6A methylation regulator is aberrantly expressed and changes with TNF-α levels in TNF-α-induced diseases, we can search the binding sites of m6A methylation regulators to differentially expressed genes via methylated RNA immunoprecipitation sequencing (MeRIP-seq) and transcriptomic RNA sequencing (RNA-seq).2) increases m6A methylation levels significantly and induces a malignant phenotype. Silencing METTL3 reversed these changes  induces hypomethylation of the METTL3 promoter, resulting in aberrant METTL3 overexpression. The miR-25–3p promotes the pancreatic ductal adenocarcinoma (PDAC) development in smokers by inhibiting PH domain leucine-rich repeat protein phosphatase 2 (PHLPP2) and activating AKT-p70S6K . Chronic changes . Given tThus, m6A modification is a complex process working as a double-edged sword for TNF-α-medicated diseases. Does the relationship between TNF-α and m6A methylation regulators are causal or associations? Therefore, unknown regulators exist between TNF-α and m6A methylation. Furthermore, TNF-α has a dual role of cytokines and inflammatory mediators. It is also worth investigating whether TNF-α and m6A methylation regulators can influence each other between different cells. For example, in TNF-α-induced diseases that concern various immune cells, can changes in the m6A methylation regulator expression levels in one cell influence the m6A methylation regulator levels and TNF-α in another immune cell? Further exploration is needed.Modulators of m6A methylation provide novel potential therapeutic targets. If altered levels of m6A methylation regulators improve disease conditions, inhibitors/activators targeting m6A methylation regulators may provide potential therapeutic possibilities. The newly identified m6A modifiers will open novel therapeutic avenues to understand the m6A methylation-associated diseases.


The present Special Issue of Entropy, entitled "Causal Inference for Heterogeneous Data and Information Theory", covers various aspects of causal inference. The issue presents thirteen original contributions that span various topics, namely the role of instrumental variables in causal inference, the estimation of average treatment effects and the temporal causal models. Four papers are devoted to the design of novel causal models using interventions. The contributions use approaches of information theory, probability, algebraic structures, neural networks and with them related machine learning tools. The papers range from the theoretical ones, the paper applying the models, to the papers providing software tools for causal inference. All papers were peer-reviewed and accepted for publication due to their highest quality contribution. Here, we shortly preview the topics of the contributions.Instrumental variable in causal inference. Papers [. Papers ,2,3 inve. Papers  deals wiEstimating average treatment effect. Papers [. Papers ,5,6,7 de. Papers ,5 approa. Papers . In the . Papers  proposed. Papers  and usesPaper  contribuPaper  investigTemporal causal models. Papers [. Papers ,9 consid. Papers  investig. Papers  proposesPaper  deals wiCausal models and modeling under interventions. Paper [s. Paper  examiness. Paper  examinesPaper  studies Universal Causality is a mathematical framework introduced in . This woPaper  developsWe are convinced that this heterogeneous collection of outstanding papers on causal inference extends the knowledge of the community working in causal inference both in theory and practical applications. We wish the readers a lot of joy by reading.


Immune-mediated inflammatory diseases, such as rheumatoid arthritis, psoriatic arthritis, peripheral and/or axial spondyloarthritis, Crohn’s disease, and ulcerative colitis, are characterized by molecular and cellular changes in the immune system. Due to the systemic nature of these diseases, organs such as the liver or cardiovascular system are often affected by the inflammatory process. Tumor necrosis factor-α inhibitor therapy reduces the activation of pro-inflammatory signaling cascades, mitigates the chronic inflammatory process by restoring cellular balance, and alleviates clinical consequences, such as pain and tissue damage. Inflammation is a regenerative response of the body to mechanical, thermal, chemical, or radiation stimuli . Trauma The interaction of various external or internal factors, such as hormonal or genetic changes, can promote the development of an immune disease in the case of a predisposition. However, while inflammation is generally beneficial, it can also cause damage to the organ itself, especially if it is excessive, directed against healthy tissue, or becomes chronic . Such chCytokines are part of the non-specific (innate) and the specific (acquired) immune defense. They are a broad group of signaling proteins through which immune cells communicate with each other and can, thus, stimulate or inhibit immune responses. Cytokines are produced transiently and act as humoral regulators activating or deactivating cells and protecting tissues from damage . The imbThe cytokine tumor necrosis factor (TNF)-α plays a central role in the pathogenic inflammatory process. It is also recognized as a superordinate, critical hub within the hierarchical structure of cytokine networks underlying various chronic inflammatory diseases . Other pDuring inflammation, TNF-α is released by macrophages, dendritic, and lymphocytic cells. It is also secreted by mast cells, nerve cells, endothelial cells, lipocytes, heart muscle cells, fibroblasts, and lymphocytes. TNF-α triggers apoptosis, cell proliferation, and cell differentiation, but also the release of other cytokines. In the chronic inflammatory state, TNF-α shifts the predominant cytokine environment towards pro-inflammatory cytokines, such as IL-1, IL-6, IL-17, IL-22, and interferon gamma (IFN-γ), while simultaneously reducing the secretion of anti-inflammatory cytokines, in particular IL-4 and IL-10 ,13.H1) and type 17 (TH17), respectively . Pr. Pr61]. Because TNF-α inhibitors have been on the market for a long