Background: University students with vocational qualifications encounter more severe cultural, academic, and self-evaluated challenges in the transitional process than their peers with an academic pathway. This study investigated the predictive effect of cultural intelligence (CI), imposter syndrome (IS), and academic resilience (AR) on school belonging (SB) and their interplay mechanism from a positive and negative perspective. Method: We recruited 326 Chinese university students with a vocational route as the research subjects and designed a parallel mediation model to assess the hypothesized construct. Result: The participants had scores above the median in CI, AR, and SB, but they also obtained scores exceeding the median in moderate IS. CI positively and significantly predicted SB both directly and indirectly through AR, while IS negatively and significantly predicted AR. AR both partly mediated the effect of CI on SB and entirely mediated the impact of IS on SB. Conclusion: CI was the most crucial factor impacting SB, followed by AR and IS among Chinese university students with a vocational education and training (VET) pathway. Strategic interventions should be adopted to enhance their abilities to cope with diverse cultures, promote their resilience in facing academic difficulties, boost their self-achievement, and foster their sense of SB. School belonging (SB) of university students has garnered considerable attention from policymakers, scholars, educators, and parents, along with the increasing diversity and openness of the higher education system worldwide in recent years ,2,3,4. GCI refers to an individual’s capacity to perform effectively in culturally diverse settings ,17. CI iIS refers to individuals’ belief that their achievements are due to dumb luck or even error, persisting that they are not as intelligent or competent as others impress, despite abundant evidence to the contrary ,23. PeopAR refers to students’ ability to accomplish favorable learning outcomes despite a disadvantaged situation . Some thThese existing studies have deepened our understanding of university students’ sense of SB and its antecedents in the transitional process. However, these representative determinants contributing to SB have not yet been integrated into a comprehensive model that can determine positive and negative factors. Specifically, little is known about the relationships between CI, IS, AR, and SB. Additionally, since SB is a growing domain at the collegiate level and is much more diverse and complex at the individual characteristic level, VET pathway university students may differ in the experience of SB compared to their peers with an academic route. Due to the significant distinctions in curriculums and examinations between education sectors , studentWith is in mind, following the suggestions that future research on SB should focus on the specifically marginalized populations using a quantitative approach , this stHypothesis 1 (H1).CI positively predicts SB.Hypothesis 2 (H2).CI positively predicts AR.Hypothesis 3 (H3).AR positively predicts SB.Hypothesis 4 (H4).CI positively predicts SB through AR.Hypothesis 5 (H5).IS negatively predicts SB.Hypothesis 6 (H6).IS negatively predicts AR.Hypothesis 7 (H7).IS negatively predicts SB through AR.The hypothesized mediation model is presented in The participants in this study were university students transitioning from the vocational education system and enrolling in a course taught by the first author to train students’ knowledge and skills in developing and filling in a questionnaire. The survey was distributed online using the Wenjuanxing survey software, also called Chinese Qualtrics, so that students could fill it out anonymously and conveniently. The data were collected from 5 to 12 January 2021; at that time, the participants had embedded into their university life for a half year. After the participants had delivered the survey, the data were filtered concerning whether the responses were random or inconsistent, such as long strings of invariant responses or extraordinary short response times. All potential participants responded to the survey; the valid number of responses was 326 after removing invalid answers. The research data were analyzed utilizing the bootstrapping procedure with 5000 subsamples to ensure the data representation.CI was assessed with a nine-item Chinese version of the Cultural Intelligence Scales Short Form, initially designed by Ang and Dyne . The resIS was evaluated with a twelve-item Chinese version of the Imposter Syndrome Scale, initially developed by Clance . This reAR was measured with a six-item Chinese version of the Academic Resilience Scale, originally conducted by Martin and Marsh . The resSB was tested with a five-item Chinese version of the School Belonging Scale, developed by Zhu and Han , who extThe data were analyzed with SPSS v.25, designed by the American International Business Machines Corporation (IBM) headquartered in Armonk, NY, USA, and SmartPLS v.3.3 software, developed by SmartPLS GmbH Company in Oststeinbek, Germany. First, the common method variance test was conducted using Harman’s single factor test  to ensurThe South China Normal University Academic Ethics Committee reviewed and authorized this study. The research ethics approval was provided to the participants with the explanatory statement and consent form.M = 20.39, SD = 1.79). Nearly 60% of the respondents came from rural areas. Approximately 93% of the participants transitioned to higher education with a direct pathway from higher vocational colleges than the remaining with an indirect two-wave pathway from a secondary vocational school to a higher vocational college and, eventually, to university. The disciplines they majored in were Business English (29.8%), Electronic Commerce (36.5%), and Internet Engineering (33.7%). The details of the participants’ demographic characteristics in the current study are presented in The participants consisted of 209 women (64.1%) and 117 men (35.9%). Their ages spanned from 17 to 29 years (p < 0.01) and SB . Similarly, AR positively and significantly associated with SB . As expected, IS was negatively significantly linked to AR  and SB , but the coefficient values were low than 0.3, representing an extremely statistically small correlations [Regarding the correlations of the variables observed, CI positively and significantly related with AR  ratio was used to calculate the mean of the correlations of all constructs. Referring to Henseler et al. , the HTM2 value . The ret-statistics value above 1.96 and p-value below 0.05 [The path coefficient values were computed using bootstrapping method with 5000 subsamples, and its significance could be ascertained by the low 0.05 . For conβ = 0.54, t = 11.82, p = 0.000) and IS  on SB were significant, the mediating role of AR was confirmed. In the first mediation model, CI positively and significantly affected students’ feelings of SB . CI also had a positively significant impact on AR . Therefore, Hypotheses 1 and 2 were fully supported. Meanwhile, AR was found to predict SB positively and significantly . Therefore, Hypothesis 3 was supported. Based on these results, the partially mediating effect was confirmed that AR mediated the relationship between CI and SB , explaining 22.70% of the total effect (ab/c). Therefore, Hypothesis 4 was supported.β = −0.24, t = −4.74, p = 0.000), supporting Hypothesis 6. However, IS was found to affect students’ sense of SB negatively but not significantly , failing to support Hypothesis 5. Based on these results, the fully mediating effect was confirmed, i.e., AR mediated the association between IS and SB , explaining 100% of the total effect. Therefore, Hypothesis 7 was supported.In the second mediation model, IS was also negatively and significantly predictive of AR (The complete pathway test results are presented in Importance-performance analysis was conducted to identify the critical constructs by contrasting the total effects of the latent variables on a specific target variable with their average latent variable scores . More prTo further position the potential areas of improvement that should pay great attention and action, an importance-performance map was created to visualize the results. The horizontal axis represents the importance, and the vertical axis represents the performance. According to Martilla and James , the impThis study sought to determine the effects of CI and IS on SB through AR among Chinese VET pathway university students. Participants’ overall means were over the midpoint of the scales, manifesting that they can make good use of intelligence to adapt to the cultural differences between university and vocational settings, effectively deal with difficulties and frustrations in professional learning, and feel supported and affirmed by the university. However, they also moderately struggled with the feeling of IS. This result coincides with previous studies wherein university students with vocational backgrounds generate self-misrecognition of their worth in higher education and their subject units relative to their peers with academic pathways . This reThe results confirmed that CI had the most significant influence on SB among Chinese VET pathway university students. The first hypothesis test showed that CI positively and significantly affected students’ sense of SB. Thus, improving sensitivity and ability to cope with cultural affairs will promote students’ feelings of belonging to the university. This deduction is supported by Du’s finding  that vocThe second hypothesis was verified by the positive and significant effect of CI on AR. This result provides empirical evidence for previous theoretical arguments. According to the transition theory assumed by Schlossberg , when stThe third hypothesis was also supported since the results disclosed that AR positively and significantly predicted SB, indicating that the higher students’ AR was, the stronger their feelings of SB became. This result aligns with the finding that AR was predictive of students’ SB ,38. As mTherefore, the fourth hypothesis emerged from this research that CI had a positive and significant effect on SB through AR. This result further confirms the transition theory and SB research that students with high CI have better AR and stronger SB ,79. NoteMoreover, the importance-performance map analysis results illustrated that CI and AR are the areas where improvement activities should be maintained to enhance their performance.In this study, IS was found to affect students’ SB, which was insignificant negatively. Therefore, Hypothesis 5 was not supported. This result contradicts the findings of Rackley , who advFor Hypothesis 6, IS was found to negatively and significantly affect AR. According to the resilience theory, the risk factors such as pessimism and diffidence contribute to high cognitive impairment and low academic performance. The strength of IS can lead to the decline of AR . Due to Notably, despite the insignificant direct effect of IS on SB, the indirect impact of IS on SB through AR was significant, indicating that Hypothesis 7 was supported. In this study, AR completely mediated the association between IS and SB among vocational route university students. The overlapping of students’ high IS and low AR can prominently impede the growth of their sense of SB . This reMoreover, according to the outcome of the importance-performance map analysis, IS is in the lower left area. As Ringle and Sarstedt , construThe results indicated that CI positively and significantly predicted SB both directly and indirectly through AR. The findings from the importance-performance map analysis also revealed that CI had the highest importance and performance in this posited model. Accordingly, keeping up the excellence of CI should be treated as the most essential work. In this regard, some measures should be considered to