The surgical education environment has been changing significantly due to restricted work hours, limited resources, and increasing public concern for safety and quality, leading to the evolution of simulation-based training in surgery. Of the various simulators, low-fidelity simulators are widely used to practice surgical skills such as sutures because they are portable, inexpensive, and easy to use without requiring complicated settings. However, since low-fidelity simulators do not offer any teaching information, trainees do self-practice with them, referring to textbooks or videos, which are insufficient to learn open surgical procedures. This study aimed to develop a new suture training system for open surgery that provides trainees with the three-dimensional information of exemplary procedures performed by experts and allows them to observe and imitate the procedures during self-practice. The proposed system consists of a motion capture system of surgical instruments and a three-dimensional replication system of captured procedures on the surgical field. Motion capture of surgical instruments was achieved inexpensively by using cylindrical augmented reality (AR) markers, and replication of captured procedures was realized by visualizing them three-dimensionally at the same position and orientation as captured, using an AR device. For subcuticular interrupted suture, it was confirmed that the proposed system enabled users to observe experts’ procedures from any angle and imitate them by manipulating the actual surgical instruments during self-practice. We expect that this training system will contribute to developing a novel surgical training method that enables trainees to learn surgical skills by themselves in the absence of experts. Surgeons traditionally learned surgical skills by the “see one, do one, teach one” method, developed by Dr. William Halsted –4. HowevSimulation-based surgical skill training is an educational approach that can provide trainees the opportunity to experience a given task or situation in a safe environment. It provides standardized and reproducible contents to practice surgical skills, allowing trainees to practice them repeatedly until they acquire the skills , 5, 7; iThere are different types and complexities of simulators for surgical training . Among tAugmented reality (AR) is a technology that expands our physical world by overlaying digital information onto it. This technology allows users to interact with the information in the real world, and AR in medical education is gathering attention because users do not have to pause or take their eyes off the surgical field when accessing the information while practicing , 14, 15.However, there have been no reports of an AR system that allows trainees to observe the open surgical procedures from any angle during training.The present study aimed to build an AR system that trainees observe and imitate exemplary procedures during practice without an instructor. This study proposes a novel suture training system for open surgery that provides three-dimensional (3D) information of experts’ procedures by combining AR technology with a low-fidelity simulator.The proposed system allows users to observe and imitate experts’ procedures by replicating and visualizing them on the surgical field. To implement this system, it was decided to replicate the motion of surgical instruments. Thus, this system consists of a motion capture system for surgical instruments and a 3D replication system of captured motion on the surgical field.Subcuticular interrupted suture was chosen as a target procedure because it is one of the problematic skills trainees must acquire early in their training. AR markers were used to track surgical instruments and the surgical field in the motion capture system. HoloLens 2  was used to replicate the procedures by displaying 3D computer graphics (3D-CG) models of surgical instruments as holograms on the surgical field. The system was developed using Vuforia Engine , Unity , and MRTK .The setup of the motion capture system is shown in Fig. pi) measured by an AR probe and the coordinates of fiducial points on the 3D-CG model in the 3D-CG model CS (qi). The coordinate transformations  were obtained respectively by the following equation and saved as text files.To replicate the motion of actual surgical instruments using AR technology, it is necessary to obtain the positional relationship between the AR marker and the actual surgical instrument. Based on the AR marker, a 3D-CG model of the surgical instrument is displayed in the same position and orientation as the actual surgical instrument. Therefore, the 3D-CG models were reconstructed by 3D scanning, and coordinate transformations between the AR marker coordinate system (CS) and the 3D-CG model CS of each surgical instrument were calculated using point set registration before motion capture. As shown in Fig. Tnd,Tf,Tskin) from the camera was tracked at 30 frames per second (fps) using our software  and forceps marker (Mf) were calculated and recorded for each frame. When users finished the procedure, they pressed the stop button, and the data were saved as text files.When performing the procedure for capturing motion, users pressed the start button in the Unity editor, and the CS of each AR marker (θ) was also recorded to replicate the open/closed condition of the forceps so that users who observe the replicated procedures can understand the correct place where the forceps should grasp the skin. Each tip of the forceps (Tip point 1 and Tip point 2) was marked and tracked from the camera. The angle was calculated using the position of the marks  and the base point (pbase) in the AR marker CS by the following equation for each frame, as described in Fig. Mnd, Mf).The forceps opening angle  that changes the angle between the forceps’ tips in the 3D-CG model.When overlaying information in AR applications, occlusion, the ability to hide 3D-CG objects located behind other objects, plays an essential role in providing the right spatial positional relationship . A hand MndSnd and MfSf, respectively, for each frame  was set at 0.05.Two experts performed subcuticular interrupted sutures five times for each shape, and both the total time in which AR markers were tracked and the procedure time were obtained in each suture. The tracked time to procedure time ratio was analyzed using one-way analysis of variance (ANOVA), followed by the Tukey-Kramer test when the ANOVA model’s findings were significant. Statistical analyses were conducted using Bell Curve for Excel . The The performance and usability of the replication system were evaluated.An expert’s subcuticular interrupted suture procedure was recorded using the motion capture system and used in the replication system. Whether HoloLens 2 detected the reference marker and at what frame rate it visualized the procedure on the surgical field were examined. For usability evaluation, whether users could see the replicated procedure and the actual surgical instruments simultaneously and imitate the procedure by manipulating them were explored. Whether the 3D-CG models were occluded by the hands when users placed their hands in front of them was also investigated.A motion capture system of surgical instruments for subcuticular interrupted suture was developed using AR markers and a camera.During the procedure, all markers were tracked from the camera simultaneously without interfering with each other. According to the experts, the markers did not interfere with the manipulation of surgical instruments or obstruct the line of sight to the surgical instruments’ tips, enabling them to perform the procedure as usual. The tracking data could be obtained at 30 fps regularly.p < 0.001 for expert 1; F  = 79.9424, p < 0.001 for expert 2), and the Tukey-Kramer test showed significant differences (p < 0.05) for all pairs of AR markers in both experts. The cylindrical AR marker could be tracked when the needle driver was rotated, whereas the square marker could not. The right-angle marker was also lost when the needle driver’s rotation switched the marker visible from the camera. For the forceps, both the square marker and the cylindrical marker were stable (1.00 ± 0.00 (Square marker); 0.99 ± 0.00  for expert 1, and 1.00 ± 0.00 (Square marker); 0.99 ± 0.01  for expert 2) ; 0.71 ± 0.07 (Right-angle marker); 0.95 ± 0.03 ); expert 2 (0.50 ± 0.03 (Square marker); 0.70 ± 0.03 (Right-angle marker); and 0.98 ± 0.01 ) Fig. . ANOVA d 2) Fig. . HoweverA 3D replication system of surgical procedures was developed using HoloLens 2.As shown in Fig. When users positioned themselves to suture in front of the skin pad, they could see the entire 3D-CG models of surgical instruments within a field of view (FOV). They could also see both 3D-CG models and the actual surgical instruments simultaneously and imitate the replicated procedure by manipulating the actual surgical instruments Fig. .Fig. 8HThe displayed 3D-CG models were occluded by the user’s hands when their hands were placed in front of them Fig. . HoweverA novel suture training system for open surgery that provides 3D information of exemplary procedures during practice by combining AR technology with a low-fidelity simulator was developed.Motion capture of surgical instruments can be done using electromagnetic, mechanical, or optical systems, and in any case, the systems must be minimal and nonobstructive . Motion AR markers are a low-cost method widely used in AR applications for CS estimation from a camera . By usinThe present replication system visualized the procedures performed by experts three-dimensionally at the same site as performed. This system allowed trainees to observe the procedures from their desired angle, even in the experts’ absence, which is not possible using conventional teaching materials. In addition, trainees could access the procedures without stopping practice because they could see both the overlayed procedures and the real surgical field simultaneously . It is aHoloLens 2 has a sufficient FOV to display the entire 3D-CG models of surgical instruments within its FOV, allowing trainees to grasp their position and orientation immediately and imitate the replicated procedures while manipulating the actual surgical instruments. This feature will likely help trainees efficiently understand the ideal procedures and recognize the differences between their procedures and experts’ procedures and what needs to be improved.The procedure was replicated at around 20 fps without hand occlusion, which was slower than the original, but the procedure’s motion was smooth. However, hand occlusion reduced the smoothness due to the lower fps. Although the central processing unit in AR devices has been improving, it needs further improvement to render 3D-CG models and the hand mesh simultaneously without degrading the user experience.Since this training system can be built by introducing AR markers and AR devices to existing low-fidelity simulators, the system will also apply to various suture practices in open surgery, such as bowel anastomosis, using low-fidelity simulators. In addition, there are commercially available devices that can track users’ fingers, and HoloLens 2 itself tracks users’ fingers. Therefore, by combining these devices with the system, it will also be able to replicate the motion of a surgeon’s fingers, such as when tying knots.Although the present system provides a new learning experience, there are some limitations. First, the accuracy of the replicated procedures to the original procedure was not validated. In addition, an objective evaluation of the training effectiveness of this system is still lacking. Further validation is needed to confirm the reliability and effectiveness of the system. Needles were not visualized, because the positional relationship between needles and needle drivers is fixed during the procedure. Visualizing needles will be necessary to practice other procedures in which the positional relationship has to be changed.Although the AR markers did not obstruct this study’s procedures, they may still be too bulky to be applied to other procedures. Technological advances in marker recognition will make the marker size smaller and solve this problem.An inexpensive motion capture system for open surgery was developed by evaluating AR markers’ shapes, and a suture training system that allows trainees to practice with replicated exemplary procedures using HoloLens 2 was proposed. This training system will contribute to helping trainees learn surgical skills by themselves without an instructor.