time, their safety profiles for vulnerable patient populations, such as pediatric patients, can also be extensively established. Importantly, as chronic diseases mainly last for the whole lifetime, the effect of TNF-α treatment on the further course of the disease, and also with regard to the total health of pediatric patients, is of great relevance. It is therefore worth mentioning that TNF-α inhibitors are currently the only biologic drug approved for the anti-inflammatory therapy of pediatric patients suffering from IBD.Furthermore, the early application of biologic agents significantly prevents treatment failure in pediatric IBD . In 2020TNF-α inhibitors have long been established for the treatment of JIA, and data for treatment duration of more than 10 years is available confirming its effectiveness and tolerability in children and adolescents . This unTherapeutic strategies such as “hit hard and early” and “treat-to-target”, especially with TNF-α inhibitors, can modulate the course of the disease enormously, as they have been shown to lead to drug-free remission, lower disease activity, and higher functional status, which ultimately leads to an improvement in patients’ quality of life ,65,66.In CD, the early and effective use of TNF-α inhibitors has also been shown to prevent the development of disease complications, for example, strictures or penetrating ulcerations and disease progression, which led to a lower risk of surgery during disease progression and significantly reduced the risk of penetrating complications, but not stenosing complications .RISK study demonstrates that patients treated early with TNF-α blockers regain weight and body growth is facilitated [The current study data provide evidence that treating patients with inflammatory diseases, such as CD or juvenile idiopathic arthritis (JIA), early after diagnosis with TNF-α inhibitors prevents not only disease progression, but also the loss of structural functioning and other disease complications ,67. Espeilitated . TNF-α iilitated .This concept of a “window of opportunity”, meaning that early treatment with TNF-α inhibitors can impact the further disease course, is also established in adult patients suffering from RA, PsA, and CD . In PsA,At present, research is being performed in order to find the most suitable treatment options for the individual patient in clinical practice. As direct head-to-head studies are scarce, several network meta-analyses have compared the various agents approved for their therapeutic utility in treating several inflammatory diseases, i.e., IBD, ankylosing spondylitis (AS), RA, and PsA.TNF-α inhibitors have proved that they continue to have an enormous relevance in the therapeutic landscape and are still established as therapeutics to control chronic inflammatory diseases despite, the era of newly developed types of treatment. This becomes evident when the different mechanisms of action are examined and compared with regard to their safety profiles and effectiveness.JAK-pot study analyzed the real world data of four classes  of second-line treatment approved for RA [The observational cohort d for RA . Their eAs such, a recent study highlighted the importance of TNF-α inhibitors in AS therapy, showing that TNF-α inhibitors were superior to IL-6, -17, -23, and JAK inhibitors regarding efficacy and safety and should be used as the preferred replacement for conventional drug therapy in patients suffering from a rapid disease progression and physical functional limitations . For theComparative studies on therapies for IBD also reflect these results, confirming the importance of TNF-α inhibitors for the treatment of inflammatory diseases. In a post-hoc analysis of pivotal clinical trials, the efficacy of biologic agents was investigated for achieving endoscopic healing in CD. The comparison revealed that both tested TNF-α blockers  were superior to vedolizumab and ustekinumab for achieving endoscopic healing of the ileum and colon in patients with CD . ConsistMoreover, the neutralization of a single pro-inflammatory cytokine, such as TNF-α, can directly lead to the improvement of symptoms, such as pain. Pain is of enormous relevance to people with RA. TNF-α has previously been regarded as a mediator of pain due to its involvement in mechanical hyperalgesia after injury . Hess anCavanagh and colleagues were able to show that the pathologically increased neuronal activity caused by peripheral inflammation in the brain can be rapidly downregulated by TNF-α inhibitors. This is underpinned by positron emission tomography studies. There is also evidence that TNF-α inhibitors alter serotonin transporter expression in the brain .The fact that TNF-α inhibitors have pain-relieving properties is another important feature in addition to inflammation control and the preservation of structural integrity, thus leading to a direct improvement in quality of life in patients.Over the years, TNF-α inhibitors’ safety profile has also been established during pregnancy and lactation. Based on the currently available study data from IBD and on rheumatic indications, TNF-α inhibitors seem to be safe and effective without a significant maternal or fetal risk  ,80,81.Presumably, this is due to the low placental transfer, i.e., of certolizumab pegol, with suggested comparable safety for etanercept .As a result of immunosuppression, patients undergoing anti-inflammatory therapy are susceptible to infections caused by bacteria, fungi, or viruses. Therapy with TNF-α inhibitors can result in the reactivation of latent infections, such as tuberculosis or the hepatitis B virus. Thus, patients need to be screened for latent infections prior to the initiation of the TNF-α therapy in order to reduce the risk of reactivations . Active Further, this systemic immunomodulation mediated by TNF-α inhibitors may lead to unpredictable reactions to vaccinations; thus, patients under TNF-α therapy should not be vaccinated with live vaccines.The long approval history of TNF-α inhibitors has allowed us to gain valuable