increase students’ sense of SB by accelerating their ability to perform effectively in diversely cultural contexts. Universities should provide more instruction and opportunities to help students adapt to the new community and develop their CI, including multidisciplinary curricular modules, cross-cultural school activities, and transitional experience sharing. Individually, students should engage in compulsory and optional cultural development events more proactively to build a close connection with the new environment and boost their sense of SB.In addition, AR was also found to act as a mediator in the relationship between IS and SB. With its location in the first quadrant and higher prioritization in the importance-performance map, AR should also be viewed as a vital element. In this vein, universities and educators should offer more academic support to promote students’ academic performance and heighten their feelings of SB by reducing course load, improving teaching methods, facilitating academic training, and putting appropriate academic stress on their professional learning . IndividNoteworthily, although IS only negatively and significantly affected SB through AR and was of the lowest priority among the three variables, IS was somewhat prevalent in this cohort of university students with vocational pathways. Therefore, more effective interventions focused on students’ beliefs about their ability should be initiated to lessen their self-underestimated syndrome to improve their AR and thus their sense of SB. Specifically, educators and parents should encourage students to recognize their worth, build confidence in their success, and regard transition based on their values and beliefs. University students with vocational qualifications should also be aware of the importance of transition experiences, understand themselves comprehensively and objectively in the changing environment, and adjust their mentality further to overcome the complex impact of two types of education.Three limitations must be acknowledged in the current study. The first limitation is that despite the assurance of anonymity and response time, this research topic is a sensitive one with the data collected by self-reporting, which may raise the social desirability bias issue and restrict the causality of the findings. Therefore, further studies should adopt more ways to reduce this bias, such as designing bogus items or incorporating a simple self-reported item. The second limitation is that the participants came from only one well-known university, which restrains the generalizability of the findings. Therefore, future research should cover more respondents from different universities that recruit students from the vocational sector to make conclusions more representative and applicable. The third limitation is that we did not consider the differences in investigated constructs in controlled variables, such as gender, residence, pathway, and discipline. Further work could involve more demographical factors, such as family background and the student wellbeing/engagement program that the university provides, in the regression analyses to detail the distinctions between variables and improve the model validity.By integrating the transition, SB, and AR theory, this research deepened our previous study to explore the mediating role of AR in the relationship between CI and SB and between IS and SB. The results revealed that VET route university students have relatively high levels of CI, AR, and SB. Meanwhile, they are also fraudulent and self-doubting when valuing their successful transition. The results also indicated that CI positively and significantly predicts AR and SB, while IS has a negatively and significantly predictive effect only on AR, but not SB. AR partly mediated the impact of CI on SB and completely mediated the effect of IS on SB. The importance-performance map analysis also identifies that CI is the most vital predictor of SB, followed by AR and IS. These empirical results expand our understanding of how positive and negative factors influence students’ mental health and well-being in transitioning from a vocational education sector to a university. This study also provides valuable insights into how to accelerate the VET pathway university students’ CI and AR, alleviate their feelings of IS, and ultimately reinforce their sense of SB by designing cross-cultural curricula and activities, developing their adaptability to new circumstances, facilitating their resilience in professional learning and academic training, enhancing their sense of self-fulfillment, and intervening early in the period of vocational education. This study could be further improved and generalized by broadening the sample diversity and including the control variables.


Implementation strategies are aimed at improving guideline adherence. Both effect and process evaluations are conducted to provide insights into the success or failure of these strategies. In our study, we evaluate the nationwide implementation of standardized structured reporting (SSR) in pathology.An interrupted time series analysis was conducted to evaluate the effect of a previously developed implementation strategy, which consisted of various digitally available elements, on SSR in pathology laboratories. A segmented regression analysis was performed to analyze the change in mean SSR percentages directly after the strategy introduction for pathology reporting and specific subcategories. In addition, we analyzed the change in trend in the weekly percentages after strategy introduction, also for subgroups of tumor groups, retrieval methods, and type of laboratory. The change in SSR use after the strategy introduction was determined for all pathology laboratories. We further conducted a process evaluation in which the exposure to the strategy elements was determined. Experiences of the users with all strategy elements and the remaining barriers and potential strategy elements were evaluated through an eSurvey. We also tested whether exposure to a specific element and a combination of elements resulted in a higher uptake of SSR after strategy introduction.p=.018) and urological (p=.003) oncological diagnoses. A significant increase was present for all oncological resections as a group (p=.007). Thirty-three out of 42 pathology laboratories increased SSR use after the strategy introduction. The “Feedback button”, an option within the templates for SSR to provide feedback to the provider and one of the elements of the implementation strategy, was most frequently used by the SSR users, and effectiveness results showed that it increased average SSR use after the strategy introduction. Barriers were still present for SSR implementation.There was a significant increase in an average use of SSR after the strategy introduction for reporting of gastrointestinal (Nationwide SSR implementation improved for specific tumor groups and retrieval methods. The next step will be to further improve the use of SSR and, simultaneously, to further develop potential benefits of high SSR use, focusing on re-using discrete pathology data. In this way, we can facilitate proper treatment decisions in oncology.The online version contains supplementary material available at 10.1186/s13012-022-01224-5. Contributions to the literatureTo the best of our knowledge, this is the first nationwide study evaluating the effect and feasibility of a fully digital multifaceted implementation strategy aimed at health care professionals in oncology.Our study showed that the various elements of the multifaceted implementation strategy, also tailored to important barriers and facilitators of the evidence-based guideline recommendation implemented, resulted in improvement of the implementation of the innovation in some but not all subgroups and feasibility results added explanations to these results on effect.Our study could serve as example to others who aim to improve the quality and safety by implementing and evaluating evidence-based guidelines using a fully digital multifaceted implementation strategy.To continuously ensure improvement in the quality of oncological care, implementation of innovations is essential. The quality of oncological care is outlined within oncological clinical practice guidelines , 2; howePrevious research confirmed the additional value of standardized structured reporting (SSR) use compared to other types of reporting, even improving patient outcomes for certain diagnoses –11. TherTo determine the effect of the implementation strategy on the change in level of proportion of SSR usage and the change in linear trend in SSR usage for the following:a) All gastrointestinal, gynecological, and urological oncology pathology reportingb) Pathology reporting per tumor group c) Pathology reporting per retrieval method (biopsies and resections)d) Pathology reporting per type of laboratory (non-academic and academic)To determine the change in the SSR use per pathology laboratory, also analyzed for the previously mentioned subgroups (b–d).To determine the feasibility of the implementation strategy by the following:a) Determining the exposure to the different strategy elementsb) Determining the experiences of the users of the implementation strategiesc) Determining perceived barriers and improvements of SSR implementationTo determine an effect and combined effect between use of implementation strategy elements by pathology laboratories and the change in level of proportion of SSR usage and the change in linear trend in SSR usage of these pathology laboratories after strategy introduction.A digitally free-offered implementation strategy, tailored to the previously found influencing factors, will have great promises for usability and practicality relative to in-person activities and even more so since the start of the COVID-19 crisis . HoweverWe evaluated the effectiveness of a multifaceted tailored implementation strategy and its different elements, aiming to improve the implementation of SSR, by conducting an interrupted time-series-analysis and determining the change in SSR use for all Dutch pathology laboratories. Simultaneously, we conducted a nationwide process evaluation to determine the exposure of pathology laboratories to the active strategy elements, the experiences of pathologists, pathology residents, and PALGA liaisons with the different strategy elements and perceived barriers and facilitators of SSR implementation. We also calculated an effect and combined-effect between the use of active elements and implementation effect. The study design is shown in Fig. Pathologists could use standardized structured formats to report diagnostic findings. The use of these so-called SSR templates by pathologists is recommended in multiple Dutch , 25 and Specifically designed websiteeLearning including instruction videos on SSR usageInformation sheet included in SSR templatesImproved feedback process, including “Feedback button”Audit and feedback reports showing local SSR usagesCommunication manualThe elements , based oAdditional information on the strategy elements, reported according to the TIDieR checklist, can be found in Additional file These strategy elements can be subdivided into passive elements  and more active elements . Three editions of the audit and feedback reports on local SSR usage were sent to the pathology laboratories including data on (1) local usage in 2019 and 2020, (2) local usage in January and February 2021, and (3) local usage in March and April 2021. An example of the first edition including fictional data is provided in Additional file Based on the results of our pilot , we deteThe effectiveness study consisted of monitoring the use of SSR templates  in all Dutch pathology laboratories by conducting an interrupted time-series-analysis. As this study was conducted on a national level, no specific inclusion criteria were applied. The dissemination process is shown