Standard game theory cannot explain the selection of payoff-dominant outcomes that are best for all players in common-interest games. Theories of team reasoning can explain why such mutualistic cooperation is rational. They propose that teams can be agents and that individuals in teams can adopt a distinctive mode of reasoning that enables them to do their part in achieving Pareto-dominant outcomes. We show that it can be rational to play payoff-dominant outcomes, given that an agent group identifies. We compare team reasoning to other theories that have been proposed to explain how people can achieve payoff-dominant outcomes, especially with respect to rationality. Some authors have hoped that it would be possible to develop an argument that it is rational to group identify. We identify some large—probably insuperable—problems with this project and sketch some more promising approaches, whereby the normativity of group identification rests on morality. An outcome is payoff dominant if all players receive a higher payoff than in any other outcome. Nash equilibrium is the central solution concept for non-cooperative game theory and all that it can predict in a game with multiple equilibria is that one of the equilibria should be chosen. If there are outcomes that are Nash equilibria but not payoff dominant, then game theory cannot explain why the payoff-dominant outcome would be played. Further, an outcome is Pareto-dominated if there is another outcome that makes at least one player better off and where no players are worse off. The Nash Equilibrium of a game may be Pareto-dominated by another outcome, but if that outcome is not a Nash equilibrium, then game theory actually predicts that it will not be played.Game theory is used to explain people’s choices, it both predicts behaviour in strategic situations and provides normative standards for rational play. However, it fails completely in certain elementary cases. It is unable to explain strategic coordination and forms of collective rationality that are familiar features of human strategic interaction. In particular, standard game theory seems powerless to explain the phenomenon where people choose mutualistic cooperation because all the individuals involved in the interaction benefit immediately, as opposed to the altruistic cooperation found in games like the prisoner’s dilemma, where cooperation brings benefits to others but at an individual cost. Intuitively, it seems obvious that mutualistic cooperation to achieve the Pareto dominant outcome should be the rational choice in common interest games. However, a principle of rational mutualistic cooperation cannot be derived from the assumptions of standard game theory.There is a vast literature on cooperation, most of it focused on the Prisoner’s Dilemma, where unilateral defection yields a higher payoff than joint cooperation, so the Nash equilibrium is Pareto-dominated. An interesting and arguably more basic problem is how players coordinate on mutually beneficial equilibria in common interest games, where there is a unique outcome whose payoffs strictly Pareto dominate all other outcomes in the game , this must necessarily be a Nash equilibrium. To see why this is so, we can draw on an important indirect argument set out by von Neumann and Morgenstern  and  are Nash equilibria, and  is strongly payoff-dominant over , as in the Stag Hunt game. Any 2 × 2 game that has positive payoffs  and  in the main diagonal and zero payoffs elsewhere is a Hi-Lo game, provided that R > P > 0.The Hi-Lo game shown in Fig. In the Hi-Lo game, there is no complication arising from risk dominance, and H seems the obviously rational strategy choice. But, again, each player has a reason to choose H if and only if there is a reason to expect the co-player to choose it also, and there can be no such reason, because the co-player has a reason to choose H if and only if there is a reason to expect the first player to choose it. We are stuck in a vicious circle that provides neither player with any reason, based on the standard assumptions of game theory, to prefer H to L.In spite of this vicious circle, the Hi-Lo game induces a powerful intuition in human decision makers that H is the rational choice, and experimental evidence confirms that virtually all players choose it . However, they are all generally agreed to be flawed.payoff-dominance principle. According to this principle, rational players choose payoff-dominant equilibria whenever they exist. However, this provides no insight into the phenomenon it is designed to accommodate, and Harsanyi and Selten acknowledged it to be an unsatisfactory and temporary workaround.Harsanyi and Selten  outcome in the Hi-Lo game is a focal point by virtue of the fact that it conspicuously offers higher payoffs than any other outcome.A t” Lewis . Many det” Lewis  showed tHowever, while salience might be part of a psychological explanation of coordination, it is not enough to ground a rational H-choice. Salience singles out a combination of actions as being conspicuous. In order for it to give players a reason to play H, it must single out a combination of actions as being the one that the player should do her part in. So we must ask why the conspicuous combination is the one in which the agent personally has reason to do her part. In answering why the agent has reason to do her part, we cannot appeal to salience, as that would be circular Gilbert .Any attempt to derive, from the standard assumptions, a reason for choosing a strategy associated with the payoff-dominant equilibrium generates a version of this vicious circle. This is now generally acknowledged by game theorists  is that, if there is no evidence favouring one possibility over another, then we should assign them the same probability. As applied to the Hi-Lo game, the principle of indifference suggests that, since Player 1 (for example) has no reason to expect Player 2 to choose H or L in the Hi-Lo game, then Player 1 should assign equal probabilities to each of these choices. Under that assumption, Player 1’s expected payoff from choosing H is obviously higher than from choosing L, because ½(2) + ½(0) = 1 and ½(0) + ½(1) = ½, therefore Player 1 will choose the expected-payoff-maximizing strategy H.with certainty, and that contradicts the assumption on which Player 1’s argument for choosing H is based, namely that Player 2 is equally likely to choose H or L.This argument is fallacious because the problem is not one of individual decision making, where standard decision theory and simple expected utility maximization apply: Player 2 is not indifferent Nature but an intelligent player who can and will formulate and respond to expectations about Player 1’s intentions. If the argument from the principle of indifference were valid, then by the common knowledge assumption, Player 2 would anticipate Player 1’s choice of H and would choose a best reply to it, namely H. But this means that Player 2 would choose H Closely related fallacies based on probabilities are discussed in greater depth by Colman et al. .What do I want? and, given my knowledge of the game and my expectations of what my co-player(s) will do, What should I do to achieve this? Team reasoning alters the unit of agency from the individual to the pair or more generally the group of players by allowing each player to ask What do we want? and What should I do to play my part in achieving this? Team-reasoning players first search for an outcome that would be best for the group of players; if such an outcome exists and is unique, then they identify and play their component strategies of the jointly optimal strategy profile.According to theories of team reasoning, players solve common-interest games like Hi-Lo or Stag Hunt by adopting a distinctive mode of reasoning from preferences to strategy choices  preferences. There is also an agency transformation, with the group of players being treated as a single entity. The agency transformation is essential to solving common interest games. To see this, consider the two-player Hi-Lo game. A theory that only involved payoff transformations and not agency transformations would not change the recommendations of standard game theory. Imagine that the players each care about the other player’s outcome and that they apply some weight λ and (1 − λ) to their outcome and the other player’s outcome respectively. In a two player game, if each player i’s individual outcome is xi then we can represent the transformed utility as λxi + (1 − λ)xj; λ = 1 corresponds to complete egoism and λ = 0 to complete altruism.  with the now conventional payoff values popularized by Axelrod . As in standard game theory, in equilibrium all beliefs turn out to be correct.Bacharach’s theory includes a parameter ω (0 ≤ ω ≤ 1), representing the probability that any individual player will be in a harach’s , 2006 prharach’s , b preseip’ Gold . The ω iIn Bacharach’s theory, a player will sometimes adopt the team-reasoning mode even without assurance that the co-player(s) have identified with the group, that is, when ω < 1, and may thus end up receiving a worse individual payoff than expected. His theory also allows the possibility that the off-diagonal outcomes in the prisoner’s dilemma,  and , are ranked higher by the team than the Nash equilibrium outcome, . In this case, a team reasoning player could play C despite a belief that the co-player(s) will certainly reason individually (ω = 0). Assuming once again that the collective payoff is simply the sum of individual payoffs, a simple and clear case in point is the Prisoner’s Dilemma game shown in Fig. In Sugden’s , 2003 th3For the same reason, in Sugden’s theory a player will not adopt team reasoning without having assurance that the co-player will also cooperate. Players engage in team reasoning only if they have reason to believe that the other player(s) identify with the group, endorse the idea of mutually assured team reasoning, and accept the idea that the goal is to maximize the collective payoff of the group Sugden , or  xj, to the Prisoner’s Dilemma in Fig. In Prisoner’s Dilemmas, as in common interest games, agency transformation is required as well as a payoff transformation. This can be revealed by applying the transformation above, where the individual Team reasoning is not the only current explanation of mutualistic cooperation. There is empirical evidence to support the idea that people team reason in common interest games  will often turn out to be incorrect.Strong Stackelberg reasoning , usually modelled as maximizing a utility function. In economics, it is actually standard to model some groups as agents, most obviously firms, but also diverse groups such as families, political parties, and trade unions. The theory of team reasoning is important because it makes space for individual and collective rationality in the same model, and shows how pursuing the group objective can be rational for the individual team members, within the standard assumptions of game theoretic rationality. Team reasoning is also relevant for philosophers who want to connect individual and collective action, and individual and collective intentions  in the Stag Hunt and  in Hi-Lo. The theory of team reasoning generalizes game theory, by introducing the possibility that groups can be the unit of agency, with standard game theory as a special case when the group only consists of one player. Team reasoning can also explain why it is sometimes rational to cooperate in a Prisoner’s Dilemma, where the Pareto-dominant outcome is not a Nash equilibrium.Team reasoning explains how it can be rational to cooperate, within the rationality assumptions of standard game theory. Theories of team reasoning allow that groups can be instrumentally rational agents with goals (which we can represent as team preference orderings) and that individuals within groups can rationally choose to do their parts in order to achieve the outcome that is ranked highest by the group. Some people have hoped we can find an argument that it is instrumentally rational to group identify. But any theory of the rational choice of the unit of agency faces the problem of how to specify goals and evaluate outcomes independent of the unit of agency. If we take our goals from our moral theory, that turns team reasoning from a theory of rational choice into a theory of moral choice, which is not intended by many of its proponents. It does not seem that one can choose one’s ultimate goals using a theory of rational choice.