insights into their long-term application. Clinical data registries are available reporting the long-term effects, which are essential to monitor the further implications or side effects of therapy that may have not become apparent for several years, such as cancer. A recent network meta-analysis assessed the risk of malignancies (such as non-melanoma skin cancer and lymphoma), tuberculosis, and infections in RA patients with different TNF-α therapies. According to their findings, none of the 10 studied anti-TNF therapies resulted in an increased risk of serious infections, malignant tumors, and tuberculosis infection compared to placebo or conventional DMARDs therapy . FurtherDue to the existing overlap of the involved signaling pathways and disease patterns, it is also possible that not only the initial manifestation influences the development and pathology of a further chronic inflammation, i.e., along the gut-liver, gut-joint, and gut-brain axes, but also that the therapeutic modulation of one disease has an impact on other organ systems . For TNFWhen comparing the effectiveness of TNF-α inhibitors and advanced therapies with other modes of action indicated for chronic inflammatory diseases, practical experience and data on the outcomes of the long-term therapeutical use of recently approved therapies are very limited, thus, data collection on efficacy and safety is needed in order to make an optimal treatment choice. Through years of experience, the safety profile of TNF-α inhibitors is well established and has even been described during pregnancy, breastfeeding, and in pediatric patients. Consequently, treatment guidelines for IBD and rheumatic diseases have been adapted accordingly and include TNF-α inhibitors in their recommendations, making TNF-α inhibitors an important option in the therapeutic landscape.Therapy with a TNF-α inhibitor has manifold effects: it effectively controls inflammation, can result in the preservation of structures, and it reduces pain . TNF-α iBased on the multiple effects of blocking TNF-α, an earlier use in the therapy algorithm has been discussed in order to benefit from the positive effects of TNF-α therapy at an earlier stage of disease. TNF-α inhibitors, when used early after disease diagnosis, can positively impact the course of disease by preventing structural damage and the development of comorbidities. This is of great relevance for preserving physical function and activities, eventually leading to an increased quality of life for patients. For vulnerable patient populations, for example, pediatric patients needing long-term medical treatment, drug tolerability and safety should be considered in addition to effectively controlling disease activity.Treatment strategies regarding the early initiation of biologics and their withdrawal upon reaching deep remission, or even discontinuation of a less effective immunomodulator, continue to be discussed in the field of chronic inflammatory diseases. The de-intensification of an anti-TNF-α treatment for patients in long-term remission may represent a goal to achieve in different clinical scenarios and aspects. De-escalation strategies may include a dose reduction or a lengthening of the drug administration intervals while maintaining the same clinical effects. In a recent systematic review, results from 20 TNF-α inhibitor de-escalation studies (14 RCTs and six non-RCTS) determining the actual reduction in the occurrence of adverse events when de-escalating the existing therapy in different inflammatory conditions, such as psoriasis, axSpA, RA, and IBD, were summarized.  While thRheumatoid Arthritis in Ongoing Remission (RETRO) study did demonstrate a successful dose reduction or even complete withdrawal of DMARDs in about half of the RA patients, meaning that their status of disease remission could be maintained without a decline in physical function [The function ,87.Dose tapering always bears the risk of disease relapse; thus, a tight monitoring of the individual disease activity is required, as reported in a systematic review by Little et al. and also in the meta-analysis by Zhang et al. ,89. A reAlthough data on the long-term outcomes of patients with CD after infliximab withdrawal are limited, long-term follow-up results over 7 years from the STORI cohort showed that about one-fifth of the patients did not restart infliximab or another biologic agent, and this did not result in major complications. Of note, 70% of the patients had no failure with the de-escalation strategy, meaning no development of a major complication and no failure of the re-initiation of infliximab therapy . In mostGomes et al. proposed that TDM may support attempts at drug withdrawal by providing guidance for the physician on whether to stop the immunomodulator or the TNF-α inhibitor when a combination therapy is used .In line with the aforementioned meta-analyses, the results of the SPARE trial were recently published by Louis et al. and reported that in CD patients in sustained steroid-free remission undergoing combination therapy with infliximab and an immunomodulating drug, the withdrawal of infliximab should only be considered after a careful assessment of the risks and benefits for the individual patient, whereas the withdrawal of the immunomodulatory drug could generally represent the preferred strategy .Taken together, as there are no guidelines available for the tapering or discontinuation of current treatments of inflammatory diseases, we suggest that tapering DMARDs should, for one, be based on shared decision making with the patient being allowed to find individual ways of reducing the drug burden, as is currently shown for RA patients.Further, to avoid the worsening of disease activity or quality of life following the drug tapering, a close monitoring of these patients should be conducted, i.e., by employing biomarkers of inflammation, such as fecal calprotectin in the case of IBD to predict a disease relapse after anti-TNF-α withdrawal or de-escalation.Because of all these reasons, early therapy