on the timeline Fig. . The preThe aggregated data based on continuous input from the pathology departments were evaluated for SSR usage on a weekly basis, 26 time points before and 26 time points after the dissemination period of the toolbox, as shown in Fig. Phase: binary indicator for which 0 = pre-introduction period and 1 = post-introduction period (for estimation of the change in mean percentages (level) change immediately after the strategy introduction)Time (in weeks): ordinal indicator expressing weeks since the start of the study (for estimation of the change in percentage with each week before the strategy introduction)Time since strategy introduction (in weeks): ordinal indicator expressing weeks since the introduction of the strategy (for estimation of the change in trend of the weekly percentage after strategy introduction)We used IBM SPSS Statistics V25.0  to analyze the primary outcome among all Dutch pathology laboratories, using descriptive statistics. To analyze the effect of the nationwide implementation strategy, we conducted an interrupted time series analysis . To do tp value of <0.05 was considered to be statistically significant, based on two sided tests.All data points of the strategy introduction period had been excluded from analysis, as introduction of the strategy was occupied . The impWe used descriptive statistics to determine the average proportion of SSR usage out of all reporting for the three tumor groups per pathology laboratory for all laboratories in the period before and after the strategy introduction. For this analysis, we also conducted a subgroup analysis per tumor group , retrieval method (biopsies and resection), and type of laboratory (non-academic and academic).Data on exposure rates were determined during the strategy introduction period in combination with a nationwide process evaluation, using questionnaires, to gather evidence on the feasibility of our multifaceted strategy , 35. We n=6) and the Dutch Pathology Residents Society (n=2). Information on the research question, target groups, and the anonymous data analysis was included in the introduction of the survey. Before starting the eSurvey, respondents provided informed consent for anonymous data analysis. Completing the questionnaire took 10 to 15 min for all target groups. Unanswered questions were not accepted. Recommendations of Fan & Yan [To determine exposure to our implementation strategy elements, we combined multiple data sources, such as Google Analytics for website usage, Cuble’s statistics for eLearning usage , and PALan & Yan  were usen=2) were excluded, since the “Feedback button” is only accessible via the SSR templates. For the eSurvey, respondents were included when >50% of eSurvey questions were answered. We used IBM SPSS Statistics V25.0 to analyze the eSurvey results. Missing data was coded as such and excluded from data analysis. We performed descriptive statistics to determine the proportions of agreement of SSR users with the feasibility and effectiveness of the different strategy elements.Data on strategy element exposure were analyzed using descriptive statistics. For the calculation of the total exposure of the active strategy elements, the pathology laboratory not using SSR (n=2) were excluded from the analysis for the “Feedback button”, since this element is only accessible via the SSR templates. Besides analysis per active element, we also grouped the users of 2 or 3 active elements, 1 active element, or 0 active elements (=reference group) in three groups to test the effect of multiple active elements use on SSR usage, also excluding the two laboratories not using SSR. The autoregressive integrated moving average (ARIMA) model including all covariates  was performed. A p value of <0.05 was considered to be statistically significant, based on two sided tests. A comprehensive overview of the effect and process evaluation, including all outcomes, is provided in Additional file For the active elements, the eLearning, the “Feedback button”, and audit and feedback reports, we tested the differences in effect between pathology laboratories who did use, in case of the eLearning and “Feedback button”, or did receive, in case of the audit and feedback, the strategy element during strategy introduction versus laboratories who did not use or receive it. We calculated the proportion of SSR usage out of all reporting per week among the groups of pathology laboratories who did and who did not use  or receive (audit & feedback) the specific active strategy element. The pathology laboratory not using SSR (n=42) are shown in Table The total included cases pre- and post-introduction were 102,587 and 110,628, respectively. We included 15,615, 57,619, and 29,623 cases pre-introduction and 16,683, 62,762 and 31,183 cases post-introduction, respectively, for gastrointestinal, gynecological, and urological oncology. The majority were resections . The amount of cases (>100) per time point is included in Additional file p=.135). The change in trend of SSR use after strategy introduction compared to before was also non-significant . The results of the subgroup analysis can be found in Table Figure p=.018) and urological tumors . For gastrointestinal tumors, the slope of the trend was declining . The increase in level was lower for gynecological tumors  compared to gastrointestinal tumors. The change in trend after the strategy introduction was lower for gynecological tumors  and higher for urological tumors  compared to gastrointestinal tumors.Trends in SSR usages per tumor group are shown in Fig. p=.007) .The level in SSR usage after introduction for resections only showed a significant increase  Fig. . The incFigure Figures n=173). Of the 13 different eLearning courses available, the first course on the introduction of SSR templates was chosen most often (n=7). This was followed by the course on using fast keys within SSR templates (n=6), the eLearning course explaining how to properly manage the settings of SSR templates (n=5), and the course on how to combine two different SSR templates (n=5). More than half (n=23) of the pathology laboratories received audit and feedback reports, of which 5 pathologists of 4 different pathology laboratories replied by asking questions and reporting feedback.Exposure rates are shown in Table The eSurvey evaluating the process of the nationwide implementation strategy yielded 53 responses: 40 pathologists, 5 pathology residents, and 8 PALGA liaisons with an average age of 44 (range 26–66) and average years of experiences of 11 (range 1–37). Respondents were working in non-academic hospitals (59%), academic hospitals (26%), and independent laboratories (15%). The majority of the pathologists (93%) was involved in either gastrointestinal, gynecological, and/or urological oncological pathology. All were aware of SSR templates and used them in clinical practice. Of the 45 pathologists (and residents), 11 stopped using a SSR template, mostly while using the template for reporting prostate biopsies.n=24) of the respondents received the toolbox. Most pathologists received the toolbox via the PALGA liaison . Three-quarter (n=6) of the PALGA liaison respondents received the toolbox via e-mail, and 5 of them forwarded it to pathologists within their laboratory. Half of the 30 respondents receiving the toolbox also entered the toolbox. The mean reasons for not consulting the toolbox were lack of need for assistance  and lack of time . Various reasons were mentioned to use the toolbox, corresponding to the widely varying rating of the toolbox with a median score of 7.0 (range 1–10).More than half , compliant with exposure rates. All implementation strategy elements scored sufficient. The updated PALGA website was used most often . All eLearning users (n=4) agreed that this could be used for resident education. Three out of 9 mentioned that the audit and feedback reports gave them new insights to improve SSR usage locally, resulting in new local agreements. The top three of the elements of respondents included all active strategy elements. Of the respondents using one or more elements, 8 out of 37 (22%) reported an effect on SSR use. Pathologists were mostly encouraged by their colleagues  to start using SSR templates. Strategy elements were reviewed as very accessible (range 75–100% agreement) and usable (range 75–100% agreement). Respondents not using elements argued that they had no specific need to use it (range 48.8–61.9%) or that they were not familiar with that particular element. The latter applied less to SSR integrated elements (range 16–17.1%) compared to external elements (range 26.2–58.5%). Including the element within SSR templates was mostly chosen as an alternative method of accessibility, for both the website and communication manual (range 61.0–71.4%). Providing audit and feedback was specifically suggested as being a responsibility for the Dutch Pathology Association by 6 out of 41 respondents (15%).In Table n=30) perceived barriers related to SSR use. Most perceived barriers were rigidity of SSR templates , time needed to use SSR, and content of templates  and SSR , the last mostly being relevant for the reporting of ovarian cancer. Potential solutions to these barriers mentioned by pathologists and pathology residents were to improve user-friendliness, readability of SSR by using less punctuation and duplicate terminology, to integrate speech recognition and automatic transfer of clinical data.Two thirds of the respondents (There was no change in SSR usage based on the audit and feedback reports.n=18), significantly increased SSR use , whereas the pathology laboratories using the “Feedback button” ≤ 3 times or not at all (n=24), SSR usages did not change after strategy introduction . This was also significant different between groups . This was a lasting effect, with no changes in trends after the introduction period .Pathology laboratories using the “Feedback button” ≥3 times during strategy introduction (n=9) did not lead to a change in SSR usage , whereas the pathology laboratories not using e-learning (n=33) increased SSR usage after strategy introduction . Both groups showed no changes in trends after implementation . Both the change in SSR use  as well as the change in trend in SSR use  were not significant between groups.The use of e-learning by pathologists of specific pathology laboratories (p=.166) compared to using 1 or 0 active strategy elements, respectively +0.8%, p=.283 and +0.6%, p=.735), and this was not significant between groups using 1 active strategy element  and 2 or 3 active strategy elements  compared to the group using 0 active strategy elements. In addition, the trend in SSR per week did not change when multiple or a single active strategy element was used, respectively −0.1% per week (p=.513) and −0.1% per week (p=.306) compared to using 0 active strategy elements , and this was also not significant between groups using 1 active strategy element  and 2 or 3 active strategy elements  compared to the group using 0 active strategy elements.Of the pathology laboratories, 7 used 0 active strategy elements, 19 used 1 active strategy elements, and 14 used 2 or 3 active strategy elements. The use of multiple active strategy elements (2 or 3) did not lead to more a change in SSR use  did not lead to a change in SSR use compared to using 1 or none active strategy.From both the effect and parallel process evaluation, we can conclude that barriers still exist, in particular for certain subgroups of reports. The presence of these persisting barriers may also explain why the use of the evaluated implementation strategy elements was still suboptimal and no combined effect was found, although dissemination of the implementation strategy was improved by incorporation of insights from our pilot study . These bOur study showed the effectiveness and feasibility of a nationwide implementation of a digital innovation in