Our objective was to investigate the efficacy of the beta-3 adrenergic receptor (β3-AR) agonist BRL37344 for the prevention of liver steatosis and inflammation associated with nonalcoholic fatty liver disease (NAFLD).Four groups were established: a control group (given a standard diet), a high-fat diet (HFD) group, an HFD + β3-AR agonist (β3-AGO) group, and an HFD + β3-AR antagonist (β3-ANT) group. All rats were fed for 12 weeks. The β3-AR agonist BRL37344 and the antagonist L748337 were administered for the last 4 weeks with Alzet micro-osmotic pumps. The rat body weights (g) were measured at the end of the 4th, 8th, and 12th weeks. At the end of the 12th week, the liver weights were measured. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were analyzed with a Hitachi automatic analyzer. The lipid levels of the triglycerides (TGs), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) and the concentrations of free fatty acids (FFAs) were also measured. An oil red O kit was used to detect lipid droplet accumulation in hepatocytes. Steatosis, ballooning degeneration and inflammation were histopathologically determined. The protein and mRNA expression levels of β3-AR, peroxisome proliferator-activated receptor-alpha (PPAR-α), peroxisome proliferator-activated receptor-gamma (PPAR-γ), mitochondrial carnitine palmitoyltransferase-1 (mCPT-1), and fatty acid translocase (FAT)/CD36 were measured by western blot analysis and RT-qPCR, respectively.After treatment with the β3-AR agonist BRL37344 for 4 weeks, the levels of ALT, AST, TGs, TC, LDL-C and FFAs were decreased in the NAFLD model group compared with the HFD group. Body and liver weights, liver index values and lipid droplet accumulation were lower in the HFD + β3-AGO group than in the HFD group. Decreased NAFLD activity scores (NASs) also showed that liver steatosis and inflammation were ameliorated after treatment with BRL37344. Moreover, the β3-AR antagonist L748337 reversed these effects. Additionally, the protein and gene expression levels of β3-AR, PPAR-α, and mCPT-1 were increased in the HFD + β3-AGO group, whereas those of PPAR-γ and FAT/CD36 were decreased.The β3-AR agonist BRL37344 is beneficial for reducing liver fat accumulation and for ameliorating liver steatosis and inflammation in NAFLD. These effects may be associated with PPARs/mCPT-1 and FAT/CD36. Nonalcoholic fatty liver disease (NAFLD), a multifactorial clinical pathological syndrome characterized by lipid accumulation in hepatocytes and hepatocyte steatosis, includes fatty liver alone and nonalcoholic steatohepatitis (NASH); NASH can slowly progress into liver fibrosis, cirrhosis and even liver cancer -induced rat models of liver fibrosis and that portal vein pressure is regulated through the adenylate cyclase (β3-AR/cyclic adenosine monophosphate) pathway. The liver pathological changes caused by CCl4 are similar to those occurring in NAFLD, such as steatosis, ballooning degeneration, inflammatory cell infiltration and fibrosis. Therefore, we hypothesized that liver β3-AR is upregulated when the sympathetic nervous system is activated in the context of NAFLD and that application of the β3-AR agonist BRL37344 will reduce lipid accumulation and inflammation in the liver. We speculate that upregulation of β3-AR expression following sympathetic nervous system overactivation is a protective mechanism against NAFLD.The main function of the beta adrenergic receptor (β-AR) is to regulate cardiac function through the sympathetic nervous system  fed a standard diet containing 5% fat, 66% carbohydrate and 23% protein with added fiber, vitamins and minerals; ② a high-fat diet (HFD) group (n = 8) fed an HFD consisting of 88% standard feed, 10% lard, and 2% cholesterol for 12 weeks ; ③ an HFD + β3-AR agonist (HFD + β3-AGO) group (n = 8); and ④ an HFD + β3-AR antagonist (HFD + β3-ANT) group (n = 8). Alzet micro-osmotic pumps were subcutaneously implanted into the HFD rats of the HFD + β3-AGO and HFD + β3-ANT groups at the end of the 8th week, and the β3-AR agonist BRL37344 (4.5 μg/(kg·h), Sigma-Aldrich B169) and the β3-AR antagonist L748337 (6 μg/(kg·h), Sigma-Aldrich L7045), respectively, were given continuously for 4 weeks. At the end of the 12th week, all rats were anesthetized through intraperitoneal injection of 10% chloral hydrate (0.3 ml/100 g) and euthanized. Femoral artery blood was collected for analysis of biochemical indicators. Liver samples were collected, snap-frozen in liquid nitrogen and then divided into two portions: the samples in the first were fixed with 10% paraformaldehyde and embedded in paraffin for morphological evaluation, and those in the second were frozen in liquid nitrogen for subsequent assays.A total of 32 male Sprague-Dawley rats (weight 200 ± 20 g) were obtained from the Animal Research Center of Harbin Medical University and raised in a specific pathogen-free animal center  with free access to food and water. After acclimation for 1 w, the rats were randomized into four groups: ① a normal (control) group (The body weights (g) of the rats in each group were recorded before the procedure and at the end of the 4th, 8th, and 12th weeks. The livers were weighed immediately after excision, and the liver weight/final rat body weight × 100% was calculated as the liver index.g to separate the serum, and the serum was stored at − 20 °C. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were analyzed with a Hitachi automatic analyzer . The levels of blood lipids, specifically triglycerides (TGs), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C), were also measured.At the end of the 12-week procedure, rat femoral blood was taken to detect liver function. After blood coagulation, the samples were centrifuged for 10 min at 1000×The frozen liver tissues were powdered in liquid nitrogen and homogenized with 10 mmol/L HEPES and 250 mmol/L sucrose  by sonication . Blood samples were centrifuged at 2000×3 samples and fixed in a 10% buffered formaldehyde solution for 24 h. The fixed specimens were embedded in paraffin after dehydration and clearing and were then made into 5-μm-thick sections for HE staining. All the sections were evaluated under a light microscope by one expert pathologist blinded to the treatments, and the NAFLD activity scores (NASs), proposed by Kleiner et al.  was used to detect lipid droplet accumulation in hepatocytes. The liver tissue was frozen and sectioned at a thickness of 10 μm with a frozen slicer (Leica CM1850). According to the instructions of the oil red O staining kit, the lipid droplets were dyed red, and the nuclei were stained dark blue. The lipid droplets were quantified using Image-Pro Plus 6.0 software.Liver samples were pretreated with 2.5% gluteraldehyde immediately after the removal, cut into the ultrathin sections (50–100 nm), prepared according to the method of Huang et al.  and obseTotal protein was extracted from liver tissues and quantified by the BCA method. Fifty micrograms of protein was loaded onto a 10% SDS-PAGE gel for electrophoresis. The membranes were routinely washed and blocked with 5% nonfat dry milk in PBST (containing 0.05% Tween 20), oscillated at room temperature for 1 h, and incubated overnight at 4 °C with β3-AR , peroxisome proliferator-activated receptor-alpha (PPAR-α) , peroxisome proliferator-activated receptor-gamma (PPAR-γ) , mitochondrial carnitine palmitoyltransferase-1 (mCPT-1)  and CD36  primary antibodies. After rinsing in TBS, the membranes were incubated with secondary antibodies and oscillated at room temperature for 1 h. Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) levels were measured as an internal control with anti-GAPDH (1:1000) antibodies . A Bio-Rad imaging system and ImageJ software were used to detect the immunoreactive bands and to quantify each sample.Total RNA was isolated by TRIzol extraction according to the manufacturer’s instructions. Reverse transcription was performed in 20 μl reaction mixtures with SYBR® Green qPCR reagents and a TaKaRa PrimeScript™ RT Reagent Kit with gDNA Eraser (Code No. RR047A) according to the manufacturer’s recommendations. An ABI 7500 Real Time PCR system (Applied Biosystems) was used to perform quantitative RT-PCR. The steady-state mRNA levels of β3-AR, PPAR-ɑ, PPAR-γ, mCPT-1 and fatty acid translocase (FAT)/CD36 were measured. The specific primers used for gene amplification in the present study are listed in Table P value less than 0.05 was considered to indicate statistical significance. GraphPad Prism 6.0  was used for the statistical analyses.All data are expressed as the mean ± standard deviation (SD). The NASs used to evaluate liver pathological changes were assessed using the Mann-Whitney test . Group data were compared using one-way ANOVA with Tukey’s post hoc test for multiple comparisons. A P < 0.05).As shown in Fig. P < 0.05).In addition, the protein and mRNA levels of β3-AR were upregulated by BRL37344 and downregulated by L748337 in HFD-fed rat livers (P < 0.05). Application of BRL37344 for 4 weeks significantly decreased the serum ALT, AST, TGs, TC, LDL-C and FFA levels in the HFD-fed rats (P < 0.05). In contrast, the serum ALT, AST, TGs, TC, LDL-C and FFA levels among rats were markedly higher in the HFD + β3-ANT group (treated with L748337) than in the HFD group (P < 0.05).As summarized in Table The occurrence of steatohepatitis in the control and test groups was investigated by liver histological examination with HE staining Fig. . TreatmeP < 0.05). After 4 weeks of BRL37344 administration, the NASs for liver steatosis, inflammation and hepatocyte ballooning degeneration in the HFD + β3-AGO group were significantly lower than those in HFD group (Table P < 0.05). In addition, in the HFD + β3-ANT group, inhibition of β3-AR expression with L748337 increased the NASs for liver steatosis, inflammation and hepatocyte ballooning degeneration and aggravated liver pathological damage (Table P < 0.05). These results indicate that β3-AR upregulation protects against liver steatosis and inflammation in this HFD-induced rat NAFLD model.Table P < 0.05).As shown in Fig. P < 0.05).In addition, the liver tissue TG, TC and FFA levels were significantly higher in the HFD group than in the control group, but β3-AR treatment reduced the levels of liver TGs, TC and FFAs. Inhibition of β3-AR produced the opposite effect in HFD-fed rats  transporters. The FAT/CD36 level was increased in the HFD group compared to the control group. β3-AR activation inhibited the protein and gene expression of FAT/CD36 in the HFD + β3-AGO group, whereas β3-AR inhibition increased the FAT/CD36 levels in the HFD + β3-ANT group Fig. d and f.The HFD rat model is prone to liver steatosis and can replicate most of the metabolic characteristics of human NAFLD; thus, this model can be used to investigate NAFLD and related metabolic syndromes . The above results indicate that activation of β3-AR can ameliorate gross morphological changes in the liver associated with NAFLD, improve liver function, regulate blood lipid and liver lipid levels, and protect against NAFLD.BRL37344 has an approximately 20-fold and 100-fold higher selectivity for β3-AR versus β2-AR and β1-AR, respectively . In the HFD + β3-AGO group, after application of BRL37344 for 4 weeks, the NASs for liver steatosis and ballooning were significantly lower than those in the NAFLD group (Table P < 0.05), and the results of oil red O staining showed that liver lipid droplet accumulation was also significantly decreased . In contrast, in the HFD + β3-ANT group, liver steatosis and ballooning were significantly aggravated (Table P < 0.05), and lipid droplet accumulation was significantly increased  after application of L748337 4 weeks. Xiao et al.  and depletion  along with a variety of pathophysiological mechanisms. Recent studies have suggested that FAs and their metabolites are the harmful factors during the development of NAFLD . In addition, in the HFD + β3-ANT group, L748337 inhibited the expression of β3-AR, increased liver inflammation, and aggravated liver pathological damage . Moreover, many studies on PPAR-ɑ activation in the liver have shown that PPAR-ɑ activation, in addition to regulating metabolic processes, can also reduce liver inflammation caused by the expression of cytokines and other compounds by inhibiting proinflammatory genes (Gervois et al. Inflammatory cell infiltration and upregulation of inflammatory mediators are secondary hits in the pathogenesis of NAFLD. It is generally believed that inflammatory factors cause hepatocyte damage by inducing ROS production and by releasing proteases and inflammatory mediators. New evidence suggests that inflammation plays a key role in promoting the progression of steatohepatitis to liver cirrhosis and liver cancer (Gao and Tsukamoto As the power of cells, mitochondria play an important role in lipid metabolism. Mitochondrial dysfunction of liver is considered to be the core of the pathogenesis of NAFLD (Khoo et al. Mitochondrial dysfunction impairs lipid metabolism, leads to excessive production of ROS, further inhibits antioxidant capacity, and causes mitochondrial damage (Begriche et al. A limitation of this study is related to a previous finding that HFD rats typically show the beginning signs of hepatic perisinusoidal fibrosis at 16 w and develop obvious fibrosis at 24 w (Xu et al. In conclusion, this study demonstrated that the expression of β3-AR is upregulated in NAFLD using an animal model of NAFLD. The experiments involving stimulation and inhibition of the expression of β3-AR have shown, for the first time, that long-term stimulation of β3-AR for 1 month can ameliorate liver lipid accumulation, liver steatosis and inflammation associated with NAFLD. These effects are probably associated with regulation of PPARs/mCPT-1 and FAT/CD36 expression. The findings indicate that upregulation of β3-AR expression is a protective mechanism against NAFLD, suggesting that β3-AR may be a new therapeutic target for NAFLD. In addition, hepatocyte steatosis, inflammation and oxidative stress are interrelated processes. Therefore, it is speculated that β3-AR activation is a complex event that protects against NAFLD. The relationship among β3-AR, liver inflammation and oxidative stress in the context of NAFLD will be the focus of further study.