with TNF-α inhibitors seems to be important for patients with chronic inflammatory diseases. With the introduction of biosimilars, this formerly very expensive therapy has been made affordable, allowing more patients to receive this important treatment. In daily practice, substantial cost savings to the healthcare system are possible if biological-naive patients are initially treated with biosimilars, or if patients who already receive the reference biological DMARDs (bDMARDs) are switched to the corresponding biosimilar product . The reaDespite their “age” and the era of newer modes of action, TNF-α inhibitors continue to be a central and proven component of the therapeutic armamentarium in chronic inflammatory diseases with easily manageable possible side effects. Therapy with a TNF-α inhibitor has manifold effects, thus, making it an inevitable part of the landscape of anti-inflammatory therapies. By modulating molecular and cellular features, TNF-α inhibitors control inflammation by reversing the inflammatory processes. Thus, TNF-α-inhibitor therapy leads to an effective reduction in inflammation, resulting in preserving organic and structural integrity and controlling pain, resulting in a better quality of life for patients.


For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare.We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals.The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships.We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support. Still, In general, the definition of SMI consists of three criteria: a psychiatric diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, illness duration of more than 2 years, and disability in functioning . A subgrDifferent services for mental health conditions have traditionally been separate from other services such as physical healthcare and social services. However, there is increasing emphasis internationally on developing a whole-system approach to improve the integration of these services to maximize an individual’s quality of life and social inclusion by encouraging their skills, promoting independence and autonomy to give them hope for the future. That leads to successful community living through appropriate support, with particular focus on patient-centered development and delivery . FurtherIn this literature review, we focus on all services for persons with SMI which are living independently in the community. These services aim to support these people in their daily life. This includes services initiated by treatment organizations, such as ambulatory interdisciplinary teams, as well as by welfare and supported housing organizations. Following McPherson et al. , who devCurrently, there is a lack of research about what is needed to successfully provide this type of intensive support for people with SMI, and especially about how this support can be organized as an integrated community-based mental healthcare approach, including housing, rehabilitation, citizenship, all areas of recovery, empowerment, autonomy, and decision-making power. We aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision and empirical findings on the ingredients of community mental healthcare. To do so, we will look in this review for both empirical evidence, as well as leading concepts in this research topic. The findings of this study contribute to the further development of community-based mental healthcare for persons with SMI and high-volume healthcare needs. This paper will address the following question: What are the current insights  regarding a community mental healthcare system to support all persons with SMI in their independent living and recovery, and stimulate further social inclusion?This review follows the PRISMA guidelines for scoping reviews . The com2.2.1.We performed a scoping review, following the steps of the framework of Arksey and O’Malley : (a) ide2.2.2.2.1.We included papers published in English from January 2011 to December 2022 in peer-reviewed journals, aimed at 18 years and older adults with severe mental illness, focusing on stimulating independent living, integrated care, recovery, and social inclusion. For reasons of comparability, and fit in Western healthcare systems, studies were included if they were conducted in Western countries only . Finally, all study designs were included, and we also included papers about interventions related to collaboration.2.2.2.Studies were excluded if (a) they primarily focused on treatment without support or care, (b) social inclusion or recovery was not the aim, (c) they focused on interventions that concentrated on one area of life and did not provide an integrated offering, or (d) if they focused on psychometric or physical diseases.2.3.To find the right search terms for our search, we used the program Research Rabbit. This program helps to explore the literature of a research topic and links authors and papers on the same topic to each other. Before conducting the search, the research team determined the eight most relevant papers on this topic and added them to the program. With the function “similar work,” we added another eight relevant papers. We formulated and combined search terms concerning: (a) population ; (b) the setting ; (c) outcomes ; and (d) contemporary paradigm . To reduce the number of irrelevant studies, exclusion terms based on the eligibility criteria were added to the search strategy .Journal of Integrated Care and the Community Mental Health Journal published in the same period (2011–2021) were reviewed. Finally, we added several papers manually in consensus with our research group that were found lacking in the results, but which did meet the inclusion criteria.We systematically searched the following electronic databases: PubMed, PsycInfo, Medline, and Cinahl . These databases were chosen to cover medical (PubMed and Medline), psychological (PsycInfo), and nursing (Cinahl) literature. After the database search, we reviewed the reference lists from papers included by title and abstract to find missing important