pathology. This provides helpful insights to be used for other related implementation studies. Remaining barriers were rigidity of SSR templates and time needed to fill in a pathology report, already known from previous studies , 38, 39 Instead of randomly choosing implementation strategy elements, we selected and developed our multifaceted implementation strategy to barriers and facilitators determined in previous studies and tested it in a small-scale setting before nationwide implementation , 20, 22.First of all, our study showed the importance of improving guideline implementation in diagnostics at a national level. Implementation decreases the variation, resulting in more standardization of diagnosis and treatment, ultimately benefiting patients. Second, in times of social distancing and also working extensively from home during the COVID-19 pandemic, our study showed that a fully digital implementation strategy facilitates continuing improvement of the implementation of a guideline recommendation. Third, international researchers and health policy makers could use our study as an example for other guideline recommendations with various adoption levels in clinical practice, for which data is already collected on a national level to be analyzed and is ready to be used to improve clinical practice. Last, by first conducting a pilot test, both the dissemination and implementation strategy were already adapted to pathologists’ needs, before scaling up to a national level.This study also had some limitations. Relatively few research resources (both time and monetary) are available for implementation studies, resulting in a continuous circle of settling for quick and easy solutions. This does not only lower the effect of implementation studies itself, but also hampers progress in implementation science. However, we still managed to gain an effect for some subgroups of reporting by the dissemination of our implementation strategy in its current composition. Another limitation concerns the low response rate to the eSurvey, resulting in less generalizable process outcomes on experiences. However, we still gathered fruitful insights into the implementation process. A last limitation is that we could not determine the effect of all different elements on SSR usage and we could not adjust for laboratory characteristics in the combined effect analysis, since this information was unavailable. Differences between academic non-academic laboratories suggested that laboratory characteristic influence the use of strategic elements. The academic laboratories showed a decrease in SSR after induction of the implementation strategy and relatively frequent used the eLearning. This might have biased the effects of eLearning on SSR use. In addition, SSR usage was measured during the COVID-19 pandemic, in which a decline in oncology diagnoses was reported . HoweverNationwide SSR implementation for pathology reporting of gastrointestinal and urological cancers was improved by the implementation of a diverse pallet of digitally available implementation strategy elements, free to use for pathologists to increase their use of SSR. For other subgroups, such as the reporting of biopsies and gynecological oncology, specific barriers are known from previous analyses and these are still hampering the implementation of SSR. Since SSR, without being mandatory, is already very frequently used in pathology practice, in coming years the focus should be on how to overcome remaining barriers of SSR use in clinical practice. Moreover, now is the time for stakeholders, such as pathologists, pathology associations, pathology and cancer registries, IT, and patient associations, to closely work together to also achieve the potential benefits of SSR use by pathologists. In addition, since pathology is world leader in SSR implementation, but lags behind in other digital transitions, close collaboration with other disciplines remains on the agenda the next years, to achieve an optimal oncological diagnostic workflow. This will result in pipelines containing structured and standardized data for all diagnostic disciplines involved in oncology care, enabling improved treatment decisions.Additional file 1. Description of data: Infographic of the toolbox including all the implementation strategy elements.Additional file 2. Changes to toolbox used for nationwide evaluation. Description of data: Three changes made to the previously tested toolbox.Additional file 3. Overview of specifications of implementation strategy elements according to the TIDieR checklist. Detailed information on the different elements of the implementation strategy, according to the TIDieR checklist.Additional file 4. Report local SSR use (audit and feedback). Report including local SSR use  used for the audit and feedback strategy element of the multifaceted implementation strategy.Additional file 5. Selection criteria qualifying cases for effect evaluation. Applied selection criteria for the qualifying cases used in the effect evaluation.Additional file 6. Overview of study outcomes. Overview of study outcomes related to the study objectives.Additional file 7. Number of included pathology reports. Table including the pathology reports included in the effect evaluation, also shown for resections, and gastrointestinal, gynecological and urological tumor groups.


Payoff, emotion, and historical memory directly determine investment decision-making for incomplete rational men in a public goods game (PGG). How these factors affect investment and cooperation behavior has not been investigated yet. Thus, we proposed a new investment model involving theses three factors to examine its coupling effect on cooperation in PGG. An emotional increment was employed to describe the emotional change in every round by supposing an investor’ pleasure to a cooperator but regret to a defector. Furthermore, an emotional index was formed by accumulating these historical changes with a memory decline effect. Then an investment formula was proposed by considering this emotional index and a historical payoff. Moreover, the cooperation level affected by these factors was investigated. Results show a mutually reinforcing relationship between emotional and payoff investments. A poor memory capacity coefficient allows defectors to change their behaviors but produces some opportunists. A large memory length results in a high cooperator fraction but is not suggested to be too large. Cooperation is typical behavior in human life and the animal world. Cooperative behavior means that a co-operator benefits other by paying some cost and that a defector gets a payoff without effort. In theory, no one prefers to take cooperative behavior under rational and natural selection. However, this is not true in real life because commonplace cooperation exists in energy development, environmental protection issues, supply chains among companies, et cetera. How to explain these cooperation behaviors in real life has become a hot topic and has attracted much attention worldwide. As the public goods game (PGG) is a helpful tool in explaining the evolution of cooperation behaviors, it is widely employed in national defense, public transport, and in environmental protection issues, et al. –5. RegarRational investments have been widely explored for many years. Many researchers proposed rational investment correlations by considering the degree of a focal player, the groups’ quality, the reputation, the payoff, et cetera. For the investment induced by the degree, a player assigns the investment to a focal player according to the degree of this focal player. This heterogeneous investment is a fixed investment because the investment is determined by the network structure and keeps unchanged from the second round –14. For Except for rational investment, emotion also affects the investment in reality. Some researchers investigated the effect of emotion on cooperation behavior and claimed that emotions could be spread in a PGG. Szolnoki et al. , 33 studα1 and α2 to characterize the strength of the emotional investment and the rational investment. At last, we examined the effect of the emotion and payoff on cooperation behavior in a PGG. The results show that there is a mutually reinforcing relationship between emotional and rational investment.Motivated by these discussions, we considered the payoff as the rational factor and introduced the effects of heterogeneous investments caused by players’ payoffs and the emotions on the evolution of cooperation in PGGs. Firstly, we introduced a memory length and a memory capacity coefficient to describe the memory-cumulative effect. Then a new emotional correlation between a player to different opponents was proposed according to the memory-cumulative effect. Secondly, an investment formula was proposed based on emotion and the effective payoff. Aiming at describing the contributions of the emotional investment and the rational investment, we used two parameters This paper is organized into the following parts. Section 2 introduces the model of heterogeneous investments induced by emotions and payoffs. Section 3 presents the results and discussion. Section 4 draws conclusions.δ. The emotional index of a cooperator increases δ when coming across a cooperator neighbor and decreases δ when facing a defector neighbor. While a defector remains unchanged in his emotional index. Thus, the emotional change in every round could be expressed as follows,Emotion is an essential part of our investment decision-making. It dynamically changes when facing different players. As shown in t = 1), all players keep a neutral attitude and accumulate their emotions according to their neighbors’ behaviors. Furthermore, this cumulative emotion is affected by memory capacity. Regularly, the current emotion is the most impressive, and the historical emotion gradually declines with time. Here, we consider a memory length of m and a memory capacity coefficient ε. Thus, the emotional index of player i on player j at step t could be expressed as,At the beginning of this game  is the investment of player i to player j at time t+1, and this investment is 0.2 at the initial time. Ωi the group centered on player i. α1 is an emotional weight, and α2 is a rational weight, α1, α2 >0. Where, ui,j(t) is the payoff of player i obtained from a group centered on player j, and can be calculated as,Where, r is the multiplication ratio, and G is the number of players in a group centered on player j.Where, i at time t can be calculated from his groups as follows,The total payoff of player i randomly chooses one of his neighbors j, and adopts the strategy of player j with a probability,All players update their strategies synchronously by means of the Fermi rule . Player si is the state value which is 0 for a defector and 1 for a cooperator. K is the intensity of noise and is usually set to 0.1, as reported by Zhang et al. [Where, g et al. .i, its coordinate value in this plan is labeled as , and its four neighbors’ coordinate values are , , , . Initially, each player has the same emotion value of 0 and the same investment value of 0.2 to his neighbors. The payoff of player i obtained from his neighbors is the sum of the total investments to his neighbors. The emotional change of player i to his neighbors in this round could also be recorded according to the emotion rules in Eq (4), the cooperation frequency tends to be stable, and this simulation can be stopped. To analyze the cooperation level, we average the results of the cooperation fraction over 20 independent Monte Carlo simulations.The paper considers a square lattice network structure with periodic boundary conditions. Matlab software is adopted to simulate the evolution of this game, and its calculation flow chart is shown in es are x+, y, Click here for additional data file.S2 Data(XLS)Click here for additional data file.S3 Data(XLS)Click here for additional data file.