Management of COVID-19 post-acute syndrome is an emerging health issue in rehabilitation. This article aims to present a proposal, based on the principles of clinical governance, health management and information technology (IT), and to respond to the need for a structured organization model for post-acute COVID-19 rehabilitation. The authors present a regional-based model of a network of clinicians and healthcare managers using a dedicated IT platform to achieve both effectiveness and efficiency objectives, to ensure coordination of the available resources and the most appropriate rehabilitative treatment for patients. The proposed post-acute COVID-19 rehabilitation network has been designed according to the model of a clinical management project within the Italian national healthcare system, and its context is an easily adjustable model for the European healthcare systems. The authors base the project on current laws and scientific guidelines in rehabilitation in Italy and in Europe and use the SWOT analysis technique to assess the proposal feasibility. The primary aims of the project are: (1) standardizing the minimum assessment tools of post-COVID-19 patients with disabilities; (2) ensuring an individual rehabilitation project for each patient with international classification of functioning, disability and health (ICF) coding and (3) reporting the activity performance with appropriate indicators. The secondary aims are: (1) developing educational programs for patients and care givers also aimed at acquiring better empowerment and positive behavior; (2) creating a regional database for data collection and (3) improving IT, and specifically tele-rehabilitation, as a suitable approach during the COVID-19 emergency and also in the future. Expected results are: continuum of care; effectiveness, efficacy and appropriateness in the delivery of rehabilitation treatments through a standardized minimum assessment and the wording of the individual rehabilitation project and a precise reporting of performance indicators to measure the effectiveness of clinical activities and the satisfaction of patients and caregivers. The assessment of results will be analyzed at three and six months to implement corrective actions according to the concept of continuous improvement of the Deming cycle. The IT remote approach allows the patient to meet the needs of proximity of care and empowerment, and, at the same time, to contain the spread of infection. This project could have a significant healthcare impact ensuring a more efficient and effective management of the demand of rehabilitation post-acute COVID-19, expanding the professional skills of the rehabilitation team members, improving both clinical and process data, in addition to optimal allocation of available economic resources. The ongoing COVID-19 pandemic is due to a new infectious disease that causes a severe acute corona virus 2 respiratory syndrome (SARS-CoV-2). The outbreak was in China at the end of 2019, but the virus spread rapidly around the world [The treatment of COVID-19 post-acute patients is an emerging challenge in rehabilitation, and a new organizational design for delivering rehabilitation care to an increasing number of patients is required. This article presents the design of an information technology (IT) based network as the structured organization model for post-acute COVID-19 rehabilitation using principles and methodologies of clinical governance, health management and IT tools.Apart from asymptomatic cases, affected patients present clinical scenarios that are different in severity and prognosis, varying from mild symptomatic cases to severe respiratory dysfunction  frequentIn 2017, the World Health Organization (WHO) “Rehabilitation 2030-a call for action” strengthened the central role of rehabilitation from both the public health and the clinical perspective . As an eThe pandemic has rapidly increased rehabilitation needs, putting both the existing organization of intensive and extensive rehabilitation services in crisis. Based on a clinical governance methodology ,15, it iIn the COVID-19 pandemic scenario, an IT system as a network based on a dedicated IT platform would be a very useful strategy to meet the needs of very different bodies such as healthcare agencies, healthcare professionals and patients with their families. The IT strategy also includes remote assistance called telemedicine, and specifically Tele-rehabilitation, to treat selected patients able to use this approach, both for clinical conditions and personal factors, and represents an opportunity for patients and professionals to implement care services, avoid difficulties of access and reduce the infection spreading ,21. FurtThe authors developed the proposal for a regional-scale model of a post-acute COVID-19 rehabilitation network according to clinical governance and health management principles ,23 throuSteps 1 and 2 cover the activities leading to the preliminary findings for the project drafting.For the first step, we performed a search on national and international guidelines databases and a search on the Italian ministry website looking for existing legislation on rehabilitation.High intensity in-patients ;Extensive intensity in-patients ;Ambulatory or home-based outpatients .The Italian health system  consistsIn addition, these categories include other specific settings such as the day hospital , and residential and semi-residential rehabilitation (considered extensive in-patient care). These last settings, although important, have not been considered in the starting phase of the project but they will be included in a successive phase. Most recently the 2011 rehabilitation national plan stated that the rehabilitation activities are based on the biopsychosocial model of the ICF and on the wording of the individual rehabilitation plan (IRP) which includes the objectives, timing and interventions to meet the physical, mental and social needs of patients.According to the 2011 Italian rehabilitation national plan ,29 and iAfter investigating the existing regulatory aspects, we carried out a feasibility study using SWOT analysis to identify and evaluate the factors that could affect the success of our proposal. SWOT is an acronym that stands for strengths, weaknesses, opportunities and threats and these categories are usually represented in a two by two matrix. SWOT analysis is a strategic planning technique taken from the business world and used by individuals or collaboration groups to analyze the factors that can strategically influence the implementation of a new project in the preliminary phase of decision process. It is used to uncover the optimal match between the internal factors, strengths and weaknesses, and the external factors, opportunities and threats, of a project. SWOT analysis can be usefully applied in medicine and health systems to evaluate the favorable and unfavorable aspects of a project . AccordiBased on the results of steps 1 and 2, the third step consists of drafting the project, with specific primary and secondary objectives, activities, indicators, timing and estimated costs, and providing for the realization of an IT platform where the different bodies  can be connected in real time, realizing the concept of the network. Networking is becoming a winning model in many fields including health care. It allows all parties to interact more quickly and to better allocate human and economic resources. There are already healthcare dedicated networks such as the oncology network in Campania region and emergency health care networks spread in many countries with structured health systems. The network model facilitates quick access to the available resources such as hospital beds or outpatient treatments and, therefore, the continuity of care from hospital (acute care) to rehabilitation , ensuring the correct clinical data transmission and reporting activities.This article presents a proposal for an IT-based network as the regional-level organization model for post-acute COVID-19 rehabilitation. Therefore, the fourth step consists of foreseeing the main expected results and providing for continuous improvement actions.This proposal is a living document, so continuous quality improvement is crucial to achieve success. The Deming cycle is a quality improvement model, well assessed both in research and business fields, that can be usefully applied in many contexts including healthcare management and rehabilitation . It consThe Deming Cycle, also called plan, do, check, act (PDCA) cycle as an acronym of its four steps, is specifically suitable for our project because of the changing pandemic scenario in which it is located. Steps three and four methodology are described in the present Methods section, but the findings are described in detail in the Results section.Based on the findings of step one and on the SWOT analysis of step two, the authors formulated the post-acute COVID-19 rehabilitation network proposal. The implementation of a regional IT platform with specific applications, and managed by a trained dedicated team, is essential to guarantee the success of the network. However, this is a very technical aspect of the project and the authors have preferred not to address it in this article because it is oriented to the aspects of clinical governance and healthcare management of the proposal rather than the technological components.Wide coverage of the post-acute COVID-19 target population in the region;The homogeneous evaluation of patients by validated assessment tools;The promptness of access to care and the availability of tailored care settings according to the complexity of the demand;Limiting the movements of people, also adopting in clinical practice IT applications such as remote access.The network enables clinicians, rehabilitation professionals, patients and services to connect in real time using IT platforms. It would guarantee:The multidisciplinary post-acute COVID-19 rehabilitation team should include all professional figures necessary, each one for their competence, including an IT specialist. The provision of rehabilitation aids to patients should include electronic equipment and remote monitoring devices if necessary, as well as other aids and orthotics. These aids will be returned at the end of treatment, subjected to sanitization according to current rules, and then reused. Personal protective equipment (PPE) for both health professionals and patients has been adopted according to the current national and regional laws and recommendations.Specific rehabilitation programs are necessary to manage the post-acute COVID-19 limitations in the following functional and activities domains: (1) respiratory functions, with particular attention to cardio-respiratory endurance and respiratory pattern; (2) neurocognitive functions with particular attention to memory deficits, sensory-motor central impairments, central and peripheral neuropathies and dysphagia; (3) motor functions including muscle strength and endurance, flexibility, joint active motion and stability also considering the preexisting clinical and general functional status; (4) emotional and psychological functions linked to the traumatic experience of the disease.