papers, and additionally, the volumes of the 2.4.After the removal of duplicate papers by the first author, the papers were screened in three rounds. In the title, abstract, full-text screenings phase, and thematic analysis, the first author screened all the hits and the second and third authors screened a random sample of 5% to ensure, and reach consensus on, fidelity to the inclusion criteria.2.5.A qualitative synthesis of included studies was performed using the method of thematic analysis. All papers were screened on elements of relevance (or ingredients needed) for current community mental healthcare with the aim to support persons with SMI in their independent living, recovery, and to stimulate further social inclusion. All papers were coded, and codes were synthesized into areas of ingredients.3.First, we present the descriptives in a PRISMA flow diagram, and a summary of the characteristics and quality of the studies included. Second, we present the results of our qualitative synthesis using thematic analysis.3.1.After the removal of duplicates and screening all papers on the title, abstract, and full text, the final sample consisted of 56 papers. n = 8), 2020 (n = 7), and 2021 (n = 9). Most of the papers were conducted in the United States (n = 17). Twenty-seven of the included papers were conducted primarily in Europe; the majority in the United Kingdom (n = 7), Netherlands (n = 5), and Sweden (n = 5). Four papers compared the situations in two countries: Australia and England, England and Italy, England and North Macedonia, and Canada and the United States. Other regions are Canada (n = 3) and Australia (n = 3). Four papers did not report their country, because they did not focus their research specifically on a country. We included 12 reviews, including three scoping reviews and four systematic reviews. In addition, we included 19 quantitative papers, including five RCTs and seven papers with a longitudinal design. We included 20 papers with a qualitative design, of which six were evaluative papers, seven opinion papers and seven descriptive papers. Finally, we included three mixed-methods studies and five expert papers. The 56 papers were published spread throughout our time frame, but by far the most papers were conducted in 2018  assertive community treatment ((F)ACT) teams. We found mainly empirical studies about the implementation and efficacy of (F)ACT and collaboration with (F)ACT teams. Of these, we found two reviews , 33, one3.2.2.Collaboration inside and outside the mental healthcare organization was studied in 20 of the included papers. Three were reviews, two were qualitative longitudinal studies, one was a quantitative longitudinal paper, three were qualitative evaluative papers, three were qualitative opinion papers, two were qualitative descriptive papers, two were mixed-method papers, and four were expert papers.Intersectoral collaboration is often mentioned in the literature found. The collaboration between mental healthcare, physical care, and social service sectors was found in four qualitative papers , 48, 49 Growing evidence shows that integrative care is the new standard of care for people with mental illnesses, with the necessity of continuity of care from the emergency department to community mental health services. Continuity of care was found in two scoping reviews , 54, oneFinally, two qualitative papers , 61 and 3.2.3.Several aspects of health were studied in 18 of the included papers. Of these 15 papers, one was a systematic-meta review, two were quantitative longitudinal papers, one was a cross-sectional paper, eight were qualitative opinion papers, two were mixed-method papers, and four were expert papers.Eight papers mention the focus on physical health in mental healthcare. Three qualitative, one mixed-method, and one quantitative paper report on the integration of physical health in mental healthcare , 65, 66.Another important aspect of health is cognitive functioning, which was found in two papers. One qualitative study mentioned that cognitive and physical health conditions might impact individuals’ ability to function in their daily lives during and after homelessness . In addiIn addition, we found two papers on psychosocial health. One quantitative study indicates that investment by teams to improve a patient’s psychosocial situation can lead to improvements in substance problems  and one Also, three qualitative papers , 68, 69 Finally, two expert papers emphasize public health as actions seek to achieve equity between groups and a state of population-level health , 53.One 3.2.4.Promoting full citizenship was a topic of relevance in 14 of the included papers. Three were reviews, two were RCTs, two were qualitative evaluative papers, one was a qualitative opinion paper, two were qualitative descriptive papers, and four were expert papers.Human rights and destigmatization contribute to promoting full citizenship and are addressed in six papers , 63, 82.In addition, several papers describe the Resource Group methodology that also promotes citizenship because the main feature of this methodology is that ownership and direction lie with the client. Of the included studies, there were two RCTs , 74 with3.2.5.Recovery of daily life was studied in 12 of the included papers. Of these 10 papers, one was a quantitative cross-sectional paper, one was a qualitative opinion paper, four were qualitative descriptive papers and four were expert papers.in vivo. Moreover, two expert papers mention that signpost self-care options  find accessible and acceptable , 63, 80 3.2.8.Well-trained staff came up as important in eight of the included papers. Of these papers, there were two reviews, one quantitative cross-sectional paper, two qualitative descriptive papers, one mixed-method study, and two expert papers.Two papers reported on education for mental healthcare staff. One review found that education for staff regarding identifying and responding to comorbidity is important .One qual3.2.9.Using digital technologies was studied in seven of the