To assess the efficacy and safety of combined loratadine and budesonide for patients experiencing AR is the aim of this study.Among the most prevalent allergic conditions that affect children is anaphylactic rhinitis (AR). It is capable of leading to physical as well as mental health issues. Concomitant use of I2 test. Without correct data or information, there is a need for Publication bias, which is assessed by performing the Begg and Egger test and generating a funnel plot.We will apply 2 independent authors in six databases, including EMBASE, Pub Med, Web of Science, China National Knowledge Infrastructure, WanFang Database, Chinese Scientific Journal Database (VIP database). Studies evaluating the efficacy and safety of combined loratadine and budesonide in patients with AR will include studies published between inception and Dec 2021. Accordingly, the data will have to be in English and Chinese. For the selection of data extraction, the studies and risk of bias assessment will be completed by 2 independent authors. Accordingly, data synthesis will be conducted through RevMan 5.3 software. The study will establish heterogeneity using the loratadine and budesonide for AR treatment.The study provides a trustable clinical foundation for OSF registration number: DOI 10.17605/OSF.IO/M2RFGEthics and dissemination: Because the present study is founded on existing studies, it does not require ethics approval. In essence, it is 1 of the most typical forms of non-infectious rhinitis, accounting for an estimated 10 to 30 percent of all adults as well as 40 percent of young persons. Past epidemiological studies have demonstrated that AR continues to increase globally. For example, the WHO has estimated that about 400 million people suffer from AR worldwide.Loratadine refers to a medication with high permeability and low water solubility, and it is usually used to treat allergic symptoms.–6 Essentially, by oxidized low-density lipoproteins, the drug is capable of reducing endothelial inflammation produced and has some level of protective impacts. Accordingly, loratadine can selectively inhibit H1 receptors situated primarily on respiratory smooth muscle cells and those that do not cross the blood-brain obstruction. At the same time, it is helpful in many situations for relieving allergic symptoms. Even though loratadine displays a clinical efficacy to treat AR, it is necessary to enhance its effect.Budesonide entails a nebulized glucocorticoid utilized in treating asthma and AR. It caused substantial decreasing adhesion molecules levels, including MIP-2 and ICAM-1, released from endothelial cells and wounded epithelial; thus, triggering neutrophil infiltration and macrophages.,11 Accordingly, budesonide is capable of decreasing proinflammatory cytokines , increasing the levels of IL-10; thus, antagonizing the impacts of earlier cytokines as well as reducing cell apoptosis.–13 However, the safety and efficiency of combining loratadine and budesonide in patients with AR have not been systematically verified. To this end, this review aims to empirically assess the safety and efficacy of combining loratadine and budesonide to treat patients experiencing AR and build reliable evidence and valuable references for clinicians and researchers to make better medical decisions. This will help n conducting further studies on the topic.2The study is registered with the Open Science Framework . Systematic reviews and meta-analyses as required by the project statement are our preference.2.12.1.1We only included randomized controlled trials published or registered before December 2021. However, we will exclude prospective randomized controlled trials, review articles, case reports and other studies that do not meet this requirement.2.1.2We will include participants of different age ranges, participants of all types of AR, regardless of their nationality, gender, race, occupation, education, severity, or etiology.2.1.3loratadine combined with budesonide to the treatment group, whereas the control group will receive only loratadine, budesonide, placebo, or they will not receive any form of treatment. We will have no limit to dose, frequency, or treatment duration.We will give the therapy of 2.1.4The clinical improvement of AR symptoms, rhinoconjunctivitis-related quality of life, occurrence of adversative events, and utilization of rescue medicine is our anticipated outcome.2.22.2.1loratadine and budesonide in patients with AR, published from inception to December 2021. We will only regard articles published in English and Chinese. A search in PubMed was performed using the following terms “(‘loratadine∗’ OR ‘budesonide∗’) AND  AND . They will assess the evaluation of efficacy as well as safety of combined 2.2.2The following clinical trial registries are what we will use to establish ongoing trials: The ClinicalTrials.gov, the Chinese clinical registry, and Google Scholarship. We will also retrieve helpful but incomplete information from the contact trial personnel.2.3We will use 2 independent authors to double-check and gather all the qualifying studies and transfer them into RevMan software. We will use a pre-defined data acquisition form to enter details, for instance “author, journal, treatment indication, population characteristics, total and per-arm sample size, publication year, comparator dose and omalizumab, study duration, and mode of administration.” In case of a disagreement between the authors, a third author will mediate to help reach a consensus.2.4Two independent authors will be used to perform a systematic review of each of the studies for the bias risk. The authors will use the Cochrane Handbook. In particular, they will rely on 6 domains, including “reporting, the bias of selection, detection, performance, attrition and other sources.” They will rate trials for every field as “high risk, low risk or unclear after evaluation.” The authors involved in the study will also be contacted to clear any missing information. In case of a disagreement between the authors, a third author will mediate to help reach a consensus2.5We pooled the study-specific estimates by utilizing fixed and random-effects models and estimated the standardized summary mean differences and the relative risks, as well as the 95% confidence intervals correspondingly. We noticed that the standardized mean difference was the mean change per standard deviation, which is critical for comparing scores in various scales.2.6We will get in touch with respective authors where there is missing information or incompleteness of data. We will wait for 1 month after sending an email to the original author to reply. After 1 month, we will exclude the incomplete data from the analysis if the author does not respond or provide the necessary data.2.7I2 (ranging from 0% to 100%) to assess the presence and degree of heterogeneity. We used a subgroup analysis for further investigation where there is high heterogeneity. We intend to use the formal test for subgroup interactions in RevMan V.5.3.We use 2.8A sensitivity analysis will be used to conduct the robustness of the critical decisions made during the monitoring review process.2.9We used a visual inspection of the Egger test and Begg funnel plots to evaluate all potential small study effects, such as an indication of publication bias.3 In particular, many people seem to experience the effects of the negative impacts of AR. Therefore, patients might resort to using medication to relieve these uncomfortable symptoms. Nevertheless, some of the most common adverse events with intranasal formulations were “poor taste, nasal burning, sedation, increased cost relative to oral formulations and more frequent dosing.” In most cases, doctors consider side effects based on the initiation of intranasal antihistamines. On this foundation, we need to strengthen our randomized controlled study on the safety and effectiveness of combining loratadine and budesonide to treat patients with AR in future studies. We also need to establish a significant scientific basis to apply this approach to clinical treatment. This will be crucial in the provision of a solid scientific foundation to use this approach in the clinical therapy of AR.AR is 1 of the most common allergic diseases worldwide, affecting 10% to 40% of the global population.Conceptualization: Jing Zhang, Dan Kan.Data curation: Jing Zhang, Dan Kan.Formal analysis: Jing Zhang, Dan Kan.Funding acquisition: Jing Zhang, Dan Kan.Investigation: Jing Zhang.Methodology: Jing Zhang, Dan Kan.Project administration: Jing Zhang.Resources: Dan Kan.Software: Jing Zhang, Dan Kan.Supervision: Jing Zhang.Validation: Jing Zhang, Dan Kan.Visualization: Jing Zhang.Writing – original draft: Jing Zhang, Dan Kan.Writing – review & editing: Dan Kan.