Glioblastoma multiforme (GBM) is the most common and also the most invasive brain cancer. GBM progression is rapid and its prognosis is poor. Therefore, finding molecular targets in GBM is a critical goal that could also play important roles in clinical diagnostics and treatments to improve patient prognosis. We jointly analyzed the GSE103227, GSE103229, and TCGA databases for differentially expressed RNA species, obtaining 52 long non-coding RNAs (lncRNAs), 31 microRNAs (miRNAs), and 186 mRNAs, which were used to build a competing endogenous RNA network. Kaplan–Meier and receiver operating characteristic (ROC) analyses revealed five survival-related lncRNAs: H19, LINC01574, LINC01614, RNF144A-AS1, and OSMR-AS1. With multiple optimization mRNAs, we found the H19-hsa-miR-338-3P-NRP1 regulatory pathway. Additionally, we noted high NRP1 expression in GBM patients, and Kaplan–Meier and ROC analyses showed that NRP1 expression was associated with GBM prognosis. Cox analysis indicated that NRP1 is an independent prognostic factor in GBM patients. In conclusion, H19 and hsa-miR-338-3P regulate NRP1 expression, and this pathway plays an important role in GBM. Glioblastoma multiforme (GBM) is the most malignant pathological type of glioma. GBMs grow rapidly, are highly malignant, and generally progress rapidly, leading to an average survival period of approximately 12 months , 4. CurrLong non-coding RNAs (lncRNAs), which are an RNA species of greater than 200 nt in length that lack protein coding functions, account for the majority of transcribed sequences in the human genome –8. LncRNNRP1 is a non-tyrosine kinase transmembrane protein composed of 923 amino acids that is widely expressed in diverse tissue types . NRP1 isWe obtained differentially expressed lncRNAs and mRNAs by analyzing GBM databases, predicted the miRNAs that could interact with them, and then constructed a lncRNA-miRNA-mRNA regulatory network. Kaplan–Meyer and receiver operating curve (ROC) analyses revealed five survival-related lncRNAs: H19, LINC01574, LINC01614, RNF144A-AS1, and OSMR-AS1. Additionally, we found that NRP1, HOXC6, and SHCBP1 mRNAs were differentially expressed in GBM and were related to patient prognosis. NRP1 is highly expressed in GBM, and it was confirmed in the Chinese Glioma Genome Atlas (CGGA) and GSE16011 databases that NRP1 expression is related to patient prognosis. Cox analysis confirmed that NRP1 was an independent prognostic factor for GBM patients. Ultimately, we propose that the H19-hsa-miR-338-3P-NRP1 pathway could be targeted for GBM treatment and/or used for clinical diagnostics.https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE103227) and GSE103229 (https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE103229) each contain five non-tumor brain specimens and five GBM specimens. The TCGA  database contains five non-tumor brain specimens and 168 GBM specimens. GSE16011 (https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE16011) contains eight non-tumor brain specimens and 148 GBM specimens. CGGA (http://cgga.org.cn/) contains 108 GBM patients. We download glioblastoma-related data according to the steps provided on these websites. Xuzhou Children’s Hospital Medical Ethics Committee approved this study protocol.The lncRNA and mRNA data of GBM patients were obtained from the Gene Expression Omnibus (GEO), CGGA, and The Cancer Genome Atlas (TCGA) databases. GSE103227 (www.r-project.org/). We defined differentially expressed lncRNAs and mRNAs as those that satisfy both |logFC| ≥1 and p-value <0.05. Then, Venn diagrams were used to display the intersection of the identified lncRNAs and mRNAs from each dataset. Then miRcode software (http://www.mircode.org/) was used to predict miRNAs that could interact with the identified lncRNAs. MiRNAs that concurrently satisfied miRDB (http://mirdb.org/), miRTarBase (https://bio.tools/mirtarbase) and TargetScan (http://www.targetscan.org/vert_72/) were defined as miRNA target genes. Finally, Cytoscape (https://cytoscape.org/) was used to generate the ceRNA network of lncRNA-miRNA-mRNA interactions.We obtained differentially expressed lncRNAs and mRNAs using the LIMMA package of R software Click here for additional data file.S2 Table(PPTX)Click here for additional data file.


The patients with TCMR and ABMR were assigned to the AR group, and the patients with normal/non-specific changes (n = 19) were assigned to the non-AR group. We analysed RNA-Seq data for identifying differentially expressed genes (DEGs), and then gene ontology (GO) analysis, Reactome, and ingenuity pathway analysis (IPA), protein—protein interaction (PPI) network, and cell-type enrichment analysis were utilised for bioinformatics analysis. We identified DEGs in the PBMCs of the non-AR group when compared with the AR, ABMR, and TCMR groups. Pathway and GO analysis showed significant inflammatory responses, complement activation, interleukin-10 (IL-10) signalling pathways, classical antibody-mediated complement activation pathways, etc., which were significantly enriched in the DEGs. PPI analysis showed that IL-10, VEGFA, CXCL8, MMP9, and several histone-related genes were the hub genes with the highest degree scores. Moreover, IPA analysis showed that several proinflammatory pathways were upregulated, whereas antiinflammatory pathways were downregulated. The combination of NFSF14+TANK+ANKRD 33 B +HSPA1B was able to discriminate between AR and non-AR with an AUC of 92.3% (95% CI 82.8–100). Characterisation of PBMCs by RNA-Seq and bioinformatics analysis demonstrated gene signatures and biological pathways associated with AR. Our study may provide the foundation for the discovery of biomarkers and an in-depth understanding of acute renal allograft rejection.Acute rejection (AR) is closely associated with renal allograft dysfunction. Here, we utilised RNA sequencing (RNA-Seq) and bioinformatic methods to characterise the peripheral blood mononuclear cells (PBMCs) of patients with acute renal allograft rejection. Pretransplant blood samples were collected from 32 kidney allograft donors and 42 corresponding recipients with biopsies classified as T cell-mediated rejection (TCMR,  Kidney transplantation is the optimal choice for patients with end-stage renal disease (ESRD). However, acute rejection (AR) cannot be avoided easily when transplanting tissue or cells from a genetically different donor to the graft recipient because the alloantigen of the donor induces an immune response against the graft in the recipient .Acute rejection can occur at any time following transplantation, usually within days to weeks. It is classified as antibody-mediated rejection (ABMR) or acute T cell-mediated rejection (TCMR). In recent years, the overall incidence of AR has decreased, and graft survival has improved with the use of effective immunosuppressive therapy. Currently, AR occurs in approximately 10–20% of cases; however, significant improvement in long-term allograft survival rates remains unrealised . It has Therefore, investigation into the signature of AR recipients is crucial for understanding the potential pathogenesis and identifying effective biomarkers of rejection. Recently, there have been many studies on biomarkers of allograft rejection. For example, many transplant centres apply donor-derived free DNA for testing AR, which can be positive even before the actual rise in serum creatinine. Some biomarkers detected by the peripheral blood mRNA assay and proteomics methods also showed good accuracy and sensitivity in the diagnosis of various types of rejection –9.RNA sequencing (RNA-Seq) is a molecular tool widely utilised by researchers to analyse global transcriptional changes, deduce pathogenic mechanisms, and discover biomarkers . BioinfoIn this study, we were able to identify the transcriptional signature in peripheral blood mononuclear cells (PBMCs) of recipients with AR, which helped to distinguish these cells from those of non-AR recipients. Through bioinformatics analysis, several genes and pathways were found to be significantly different between AR and non-AR recipients, including interleukin-10 (IL-10), VEGFA, CXCL8, and histone-related genes, and also IL-10 signalling pathways. Moreover, we found a combination of four genes which could be used to accurately diagnose AR. Thus, this study may provide the basis for further investigations into allograft rejection.n = 18; ABMR, n = 5) and 19 non-AR recipients with stable kidney function and a normal histology. The classifications for the histopathological diagnosis of renal allograft biopsy were based on the Banff 2017 classification  ≥18 years of age, regardless of gender and ethnicity; (2) with ESRD undergoing treatment for ≥3 months; and (3) voluntarily joined the study and signed informed consent. Exclusion criteria were patients with (1) acute kidney injury, (2) active inflammatory diseases, (3) other concomitant diseases , and (4) pregnant and lactating women. Based on these criteria, 32 donors also participated in the RNA-Seq cohort study. PBMCs were isolated from the blood of 32 donors and 42 recipients, including 23 biopsy-proven AR recipients  was extracted from PBMCs using TRIzol reagent (Invitrogen) according to the manufacturer's protocol. The quantity and quality of the RNA isolated from the PBMCs were measured using a NanoDrop2000 spectrophotometer . The Agilent 2100 Bioanalyzer  was used to measure RNA integrity, reported as the RNA integrity number.2-transformed, quantile-normalised, and corrected for experimental batch effects using the ComBat R package to compare transcription levels across samples. Then, the normalised