(1)Standardizing the minimum assessment tools set  both for(2)Planning the IRP for each patient including the rehabilitation treatment setting , timed programs, objectives identified by the appropriate ICF codes, and the team of professionals involved to guarantee efficacy, efficiency and appropriateness of care and patient satisfaction;(3)Reporting the performance of the activities by indicators  at three(a)Process indicators: waiting time in days for the first assessment, number (No.) of assessments based on the minimum tools set/No. of total assessments, No. of individual rehabilitative plans/No. of patients treated in all settings;(b)Outcomes indicators: changes in Modified Barthel Index scores, Health Survey SF 12 scores , EuroQual EQ 5D scores , No. of adverse events during Tele-rehabilitation/No. of adverse events during home-based rehabilitation face to face plus remote.In order to guarantee efficiency, efficacy, safety and appropriateness in the rehabilitation management of the patient suffering from disability due to COVID-19, the present project proposal identifies the primary objectives as follows:One of the primary objectives of the project is to develop standardized minimum assessment tools set for patients cured from COVID-19 and with disabilities, to be applied as early as possible during the acute hospital stay or, at the latest, before discharge from an acute setting. It is really important to have precise criteria for the safe discharge of post acute COVID-19 patients from the acute wards towards rehabilitation . The conPlanning the IRP for each patient is another primary objective. It uses the parameters of impairment, activity limitation and restriction of social participation as listed in ICF. The peculiarity and novelty of the corona virus pathology requires specific attention in considering the significant ICF categories for each patient to plan the rehabilitative interventions. For example, consideration of impairments such as respiratory function and swallowing are mandatory for the correct management in a rehabilitation setting. The minimum assessment tools set is based on the current recommendations present in the most recent literature ,38 and aThe indicators of clinical performance, both process indicators and outcomes indicators, are the third main objective, and they are essential for monitoring the project activities and allowing adjustments in time to get optimal outcomes.Educational programs for patient and caregiver also aimed at acquiring better empowerment and positive behaviors such as stopping smoking (pre-habilitation);Creation of a regional database for data collection;Improving IT, and specifically Tele-rehabilitation, by training the rehabilitation staff in the use of telemedicine devices, implementing facilities and clarifying legal aspects.Secondary objectives of the project are:In critical times like the COVID-19 pandemic, IT can support, without ever replacing, human resources in medicine, and there are already experiences of Tele-rehabilitation in different fields . In our The assessment of results will be carried out at three months and six months, and corrective actions will be planned through the Deming Cycle model.Dedicated post-acute COVID-19 intensive and extensive rehabilitation beds, which in every case can be totally or partially reconverted to general rehabilitation at the end of the COVID-19 pandemic;Easy access to rehabilitation care;Timely rehabilitation management also for patients at home;Continuum of care and appropriate levels of care in the different settings;Improvement of the quality perceived by patients (customers satisfaction) with the empowerment of patients and their family;Monitoring the activities by performance indicators  and manaCompliance with COVID-19 guidelines to prevent and contain the infection spread ;Creation of regional database for collecting data to support future planning decisions in the field.Based on the network proposal, we can expect to guarantee to post-acute COVID-19 patients with disabilities, consequent to the disease or its treatments, the best possible recovery of individual skills and social participation through a multidisciplinary, multi-professional and continuity care path with significant technological, economic and social impact. Specifically, we can expect:We hope to meet these optimal results in six months with a three months first milestone see .In particular we expect that hospitalized patients with multi-organ involvement and severe disease will mostly require intensive or extensive rehabilitation, and home-treated patients will be able to continue rehabilitation in the home setting with only a few exceptions requiring an intensive or extensive setting. Therefore, depending on the different rates of home patients, hospitalized patients including ICU patients, and on the number of patients healed, each region can plan the number of intensive and extensive rehabilitation beds in order to meet the expected demand. However, for most patients, the appropriate intervention strategy will be home rehabilitation that can be managed in the two modalities, in person or by Tele-rehabilitation, not necessarily alternative but also concurrent or subsequent.Furthermore, in order to limit the risk of the spread of the contagion, we exclude the day-hospital and the ambulatory settings in the starting phase as well as the residential and semi-residential setting, but we consider they may be included in the network offers in the future, according to the Deming Cycle for continuous quality improvement. Our approach results in the optimization of the risk-benefit ratio  with a significant reduction in direct and indirect costs.The innovative aspects of the project are both the network organization and the possibility to manage the home-based rehabilitation in two ways: as usual with the therapist in person at the patient’s home, or by remote with the therapist supervised IT-assisted way, also called Tele-rehabilitation. As already mentioned in Methods, the network model is a very well assessed organizational model in many fields of medicine and healthcare management, such as emergency, cancer care and also rehabilitation, while Tele-rehabilitation has not been sufficiently promoted.Tele-rehabilitation, even if it cannot completely replace conventional rehabilitation, has a potential application particularly suitable for the current emergency situation. Several studies have evaluated the possibility of using technology  for an alternative or additional connection method between patients and healthcare professionals ,40,41,42The COVID-19 emergency quickly imposed a huge change in the health system organization and has brought about new crises. As always it can be seen that the standardization of care improves the effectiveness, the efficiency and the appropriateness of services. A rehabilitation network for post-acute COVID-19 patients will guarantee equality of access and evaluation to all patients, uniformity of care, taking into account any personal peculiarities and family environment. The first step towards getting these optimal results is to define the minimum criteria for the safe discharge of post-acute COVID-19 patients from hospital to a specialist facility or home. Moreover, it would allow better monitoring of interventions and reporting through shared data flows. In our opinion, it is crucial to adopt specific actions aimed at organizing the rehabilitation network for post-acute COVID-19 patients; in this way we can guarantee the effective management of rehabilitation demand, customer satisfaction and the proper allocation of available economic resources. Specifically, Tele-rehabilitation may play a central role in the change in delivering rehabilitation activities and in the inclusion of patients with restricted access to rehabilitation, such as post-acute COVID-19 patients. Of course, older people may have difficulty in using IT devices. However, the Italian Higher Institute of Health  has receWe estimated that a regional network IT platform has an initial cost of about 300,000 Euros, the annual cost of the software update is approximately 10,000 Euros and the annual cost of a small regional supportive team of four people is about 100,000 Euros. Each local health authority has to sustain the costs of updating their systems. Although there are still barriers, such as the availability of technological instruments at the patients’ home and a possible lack of IT competence, we already have the model of the oncology network in Campania Region that provides extremely simple access with a very short training in the context of all healthcare professionals  ordinary daily work and patients’ daily activities by using computers, tablets and/or smart-phones. Furthermore, in the future, Tele-rehabilitation will be able to expand the offer of assistance to patients who experience barriers to access care facilities. Of course, many aspects of Tele-rehabilitation are still under observation, especially personal data protection and legal implications if any side effects or complications should occur. To limit adverse events and any legal disputes it is important to give written information to be followed in case of adverse events (such as pain) and to obtain an informed written and detailed consent from the patient. Another criticism of our proposal is represented by not having involved the project stakeholders, represented by patients and their relatives, in the development of the proposal, as is usual. The stakeholders should certainly be involved in the process of revision in the near future. Finally, although the IT platform is a central element of the project, it is also a very technical aspect of the project, and the authors have preferred not to address it in this article. However, they reserve the opportunity to present the platform structure in a dedicated article.Continuity of care from an acute hospital stay to post-acute inpatient and outpatient or home-based rehabilitation care, patients’ assessment based on a minimum assessment tools set and early onset of the treatment of disabilities;Optimal clinical governance, even in emergency conditions, in terms of equal access to care, efficiency, efficacy, safety and appropriateness of rehabilitation treatments;Technological promotion in IT health care, and specifically in Tele-rehabilitation.Customers’ satisfaction in terms of reduction of disability and improvement of quality of life.This project aims to support healthcare systems, specifically the Italian regionally-based healthcare system, and the patients cured from the COVID-19 infection, by offering an organization model of a dedicated network for post-acute COVID-19 rehabilitation which enables:This model offers the advantage of being applicable in different contexts, not only in the Italian regions but also in other countries and highlights the importance of communication and of the working team including clinicians, rehabilitation professionals, healthcare managers, patients and caregivers in the pursuit of the objectives of clinical governance and healthcare management. Rehabilitation is strategic in the context of healthcare strategies oriented to the burden management of post-acute and chronic diseases. The ongoing COVID-19 infection, although it is an acute disease, is assuming some characteristic of sub-acute diseases including persistent disabling outcomes and growing needs of rehabilitative treatments. The innovation of the project consists in adopting an emergency management strategy based on a web connection to manage the rehabilitative needs in real time in the COVID-19 pandemic scenario. IT can also support the home care setting by Tele-rehabilitation, considered not alternative, but complementary, to the treatment in person. Our proposal can, therefore, contribute to healthcare decisions and clinical governance strategies both at the regional and national level in Italy as well as in other countries.