Prostate cancer is a hormone-dependent malignancy, whose onset and progression are closely related to the activity of the androgen receptor (AR) signaling pathway. Due to this critical role of AR signaling in driving prostate cancer, therapy targeting the AR pathway has been the mainstay strategy for metastatic prostate cancer treatment. The utility of these agents has expanded with the emergence of second-generation AR antagonists, which began with the approval of enzalutamide in 2012 by the United States Food and Drug Administration (FDA). Together with apalutamide and darolutamide, which were approved in 2018 and 2019, respectively, these agents have improved the survival of patients with prostate cancer, with applications for both androgen-dependent and castration-resistant disease. While patients receiving these drugs receive a benefit in the form of prolonged survival, they are not cured and ultimately progress to lethal neuroendocrine prostate cancer (NEPC). Here we summarize the current state of AR antagonist development and highlight the emerging challenges of their clinical application and the potential resistance mechanisms, which might be addressed by combination therapies or the development of novel AR-targeted therapies. Second-generation AR antagonists including enzalutamide, darolutamide, and apalutamide for prostate cancer treatment increase patient survival.Second-generation AR antagonists only provide a temporary response and resistance eventually develops.Diverse mechanisms were reported regarding the resistance to second-generation AR antagonists.What is the mechanism of treatment-induced NEPC (t-NEPC) and what is the connection between t-NEPC and second-generation AR antagonists?How to address the second-generation AR antagonist-induced resistance?What is the progress of alternative AR-targeted therapy?The incidence of prostate cancer ranks second among men worldwide and represents one of the leading causes of cancer death, with an estimated about 1.4 million new cases and 375,000 deaths worldwide in 2020 , nilutamEnzalutamide  is the first FDA-approved second-generation AR antagonist for the treatment of CRPC and exhibits a much higher AR-binding affinity in comparison to the first-generation AR antagonists. It competitively binds to the ligand-binding domain (LBD) of AR and inhibits androgen binding, nuclear translocation, DNA binding, and co-activator recruitment , 27. EnzSeveral clinical trials are currently underway investigating novel AR antagonists with the potential to conquer the shortcomings of the present AR antagonists Table . ProxaluAgents that target regions of AR other than the LBD are in development as well, with the potential to counteract constitutively activating AR splice variants and AR point mutations. EPI-7386, for instance, is a second-generation NTD inhibitor (aniten) that is more active and more metabolically stable than EPI-506 (EPI-002 pro-drug) and has demonstrated a 20-fold improvement in AR-driven cellular potency compared to EPI-002 . A phaseAlthough second-generation AR antagonists have become mainstays for the treatment of both CSPC and CRPC patients, their clinical benefits have been limited by potential side effects and especially by induced drug resistance. As mentioned above, the long half-lives and high levels of enzalutamide and BMS-641988 in the CNS may induce seizures in a small proportion of prostate cancer patients, as these AR antagonists can competitively bind and inhibit GABA-α activity , 54, 55.Overall, administration of second-generation AR antagonists to patients in different stages of disease has resulted in a moderate survival benefit. However, several studies have indicated that about 30–60% of patients who receive second-generation AR antagonists eventually progress to death , 34, 39.Genomic analyses have indicated that 15–20% of CRPC patients harbor AR mutations , 73. ColAR gene is comprised of eight canonical exons  [v567es also promote the function of AR-FL by facilitating its nuclear localization and DNA binding in the absence of androgen or even in the presence of enzalutamide [AR alternative splicing (AS) events resulting in the absence of the LBD from AR isoforms is another major resistance mechanism relevant to prostate cancer . The humons Fig.  encoding factors , 64, and factors –89. AR-v (AR-FL) –92. On tlutamide , 93, 94.AR gene amplification, enhanced transcription activation, or increased AR stability at the mRNA/protein level. Studies have shown that about 80% of tumors overexpressing AR exhibit AR amplification [AR locus, and that AR overexpression is sufficient to confer resistance to AR antagonists in clinical practice [AR transcription or increased stability of AR protein/mRNA is sufficient to upregulate AR levels without AR gene amplification [AR overexpression is also considered a mechanism of resistance to AR antagonists, and can result from fication , 96. Syspractice , 74, 97.practice . Enhancefication –101, andfication . InteresNR3C1 (encoding GR) and SLC7A11, and upregulates their expression in both ADPC and CPRC cell models. Transcriptome analysis further demonstrates that enzalutamide induces global upregulation of a number of cancer-related genes. Mechanistic studies have revealed that this process is assisted by the pioneer factor GATA2 and the mediator complex [Although second-generation AR antagonists are typically considered “pure” antagonists, our recent studies have found that these agents function as partial agonists as well , 104. We complex . Interes complex , 109. Th complex , 108. Ch complex . In concAR locus alone can range from AR LBD point mutations to alternative splicing events, to overexpression that increases the sensitivity of AR to hormone stimulation, to loss of the antagonist binding region or other changes that mediate antagonist-agonist switching of the second-generation AR-targeted therapies [AR gene, tumor heterogeneity can also contribute to AR antagonist resistance through other pathways independent of AR.Tumor heterogeneity is one of the major drivers of cancer progression and represents one of the primary challenges in cancer treatment. Tumor heterogeneity exists both in nascent prostate cancers and following antagonist-driven evolution, and contributes to CRPC progression and drug resistance –114. As herapies , 64. OutPTEN, RB1, TP53, or SOX2 enables tumors to become AR independent and activates neuroendocrine differentiation, which is emerging as an increasingly recognized mechanism of resistance to AR-targeted therapies. It has not been established whether these alternations pre-exist within a subset of prostate epithelium cells that are intrinsically resistant to AR-targeted therapies or whether they are induced during the course of treatment with AR-targeted therapies. A recent whole-exome sequencing and immunohistochemistry (IHC) study in 37 prostate cancer patients before ADT has shown that loss of chromosome 10q (containing PTEN) and alterations to TP53 are predictive of poor response to enzalutamide. A subset of prostate cancer exhibits greater histologic and genomic diversity, accompanied by a higher fitness to resist therapy [PTEN, RB1, and TP53 are characteristic of treatment-induced NEPC patients [MYC or knockdown of PTEN/RB1/TP53 drives lineage plasticity models to shift from CRPC to NEPC [Lineage plasticity is driven by alterations in  therapy . In addi therapy . A relat therapy , 115. Repatients –118. Exp to NEPC –122.Activation or deactivation of other pathways including Wnt-β-catenin, PI3K–AKT-mTOR, and DNA repair are also reported to be associated with resistance to AR antagonists, as summarized by Schmidt et al. , 123. Stv567es that lack the LBD and contribute to prostate cancer progression and resistance to AR antagonists [In reviewing the mechanisms of AR antagonist resistance, changes in the AR signaling pathway stand out as one of the primary reasons, with accumulating studies demonstrating that events including AR point mutation, rearrangement, amplification, and transcriptional upregulation of AR variants can result in the failure of AR antagonist treatment and in some cases can mediate antagonist–agonist switching. Additionally, side effects such as seizure and cardiovascular disease have limited the clinical benefits of second-generation AR antagonists. Although darolutamide and proxalutamide show clinical efficacy in CRPC patients harboring point mutations within the AR LBD , 44, theagonists , 125–128agonists , 130. Asagonists –134. Theagonists .The emergence of gene-targeted therapies for different diseases may be a more straightforward approach to confronting AR splicing variants and point mutations. PROteolysis-TArgeting Chimeras (PROTACs) have been recognized as a promising technology to chemically knock down targeted genes at the protein level, particularly in the context of cancer . PrelimiGR and SLC7A11, in comparison with 10 μM of enzalutamide [Although second-generation AR antagonists have prolonged prostate cancer survival time, side effects and the rapid evolution of drug resistance remain stumbling blocks associated with the use of AR antagonists in clinical practice. One possible contributor to both the side effects and the induction of drug resistance is the high dose of AR antagonists currently administered to patients. Indeed, our study has found that 25 μM of enzalutamide that imitates the real dose of enzalutamide in patients induced higher expression of cancer-related genes such as lutamide . Therefolutamide . A phaselutamide . Other plutamide , 152, whlutamide , 154. Talutamide , 156. FuSequencing treatment strategies with different inhibitors have achieved initial success in CRPC. A phase II clinic trial has shown that using a sequencing strategy of abiraterone acetate followed by enzalutamide in CRPC patients provides a clinical benefit , althougNotably, although GR pathway activation has been considered one of the principal mechanisms of resistance to AR antagonists , 24, 41,AR alteration, reprogramming of AR transcriptional activity by induced AR antagonists, and both pre-existing and therapy-driven tumor heterogeneity contribute to prostate cancer resistance and tumor progression. These obstacles might be addressable through the joint efforts of both clinical doctors and basic researchers to develop novel inhibitors or other technologies targeting AR and to explore combination/sequencing therapeutic strategies.In conclusion, three second-generation AR antagonists have been developed through interdisciplinary efforts during the past decade, and their approval for prostate cancer treatment has significantly improved survival and decreased prostate cancer-related death worldwide, particularly in patients with mCSPC and CRPC. At the same time, drawbacks of these AR antagonists have gradually emerged, especially the ability of second-generation AR antagonists to induce resistance and progression of patients from CRPC to t-NEPC. Mechanistic studies indicate that