bulk RNA-Seq expression data (FPKM) of each gene were calculated based on the length of the gene and read count mapped to said gene. Differential gene expression analysis between patients with AR and non-AR was performed using the Limma package in R (2 fold change (FC) of 1 and p-value of 0.05 were set as the threshold for significantly differentially expressed genes (DEGs).MicroRNA-Seq was performed on an Illumina Hiseq X Ten sequencer by following the manufacturer's protocol (Illumina Inc.). The raw RNA-Seq data were processed as follows: clean reads of good quality were first aligned to human reference databases, namely the hg38 human genome, exon, splicing junction segment splicing junction, and contamination databases including ribosomal and mitochondrial RNA sequences using the BWA alignment algorithm. The feature count was used to count the read numbers mapped to each gene. The read counts were logage in R . A log2 https://david.ncifcrf.gov/home.jsp), which provides a comprehensive set of functional annotation tools for investigators to understand the biological meaning behind a large list of genes (https://reactome.org/) which is a free, open-source, curated, and peer-reviewed pathway database . For the search parameters, the organism queried was set to homo sapiens, the required confidence score was set to 0.9 (highest confidence), and the interactors shown were set to no more than 20. The edges reflected the strength of evidence and were drawn with up to three different thickness values: medium (0.400), high (0.700), and highest (0.900). The false discovery rate was set to 0.05. The search results were then imported into Cytoscape (version 3.8.2) for further analysis. The hub genes were identified using the CytoHubba plugin with the degree score, and the top 10 genes were finally selected   , a bioinhttps://cibersort.stanford.edu/) (t-test was used to determine the population change for each cell type between patients with AR and non-AR at the cut-off of p < 0.05.The deconvolution method using the Cell-type Identification By Estimating Relative Subsets of known RNA Transcripts (CIBERSORT) algorithm was also performed to estimate the population percentage of immune cells for each sample from the bulk RNA-Seq profile (rd.edu/) . Based oWe utilised an ingenuity pathway analysis (IPA) to further mine the potential pathways related to the DEGs. The IPA is a web-based software application for the analysis, integration, and interpretation of data derived from gene expression experiments, including RNA-Seq, microRNA and SNP microarrays, metabolomics, proteomics, and small-scale experiments that generate gene and chemical lists. A downstream effect analysis was used to predict cellular functions, disease processes, and other phenotypes impacted by patterns in the analysed data set. In addition, an upstream regulator analysis was done to identify regulators  directly linked to the targets in the analysed data and whose activation or inhibition may account for the observed changes. A positive Z-score indicated that the pathway was promoted, whereas a negative value indicated that the pathway was suppressed.t-test, and the comparison between the categorical variables was performed using the chi-squared test. When the two-sided test yielded a p < 0.05, the difference was considered statistically significant. All data were statistically analysed using SPSS Statistics v20 , and statistical charts were created using GraphPad Prism software  or R software (v. 3.3.2).Continuous variables with normal distribution were expressed as mean ± SD, and variables with a skewed distribution were represented by the median (interquartile range). Categorical variables were expressed in terms of rate (%) or composition ratio (%). The comparison between the two groups of continuous variables was analysed using a Student's p = 0.042), and the glomerular filtration rate (GFR) was significantly reduced (p = 0.019) in AR recipients than in non-AR recipients. There were no statistically significant differences between the two groups in terms of recipient or donor age or sex, induction type, kidney disease, HLA mismatch, cold ischaemia time, blood urea nitrogen, serum creatinine, urine protein, and uric acid (p > 0.05).We performed RNA-Seq on 74 pretransplant blood PBMC samples collected from 32 kidney allograft donors and 42 corresponding recipients, whose kidney biopsies were classified as AR, including 18 and 5 patients with TCMR and ABMR, respectively, and also 19 patients with non-AR. The demographic and clinical characteristics of the patients are presented in 2 FC > 1 and p < 0.05, as the thresholds for differential gene expression  from patients with non-AR (n = 18). Hierarchical clustering heatmap analyses of DEGs among different groups were shown in A total of 1,036 genes were identified as DEGs distinguishing the PBMCs of patients with ABMR from those of non-AR individuals, among which 730 were upregulated and 306 were downregulated . SeveralThe DEGs were further analysed using DAVID tools, which were also used for the analysis of BPs, CCs, and MF. As shown in As shown in As shown in As shown in Owing to the fact that the PBMC-RNA-Seq profile is likely a mixture of RNA from multiple cell types, we used bulk RNA cell-type enrichment analysis using the gene expression data to recover the identity of the cell types found in AR and non-AR samples with the gene signature expression-based cell-type enrichment tool xCell, and also CIBERSORT.Cell-type ESs across 64 immune and stromal cell types were obtained for PBMCs using xCell. Our data analysis demonstrated that there were 14 cell types differentially enriched in AR vs. non-AR recipients (FDR < 0.1), with 4 of 14 cell types positively enriched and the remaining 10 negatively enriched .The relative or absolute leukocyte cell subset population percentages were deconvoluted from RNA-Seq using the expression profiles of sorted immune cells. p < 0.05).Cell types were also quantitated following analysis of AR vs. non-AR donors, and six cell types were differentially enriched at FDR < 0.1 . Figure y-axis represents the –log10p-value of enrichment significance of IPA pathways by Fisher's exact test. We found that LXR/RXR activation was detected with a negative Z-score in the four groups  curve analysis to determine the power of DEGs for the diagnosis of AR . InteresWith the effective use of immunosuppressive drugs, the rate of acute renal graft rejection has declined in recent years. Kidney allograft rejection is associated with molecular changes in renal allograft tissue, which reflect transcription changes in resident cells or changes in cell populations, such as effector T cells, macrophages, and natural killer (NK) cells , 25. Thevia many BPs, including regulating the migration of immature lymphoid progenitor cells, the recirculation of mature naïve T and B lymphocytes, and the homing of antigen-specific effector T cells. It also regulates the migration of antigen-presenting cells, such as dendritic cells and monocytes or macrophages. Recently, many studies have reported that several members of the CXC family of chemokines show significant differences with different types of allograft rejection. A study revealed that mRNAs for four chemokines  were positively enriched in TCMR urine compared with non-rejection urine. Similarly, mRNAs for six chemokines  were positively enriched in ABMR urine compared with non-rejection urine (p < 0.0001) (p < 0.001), and was hence a good diagnostic biomarker . Moreover, the serum protein level of CXCL13 detected by ELISA was 2.2 times higher in the acute group than in the stable group . Our study showed that CXCL8  was significantly increased in PBMCs from the AR group. However, few studies have investigated its performance in patients with AR. Given that several members of the chemokine CXC family have previously been shown to be effective at diagnosing allograft rejection, CXCL8 requires further investigation as a biomarker in the future.In our study, the PPI network showed several significant genes with high confidence, including IL-10, VEGFA, CXCL8, MMP9, and histone-related genes . Chemoki 0.0001) , 27. AddMoreover, our PPI network demonstrated that IL-10 showed strong interactions with other genes, suggesting a contribution to the AR process. Similarly, Verma et al. . It is ein vivo and ex vivo, including IL-10, mononuclear cell chemokine-1 (MCP-1), IL-8, E-selectin, ICAM-1, and VCAM-1  is an essential growth factor that participates in various pathophysiological processes, including embryonic development, repair of traumatised tissue, ischaemia, inflammation, and tumour occurrence by promoting angiogenesis. Tambur et al.  and Ahard VCAM-1 –35. The d VCAM-1 . The cond VCAM-1 . SimilarAs described previously, both GO and pathway analysis showed that genes related to the immune system, complement activation, and inflammatory response were significantly enriched in the AR group. Classical antibody-mediated complement activation mediates many of the downstream effects of antibodies, which are affected by many factors, including antigen density and configuration ratio, antibody abundance, antibody titre and isotype, and complement regulation by the target tissue. The C1r and C1s serine proteases are transactivated and acquire the ability to cleave C4 into C4a and C4b fragments when C1q binds to IgG-or IgM-containing immune complexes . PathwayBased on the IPA analysis, the PPAR signalling pathways and LXR/RXR activation were predicted to be downregulated, suggesting that they may play an important role in acute renal allograft