Comparative analysis of the syncytiotrophoblast in placenta tissue and trophoblast organoids using snRNA sequencing.

The outer surface of chorionic villi in the human placenta consists of a single multinucleated cell called the syncytiotrophoblast (STB). The unique cellular ultrastructure of the STB presents challenges in deciphering its gene expression signature at the single-cell level, as the STB contains billions of nuclei in a single cell. There are many gaps in understanding the molecular mechanisms and developmental trajectories involved in STB formation and differentiation. To identify the underlying control of the STB, we performed comparative single nucleus (SN) and single cell (SC) RNA sequencing on placental tissue and tissue-derived trophoblast organoids (TOs). We found that SN was essential to capture the STB population from both tissue and TOs. Differential gene expression and pseudotime analysis of TO-derived STB identified three distinct nuclear subtypes reminiscent of those recently identified in vivo . These included a juvenile nuclear population that exhibited both CTB and STB marker expression, a population enriched in genes involved in oxygen sensing, and a fully differentiated subtype. Notably, suspension culture conditions of TOs that restore the native orientation of the STB (STB out ) showed elevated expression of canonical STB markers and pregnancy hormones, along with a greater proportion of the terminally differentiated mature STB subtype, compared to those cultivated with an inverted STB polarity (STB in ). Gene regulatory analysis identified novel markers of STB differentiation conserved in tissue and TOs, including the chromatin remodeler RYBP, that exhibited STB-specific RNA and protein expression. Finally, we compared STB gene expression signatures amongst first trimester tissue, full-term tissue, and TOs, identifying many commonalities but also notable variability across each sample type. This indicates that STB gene expression is responsive to its environmental context. Our findings emphasize the utility of TOs to accurately model STB differentiation and the distinct nuclear subtypes observed in vivo , offering a versatile platform for unraveling the molecular mechanisms governing STB functions in placental biology and disease.

The trophoblast surface becomes refractory to adhesion by congenitally transmitted Toxoplasma gondii and Listeria monocytogenes during cytotrophoblast to syncytiotrophoblast development.

The placenta is a critical barrier against viral, bacterial, and eukaryotic pathogens. For most teratogenic pathogens, the precise molecular mechanisms of placental resistance are still being unraveled. Given the importance of understanding these mechanisms and challenges in replicating trophoblast-pathogen interactions using in vitro models, we tested an existing stem-cell-derived model of trophoblast development for its relevance to infection with Toxoplasma gondii. We grew human trophoblast stem cells (TSCT) under conditions leading to either syncytiotrophoblast (TSSYN) or cytotrophoblast (TSCYT) and infected them with T. gondii. We evaluated T. gondii proliferation and invasion, cell ultrastructure, as well as for transcriptome changes after infection. TSSYNs cells showed similar ultrastructure compared to primary cells and villous explants when analyzed by transmission electron microscopy and scanning electron microscopy (SEM), a resistance to T. gondii adhesion could be visualized on the SEM level. Furthermore, TSSYNs were highly refractory to parasite adhesion and replication, while TSCYTs were not. RNA-seq data on mock-treated and infected cells identified differences between cell types as well as how they responded to T. gondii infection. We also evaluated if TSSC-derived SYNs and CYTs had distinct resistance profiles to another vertically transmitted facultative intracellular pathogen, Listeria monocytogenes. We demonstrate that TSSYNs are highly resistant to L. monocytogenes, while TSCYTs are not. Like T. gondii, TSSYN resistance to L. monocytogenes was at the level of bacterial adhesion. Altogether, our data indicate that stem-cell-derived trophoblasts recapitulate resistance profiles of primary cells to T. gondii and highlight the critical importance of the placental surface in cell-autonomous resistance to teratogens.IMPORTANCECongenital toxoplasmosis can cause a devastating consequence to the fetus. To reach the fetus's tissues, Toxoplasma gondii must cross the placenta barrier. However, how this parasite crosses the placenta and the precise molecular mechanisms of placental resistance to this parasite are still unknown. In this study, we aimed to characterize a new cellular model of human trophoblast stem cells to determine their resistance, susceptibility, and response to T. gondii. Syncytiotrophoblast derived from trophoblast stem cells recapitulate the resistance profile similarly to placenta cells. We also showed that these cells are highly resistant to Listeria monocytogenes, at the level of bacterial adhesion. Our results suggest that resisting pathogen adhesion/attachment may be a generalized mechanism of syncytiotrophoblast resistance, and trophoblast stem cells represent a promising model to investigate cell-intrinsic mechanisms of resistance to pathogen adhesion and replication.

Human trophoblast stem cells can be used to model placental susceptibility to Toxoplasma gondii and highlight the critical importance of the trophoblast cell surface in pathogen resistance.

The placenta is a critical barrier against viral, bacterial, and eukaryotic pathogens. For most teratogenic pathogens, the precise molecular mechanisms of placental resistance are still being unraveled. Given the importance to understand these mechanisms and challenges in replicating trophoblast- pathogen interactions using in vitro models, we tested an existing stem-cell derived model of trophoblast development for its relevance to infection with Toxoplasma gondii . We grew human trophoblast stem cells (TS CT ) under conditions leading to either syncytiotrophoblast (TS SYN ) or cytotrophoblast (TS CYT ) and infected them with T. gondii . We evaluated T. gondii proliferation and invasion, cell ultrastructure, as well as for transcriptome changes after infection. TS SYNs cells showed similar ultrastructure compared to primary cells and villous explants when analyzed by TEM and SEM, a resistance to T. gondii adhesion could be visualized on the SEM level. Furthermore, TS SYNs were highly refractory to parasite adhesion and replication, while TS CYT were not. RNA-seq data on mock-treated and infected cells identified differences between cell types as well as how they responded to T. gondii infection. We also evaluated if TS SC -derived SYNs and CYTs had distinct resistance profiles to another vertically transmitted facultative intracellular pathogen, Listeria monocytogenes . We demonstrate that TS SYNs are highly resistant to L. monocytogenes , while TS CYTs are not. Like T. gondii , TS SYN resistance to L. monocytogenes was at the level of bacterial adhesion. Altogether, our data indicate that stem-cell derived trophoblasts recapitulate resistance profiles of primary cells to T. gondii and highlight the critical importance of the placental surface in cell-autonomous resistance to teratogens.