included papers. Of these seven papers, three were reviews, one was a qualitative descriptive paper, one was a mixed-method study, and two were expert papers.One scoping review  found th3.2.10.Housing and living environment came up as important in five of the included papers. Two were reviews, one was a quantitative cross-sectional paper, one was a qualitative descriptive paper, and one was an expert paper.One review  describeFurthermore, one expert paper  and one 3.2.11.Sustainable policies and funding came up as important in four of the included papers. Of these four papers, one was a scoping review, one was a qualitative descriptive paper, and two were expert papers.One expert paper states that the integration of community mental healthcare services, sectors, and collaboration with the social network of the service user can be hindered by a financing system that favors institutional care. Therefore, it is recommended to create a flexible financing system that allows incentives for different services that address the relevant life domains of people with SMI in the community . Another3.2.12.Reciprocity in relationships is a topic of interest in three of the included papers. Of these three papers, one was a qualitative opinion paper, one was a qualitative descriptive paper, and one was an expert paper.This topic is about the reciprocity in relationships between clients and caregivers, but also in contributions to society by all people. One qualitative paper shows the importance of establishing and maintaining contact between the caregiver with the service user, by building a mutual relationship of trust . Therefo4.4.1.With this scoping review, we aimed to give a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision explained in areas of ingredients. To our knowledge, there are still a few publications that attempt to combine all the necessary elements for community mental health , 83, 84.We aimed to give an overview of the existing and upcoming insights on community mental healthcare for people with SMI. Based on the number of papers found, most attention is paid to several aspects of health, multidisciplinary teams, collaboration within and outside the organization, collaboration with the social network, and supporting full citizenship. However, empirical evidence from quantitative studies was found in only four of the 12 areas based on our included papers: multidisciplinary teams; collaboration with the social network; collaboration within and outside the organization; and supporting full citizenship. Nevertheless, the other areas that are not yet supported by evidence in this scoping review are no less important for community mental healthcare. Although no empirical research has yet been done on these topics, they are being addressed in several papers. This shows that there is increasing attention to them in the field.Notably, given the low number of included empirical studies from the welfare or supported housing sector, we can conclude that little empirical research has been done on community mental healthcare in these sectors for this target group. The few empirical studies we from the mental health care sector and were primarily about (F)ACT and the Resource Group methodology. Even though (F)ACT has been around for a few decades, this shows that for the last 10 years (F)ACT has remained an important model within community mental healthcare for this target group to achieve recovery. Additionally, given the number of papers reporting on it and the evidence provided, collaborative mental healthcare within teams, organizations, and clients and their social network has been seen as important over the past decade.In addition to the topics found that received attention for more than 10 years within community mental healthcare, such as recovery, tailored support, and multidisciplinary teams, we found several papers that are about more recent and innovative areas. Such as, reciprocity in relationships; sustainable policy and funding; using digital technologies; and supporting full citizenship. The results from this scoping review show that in recent years new shifts are taking place in the field of mental healthcare, whereby there is more attention paid to full citizenship, but empirical research is still lacking. Further, the more innovative areas were published in more recent literature, but frequently in expert papers. Due to the few RCTs found, we cannot conclude that these areas are also the most important, but we could say that these areas can form the basis for further research in community-based mental healthcare to provide social inclusion and recovery in the future.Recovery was one of our research terms and we expected recovery to be an important part of our scoping review because more and more studies have been conducted on the areas of recovery. Ten included papers reported on the recovery of daily life, but no empirical studies were found on that topic. This is probably due to the exclusion of intervention studies that focus on a single life domain and did not seek collaboration, which is often the case in studies of recovery and all aspects of health. The upcoming attention to recovery-based care for persons with SMI is also shown in recent scoping reviews. Bitter et al. , in theiFurther, we found many papers concerning multidisciplinary teams. Peer supporters , 51, 53,Additionally, intersectoral collaboration appears regularly in the literature. First, several papers studied the collaboration with primary care to provide the physical health of people with SMI and the importance of attention being paid to clients’ physical health in mental healthcare. This builds on previous research that shows that people with SMI experience premature mortality of around 15–20 years earlier than the general population , have a Intersectoral collaboration is often recommended in the literature found, but, notably, the literature found does not elaborate on what integrated collaboration should look like in practice. Possibly that is because other literature confirms