rejection. Metabolomics, lipidomics, functional metabolic assays, and single-cell analysis of cultured human macrophages revealed that PPARα regulates macrophage glycolysis, citrate metabolism, and mitochondrial membrane sphingolipid metabolism and suppresses its inflammatory properties. Treatment with the PPARα agonist suppressed the development of vein graft lesions, while silencing of PPARα in macrophages promoted vein graft lesion development . Thus, PIn addition, we constructed an ROC curve to determine the power of DEGs for the diagnosis of AR . InteresNevertheless, this study has a few limitations. First, the sample size was relatively small and larger meta studies need to be performed to validate our findings. Second, the transcriptional profiles identified in the current investigation need to be validated using additional RNA-Seq studies of PBMCs and kidney allograft biopsies for validation. Third, patients with high sensitivity must receive immunosuppressive drug treatment before transplantation. Moreover, different patients usually accept different treatment methods and this may have had an unaddressed effect on our results. Future work should take these limitations into account when testing the clinical utility of the identified biomarkers in blinded prospective studies.Hence, our study showed that several classical pathways and BPs of DEGs, such as complement activation, immune response, and inflammation, were significantly enriched in the AR and non-AR groups. We also found that some pathways and molecules may contribute to the occurrence of AR, whose role in AR has rarely been reported in the past, including the IL-10 signalling pathway, IL-10, CXCL8, and VEGFA. Moreover, we identified a potential 4-gene combination with a ROC AUC of 92.3% (95% CI 82.8–100) for discrimination between AR and non-AR, which requires further validation. Thus, here the characterisation of PBMCs by RNA-Seq and bioinformatics analysis demonstrated the gene signatures and biological pathways associated with patients with AR and non-AR, thereby providing a framework for the discovery of potential biomarkers and an in-depth understanding of acute renal allograft rejection.https://www.ncbi.nlm.nih.gov/sra/?term=PRJNA782682).The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: NCBI with accession number PRJNA782682.  and Sino-German Centre (grant number GZ1572).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. The reviewer NN declared a shared affiliation with one of the authors, JQ, to the handling editor at time of review.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Decades of initiatives have striven to fix the so-called “leaking pipeline” problem—persistent high attrition of women from the career/educational path toward STEM professorship. Though these initiatives call on academics to increase female retention along this path, it remains unknown whether academics actually prioritize this goal. To investigate this, we tested whether academics would prioritize female retention at the cost of a competing goal when giving career advice to students at risk of leaving the “pipeline.” We present results from a national survey in which United States professors (n = 364) responded to vignettes of three hypothetical undergraduates, rating the extent to which they would encourage or discourage each student from pursuing a PhD in physics. Professors were randomly assigned vignettes with either male or female gender pronouns. Two vignettes featured students who cogently explained why remaining in the physics pipeline would not match their individual goals and interests, while another vignette presented a student with goals and interests that clearly matched pursuing physics graduate school. Professors who received female-gendered vignettes were thus forced to choose between prioritizing striving to increase female retention in physics and acting in the best interest of the individual student. We present evidence that professors seem prepared to encourage women more strongly than men to remain in physics, even when remaining is contrary to the stated goals and interests of the student: Our logistic regression results suggest that professors have higher odds of encouraging women over men, net of vignette and other controls. We also find that male professors have higher odds of encouraging undergraduates and find no evidence that, relative to non-STEM professors, STEM professors have higher odds of encouraging women over men. The metaphors we choose to describe an issue both shapes and reveals how we think about it . In UnitThe metaphor captures troubling, persistent patterns of female attrition on the path toward tenured STEM professorship in the United States, with attrition conceptualized as “leaks” from the pipeline. In some fields in the United States, like physics, women have long been underrepresented at each career/educational step. Women comprise only 16% of physics faculty and leave at much higher rates than men at early stages of physics education , with onA wealth of research conducted in the Western world suggests this longstanding underrepresention is due to a thicket of entrenched injustices hindering women in STEM, causing the so-called “leaks.” Stereotypes that link men but not women with scientific ability , social Although efforts to support women in STEM seek to redress the injustices responsible for underrepresentation, they often measure their success in terms of representation itself. United States universities, agencies, popular news and scholars closely track changes in female representation, celebrating gains . ScholarEchoing the push to increase female representation in academic STEM, do academics prioritize “sealing the leaks?” If something is a priority, we place more importance on it than other considerations, trading off those other considerations for the sake of the thing we prioritize. “Work-life balance,” for example, exemplifies this idea. What makes both “life” and “work” priorities is that we place enough importance on each of them to constantly trade-off one at a cost to the other. A clear indication that academics prioritize female retention in STEM academia would be if, when advising students on career choices, academics strive to increase female retention at a cost to a competing goal they also consider important.matching mindset. A strong motivation to seal the “leaks,” by contrast, could propel us to keep “mismatch” career options on the table if the individual in question is a woman reconsidering plans in STEM. We refer to this goal–striving to increase female representation on the path toward tenured STEM professorship–as the female retention mindset.When we advise someone on career/educational choices, we often prioritize that individual’s best interests. It is popularly believed that the careers to which we “match” are those in our best interests to pursue . When seTo assess whether academics prioritize female retention, we tested whether academics would act on the female retention mindset at a cost to a competing goal–in this case, the matching mindset. The key difference between these two mindsets is this: While the matching mindset implores academics to encourage pursuing STEM academia based on to the degree to which someone–be it a male or female–seems to “match” with academic STEM, the female retention mindset implores academics to change their advice for women. In effect, a trade-off between these two mindsets would manifest as follows: Preferentially encouraging women to pursue academic STEM more than otherwise identical men across varying degrees of “match”/“mismatch” with academic STEM.To test if academics would make such a trade-off, we used a national survey of professors (n = 364) from United States colleges and universities . We presTo detect the female retention mindset, professors were randomly assigned male or female student vignettes. Our female vignettes depict undergraduates who are well-known as crucial “leaks”: undergraduate women considering physics graduate school. The jump from college to graduate school is an important juncture on the path toward STEM professorship within the United States. This juncture marks the start of training devoted expressly to becoming an academic. For STEM fields with persistent female underrepresentation at the undergraduate level, like physics, this juncture accounts for a steep decline in female representation . PhysicsTo force a trade-off between the matching mindset and the female retention mindset, we presented each professor with three vignettes of undergraduates reconsidering physics graduate school. One vignette depicts a student who shows signs that he/she is well-“matched” to a career in academic physics. He/she has plentiful enthusiasm and merit, but, harboring unjustified self-doubt, is in need of a bit of encouragement to go to physics graduate school. The other two vignettes describe students who show signs physics graduate school is not in his/her best interests. One undergraduate presents strong signs that he/she has permanently lost interest in physics, and the other presents a reason pursuing a physics PhD conflicts with his/her personal goals. Dead-set on becoming a physics professor, but only accepted to PhD programs unlikely to lead to professorship, he/she does not want to enroll.H1: Professors have higher odds of encouraging female undergraduates than male undergraduates, net of controls.Within the efforts to support women in STEM, female underrepresentation at each step on the path toward tenured STEM professorship is treated as a key metric of social progress. We reasoned that, in line with this focus on