Second-generation AR antagonists are effective against some of these castration-resistant prostate cancers, but their structural variety is still limited. In this study, we designed and synthesized 4-methyl-7-coumarins as AR antagonist candidates and evaluated their growth-inhibitory activity toward androgen-dependent SC-3 cells. Coumarinamides with a secondary amide bond did not show inhibitory activity, but their N-methylated derivatives exhibited AR-antagonistic activity. Especially, 19b and 31b were more potent than the lead compound 7b, which was comparable to hydroxyflutamide (2b). Conformational analysis showed that the inactive coumarinamides with a secondary amide bond have an extended structure with a trans-amide bond, while the active N-methylated coumarinamides have a folded structure with a cis-amide bond, in which the two aromatic rings are placed face-to-face. Docking study suggested that this folded structure is important for binding to AR. Selected coumarinamide derivatives showed AR-antagonistic activity toward LNCaP cells with T877A AR, and they had weak progesterone receptor (PR)-antagonistic activity. The folded coumarinamide structure appears to be a unique pharmacophore, different from those of conventional AR antagonists.First-generation nonsteroidal androgen receptor (AR) antagonists, such as flutamide ( We have previously reported on the unique conformational properties of aromatic amide compounds . Al. Al30]. 1H and 13C NMR spectra were recorded on a JEOL ECA 600 , or Bruker 600 spectrometer . Mass spectral data were obtained on a Bruker Daltonics microTOF-2focus , Thermo Scientific Q-Exactive or Waters Q-TOF Premier in the positive ion detection mode .All reagents were purchased from Sigma-Aldrich Chemical Co. , Tokyo Kasei Kogyo Co. , Wako Pure Chemical Industries , or Kanto Kagaku Co., Inc. . Silica gel for column chromatography was purchased from Kanto Kagaku Co., Inc . ο-Anisoyl chloride  was added to a solution of 7-amino-4-methylcoumarin  in pyridine (3 mL), and the mixture was stirred at 50 °C for 2 h. The mixture was poured into 2 M HCl (30 mL), and the precipitates were collected, washed with water, and a mixture of chloroform and methanol to give 23a .n-hexane. A solution of 23a  in DMF (1 mL) was added to a suspension of sodium hydride in DMF (2 mL). After 20 min, iodomethane  was added to the mixture. After 5 h, the reaction mixture was poured into water and extracted with ethyl acetate. The organic layer was washed with brine, dried over magnesium sulfate, and concentrated. The residue was purified by silica gel column chromatography (ethyl acetate:hexane = 1:1) to give 23b .Sodium hydride  was washed with 2. Then, 10 μL of medium was removed from each well and replaced with 10 μL of drug solution supplemented with serial dilutions of test compound or DMSO as a dilution control in the presence of 1 nM DHT, and the plates were incubated for 3 days. The cell number was determined using a Cell Counting Kit-8  according to the manufacturer’s instruction. This parameter is proportional to the number of living cells in the culture. IC50  according to the manufacturer’s instruction. This parameter is proportional to the number of living cells in the culture. All experiments were performed in triplicate or more.LNCaP cell growth inhibition assay was performed as the previous report ,28,31. B2 for 24 h. Then, 10 μL of medium was removed from each well and replaced with 10 μL of drug solution supplemented with serial dilutions of test compound or DMSO as a dilution control in the presence or absence of 1 nM progesterone, and incubation was continued for 24 h. Then, the medium was aspirated, and the cells were fixed with 100 μL of 1.8% formalin in PBS. The fixed cells were washed with PBS, and 75 μL of assay buffer  was added. The mixture was incubated at room temperature with shielding from light for 2 h, and then the reaction was terminated by the addition of 100 μL of NaOH. The absorbance at 405 nm was measured with a microplate reader.Alkaline phosphatase assay was performed based on the previous report ,32. BrieN-alkyl-arylcarboxamido)coumarins as AR antagonist candidates, using compound 7b as a lead compound. The AR-antagonistic activity of the synthesized coumarinamide derivatives was examined in terms of growth-inhibitory activity toward SC-3 cells. Coumarinamides with a secondary amide bond were inactive, but their N-alkylated derivatives exhibited AR-antagonistic activity. Among them, compounds 19b and 31b showed more potent AR-antagonistic activity than the lead compound 7b, and they were comparable in potency to hydroxyflutamide (2b). Conformational analysis and docking study revealed that the folded structure of coumarinamides associated with the cis-amide bond is important for binding to AR. The selected coumarinamide derivatives showed AR-antagonistic activity toward LNCaP cells with T877A AR and had weak PR-antagonistic activity. The detailed action mechanism of novel coumarinamides as AR modulators including AR-binding ability and transcriptional regulation should be elucidated in the future works, as the folded coumarinamide is a different pharmacophore from those of conventional AR antagonists, and these compounds may be promising candidates for the treatment of prostate cancer.We synthesized a series of 4-methyl-7-(


Qualitative methods are proving to be important tools for studying the multi-faceted experience of living with aging, with a focus on the arts. Ethnographic methods are productive ways to discover and examine music in everyday life. Systematically studying the normal and often taken-for-granted ways aging adults experience music, in the full range of settings where they can be found, can abide by the first rule of translational science research: to design and conduct research in order to facilitate the efficient and timely development and application of clinical and caring interventions. This presentation will review a series of ethnographic studies of music experiences in residential facilities, dementia respite groups, family, and hospice. We will suggest ways to apply findings from these studies to enlighten volunteer hospice workers’ protocols for care.


Vitamin K antagonist (warfarin) is the most classical and widely used oral anticoagulant with assuring anticoagulant effect, wide clinical indications and low price. Warfarin dosage requirements of different patients vary largely. For warfarin daily dosage prediction, the data imbalance in dataset leads to inaccurate prediction on the patients of rare genotype, who usually have large stable dosage requirement. To balance the dataset of patients treated with warfarin and improve the predictive accuracy, an appropriate partition of majority and minority groups, together with an oversampling method, is required.To solve the data-imbalance problem mentioned above, we developed a clustering-based oversampling technique denoted as DBCSMOTE, which combines density-based spatial clustering of application with noise (DBCSCAN) and synthetic minority oversampling technique (SMOTE). DBCSMOTE automatically finds the minority groups by acquiring the association between samples in terms of the clinical features/genotypes and the warfarin dosage, and creates an extended dataset by adding the new synthetic samples of majority and minority groups. Meanwhile, two ensemble models, boosted regression tree (BRT) and random forest (RF), which are built on the extended dataset generateed by DBCSMOTE, accomplish the task of warfarin daily dosage prediction.R-squared (R2) of 0.424 and the smallest mean squared error (mse) of 1.08. In terms of the percentage of patients whose predicted dose of warfarin is within 20% of the actual stable therapeutic dose (20%-p), DBCSMOTE-BRT can achieve the largest value of 47.8% among predictive models. The more important thing is that DBCSMOTE saved about 68% computational time to achieve the same or better performance than the Evolutionary SMOTE, which was the best oversampling method in warfarin dose prediction by far. Meanwhile, in warfarin dose prediction, it is discovered that DBCSMOTE is more effective in  integrating BRT than RF  for warfarin dose prediction.DBCSMOTE and the comparison methods were tested on the datasets derived from our Hospital and International Warfarin Pharmacogenetics Consortium (IWPC). As the results, DBCSMOTE-BRT obtained the highest Our finding is that the genotypes, CYP2C9 and VKORC1, no doubt contribute to the predictive accuracy. It was also discovered left atrium diameter, glutamic pyruvic transaminase and serum creatinine included in the model actually improved the predictive accuracy; When congestive heart failure, diabetes mellitus and valve replacement were absent in DBCSMOTE-BRT/RF, the predictive accuracy of DBCSMOTE-BRT/RF decreased. The oversampling ratio and number of minority clusters have a large impact on the effect of oversampling. According to our test, the predictive accuracy was high when the number of minority clusters was 6 ~ 8. The oversampling ratio for small minority clusters should be large (> 1.2) and for large minority clusters should be small (< 0.2). If the dataset becomes larger, the DBCSMOTE would be re-optimized and its BRT/RF model should be re-trained. DBCSMOTE-BRT/RF outperformed the current commonly-used tool called Warfarindosing. As compared to Evolutionary SMOTE-BRT and RF  models, DBCSMOTE-BRT and RF models take only a small computational time to achieve the same or higher performance in many cases. In terms of predictive accuracy, RF is not as good as BRT. However, RF still has a powerful ability in generating a highly accurate model as the dataset increases; the software “WarfarinSeer v2.0” is a test version, which packed DBCSMOTE-BRT/RF. It could be a convenient tool for clinical application in warfarin treatment. Patients who have atrial fibrillation, valvular heart disease, thromboembolic disease, etc. need a long-term oral anticoagulant therapy. Vitamin K antagonist is the most classical and widely used oral anticoagulant with assuring anticoagulant effect, wide clinical indications and low price. Warfarin is the main Vitamin K antagonist comprehensively used in the clinic around the world. In recent years, although new oral anticoagulants (NOACs) are easy to use, they are relatively expensive, and their indications are relatively limited. Specific antagonists of NOACs are expensive and have not yet been marketed in China. NOACs efficacy can hardly be evaluated by routine tests or blood concentration tests. In contrast, although warfarin needs to monitor international normalized ratio (INR) –3 for stWarfarin dosing should be precise for each patient. However, warfarin dosage requirements of different patients vary largely. For an individual patient, before the INR becoming stable within the therapeutic range and his or her stable dose being figured out, he or she has to endure quite a long time of numerously blood tests and dosage adjustments. And this process is mainly depended on doctor’s experience. To improve the predictive accuracy, many works have developed their warfarin dose predictive models –8 based In 2018, Saffian et al. analyzed 22 predictive models for warfarin dose prediction before 2018 , and conTo balance the data and improve the overall predictive accuracy, appropriate partition of majority and minorities followed an oversampling technique is needed. In our previous works , 22, thek-mean algorithm was used to distinguish the majority and minority  < 1, create φ*Nmino synthetic samples by using φ nearest neighbours of each minority sample, and φ*Nmino synthetic samples are generated as the way under Ns < Nmino (r < 1).Let f of new samples is the weighted dosage sum of neighbours, which is denoted as the form.The dosage α = 1/l. The weight of dosage is calculated by the distance reciprocal of a new sample to its parent.Here, r}, needs to be optimized.It is hard for a human to configure the parameters for DBCSMOTE, that will make the accuracy of the predictive model highest. As for DBSCAN, two parameters MinPts and Eps need to be optimized. For SMOTE, the oversampling ratio combination, denoted as {X =  be the variable of objective function z(X). The optimization problem can be formulated as follow.The optimization problem is to find the best parameters of DBCSMOTE (i.e. DBSCAN and SMOTE), which lead to the smallest error of the predictive models such as BRT and RF. Let Where,z(X) contains three sub functions. z1(X) calculates the mean squared error of X with respect to the training and validation sets, respectively. z2(X) calculates the mean squared error with respect to the samples, whose observed dosage f is larger than 4.2 mg/day or smaller than 1.5 mg/day. z3(X) calculates the R2 of X on the training and validation sets, respectively. K is an amplification constant in z(X) only for observing z(X). We set K to 20, which makes z(X) > 1.The objective function msetrain and msevalid indicate the mse on the training and validation sets, respectively. R2train and R2valid indicate the values of R2 on the training and validation sets, respectively. For mse and R2 calculation, a temporal predictive model-CART, which is built on the training set extended by X, is used. This is a low-complexity model with convenient use for evaluation on parameters of DBCSMOTE in each iteration.In , msetraiX} (feasible setting of parameters);Step 1: Give a set of feasible solutions {X in {X};Step 2: Select a candidate X to generate an extended training set;Step 3: Run DBCSMOTE with Step 4: Create a CART model on the extended training set and validated on the validation set;mse and R2 of the CART model, and then calculate the value of z(X);Step 5: Calculate the X}; the candidate that obtained the smallest value of z(X) represents the best solution (parameters) of DBCSMOTE.Step 6: Traverse all candidates in {A greedy strategy is used to evaluate the quality of DBCSMOTE and search the solution to the optimization problem . The floIn previous works , 22, a pThe flow of DBCSMOTE-BRT/RF is as follow:Step 1: Divide the original dataset into three subsets, i.e. training set, validation set and test set;Step 2: Run the greedy strategy to optimize the parameters of DBCSMOTE;Step 3: Keep minority and majority clusters with these optimized parameters;Step 4: Use SMOTE to synthesize new samples for extending the training set;Step 5: Build the BRT/RF model on the extended training set, validate it on the validation set, and output dose prediction on the test set.R-squared and 20%-p, will be displayed at right-bottom.Figure Additional file 1. DBCSMOTE.zip, code files for generating minority and majority clusters in Matlab. DBCSMOTE_demo.m: the demo of DBCSMOTE together with random forest, which gives the estimated dosage. ‘num’ indicates the number of iterations of running DBCSMOTE. In each iteration, ‘evaluatePop’ calls the function to evaluate the oversampling quality. ‘train.txt’, ‘validate.txt’ and ‘test.txt’ are sub sets used for training, validation and testing. DBSCAN_fun.m: the function of algorithm DBSCAN. It conducts the clustering with two parameters (Eps and MinPts) on an input dataset and returns the samples of minority clusters and the number of clusters. RandomForest.m: the function of random forest. Random forest is an ensemble model of CARTs, which are the weak regression models. They are built on the extended training set, which is extended by DBCSMOTE. CARTprediction.m: the function of CART algorithm. This is a weak regression model of random forest. Meanwhile, this is the tool for evaluating the oversampling quality, which is generated by DBCSMOTE.