HIGH/NEHIGH prostate cancer and revealed that these double-high cases are majorly present in castration-resistant prostate cancer with a less neuroendocrine-transdifferentiated state. We then reviewed 8,194 prostate cancer cases with available immunohistochemistry reports and found 2.3% cases (n = 189) that showed at least one of the NE markers  being positive in at least 5% of epithelial cells. Within these 189 cases, we observed that 81.0% cases (n = 153) showed AR positive and 19.0% (n = 36) showed AR negative. Patients with AR loss tumors demonstrated a correlation with adverse clinical stages, indicating a trade-off between AR and advanced disease in neuroendocrine differentiation. Using multiplex immunofluorescence staining, we observed the co-localization of AR and NE markers in prostate cancer cells. In addition, data mining of single-cell transcriptome further confirmed the existence of ARHIGH/NEHIGH prostate cancer cells in castration-resistant samples and suggested that AR still exerts its androgen response and anti-apoptotic effect in these double-high cells. Thus, our study provides a better understanding of AR signaling in the cellular plasticity of prostate cancer with neuroendocrine differentiation and allows new insights into the therapeutic development.The androgen receptor (AR) signaling is a key contributor to tumorigenesis and the progression of prostate cancer. A subset of patients may develop neuroendocrine (NE) features, resulting in resistance to androgen deprivation therapy and poor prognosis. In this study, we combined immunostaining and bulk and single-cell transcriptome analyses to better characterize the status of AR in prostate cancer with neuroendocrine differentiation. The exploration of online datasets indicated the existence of AR Androgen receptor (AR) and AR signaling are critical in the development and progression of prostate cancer . ActivatProstate cancer with neuroendocrine differentiation is typically defined by the heterogeneous histological expression of several NE markers in at least 5% of epithelial cells, including chromogranin A (CHGA), synaptophysin (SYP), neural cell adhesion molecule 1 (NCAM1), and enolase 2 (ENO2) . WHO 201An increasing number of studies have investigated the clinicopathology and molecular character of prostate cancer with neuroendocrine differentiation in the past years, but the understanding of AR status in prostate cancer neuroendocrine differentiation progression remains controversial. Prostate cancer with neuroendocrine differentiation was usually considered as AR-null with resistance to the AR-directed interventions –16. A prHIGH/NEHIGH prostate cancer and revealed that these double-high cases are majorly present in CRPC with a less neuroendocrine-transdifferentiated state. We then reviewed all pathology-confirmed prostate cancer cases with available immunohistochemistry reports in Ren Ji and Xinhua Hospital from 2009 to 2021. Of 8,194 cases, 2.3% (n = 189) showed any one of the NE markers  being positive in at least 5% of epithelial cells, among which 81.0% (n = 153) showed AR positive and 19.0% (n = 36) showed AR negative. The clinicopathological evaluation showed that a patient with AR loss tumors associated with adverse clinical stages, indicating a trade-off between AR and advanced disease in neuroendocrine differentiation. Using multiplex immuno-fluorescence staining, we observed the co-localization of AR and NE markers in prostate cancer cells. In addition, data mining of single-cell transcriptome further confirmed the existence of ARHIGH/NEHIGH prostate cancer cells in castration-resistant samples and suggested that AR still exerts its androgen response and anti-apoptotic effect in these double-high cells. Thus, our study provides a better understanding of AR signaling in cellular plasticity in prostate cancer with neuroendocrine differentiation and allows new insights into therapeutic development.The aim of our work was to shed further light on a better understanding of AR status in prostate cancer with neuroendocrine differentiation. We combined immunostaining, bulk RNA sequencing, and single-cell transcriptome sequencing to assess the AR status in prostate cancer with neuroendocrine differentiation. The exploration of several online bulk RNA sequencing datasets indicated the existence of ARWe retrospectively reviewed all 8,194 patients with pathologically proven prostate cancer and available immunohistochemistry reports who have visited the Department of Urology in Ren Ji and Xinhua Hospital for a period of 13 years from 2009 to 2021. The reviewed clinical data obtained from electronic records included age, Gleason Score, clinical TNM stage, hormone treatment status, and serum prostate-specific antigen (PSA) level. These clinical data had been reviewed by urologists . The clinical TNM stage was determined according to the American Joint Committee on Cancer staging system. The PSA serum level depended on the most recent time before sample acquisition. The pathological samples had been reviewed by a pathologist (ZJ) and were classified morphologically according to WHO . Categorical variables between groups were tested by using chi-square test or two-tailed Fisher’s exact test. Continuous variables between groups were tested by using unpaired t-test. The relationships between continuous variables were tested by Pearson’s correlation coefficient. P < 0.05 was considered statistically significant .Patient prostate tissue samples derived from radical surgery or puncture biopsy were made into 4-μm formalin-fixed paraffin-embedded sections on adhesive-coated glass slides. Antigen retrieval was performed with EDTA solution (pH = 9.0) at 95°C for 20 min after deparaffinizing the formalin-fixed paraffin-embedded sections. Human sections were blocked by 10% horse serum at room temperature for 1 h and then stained with primary antibodies targeting AR , CHGA , SYP , and NCAM1  at 4°C overnight. Secondary anti-rabbit/mouse antibody (Jackson ImmunoResearch Laboratories) was diluted at 1:500, and the sections were incubated at room temperature for 1 h.Multiplex immunofluorescence staining was also performed on 4-μm formalin-fixed paraffin-embedded sections. Antigen retrieval was performed with EDTA solution (pH = 9.0) at 95°C for 20 min after deparaffinizing the formalin-fixed paraffin-embedded sections. Human sections were blocked by 10% horse serum with 0.3 M glycine at room temperature for 1 h and then stained with primary antibodies targeting AR  at 4°C overnight. Secondary anti-rabbit antibody (Jackson ImmunoResearch Laboratories) was diluted at 1:2,000, and the sections were incubated at room temperature for 1 h. Horseradish peroxidase (HRP) was permanently fluorescence-labeled in secondary antibody by TYR-Cy3 (Recordbio) at room temperature for 10 min. Then, antigen retrieval was performed again with EDTA solution (pH = 9.0) at 95°C for 20 min. Human sections were blocked by 10% horse serum with 0.3 M glycine at room temperature for 1 h and then stained with primary antibodies targeting SYP  at 4°C overnight. Secondary anti-rabbit antibody (Jackson ImmunoResearch Laboratories) was diluted at 1:2,000, and the sections were incubated at room temperature for 1 h. HRP was permanently fluorescence-labeled in secondary antibody by TYR-488 (RecordBio) at room temperature for 10 min. DAPI , diluted 1:1,000 in PBS, was used for nuclear staining.KLK3, KLK2, STEAP4, TMPRSS2, FKBP5, ALDH1A3, NKX3-1, PPAP2A, PMEPA1, and PART1) and 10 NE signature genes  as input. The ssGSEA method integrated the difference of empirical cumulative distribution functions between the genes inside and outside the gene set, resulting in a signature score that reflects the absolute enrichment degree of the given gene set in each sample (Bulk RNA sequencing data of prostate cancer were collected from online datasets The Cancer Genome Atlas (TCGA) , SMMU 2, DKFZ 2, GSE7793h sample .EPCAM, CDH1, KRT5, KRT8, KRT 14, and KRT18. Uniform Manifold Approximation and Projection was used to visualize each epithelial cell cluster. Differentially expressed genes between two cell groups were determined by using FindMarkers function in Seurat package. For pathway enrichment assessment, only differentially expressed genes with fold-change >1.2 and P <0.01 were input into GSEA function in clusterProfiler package v3.18.1.The single-cell transcriptome cohort consists of six CRPC patient samples from our center which has been published previously (GSE137829) . The seqTo investigate the AR status in prostate cancer with neuroendocrine