retention, female retention is a priority in the minds of academics. One clear sign academics hold such a priority would be if academics act on the female retention mindset, shaping how they advise students on career/educational choices, at a cost to a second priority that also shapes their advice. To test this, we designed our vignettes to force professors to choose between these two mindsets. We depicted two undergraduates who shows strong signs of a “mismatch” to academic physics and one undergraduate who shows strong signs of a “match,” expecting to spur professors’ advice toward opposite ends of the encourage/discourage spectrum and randomly assigned professors male or female vignettes. We expected that professors will have higher odds of encouraging a female undergraduate on the fence about physics graduate school than males, even accounting for whether the undergraduate in question is a “match” or not. We present this as our first hypothesis:H2: The odds of a professor encouraging a given undergraduate differs between male and female professors, net of controls.Studies have shown that attitudes about women in STEM differ between men and women in the United States Some work has suggested male and female STEM faculty differ as to whether they give preference to males or females in hiring decisions . Other wH3: Professors in STEM department(s), more than those not in STEM-department(s), have higher odds of encouraging undergraduates, net of controls.H4: Professors in STEM department(s), more than those not in STEM-department(s), have higher odds of encouraging female undergraduates than male undergraduates, net of controls.Though there is widespread enthusiasm in United States academia to support women in STEM, the STEM academy is especially rich with zeal and resources devoted to that mission. By virtue of that concentrated enthusiasm, we reasoned that the career/educational advice of STEM professors would be more closely aligned to the female retention mindset than the matching mindset, relative to their non-STEM colleagues. We thus expected to find that a professor’s affiliation or lack thereof with a STEM department would influence his or her decision to encourage. We also expected to find that, compared to non-STEM professors, STEM professors would encourage female students more often than male students, even when accounting for whether the undergraduate in question is a good “match” for academic physics or not and other predictors. We present this as our third and fourth hypotheses:Our contact list of professors was collected from directories on university websites from a total of 120 universities during spring 2018. To ensure our professors hailed from geographically diverse set of universities with varying levels of institutional prestige, universities were selected from United States News’ 2018 lists for top public, national, liberal arts and regional universities, with 20 universities randomly chosen from each list. For this randomization, we randomly sampled without replacement from 1 to the length of the list using the sample function in R . InsofarRespondents were presented with three vignettes, each describing the situation of a hypothetical student asking for advice. With each vignette, respondents were prompted with the question: “If you were the professor being asked for advice, to what extent would you discourage or encourage him/her to go to graduate school for physics?” (“him” and “her” set to match the gender of the vignette). To respond, they were provided a six point scale, with three possible magnitudes of each encouragement and discouragement: slightly, moderately, strongly. For each respondent, the vignette order was randomized. Respondents were randomly assigned male and female versions of the vignettes, differentiated only by male and female pronouns. In both cases, randomization was achieved using the built-in survey features in Survey Monkey. The gender of the vignettes was the same across all three vignettes . An example of this question and vignette pair in presented in Though vignettes are an imperfect tool to investigate what people believe and how they would act, our research objectives made vignettes an apt choice. We recognize that advisory conversations between professors and students are more nuanced in real life than what was captured in our survey. A professor would likely engage the student in conversation, settling on what they would advise the student only after considering many details. A professor’s advice would likely be nuanced in a way that a one-dimensional scale could not capture. Ultimately, however, our objective was not to get an accurate picture of how professors act in these advisory roles. Instead, we wanted to get a snapshot of beliefs that would likely guide conversations of these sort–beliefs that would likely influence a course-grained judgment to encourage or discourage the undergraduate to remain on the STEM academic path. Indeed, vignettes are often used for this reason —to “clarKey to our study was assessing the impact of student gender on professors’ advice while accounting for how their advice was affected by whether a student “matched” to a career in academic physics or not (See introduction). Accordingly, a key dimension by which we wanted our hypothetical students to vary considerably was the degree to which each student was a good “match” for a career in academic physics. Constructing a case that most would consider a good “match” was easy to achieve with a single vignette depicting a student both exceptionally good at and enthusiastic about physics (“Imposter syndrome” vignette). What constitutes a bad “match” for a given career–and for academic physics in particular–is, however, more subjective. For this reason, we included not one, but two vignettes we judged to be cases of students who, by popular ideas of what constitutes a good “match,” showed clear signs of a “mismatch” . We reasoned that, between those two vignettes, our survey would be able to capture some of the effect of a “mismatch” on professors’ choices.We crafted our vignettes to strike a balance between two ends. First, the vignettes are meant to have enough nuance to portray students who seem realistic, so that professors could respond to them as they would to real students. Second, the vignettes needed to give readers strong reasons to interpret each student as the “match” or “mismatch” that we sought to depict. Our vignettes are shown below for the male version of the vignettes . We title each vignette as the reason the given student was reconsidering physics graduate school.To ask for advice about graduate school, a junior physics major goes to a professor at his school. He has been planning to go to graduate school for physics for a while now, but has been having second thoughts while putting together his applications. He loves the work involved in physics and is passionate about the subject, but he frequently worries that he is not good enough at physics and the performance of other physics majors in his program is leaps and bounds better than his. The professor, however, knows that his doubts are unjustified: He is among the top physics majors of his graduating class and his physics professors consistently praise him for outstanding work. He wants to know what the professor thinks he should do.A senior physics major needs to make a decision about graduate school and goes to a professor at his school to ask for advice. He tells his professor that he is passionate about physics and has, for years, envisioned a career as a physics professor for himself. Unfortunately, his application was not strong enough to get him accepted into a highly ranked Ph.D. program. The one university that accepted him rarely produces graduates that go on to become professors. He expects graduate school will be a hard venture and doesn’t think the struggle would be worth it if he does not go on to become a physics professor. He wants to know what the professor thinks he should do.A junior physics major is having doubts about his plans to go to graduate school for physics and goes to a professor at his school to ask for advice. He is one of the top students in his class, professors consistently praise his work, and he is confident that he could handle graduate school in physics. He is concerned, however, that his enthusiasm for physics has dwindled, and that, for the past few semesters, he feels like he is just going through the motions and not enjoying his classes. He can’t picture how graduate school would revive his excitement for physics. Initially, physics used to be as much as a hobby as it was his major, but now he does not touch the subject outside of his assigned coursework. He wants to know what the professor thinks he should do.To test our three hypotheses, we used mixed effects logistic regressions with professor’s choice to encourage an undergraduate as the outcome, vignette type, undergraduate gender and professor gender as predictors, and random intercepts grouped by professor to account for each professor making multiple choices. For ease of interpretation, we exponentiated raw regression coefficients to produce adjusted odds-ratios for which we report point and interval (95% confidence) estimates. The statistical significance of individual coefficients was determined via two-tailed likelihood ratio tests (LRT) and overall model goodness-of-fit via LRTs of the target model compared with a null, intercept-only, model. All statistical analyses were performed in R v. 4.1 .In this study, we aimed to assess whether academics prioritize increasing female retention on the path toward