Antibiotic resistance is a problem for human health, and consequently, its study had been traditionally focused toward its impact for the success of treating human infections in individual patients . Nevertheless, antibiotic-resistant bacteria and antibiotic resistance genes are not confined only to the infected patients. It is now generally accepted that the problem goes beyond humans, hospitals, or long-term facility settings and that it should be considered simultaneously in human-connected animals, farms, food, water, and natural ecosystems. In this regard, the health of humans, animals, and local antibiotic-resistance–polluted environments should influence the health of the whole interconnected local ecosystem . In addition, antibiotic resistance is also a global problem; any resistant microorganism (and its antibiotic resistance genes) could be distributed worldwide. Consequently, antibiotic resistance is a pandemic that requires Global Health solutions. Social norms, imposing individual and group behavior that favor global human health and in accordance with the increasingly collective awareness of the lack of human alienation from nature, will positively influence these solutions. In this regard, the problem of antibiotic resistance should be understood within the framework of socioeconomic and ecological efforts to ensure the sustainability of human development and the associated human–natural ecosystem interactions. One Health, first used in early twentieth century, expands the integrative thinking about human and animal medicine, including for the first time ecology, public health, and societal aspects (The problem of antibiotic resistance (AR) has been traditionally addressed by focusing on human-linked environments, typically health care facilities. Nevertheless, it is now generally accepted that most ecosystems may contribute to the selection and spread of AR . A key c aspects . In the  aspects . ConsequGlobal Health is based on a broad collaborative and transnational approach to establish “health for all humans.” In this case, it focuses AR at a general  scale, considering that the selection and global spread of antibiotic-resistant bacteria (ARBs) and antibiotic resistance genes (ARGs) are a problem that influences the health of human societies with disparate social and economic structures and is linked to many societal and ecological factors . InterveOf course, the Global Health concept of “health of an environment”  or, in gThe construction of human societies reflects the tension between individual freedom and social rules/laws. The implementation of different social rules/laws for regulating human activities within a society is mainly based on moral , in opposition to other more autocratic regimens where decisions are implemented top-down, had been the subject of debate from the early beginning of democratic revolutions . In thisresistome, understood as the set of genetic elements that can confer AR, irrespectively of the level of resistance achieved, in a given organism/microbiome was coined  or recruitment of ARGs through horizontal gene transfer (HGT), transformation included. AR mutations are generally confined to their original genomes, propagating vertically and not spreading among bacterial populations, although some few exceptions of horizontal transfer of chromosomal regions containing AR mutations have been described . The setConcerning their relevance for acquiring AR, ARGs can be divided in two categories. The first one comprises the genes forming the intrinsic resistome , which imobilome, is formed by ARGs located in mobile genetic elements (MGEs) that can be transferred both vertically and horizontally, hence allowing AR dissemination among different bacteria , the burden for human health might eventually be lower. Nevertheless, it is relevant to highlight that AR transmission cannot be understood just by analyzing the genetic mechanisms involved and the consequences of such acquisition for the bacterial physiology. Indeed, as discussed below, there are ecological and socioeconomic elements that strongly influence AR dissemination.HGT-mediated AR is a hierarchical process  in whichThe evolution of AR comprises the emergence, the transmission, and the persistence of ARBs . ConcernIt is generally accepted that non-clinical ecosystems are often primary sources of ARGs . As abovDespite that the homogenization of hosts may help in AR transmission, the spread of ARBs has some constraints, because the differential capability of each bacterial clone for colonizing different hosts may modulate their dissemination. Indeed, while some species and clones are able to colonize/infect different animal species, humankind included, several others present some degree of host specificity . FurtherIt is worth mentioning that, because humans constitute a single biological species, the human-associated organisms spread easily among all individuals. In fact, more prominent differences in humans’ microbiome composition can be observed between individuals than among ethnic groups, even though, as expected, the resemblance in microbiotas is higher among those groups that are geographically clustered . Some grAs stated above, there is a global increasing permeability of the natural biological barriers that have historically prevented bacterial dissemination through different ecosystems. Besides local spread of AR in environments shared by animals and humans, which has to be addressed under a One Health approach, AR can disseminate worldwide  by econoA final issue concerning AR is its stability in the absence of selection. It has been proposed that the acquisition of AR reduces bacterial competitiveness in the absence of antibiotics (fitness costs) ; certainPollution of natural ecosystems is associated with activities that have driven relevant economic transition, in principle favoring human welfare, such as mining, industry, intensive land use, or intensive farming, among others. Notwithstanding, globalization of health services, as well as the shift toward intensive farming, besides their positive contribution to human well-being, has rendered an increasing pollution by compounds with pharmacological properties of natural ecosystems, particularly water bodies, which may disrupt the stability of these ecosystems . Among tHowever, antibiotics are not the unique pollutants that can prime the selection and spread of AR. In this regard, it is important to highlight that heavy metals are one of the most abundant pollutants worldwide . Their aAlthough most published works analyze the effect of different pollutants on their capacity to select ARBs or ARGs, it is important to highlight that ARGs should also be considered pollutants themselves. Actually, a recent work indicates a close relationship between the abundance of ARGs and fecal pollution . In thisIn addition to the aforementioned pollutants with a direct effect in AR selection, it is worth noting that there are other abundant contaminants, such as sepiolite  or microplastics, present in almost all aquatic ecosystems, which can favor the transmission of ARGs or MGEs between bacterial species , hence aFinally, the possible effect of climate change on the spread of AR is worth mentioning. Indeed, it modifies the biogeography of vectors  involved in the spread of infectious diseases . In addiIt is relevant to mention that increased pollution and climate change are the unwanted consequences of human development. It would then be worth discussing how human development in general may impact (positively and negatively) AR, a feature that is analyzed below.Human development is a necessity of our human behavior, although different models of development have been and are proposed, each one producing different impacts in the structure of human societies and on the preservation and stability of natural ecosystems . NeverthA continuously repeated mantra in worldwide AR policies is that the abusive consumption of antibiotics for the treatment or prevention of infections in humans and animals constitutes the major driver of AR. However, we should keep in mind that antibiotics constitute an important example of human progress supporting individual and global human health. In fact, the origin of the massive production of antimicrobials was a consequence of the needs resulting from World War II in the 1940s. This was followed by many decades of human progress, most importantly by the common understanding of equal human rights, which was followed by the economic and social development (including medicine and food industry) of densely populated regions in the planet, including India and China. These countries are currently among the leaders in the production and consumption of antimicrobial agents. Notwithstanding, as in any area of economy, progress bears a cost that, in this case, is antibiotic pollution of the environment, globally accelerating the process of the emergence, the transmission, and the persistence of ARBs .The non-controlled use of antibiotics is facilitated in LMICs with disparate economic growth by different factors. Heterogeneous regulation of antibiotic sales and prescriptions (often weak or missing) and the increase of online on-bulk sales in recent years contribute to their overuse . Most ofDespite this situation, it is important to highlight that human consumption of antibiotics is an unavoidable need to preserve human health. In fact, most health problems dealing with infections in LMICs are still caused by a poor access to antibiotics, not by an excessive use of them. Proof of this is the fact that the distribution of antibiotics has reduced endemic illnesses and children mortality in Sub-Saharan Africa . This meConsequently, besides a Global Health problem, AR has an important economic impact , hence cWhen talking about reducing antibiotic consumption, it is important to remind that up to two-thirds of overall antibiotic usage is for animal husbandry . FurtherEconomic development has facilitated as well more global transport, waste disposal, and tourism, favoring AR spread within and between different geographical areas . HoweverEven when wastewater-treatment plants are available, the presence of ARBs in drinking, fresh, and coastal waters, as well as in sediments nearby industrial and urban discharges, has been described in several countries . As in tThe examples discussed above justify that human health in general and AR in particular are closely interlinked with economic development . EconomiDifferent socioeconomic factors can modulate the spread of infective bacteria in general and of AR in particular. Among them, the increasing crowding of humans and foodborne animal populations favors transmission at the local level , whereas trade of goods and human travel  favor woBesides these global changes in social behavior, linked to economic