that this collaboration is not easy to achieve . IntegraIn recent years, citizenship for people with (severe) mental health problems is a topic that has received increasing attention . CitizenInternational Journal of Integrated Care and Community Mental Health Journal. Remarkably, the term “SMI” appears just once in the titles and abstracts of the volumes of 2011–2021 of the first journal. Moreover, in the Community Mental Health Journal we found several papers about community care, but only a few in combination with SMI. This confirms the idea that little research has been done on this topic. Besides that, many papers also seem to be written from the point of view of the mental healthcare sector. Loneliness, debts, and poverty are important topics in community care, but there does not yet seem to be much published about these main topics in social services because they did not show up in the results of the papers found. In addition, research in the shelter and supported housing sector is still limited  work, and papers primarily focused on recovery. Nevertheless, interventions are the important link between theory and practice and are worth mentioning. The literature proves their importance because of the many available interventions for this target group to improve, for example, lifestyle , 101, inFinally, it was difficult to compare the papers. One example is the difficulty of comparison in the context of national differences in legal frameworks and public policies. Not every recommendation could be implied in all societies. We tried to take this into account to some extent by including only Western literature. In addition, for both the target group and the outpatient setting, a very varied vocabulary is used in the various papers and the general terms do not mean the same in every article. First, the term “supported housing” is used for support to people in a 24/7 aggregated setting, but also with regard to clients who live independently in the community with 24/7 available support, which is what we were looking for. Second, the term “SMI” is interpreted differently. Some papers are limited to clients with schizophrenia and bipolar disorder, while other papers focus more on autism and anxiety. Other requirements for SMI are also handled differently. Several papers seem to focus more on common mental illnesses rather than SMI. This makes it hard to compare and generalize the different papers on this topic. Previous research has already indicated that varying terminology is used internationally to describe the different housing settings and approaches to the provision of housing and support . Further4.2.The main strength of our review is the broad and systematic search. We used several search strategies, including database search, hand-searching the reference lists and leading journals to find as complete an overview as possible of all papers on our topic. We have done everything possible to find all relevant papers from the past 10 years. To ensure that we did not miss innovative topics, we did not choose certain study designs as inclusion criteria. This also has the advantage that we could find enough papers. As a result, there are large differences between the study designs in the papers. This creates more difficulties when comparing the papers and ingredients. It is hard to conclude which ingredient is more important for community-based mental healthcare than another. Nevertheless, to the best of our knowledge, this is the first scoping review on all developments in community mental healthcare and gives a good overview of the current relevant topics. Notably, less than half of the included papers are empirical studies, and a large part of the included papers was composed of descriptive or opinion papers. More empirical research is needed on this subject.Conducting a scoping review provides a broad view of the literature, but it also has some limitations. One of these includes the search terms. With these search terms, it was not possible to find everything in the field through database search due to the variation in terminology, and in recent years the main focus of the research has been on individual interventions. Despite all efforts, including the Research Rabbit software and hand-search, there is still the possibility that we missed some relevant papers. The second limitation of our study is the generalizability of the conclusions. We did not use search terms in our search strategy to find specific themes, such as citizenship and social work, but these themes are related to our search terms recovery, participation, social inclusion, and empowerment. The final limitation concerns citizenship. Despite the increasing attention being paid to citizenship in the scientific literature, we included only a few citizenship papers. Due to the target population of our broader study, we only included papers on adults with SMI while the citizenship papers focus on (common) mental illness. Nevertheless, the focus on citizenship is a relevant development that deserves attention in this scoping review.5.This scoping review aimed to give a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision in the areas of ingredients. We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention paid to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. No earlier, international study has connected all the current elements of good community mental healthcare together. Thus, our research contributes to the existing research and adds value to future research on community-based mental healthcare. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.CvG contributed to the development of the search question and strategies, screening papers and analysis, and to the main part of the manuscript. DR and MvV participated in the development of the search question and strategies, participated in screening papers, the thematic analysis, and writing the manuscript. JvW and TvR participated in the development of the search question, strategies, and supervised advancement of the project. All authors contributed to the article and approved the submitted version.This scoping review belongs to a broader project which received ethical approval from the Ethics Review Board Tilburg School of Social and Behavioral Sciences and was funded by three organizations for supported housing and shelter in Netherlands: Kwintes, Leviaan, and HVO Querido.