STEM professorship. As one way to detect such a priority, we sought to test if academics would strive to increase female retention at the cost of a second goal that they consider important–in this case, striving to “match” individuals to careers. Our approach, however, presumes that the professors’ advice was substantially affected by whether an undergraduate showed signs of “matching” or “mismatching.” In other words, that professors’ advice shifted toward opposite ends of the encourage/discourage spectrum for “match” and “mismatch” vignettes. Our results suggest that our study design achieved that end. Vignette type substantially affected professors’ choices. Professors almost unilaterally encouraged the “match” undergraduate (“Imposter syndrome” vignette: 98% encouragement) while their reactions were mixed to the “mismatch” undergraduates .p = 0.05). Likewise, across all three vignettes, a larger proportion of professors chose to encourage female undergraduates more often than males across all three vignettes (p = 0.004). By the same token, for all vignettes, a smaller portion of female professors chose to encourage relative to male professors  impact their choice to encourage an undergraduate, we built a mixed effects logistic regression with the professor’s choice as the outcome and vignette type, undergraduate gender, and professor gender as predictors . The ‘maignettes . These rofessors . Finallyχ2 = 2.59, df = 1, p = 0.11).To test our fourth hypothesis, that professors in STEM department(s) are more likely to encourage female than male undergraduates, we added to our model an interaction term between professor’s department (STEM or non-STEM) and student gender . HoweverWe are now decades into campaigns to create what one oft-cited national report called “an environment of encouragement” for women in STEM . We founOur results suggest increasing female representation in the STEM academy is a genuine priority of professors. Reshaping the demographics of the STEM academy calls for trading-off other goals for making career choices. Our data show professors are willing to make such a trade-off. Professors appear to consider it an important goal to give career advice in advisees’ best personal interests. It is popularly believed that those careers to which we “match” are those in our best interests, and, likewise, our data show professors’ advice was strongly shaped by whether an undergraduate showed signs of “matching” or “mismatching” with academic physics ; Table 1Concretely, our results suggest that the trade-off professors are willing to make between striving to “match” and increasing female retention is this: for both undergraduates who claim they have permanently lost interest in physics and those who claim academic physics conflicts with their personal goals, professors preferentially encourage women to nevertheless pursue physics graduate school ; Table 1In the search for strategies to support women in STEM, research has hitherto focused on how STEM academics influence women’s decisions to continue on the path toward STEM professorship . STEM acOur study is not without limitations. First, though we sought to investigate attitudes about women pursuing STEM academia, our vignettes only depicted undergraduates in physics reconsidering plans to continue on to a physics PhD. Attitudes may vary for other STEM fields and other junctures on the career/educational path toward STEM academia. Second, though our study necessitated that we only capture some of the effect of how professors evaluate students based whether students “match” or “mismatch,” our study would benefit from a validated construct of our proposed “match” vs “mismatch” dimension . We neitWe tested only one way a priority on “sealing the leaks” could manifest within the academic community. Of course, faculty members may be eager to encourage undergraduate women to enter STEM academia, while they and the academy remain systematically and attitudinally biased against women in STEM in other ways. We hope that the evidence we found that academics preferentially encourage women to pursue physics academia more than men will help distinguish where gender bias in STEM persists and, more broadly, help the academy fine-tune its diversity initiatives to best support women in STEM.


The immune checkpoint blockade therapy has completely transformed cancer treatment modalities because of its unprecedented and durable clinical responses in various cancers. With the increasing use of immune checkpoint blockades in clinical practice, a large number of patients develop acquired resistance. However, the knowledge about acquired resistance to immune checkpoint blockades is limited and poorly summarized. In this review, we clarify the principal elements of acquired resistance to immune checkpoint blockades. The definition of acquired resistance is heterogeneous among groups or societies, but the expert consensus of The Society for Immunotherapy of Cancer can be referred. Oligo-progression is the main pattern of acquired resistance. Acquired resistance can be derived from the selection of resistant cancer cell clones that exist in the tumor mass before therapeutic intervention or gradual acquisition in the sensitive cancer cells. Specifically, tumor intrinsic mechanisms include neoantigen depletion, defects in antigen presentation machinery, aberrations of interferon signaling, tumor-induced exclusion/immunosuppression, and tumor cell plasticity. Tumor extrinsic mechanisms include upregulation of other immune checkpoints. Presently, a set of treatment modalities is applied to patients with similar clinical characteristics or resistance mechanisms for overcoming acquired resistance, and hence, further research is required. Since the approval of the first CTLA-4 blockade by the US Food and Drug Administration (FDA) in 2011 –6. Due tIn this review, we clarify the principal elements of AR to ICBs including the (1) definition of AR; (2) clinical characteristics of AR; (3) underlying mechanisms of AR; and (4) potential strategies to overcome AR. We hope that this review will help researchers and clinicians recognize AR to ICBs more comprehensively and in detail.Primary resistance occurs when cancer cells do not respond to immunotherapy, whereas AR normally occurs as disease progression after an initial response. Contrary to primary resistance, the current definition of AR is highly heterogeneous among groups or societies. Different researchers define AR differently when they explore the underlying mechanisms or design clinical trials, with the main controversies being prior response , 11 whe, 12 a c, 13 whe. HoweverAR is considerably different from primary resistance to ICB therapy based on three aspects— (1) immunophenotypes: AR mainly occurs in inflamed tumors, while primary resistance occurs in excluded or desert tumors, which lack sufficient immune infiltration ; (2) undUnlike primary resistance, the rates of AR have not been routinely reported and thus are not characterized across tumor types. Based on available data of response duration time, Schoenfeld et al. inferred the AR rate and found that AR rate ranges from 11% to 71% among different tumor types, with the median of 39%, and a tumor with a lower response rate has a higher AR rate . AdditioIn the population of patients with response to ICBs, the median duration of response (DOR) was heterogenous among different tumor types, lines of therapies, or PD-L1 levels. Patients with melanoma had the longest DOR, with the median of more than four years. While the median DOR in other tumor types was usually less than two years, indicating that more than half responders would progress within two years 1 inhibitor therapy, approved by the US FDA, although it has many shortcomings . HoweverAfter the initiation of ICBs, responders experienced genomic contraction, loss of the tumor cells expressing specific neoantigens, expansion of specific T cells targeting the corresponding neoantigens, and upregulation of other checkpoints , with the left cancer clones more resistant to the activated immunity . Gu et aThe second type of resistance to immunotherapy is AR in sensitive tumor cells, also called “homeostatic resistance” . It is eIt is difficult to study the underlying mechanisms of AR following the two categories mentioned above, although they are easy to understand. Regarding a specific mechanism underlying AR (such as a certain gene mutation), researchers have not been able to determine whether this trait pre-exists in the tumor or is truly acquired at the individual cell level  in the resistant tumor is also confirmed by other groups , although it mainly occurred in patients resistant to ICBs , with a significant difference (p = 0.03)  . Additio therapy . These pB2M in ICBs immunotherapy. Three retrospective studies of patients with colorectal carcinoma both found that a B2M mutation was more likely to happen in the microsatellite instability-high (MSI-H) patients and the B2M status was not associated with tumor immune infiltration  can present the antigen, independent of beta-2-microglobulin or beta-2-microglobulin, playing a different role in primary resistance compared to AR. Rizvi et al. also reported a patient with biallelic B2M mutation responding to anti-PD-1 therapy, with IHC validating the beta-2-microglobulin loss  to small-cell lung cancer (SCLC) is considered to be one of the AR mechanisms to target therapy . It is ttors use . There ators use –112. TheAnother issue is the epithelial−mesenchymal transition (EMT). EMT is thought to be associated with extensive anti-tumor therapy resistance , 113. Se+BTLA+ tumor- infiltrating lymphocytes exerted better anti-tumor immunity than the BTLA- counterpart  signaling fail ICBs against cancer, but these tumors still maintain sensitivity to the T cell-based adoptive cell therapy (ACT). Kalbasi et al. reported that ACT was effective against tumors with JAK2 loss . As tumoSince tumor-induced exclusion/immunosuppression involves the activation of multiple signaling pathways, pharmacological inhibition would be effective in this regard, including pathways of Wnt/β-catenin, PI3K-Akt, IFN-β/NOS2, CSF-1, TGF-β, adenosine, and IDO. Additionally, microenvironment-targeting combinations are also the future directions of cancer immunotherapy and can be referred to in another review .Epigenetic modulation is an effective approach to restrict tumor cell plasticity, but concrete strategies need to be explored , 149. TaTheoretically, the sequential inhibition of other immune checkpoint receptors such as TIM-3, LAG-3, and VISTA can help overcome AR. Indeed, dozens of early-phase clinical trials have been initiated to explore the clinical efficacy of these checkpoint blockades with or without another checkpoint blockade, which can be referred to in other reviews –156. TIGhttps://clinicaltrials.gov, NCT03793179) will preliminarily answer the question about which is superior between prior ICB plus chemotherapy and chemotherapy alone for the patients with AR to ICBs.Since the guidelines or expert opinions about the treatment after ICB failure are scarce, there are various approaches in clinical practice to treat patients with AR to ICBs. Continuation of prior ICB combined with other therapies, such as chemotherapy, anti-angiogenesis therapy, radiotherapy, target therapy, and another immune checkpoint inhibitor, is frequently used. Another approach usually used is by changing immunotherapy into classical later-line modalities of chemotherapy. The evidence to support these attempts is at its infancy and arises a core question as to whether to stop using the prior ICBs. The INSIGNA study  and the non-genetic approaches . Tumor cell plasticity preserves the great potential for AR. One important issue is transdifferentiation from NSCLC cells to SCLC cells, the other is the EMT program. The tumor extrinsic mechanisms of AR are mainly through the upregulation of other immune checkpoints, such as TIM-3, LAG-3, and VISTA. The potential strategy to overcome AR is to apply a set of modalities to patients with the same clinical characteristics or resistance mechanisms. Although not discussed in this review, monitoring resistance is an important issue, and the circulating tumor DNA could be an effective tool.With the increasing use of ICBs in clinical practice, a large number of patients develop AR. However, the knowledge about AR to ICBs is limited and poorly summarized. Through reviewing the published papers associated with this term, we clarified the principal elements of it. The definition of AR to ICBs is inconsistent at present, but expert opinions are available for this question. Oligo-progression is the main resistance pattern. The underlying mechanisms of AR involve tumor intrinsic factors and extrinsic factors. Neoantigen depletion can protect tumor cells from immune attack, however, it is unclear whether the depletion of neoantigens is a consequence of Darwinian natural selection with the neoantigen-expressing clones being eradicated or is a biological adaptation at an individual cancer cell level. Antigen presentation deficiency can also protect tumor cells from being recognized and killed by the immune cells, which includes biallelic One of the future directions in this field is to explore the mechanisms underlying AR to ICBs more comprehensively. New tools, such as CRISPER screen, single-cell RNA sequencing, and spatial multi-omics, will fuel the related research. It is worthy of noting that many mechanisms of primary resistance to ICBs have not been completely elucidated in the field of AR. For example, gut microbiota and tumor metabolism have been acknowledged to play important roles in primary resistance to ICBs –159, whiQC conceptualized this review. BZ searched the papers and drafted the manuscript. YG, PZ, and QC revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the Natural Science Foundation of China (Grant No. 82072597 and No. 81974483).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.


The current Indian scenario follows the western cardiac rehabilitation protocol; hence the primary aim of the study is to develop a cardiac rehabilitation phase 1 protocol for the Indian scenario. The protocol will be used in the study as standard rehabilitation protocol for the intervention groups. The literature suggests the use of Pranayama and chair aerobics to improve the anxiety in CABG patients. This study also aims to provide the answer for the effect of Pranayama and chair aerobics on anxiety and exercise tolerance in CABG patients. And also try to find out which among the two intervention is superior among one another.The cardiac rehabilitation protocol will be validated by experts in the field and applied in the patients and the results will be analysed. Then the protocol will be used as the standard rehabilitation protocol in both the groups. 100 patients will be randomised and allocated into 2 groups. Group 1 will receive Nadi Sodhana Chair aerobics for 15 minutes along with phase I cardiac rehabilitation. The group 2 will receive Chair aerobics for 15 minutes along with phase I cardiac rehabilitation. The outcome measures will be taken before the surgery and on the post-operative day 7. The primary outcome measures are Hospital anxiety and depression scale (HADS) and Heart rate and the secondary outcome measure is 6-minute walk test. The intention to treat analysis will be done after the data collection.The data will be analysed using unpaired t test, p value <0.05 will be considered significant.The result will give a new insight into the field of cardiac surgery, where the effect of pranayama and chair aerobics on anxiety and functional outcome will be proved.CTRI/2021/09/037008.This trial is prospectively registered in CTRI, the registration number of the trial is What is already known about this subject? The effect of Pranayama and chair aerobics on various components like pain, peak expiratory flow after CABG is proven in different studies. The phase 1 cardiac rehabilitation is practiced and adopted from western protocol.What does this study add? The study will give a new insight into the field of cardiac rehabilitation. Definite phase I cardiac rehabilitation protocol for Indian population is not exist in the literature. The Indian set up is using the western protocol, which is not suitable for the Indian population hence could not achieve the expected outcome on discharge. We believe that this study will provide a definite phase I cardiac rehabilitation protocol for the Indian population. This can be followed in the community. Also, this study aims to explore the unexplored area of anxiety after CABG. Where the effect of the Pranayama and chair aerobics will be identified. And also give idea about which treatment technique is superior, and feasible for the patients.How might this impact on clinical practice? The study will provide a new phase I cardiac rehabilitation protocol for the Indian population. The protocol can be practiced in the Indian scenario. This will help to improve the exercise tolerance of the patients after the surgery. The study will recommend the feasible and effective technique for relieving the anxiety and improving the exercise tolerance in CABG patients. This can be implemented as a best practice in reducing anxiety after CABG. The innountries . The plaountries . The risountries . In the ountries . Coronarountries . It is tountries . Depressountries  Depressiountries . Anxietyountries . This inountries . Cardiacountries . Accordiountries . The inpountries . The carountries . Practicountries . Improviountries . The litThe trial design is Randomized clinical Trial, outcome assessor blinded double arm trial. The participants will be recruited from department of cardio-thoracic and vascular surgery, Justice K S Hegde charitable hospital.CABG patientsAge: 30–80 yearsHADS anxiety cut off score 7Both gendersPatients with multiple procedures LVEF < 40%Patients who receive anxiolytics, sedatives, or hypnoticsCardiac FailureHeart TransplantationEssential HypertensionDiabetic Autonomic NeuropathyNeurological DisordersPatients on mechanical ventilatorInterventions: Ethical approval is obtained for the study. Verbal advertisement will be given to the patients of JUSTICE K S HEGDE CHARITABLE HOSPITAL who is undergoing cardiac surgery (CABG) and willing to participate in the study.Written permission to conduct this study is obtained from the Head of the cardio-thoracic and vascular surgery Department. Informed consent will be obtained from patients. Following the completion of baseline data collection, patients will be allocated into two groups based on computer generated randomization and sequentially numbered, opaque, sealed envelopes (SNOSE).The study has 2 phases. In first phase the phase 1 cardiac rehabilitation will be validated by experts and then will be applied to patients and obtain the results. In the second phase, the proposed rehabilitation protocol will be applied to the patients in both the groups.Baseline data will be obtained prior to intervention .Prior to intervention (on pre-operative day) outcome scores will be taken.Patients will be randomized into 2 groups based on the SNOSE method.Group 1 will receiveYoga therapy (Pranayama)The yoga