development, more specific socioeconomic factors , sociocultural aspects , and personality dimension highly influence antibiotic use and AR transmission . For insConsistent with the sociological elements of AR, many of the aspects influencing AR reviewed above depend on social norms . In the Interestingly, the AR problem is a bottom-up process, where small emergent changes  cumulatively escalate to gain a global dimension. Frequently, that occurs by crossing tipping points, that is, points where the local AR incidence becomes significant enough to cause a larger, eventually Global, Health problem. Because of that, the implementation of solutions should be adapted to the control of critical tipping points in the small groups of individuals to disrupt the bottom-up processes. However, as AR spread can occur everywhere and at any time, global surveillance and mechanisms of control should be implemented to prevent a top-down process of global AR expansion.Individual selfishness for AR is the cornerstone of social norms. This concept was coined and developed by one of us over a decade ago . Let us At the individual level, there is inertia that precludes changing habits, until a tipping point is crossed and health is compromised. The conclusions of studies mainly based on long-term cohort analysis, such as the Framingham program for the influence of diet or smoking on personal cardiovascular disease , have be1. It is commonly accepted that social norms are mainly created by learning and education, a rational path that promotes health , and global  scale . The recNotwithstanding, two reasons that have been proposed to explain the low prevalence of COVID-19 in Japan were related with social norms more than with biological issues. These reasons, which are not common to other countries, were the socially accepted use of face masks and the mandatory vaccination of all the population against tuberculosis, which might protect from SARS-CoV-2 infection , a featuThe loss of social prestige of individuals taking antibiotics without prescription, as well as the pharmacies delivering these drugs or do not respect environmental protection, or the overconsumption of antibiotics in hospitals or in farms, or even in certain countries, is progressively constituting a “social norm,” converted in rules able to reduce AR emergence and spread. Of course, family and school education, as well as governmental campaigns, including the use of social media  reinforcControlling resistance not only requires establishing local interventions, which could be relatively easily implemented, but would also require global interventions that every country should follow, despite their disparate regulatory systems. Local and global interventions are necessarily intertwined; for example, the use of a new drug to treat a single individual depends on regulations at the county level , but the worldwide prevalence and transmission of resistance to this drug, as well as the regulations of its use, should be established internationally .Three main interventions to tackle AR have been historically considered: first, reduction of the antibiotic selective pressure by decreasing antimicrobials use; second, reduction of transmission of ARBs using improved hygienic procedures that prevent spread; third, development of novel antimicrobials with limited capacity to select ARBs or the design of new treatment strategies based on use of non–antibiotic-based approaches or, more recently, on the exploitation of trade-offs associated with AR evolution . These iHaemophilus influenzae and Streptococcus pneumoniae has been demonstrated to be an effective intervention for reducing AR  , not onlConcerning the development of new antimicrobials , while tFrom a conservative point of view, based on the use of the drugs we already have, it would be desirable to fight AR using evolution-based strategies for developing new drugs or treatment strategies. Regarding this, the exploitation of the evolutionary trade-offs associated with the acquisition of AR, as collateral sensitivity, could allow the rational design of treatments based on the alternation or the combination of pairs of drugs .In addition to interventions that reduce the selective pressure of antibiotics or that implement new therapeutic approaches, reducing transmission is also relevant to fight infections. The development of drugs or conditions (as certain wastewater treatments) able to reduce mutagenesis or to inhibit plasmid conjugation may also help in reducing the spread of resistance . BesidesConcerning trade of goods, it is relevant to remark that, although there are strict regulations to control the entrance of animals or plants from sites with zoonotic of plant epidemic diseases , there aBdellovibrio to eliminate pathogens without the need for antibiotics has been proposed; although its utility for treating infections is debatable, it might be useful in natural ecosystems  aspects of AR  should bosystems . More reosystems , a featuce model . Howeverce model , a featuce model  or the uce model  has beenThe recent crisis of COVID-19  resembleThis reflection on how infectious diseases in general should be faced by the society was published at 1624, but the idea behind still applies nowadays, especially for AR.All authors have contributed to the concept of the review and in its writing.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.


Long non-coding RNAs (lncRNAs) play pivotal roles in various kinds of human diseases, especially in cancer. However, regulatory role, clinical significance and underlying mechanisms of lncRNAs in colorectal cancer (CRC) liver metastasis still remain largely unknown. This study aimed to report a novel lncRNA, lnc-HSD17B-11:1, and its functional role in CRC progression.In vitro and in vivo functional experiments were performed to investigate the effects of lnc-HSD17B11-1:1 on tumor growth and metastasis in CRC. Mechanistically, Base Scope, bioinformatics analyses, dual luciferase reporter assay and RNA immunoprecipitation experiments were performed to confirm the association of lnc-HSD17B11-1:1 and miR-338-3p. Dual luciferase reporter assay, qRT-PCR and western blot analysis were performed to assess the relationships among lnc-HSD17B11-1:1, miR-338-3p, and MACC1.Differentially expressed lnc-HSD17B11-1:1 was screened and identified from a lncRNA profile microarray. Quantitative real-time PCR was used to determine the expression levels and prognostic values of lncRNA in CRC cohorts. p = 0.043), clinical stage (p = 0.027), distant metastasis (p = 0.003) and poor prognosis of patients with CRC. lnc-HSD17B11-1:1 promoted CRC cell proliferation, mobility and invasion in vitro and in vivo. Mechanistic analysis revealed that lnc-HSD17B11-1:1 may act as a competing endogenous RNA (ceRNA) by acting as a sponge for miR-338-3p to upregulate the expression of MACC1.Evidently up-regulation of lnc-HSD17B11-1:1 in CRC primary tissues was correlated with the depth of invasion (These findings suggest that lnc-HSD17B11-1:1 promotes CRC progression through lnc-HSD17B11-1:1/miR-338-3p/MACC1 axis and this might serve as a new diagnostic marker or target for treatment of CRC. Colorectal cancer (CRC) is the third most common cancer and the fifth most common cause of cancer-related death in China . The mosLong non-coding RNAs  are recently discovered as a novel class of genes with regulatory functions but lacked protein-coding ability. Several studies have identified and reported important roles of lncRNAs in varied cellular processes, including X chromosome inactivation, splicing, imprinting, epigenetic control, and gene transcription regulation . MoreoveTo explore the role of lncRNAs played in CRC and CRLM process, lncRNA microarray using the “LncRNA + mRNA Human Gene Expression Microarray V4.0” was performed and identified a novel CRC-related lncRNA lnc-HSD17B11-1:1. Subsequently, the clinical significance of lnc-HSD17B11-1:1 expression in CRC was explored to gain insights regarding the function and underlying molecular mechanisms of lnc-HSD17B11-1:1 in CRC development and progression. Our data revealed remarkable upregulation of lnc-HSD17B11-1:1 in CRC tissues, association with clinical stage and pathological grade and positive correlation with MACC1 expression. The up-regulation of lnc-HSD17B11-1:1 or MACC1 was closely related to the poor prognosis of patients with CRC. Further functional and mechanistic investigations revealed that lnc-HSD17B11-1:1 could promote cell proliferation and metastasis by acting as a sponge for miR-338-3p in order to relieve micro-RNA repression for MACC1 target gene. Therefore, our data demonstrated that lnc-HSD17B11-1:1 might act as an oncogene in CRC progression, act as a valuable marker and independent prognostic factor for CRC diagnosis, therapy and survival.This study was approved by local Research Ethics Committee of Peking University Peoples Hospital. Patients who participated in this study were fully informed. After informed, they signed written consents. All the animal experiments involved in this study strictly conform to animal ethics and had approval from the local Research Ethics Committee of Peking University Peoples Hospital, which adheres to generally accepted international guidelines for animal experimentation.A total of 160 CRC patients who underwent surgery at the Peking University People’s Hospital between 2014 and 2017 were included in this study. Fresh colorectal tumor tissues and matched normal colorectal mucosal tissues were obtained from all the patients. The specimens were obtained and immediately frozen in liquid nitrogen and stored at −80°C until RNA or protein extraction.2) were maintained at 37°C in a humidified atmosphere containing 5% CO2.The human CRC cell lines SW480, SW620, LoVo, HCT116, HT29, RKO, LS174T, and the normal human colon epithelial cell line NCM460 were purchased from the American Type Culture Collection  and were subcultured and preserved. SW480 and SW620 cells were cultured in l-15 medium supplemented with 10% fetal bovine serum  and 100μg/mL streptomycin (Sigma-Aldrich), NCM460, HT-29, HCT116, LS174T and RKO cells were cultured in RPMI1640 medium containing 10% FBS (Gibco) and 100μg/ml streptomycin (Sigma-Aldrich), and LoVo cells were cultured in DMEM medium supplemented with 10% FBS (Gibco) and 100μg/mL streptomycin (Sigma-Aldrich). All these cell lines except SW480 and SW620  according to the manufacturer’s instructions. The quality and quantity of isolated RNA were detected by Nanodrop 2000 spectrophotometer  and the integrity was examined by Agilent 2100 Bioanalyzer . Next, the purified RNA was treated with RiboZero rRNA removal kit  to deplete the rRNA according to the manufacturer’s protocol. The rRNA-depleted RNA samples were randomly fragmented into small pieces and synthesized cDNA with a random primer. The PCR