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The loss of teeth, associated with sunken lips and cheeks, has a debilitating psychological effect on a person. It is essential for clinicians to incorporate facial esthetics into their treatment plan for complete denture patients in order to improve the patients’ confidence and quality of life. Cheek plumpers ensure adequate support to facial muscles, which, in turn, minimizes the appearance of wrinkles, lines, and sagging over time. This case report describes the fabrication of detachable cheek plumpers using magnets to enhance the facial esthetics of a completely edentulous patient. Magnet-retained cheek plumpers, being small and lightweight, allow ease of placement and cleaning without the addition of weight to the prosthesis. Facial esthetics is increasingly seen as an important factor for the overall health and well-being of individuals . NaturalWith aging, the processes and functions of our bodies change. One of the most affected parts is the midface area, considered to be the most prominent facial region. Aging comes with changes in not only how these areas look but also in how they function. This causes several age-related ailments such as wrinkles, sagging cheeks and lips, and volume loss .Cheek plumper, also known as the cheek lifting appliance, provides an effective way of lifting and supporting the cheeks. It is a type of prosthesis that acts as a foundation for the facial structure, providing support and structure to the face -8. It isThe detachable cheek plumpers provide advantages over the conventional, undetachable ones. The ability to easily attach and remove them offers convenience, control, and comfort . They prThis case report describes the fabrication of detachable cheek plumpers using magnets to enhance the facial esthetics of a completely edentulous patient.A 65-year-old female patient with no history of trauma presented to the department of prosthodontics for the replacement of missing teeth that had resulted in the inability to eat. The patient also complained of sunken cheeks Figure .The history of the patient revealed that she lost the teeth gradually over a period of four years after they became mobile. She was edentulous for a period of two years. On intra-oral examination, the patient was found to have moderately resorbed maxillary and mandibular edentulous ridges. Extraoral examination revealed sunken cheeks and unsupported oral musculature. The patient’s straightforward request was to improve facial esthetics while replacing the missing teeth. Various treatment options were discussed with the patient, subsequent to which she opted for a removable complete denture with detachable cheek plumpers.All steps in complete denture fabrication were completed to the try-in stage. At the try-in stage, cheek plumpers were made in wax as separate portions on the buccal surface of the complete trial denture Figure .The cheek plumpers were superficially attached to the buccal surfaces on the right and left sides and tried in the mouth to determine the amount of desired cheek support appropriate for comfort, function, and esthetics. Once this was determined, they were again separated from the complete denture. The dentures and cheek plumpers were processed separately. Button magnets  that were encased in steel casing were then placed in each of the hollowed buccal extensions using self-cure acrylic Figure .Corresponding to this buccal extension, hollowed cavities were made on the buccal surface of the denture on the right and left sides approximately in the molar region. Magnets were then placed in these cavities using self-cure acrylic resin and care was taken to align the poles properly. The cheek plumpers snapped into position as a result of strong, attractive forces between the magnet in the polished buccal surface of the denture and the intaglio surface of the buccal extension. During denture delivery, the patient was educated on how to insert the denture and cheek plumpers Figure .The patient was asked to insert the complete denture followed by a cheek plumper on either side Figure .Periodic follow-up revealed that the patient adjusted very well to the prosthesis.Loss of teeth, associated with sunken lips and cheeks, has a debilitating psychological effect on a person . Proper Detachable cheek plumpers provide multiple advantages such as easy insertion and removal, reduced height, prevention of muscle fatigue, and easier cleaning. The patient can wear the dentures even without cheek plumpers if muscle fatigue sets in. Various attachments such as press buttons , double Magnet-retained cheek plumpers can be discretely and easily worn due to their lightweight . The pluLimitation of magnet retained cheek plumpers are magnets that cannot be used on patients who are allergic to metal. Patients should be informed that the magnetic field used in magnetic resonance imaging (MRI) tests causes damage to the magnetic assembly. For MRI tests, patients must remove their dentures. The magnetic assembly should be kept away from temperatures exceeding 150°C.Reconstructive plastic surgery, injections of botulinum toxin, and tightening procedures such as laser resurfacing are all known to be effective methods for correction . HoweverThe functioning of various muscles in the face is hindered when the lips and cheeks are not supported. This leads to wrinkles and a sagging appearance of the lips and cheeks. This case report presents a successful management of sunken cheeks using detachable magnet-retained cheek plumpers. Magnet-retained cheek plumpers, being small and lightweight, allow ease of placement and cleaning in the mouth without the addition of weight to the prosthesis.