differentiation, we first analyzed the bulk RNA sequencing datasets consisting of hormone-naïve prostate cancer cohorts  and 10 NE signature genes , respectively, as described previously  and prostate cancer with neuroendocrine features (CRPC-NE). When focusing on CRPC-NE, we observed that the ARHIGH cases: in the SU2C/PCF dataset, a high level amplification of AR copy number was detected in 53.6% of the ARHIGH/NEHIGH cases but none in the ARLOW/NEHIGH cases ; in the Beltran 2016 dataset, the AR signature positively correlated with the AR CNV  in these two CRPC datasets  showed at least one of the NE markers  being positive in at least 5% of epithelial cells. n = 153) and negative (AR-) in 19% cases (n = 36). Moreover, the NE positive cases showed a slightly higher incidence of AR- than NE-negative cases . Though 39.2% (n = 74) cases had received hormone treatment, none of these cases met the diagnostic criteria of CRPC according to the EAU-EANM-ESTRO-ESUR-SIOG guidelines on prostate cancer at the time of tissue acquisition . Within the 189 cases, AR- cases were positively correlated with higher T stage , lymph node metastasis rate , and distant metastasis rate  than AR+ cases. Gleason Score is another widely used index to evaluate the malignancy of prostate cancer, but it could not be assigned if areas of tumor lack glandular differentiation due to neuroendocrine transdifferentiation or treatment-induced reaction. AR- cases showed a higher rate of patients with non-applicable Gleason Score than AR+ cases  because of the higher proportion of small or large cell carcinoma . On the other hand, within all of the rest of the cases with applicable Gleason Score, AR- cases showed a higher rate of patients with Gleason Score 9 to 10 than AR+ cases , indicating the much poorer differentiation in tumors from AR- cases. AR+ cases showed a higher median serum PSA level than the AR- cases , indicating the retained function of AR signaling.We focused on these 189 prostate cancer cases with neuroendocrine differentiation and summarized the baseline and clinicopathological characteristics in uisition . The proWe next grouped these 189 cases by hormone treatment status and further analyzed the clinical characteristics within each subgroup. The results were similar in both hormone-naïve and hormone-treated settings: AR- cases were associated with higher TNM stages and poorer Gleason Score in comparison to AR+ cases  and divided them into the ARHIGH/NEHIGH and ARLOW/NEHIGH groups according to the expression level of AR. Within the cells from NEHIGH clusters, the median expression level of AR was first determined, and cells with AR expression higher than the median level were attributed to the ARHIGH/NEHIGH group, while the rest were attributed to the ARLOW/NEHIGH group. We identified differentially expressed genes between these two groups and performed a pathway enrichment assessment. The results showed top-enriched Hallmark and Gene Ontology Biological Process pathways  in the ARHIGH/NEHIGH or ARLOW/NEHIGH group  . We extrHIGH/NEHIGH cases rises in castration-resistant prostate cancer cohorts than in hormone-naïve prostate cancer cohorts. Consistently, other groups also reported the co-expression of AR and NE genes in castration-resistant prostate cancer by using both molecular profiling and histological assessments  with any one of the NE markers  being positive in at least 5% of epithelial cells. Moreover, 81.0% (n = 153) of 189 cases showed AR+. By using serial pathological sections, we observed positive-stained AR and representative NE markers in the same area of tissue , Science and Technology Commission of Shanghai Municipality (19XD1402300), Shanghai Municipal Health Commission , Shanghai Shenkang Hospital Development Center , the Program for Professor of Special Appointment (Eastern Scholar) at Shanghai Institutions of Higher Learning (TP2017029); Shanghai Municipal Education Commission-Gaofeng Clinical Medicine Grant Support .We are grateful to the patients and their families who contributed to this research. We thank Lucky Wong for discussion of this study.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Together with prevention and promotion, cure and palliation, rehabilitation is one of the five health strategies recognized by the World Health Organization (WHO) , 2. HoweThe need for rehabilitation arises when a person experiences a limitation in functioning , 5 assocAs was first proposed by the Physical and Rehabilitation Medicine Section of the Union of Medical Specialists in Europe in 2007  and reviThe notion of functioning, which plays a fundamental role in rehabilitation, comes from WHO's International Classification of Functioning, Disability and Health (ICF) , a grounThe ICF is “inextricably entwined with the emergence of rehabilitation as the key health strategy of the 21st century” . The strThe introduction of our current understanding of rehabilitation, with functioning as its fundamental concept, allows us to identify a range of grand challenges to the advancement of rehabilitation sciences. These challenges have informed the architecture of the specialty sections of this journal.Recognizing the fundamental role functioning has in rehabilitation, this journal contains a specialty section dedicated to the topic of human functioning. With this section, the journal aims to contribute to the development of the human functioning sciences. Similar to the interdisciplinary field of neurosciences that has been driving discovery and innovation, the human functioning sciences are an emerging scientific field that integrates a wide range of disciplinary perspectives and methodological approaches , 20.Rehabilitation 2030, we include a specialty section devoted to the challenge of strengthening rehabilitation (Following on WHO's call for action in litation , in linelitation . To encolitation , 29.The successful implementation of rehabilitation depends on the collaboration across sectors, including health, education, labor, and social welfare. At the level of the individual person, cross-sectorial rehabilitation supports persons in achieving optimal performance in interaction with their immediate environment. Beyond what cross-sectorial rehabilitation services can offer, optimal performance depends on an explicit effort by societies to provide persons with limitations in functioning with fair opportunities  and an aGoals and targets of interventions in rehabilitation can be comprehensively represented by the conceptual framework of the ICF and its categories , 32. TheThe scientific foundation for rehabilitation interventions is based on an in-depth understanding of how they work. At the level of intrinsic health capacity and personal psychological factors, translational research aims to translate our understanding of biological mechanisms, and this knowledge can inform the development of clinical interventions. The motivation to develop new interventions based on novel insights can come from basic science, from clinicians, or both working in concert. At the level of a person's performance in interaction with the physical and social environment, translational research aims to translate our understanding of barriers and facilitators into interventions useful for professionals in the health, educational, labor, and social sectors. Accordingly, the aim of this specialty section is to provide space for the publication of translational research that involves the development of novel interventions based on new insights into intervention mechanisms, or research that advances our understanding of interventions used in rehabilitation practice.The specialty sections focusing on specific health conditions pursue two aims. First, the explicitly broadly-named specialty section on “Medical and Surgical Conditions” provides a unique space for the publication of research across a wide range of medical and surgical health conditions that may benefit from rehabilitation . Second,The mission of this journal is to tackle the grand challenges facing us in the advancement of the rehabilitation sciences. Each specialty section addresses the key research areas that affect not only how rehabilitation interventions are provided to specific populations, but also the structure of the health system in which these interventions take place. The journal recognizes the salience of fundamental concepts that have shaped, and will continue to shape, the development of rehabilitation into the future. Prominent among these is the notion of human functioning, the ICF concept that captures the aim and objective of rehabilitation, the social importance of rehabilitation intersectorially, and the need to be able to translate innovations into practice in a manner that addresses the lived experience of health. The comprehensive concept of functioning serves as a starting point for the full range of scientific approaches and theories and taking different perspectives, including clinical, biomedical, psychological-behavioral, or socio-humanistic.Across the specialty sections, the journal encourages the publication of methodological developments. This includes studies that address the challenges of applying various research designs and quantitative as well as qualitative methods for rehabilitation research. Of special interest are the opportunities arising from the use of quasi-experimental study designs . In the In conclusion, to address the grand challenges in rehabilitation sciences, the journal aims to continuously and dynamically develop its specialty sections to reflect emerging scientific advances and author contributions.GS conceptualized and wrote the manuscript with support from Professor Jerome Bickenbach, Melissa Selb, and Susanne Stucki.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.