amplification products of cDNA were purified with AMPure XP kit .CT–ΔΔ method.Reverse Transcription Polymerase Chain Reaction was carried out using a One Step SYBR PrimeScript RT-PCR kit  and Real-time PCR detection system  to evaluate the expression of lnc-HSD17B11-1:1. The miRNA miR-338-3p was obtained using the PureLink miRNA isolation kit (Invitrogen), and the quantification of miRNA expression was performed using a TaqMan MicroRNA assay kit . The expression of GAPDH genes was assessed simultaneously in all samples as an internal control for lncRNA/mRNA and miRNA expression, respectively. The relative gene expression was determined by 2CT–ΔΔ method.For lncRNA quantification, GAPDH was used as an internal control, and PrimeScriptTM RT MasterMix (TAKARA) was used for reverse transcription and real-time PCR. The primer sequences were as follows: lnc-HSD17B11-1:1 forward: 5′-CTCTGGAACCTGAGGAAGTGG-3′, lnc-HSD17B11-1:1 reverse: 5′-ACGCCTAGTTTTCGGCACTC-3′; MACC1 forward: 5′-CTCTGGAACCTGAGGAAGTGG-3′, lnc-HSD17B11-1:1 reverse: 5′-ACGCCTAGTTTTCGGCACTC-3′; GAPDH forward: 5′-CACCCACTCCTCCACCTTTG-3′, GAPDH reverse: 5′-CCACCACCCTGTTGCTGTAG-3′. All reactions were performed in triplicate. The fold change for each gene relative to the control group was calculated using 2in vitro assays, to interfere the expression of lnc-HSD17B11-1:1, siRNA interference sequences targeting Lnc-HSD17B11-1:1 were designed and synthesized , and a final concentration of 50nM were used for transient transfection. To overexpress lnc-HSD17B11-1:1, full-length human lnc-HSD17B11-1:1 cDNA was cloned into pcDNA3.1 expression vector . Lipofectamine 3000  was used for transfection according to the manufacturer’s instructions.For in vivo studies, lnc-HSD17B11-1:1 overexpression cell line was used. The lnc-HSD17B11-1:1 gene was cloned into a lentivirus vector LV-GFP-Puro, and SW480 cells were used for infection. Stable transfection of cells was done by puromycin antibiotic selection at a concentration of 2.5 ug/ml for 7 days.For 3 cells) were seeded in 96-well plates in complete medium and infected with lnc-HSD17B11-1:1, mock, si-lnc-HSD17B11-1:1 and si-NC. Cell proliferation assay was conducted with Cell Counting Kit-8 (CCK-8) in accordance with the manufacturer’s instructions. Cells in each group were detected for 6 replicates. Cell proliferation was measured by the CCK-8 method according to the manufacturer’s protocols using a microplate reader  to measure the absorbance. For colony formation assay, transfected cells were seeded in six-well plate and incubated for 14 days. Then, all the wells were fixed with 4% paraformaldehyde, and stained with 0.1% crystal violet. Image J software was used for statistical analysis of the form colonies.HCT116 and SW480 cells (3 × 105) in serum-free media were placed into the upper chamber while media containing 20% FBS was placed in the lower chamber as a chemoattractant to perform migration assays (without Matrigel) and invasion assays  at 24 h post-transfection. The non-invading cells were erased with cotton swabs after incubation for 48 h. Cells penetrated down to the bottom of the membrane were stained with methanol 0.1% crystal violet. Images were captured by the microscope. The ImageJ software was used for statistical analysis of the number of the cells.HCT116 and SW480 cells were seeded in six-well plate. Then, a vertical wound was scratched with a 200 ul microtip in the middle of the wells after 24 h transfection. The width of wounds was measured in three independent positions per group and normalized to control group after 24 h cultured in serum-free medium. Cell invasion assay was carried out using Corning Polycarbonate Membrane insertion transwell chamber . cells  into the dorsal region near the thigh. Four mice were included in each group. The tumor length and width of the mice were measured to assess the tumor size every 7 weeks.Six-week-old Balb/C nude (nu/nu) mice were purchased from Beijing weitonglihua Experimental Animal Technology Co., Ltd. The tumors were generated by subcutaneously injecting 2 × 10® Protease III at 40°C for 30 min, and the samples were rinsed twice in distilled water between treatments. BaseScope probes  with positive control  were then applied and samples were incubated for 2 h at 40°C in a HybEZ oven by the reagents AMP0 (30 min at 40°C), AMP1 (15 min at 40°C), AMP2 (30 min at 40°C), AMP3 (30 min at 40°C), AMP4 (15 min at 40°C), AMP5 (30 min at 25°C), and AMP6 (15 min at 25°C). The slides were rinsed with wash buffer (twice for 2 min) between AMP incubation steps. Finally, the slides were treated with Fast Red for 10 min at 25°C in the dark and counterstained with Gill’s hematoxylin, dried for 15 min at 60°C, and mounted in VectaMount permanent mounting medium .BaseScope assays were performed according to the manufacturer’s instructions . The tissues were sectioned into 5-μm thickness, placed onto Superfrost Plus slides , and allowed to dry overnight at 25°C. The sections were then baked at 60°C for 1 h before deparaffinizing in xylene (twice for 5 min) and ethanol (twice for 2 min) and dried by baking at 60°C for 2 min. Hydrogen peroxide was applied for 10 min at 25°C, and target retrieval was performed for 15 min at 100°C. This was followed by application of RNAscopeThe sequences of lnc-HSD17B11-1:1 and MACC1 3′UTR and their corresponding mutant versions without miR-338-3p binding sites were synthesized and subcloned into luciferase reporter vector psiCHECK2 , and were named as lnc-HSD17B11-1:1-WT, lnc-HSD17B11-1:1-Mut, MACC1 3′UTR-WT and MACC1 3′UTR-Mut, respectively. All these plasmids were validated by sequencing. The relative luciferase activity was examined by dual Luciferase assay kit  in accordance with the manufacturer’s protocol.RNA Immunoprecipitation was conducted using the Magna RIP kit  according to the manufacturer’s instructions. SW480 cells were harvested 48 h after transfection of miR-338-3p mimic or miR-NC, and lysed using incomplete RNA lysis buffer. The cell lysates were then incubated with magnetic beads followed by conjugation with anti-Argonaute2 (AGO2)  or negative control IgG antibody  at 4°C for 4 h. The beads were washed using washing buffer. The immunoprecipitated RNA and protein were purified and enriched to detect target RNAs and AGO2 by qRT-PCR and western blotting.The total protein of CRC cells was exacted using RIPA buffer, separated by 10% SDS-PAGE, and electrophoresed onto a PVDF membrane . The membranes were blocked with 5% skimmed milk powder and incubated with primary antibodies against MACC1 (1:1000) , and GAPDH (1:5000)  at 4°C overnight and then incubated with secondary antibodies (1:5000)  at room temperature for 2 h. Finally, the bands were examined by ImmobilobTM Western Chemiluminescent HRP Substrate .t-test (two-tailed). The differences between three or more groups were assessed by one-way ANOVA or χ2 test. The survival rates were evaluated by Kaplan–Meier method and tested by log-rank test. The effects of clinical variables on the overall survival of CRC patients were determined by univariate and multivariate Cox proportional hazards regression model. In the multivariate Cox proportional hazards regression model, age, gender, T stage, clinical stage and distant metastasis were adjusted for variable analysis. The correlation between groups was analyzed by Pearson correlation. P-values of < 0.05 were considered to be statistically significant.Statistical analyses were performed by SPSS 22.0  and GraphPad Prism 8.0 . The data were presented as means ± standard deviation (SD). The significance between two mean values was assessed using unpaired Student’s p < 0.05, a total of 332 distinguishingly expressed lncRNAs were found between CRC liver metastatic tissues and primary tissues, among which 234 were upregulated while 98 were downregulated in liver metastatic tissues. The top 10 upregulated and downregulated lncRNAs were listed in 1In order to demonstrate the expression levels of lncRNA in CRC, we previously applied lncRNA microarray and explored the global expression profiles of lncRNAs in CRC primary tissues and liver metastatic tissues . With a p = 0.043), clinical stage (p = 0.027), and distant metastasis (p = 0.003). Kaplan–Meier survival curve indicated that the expression levels of lnc-HSD17B11-1:1 were inversely correlated with the overall survival of CRC patients  of miR-338-3p. Dual luciferase reporter assay were performed to validate the prediction. As expected, the results showed that miR-338-3p mimics could significantly decrease the luciferase activity of MACC 1 3′UTR-WT group compared with control groups (According to TargetScan,l groups . Moreovel groups .Additionally, we found that overexpression of lnc-HSD17B11-1:1 or downregulation of miR-338-3p dramatically increased the levels of MACC1 while knockdown of lnc-HSD17B11-1:1 or upregulation of miR-338-3p remarkedly decreased the expressions of MACC1 . MoreoveTo ensure whether MACC1 is co-overexpressed with lnc-HSD17B11-1:1 in CRC patients, the levels of MACC1 were examined in the 160 pairs of CRC tissues and para-cancerous tissues by qRT-PCR. The results demonstrated that MACC1 was considerably upregulated in CRC . Pearsonin vivo and in vitro demonstrated that lnc-HSD17B11-1:1 significantly promoted proliferation and metastatic abilities of CRC cells, while knockdown of lnc-HSD17B11-1:1 showed an inverse effect.Some lncRNAs were reported to function as oncogenes or tumor suppressors in different types of cancers including CRC . only feA growing body of research suggests that some lncRNAs could serve as sponges for miRNAs to regulate the expression of target mRNA in CRC . For insMACC1 is a vital gene with the invasive behaviors and postoperative liver metastasis in colon cancer . We founTaken together, our results demonstrate that lnc-HSD17B11-1:1 plays an important role in the progression of human CRC by functioning as a ceRNA to regulate the expression of MACC1 through miR-338-3p sponge activity. The pleiotropic effects of lnc-HSD17B11-1:1 on the pathogenesis of CRC suggests that it has the potential to act as a potential target for CRC therapy.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.The studies involving human participants were reviewed and approved by the Research Ethics Committee of Peking University Peoples Hospital. The patients/participants provided their written informed consent to participate in this study. The animal study was reviewed and approved by the Research Ethics Committee of Peking University People’s Hospital.WZ, BW, and SW conceived the study and participated in its design and coordination. WZ drafted and revised the manuscript. KJ and ZS collected the clinical data and helped with the statistical analysis. ZZ and QW performed the experiments. SW conceived the study and revised the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.