will be delivered by a trained personal. The Nadisodhana pranayama will be delivered once in a day. The vitals will be monitored throughout the procedure and the position will be according to the cardiac rehabilitation.Nadi Sodhana PranayamaThe individual will be made in Sukhasana (comfortable posture). Patient will be instructed to open the right hand and bend the index finger bent index and middle fingers against the palm. Close the right nostril using the thumb, while the fourth and fifth fingers will used for the left nostril. The patient will be then instructed to place the right thumb against the ala at the end of the nostril to close it and similarly pressed the fourth and fifth fingertips against the left nostril. The procedure will be continued for 15 minutes .GROUP 2 will receiveChair aerobicsPOD 3–41. Alternate heel digs with bilateral biceps curl – 8 repetitions2. V- step with bilateral hammer curls – 8 repetitions3. Lateral step touch with bilateral biceps curl – 8 repetitions4. Knee lift – 8 repetitionsPOD 5–71. Alternate heel digs with bilateral arm curl – 16 repetitions2. V- Step with bilateral hammer curls – 16 repetitions3. Lateral step touch with bilateral arm curl – 16 repetitions4. Knee lift – 16 repetitionsThe intensity of the exercises is low and as tolerated by the subject based on RPE Borg’s scale. The total time duration will be 15 minutes.And will receive cardiac rehabilitation phase 1 protocol.All the outcome measures such as HADS, 6MWT and HR, will be taken on preoperative day and on POD 7.Statistical analysis will be done after completing the sample collection. Intention to treat analysis will be done.Based on the mother article, standard Deviation in the intervention group is 6.10 beats per minute . Mean diIntention to treat analysis will be done after completing the sample collection.Data will be analysed using unpaired t test. p < 0.05 will be considered significant.The study aims to develop a phase 1 cardiac rehabilitation protocol, the phase 2, 3 and 4 is beyond the scope of the study. The study duration is phase 1 cardiac rehabilitation the prolonged effect of the Pranayama and chair aerobics is beyond the scope of the study.Price KJ et al put forward a question that is there any international consensus for cardiac rehabilitation? They found and suggested that a new protocol guided with aerobic exercise and resistance training should be formulated. This study is the base for the first stage of our study which aims to formulate a phase 1 cardiac rehabilitation.  we are a


To resolve whether the lack of AR is the driving factor for the emergence of the NE phenotype, molecular, cell, and tumor biology analyses were performed on 23 xenografts derived from patients with PC, recapitulating the full spectrum of genetic alterations proposed to drive NE differentiation. Additionally, phenotypic response to CRISPR/Cas9-mediated AR KO in AR+ CRPC cells was evaluated. These analyses document that (a) ARSi-resistant NEPC developed without androgen deprivation treatment; (b) ARS in ARSi-resistant AR+/NE+ double-positive “amphicrine” mCRPCs did not suppress NE differentiation; (c) the lack of AR expression did not necessitate acquiring a NE phenotype, despite concomitant mutations/deletions in PTEN and TP53, and the loss of RB1 but occurred via emergence of an AR–/NE– double-negative PC (DNPC); (d) despite DNPC cells having homogeneous genetic driver mutations, they were phenotypically heterogeneous, expressing basal lineage markers alone or in combination with luminal lineage markers; and (e) AR loss was associated with AR promoter hypermethylation in NEPCs but not in DNPCs.Resistance to AR signaling inhibitors (ARSis) in a subset of metastatic castration-resistant prostate cancers (mCRPCs) occurs with the emergence of AR S-transferase π [GSTP1]), but not AR , and hK2 (KLK2) with no expression of NE markers  is subverted from a growth suppressor of c-Myc expression to a cell autonomous oncogenic stimulator of c-Myc expression and thus malignant growth –26. Due – (+ adenocarcinoma (ARPC) “losing” its luminal cell differentiation via the loss of AR activity , such as abiraterone acetate (Abi), enzalutamide (Enza), and apalutamide, were developed and clinically documented to increase the survival of men with mCRPC, progressing after first-line ADT and when given in combination with first-line ADT . Despite– . The proactivity –34. It hhenotype –35.n = 23) of previously characterized patient-derived xenografts (PDXs) in addition to several newly established PDXs, which collectively recapitulate the full spectrum of clinically important genetic alterations in mCRPC. Second, hypermethylation of the AR promoter as a putative mechanism for the loss of AR expression was evaluated. Third, the in vitro and in vivo growth characteristics versus marker expression of the ARPC LNCaP-95 (LN-95) mCRPC cells initially exhibiting AR activity were determined following CRISPR/Cas9 dependent elimination of total AR protein expression.Therefore, to interrogate the relationship between ARSi resistance and NE differentiation, 3 complementary approaches were taken. First, the growth characteristics and expression of basal versus luminal versus NE lineage markers were evaluated in a large series  and hemizygous deleterious mutation (R130Q) in PTEN with a loss of PTEN protein expression . They also expressed REST and YAP1  metastasis at rapid autopsy , which are consistent with the PDX. Despite the patient never being exposed to ARSi treatment, the in vivo growth of BCaP-1 PDX is ARSi resistant because it grows equally well in intact or castrated hosts, with a doubling time of 20 ± 5 days  allele and loss of the other WT RB1 allele  mRNA  PC (DNPC) heterogeneously composed of cells expressing both basal and luminal cell characteristics, suggestive that their cancer-initiating cell was an AR– progenitor cell whose malignant transformation did not require exposure to ARSis.The BCaP-1 PDX was derived from a soft tissue metastasis adjacent to the right tibia obtained at rapid autopsy from a 63-year-old African American patient, who, at the time of initial presentation, had bone and lymph node metastases and an initial diagnostic prostate biopsy that was positive for carcinoma with a Gleason sum score of 9. Over the next year, the patient was treated with ADT followed by palliative external beam radiation of the bone before death but never received treatment with next-generation ARSis . At auto± 5 days , which warcinoma . Based u3 R175H;  coupled 1 allele . These cdeletion , resultideletion . They alB1 S45F; , which wB1 S45F; , presumaand Ki67 , with a and Ki67 . This isGR) mRNA  and no eal cells . Howevernd KRT18 , while h18  who underwent resection for a noninvasive urothelial carcinoma of the bladder a year before having a prostate biopsy that was positive for Gleason 9 PC with perineural invasion. Over the next 3 years, the patient had a radical prostatectomy for locally advanced disease , followed by ADT, external beam radiation, taxane chemotherapy, and olaparib before undergoing a rapid autopsy upon his death  (TP53 (R282W), and no expression of PTEN due to homozygous deletion. In addition, they minimally expressed RB1 mRNA with no detectable nuclear expression of RB1 protein (KLK3 (PSA), FOLH1 (PSMA), or NKX3.1   or mutat protein . None of protein  and Ki67 protein . They dir NKX3.1 . Again, essed GR . All 3 hessed GR . Again, B13 mRNA  and protB13 mRNA  than ARPn factor .KRT8 , FOLH1, KLK2, and KLK3 , and mutated PTEN (V317fs), but with no expression of NE markers like CHGA, CHGB, and SYP  and then a PC vaccine (GVAX), followed by ADT, docetaxel plus strontium-89, external beam radiation, Abi, etoposide, and cisplatin ; ref. 46ted TP53 . The mosted TP53 . Similarlized PC . Essentilized PC . A high and Ki67 . LvCaP-1and KLK3 , but witand KLK3 . This is3 R248Q; , SOX2, m and SYP . LvCaP-1 and SYP , p75 , mutated PTEN (V317fs), mutated SPOP (F133L), and mutated ATRX  media containing a low level of androgen . ARSi reSYP, CHGA, or CHGB  than the parental AR-expressing LN-95 cells in castrated male hosts  as the parental LN-95 cells despite the loss of AR expression  showed differential methylation consistent with the suppression of the NE phenotype in the DN versus NE PDXs (CHRNB2) was the promoter methylation pattern in the LvCaP-2/-2R amphicrine PDXs, consistent with that expected based on the NE phenotype in LuCaP 93  and growth arrest ; or (b) an AR– prostate progenitor cell is the cancer-initiating cell and gives rise to malignant progeny heterogeneously expressing various combinations of basal and luminal markers . In this second scenario, no promoter hypermethylation-dependent silencing of AR would be necessary for selective outgrowth of these DN cells under extreme androgen deprivation. Presently, these PDX models are being utilized to resolve whether adaption versus selection is the mechanism for the emergence of ARSi-resistant DNPC. Earlier studies demonstrated that PC with a luminal phenotype could be derived from genetically manipulated primary human benign prostate basal cells, suggesting that histology does not necessarily correlate with cell of origin  an initially ARf origin .– PCs are increasing . WNB, YZ, IMC, SLD, LA, RAP, BH, RC, AKM, SLZ, JEH, JL, AMDM, EC, JX, SY, MCH, PSN, WGN, WBI, and JTI analyzed and interpreted the data . WNB, YZ, IMC, SLD, LA, RAP, BH, RC, AKM, SLZ, JEH, JL, AMDM, EC, JZ, SY, MCH, PSN, WGN, WBI, and JTI wrote, reviewed, and/or revised the manuscript. YZ, IMC, JEH, EC, and JL provided administrative, technical, or material support . WNB and JTI supervised the study.