Andrographolide Attenuates Inflammation Due to Intra-Abdominal Sepsis by Enhancing Bacterial Clearance in Mice.

Purpose: Intra-abdominal infection is a complex pathophysiological process involving multiple systems and organs of the body. Abdominal infections complicated by severe sepsis or septic shock have a high mortality rate of 30-50%. Therefore, novel strategies to treat sepsis are urgently needed. Methods: Andrographolide (AD), the main active ingredient of Andrographis paniculata, reportedly exerts beneficial effects on mice with sepsis. However, its exact mechanism of action in attenuating inflammation due to intra-abdominal sepsis remains unclear to date. Hence, this study aimed to examine the therapeutic effects of AD on cecal ligation and puncture (CLP)-induced sepsis and elucidate the underlying mechanisms. Results: Results showed that AD therapy could significantly improve the 7-day survival rate and alleviate pathological organ injury in mice with CLP. In addition, AD treatment decreased the levels of proinflammatory factors, such as tumor necrosis factor-α and interleukin (IL)-6 in the peritoneal cavity fluid and blood and increased the level of anti-inflammatory factor IL-10 in the peritoneal cavity fluid of mice with CLP. Moreover, bacterial counts in the blood and peritoneal lavage fluid were lower in the mice treated with AD than in those untreated. Mechanistically, AD treatment increased the percentage and phagocytic activity of macrophages in the peritoneal cavity. Conclusion: These data showed that AD can improve the survival of mice with intra-abdominal sepsis by enhancing bacterial clearance, as evidenced by the increased percentages and phagocytic activity of macrophages in the peritoneal cavity. This study is the first to demonstrate the protective effects of AD against intra-abdominal sepsis.

(Tn5-)FISH-based imaging in the era of 3D/spatial genomics.

3D genomics mainly focuses on the 3D position of single genes at the cell level, while spatial genomics focuses more on the tissue level. In this exciting new era of 3D/spatial genomics, half-century old FISH and its derivative methods, including Tn5-FISH, play important roles. In this review, we introduce the Tn5-FISH we developed recently, and present six different applications published by our collaborators and us, based on (Tn5-)FISH, which can be either general BAC clone-based FISH or Tn5-FISH. In these interesting cases, (Tn5-)FISH demonstrated its vigorous ability of targeting sub-chromosomal structures across different diseases and cell lines (leukemia, mESCs (mouse embryonic stem cells), and differentiation cell lines). Serving as an effective tool to image genomic structures at the kilobase level, Tn5-FISH holds great potential to detect chromosomal structures in a high-throughput manner, thus bringing the dawn for new discoveries in the great era of 3D/spatial genomics.

Trophoblast organoids with physiological polarity model placental structure and function.

Human trophoblast organoids (TOs) are a three-dimensional ex vivo culture model that can be used to study various aspects of placental development, physiology, and pathology. Previously, we showed that TOs derived from full-term human placental tissue could be used as models of trophoblast innate immune signaling and teratogenic virus infections. Here, we developed a method to culture TOs under conditions that recapitulate the cellular orientation of chorionic villi in vivo , with the multi-nucleated syncytiotrophoblast (STB) localized to the outer surface of organoids and the proliferative cytotrophoblasts (CTBs) located on the inner surface. We show that standard TOs containing the STB layer inside the organoid (STB in ) develop into organoids containing the STB on the outer surface (STB out ) when cultured in suspension with gentle agitation. STB out organoids secrete higher levels of select STB-associated hormones and cytokines, including human chorionic gonadotropin (hCG) and interferon (IFN)-λ2. Using membrane capacitance measurements, we also show that the outermost surface of STB out organoids contain large syncytia comprised of >50 nuclei compared to STB in organoids that contain small syncytia (<10 nuclei) and mononuclear cells. The growth of TOs under conditions that mimic the cellular orientation of chorionic villi in vivo thus allows for the study of a variety of aspects of placental biology under physiological conditions.

Applications of functional nanoparticle-stabilized surfactant foam in petroleum-contaminated soil remediation.

Surfactant foam (SF) can be used to remediate petroleum-contaminated soil because of its easy transfer to inhomogeneous and low-permeability formations. Nanoparticles (NPs) not only stabilize SF under extreme conditions but also impart various functions, aiding the removal of petroleum contaminants. This review discusses the stabilization mechanisms of nanoparticle-stabilized SF (NP-SF) as well as the effects of NP size, chargeability, wettability, and NP-to-surfactant ratio on foam stability. SF stabilized by inert SiO2 NPs is most commonly used to remediate soil contaminated with crude oil and diesel. Low dose of SF stabilized by nano zero-valent iron is cost-effective for treating soil contaminated with chlorinated organics and heavy metal ions. The efficiency and recyclability of Al2O3/Fe3O4 NPs in the remediation of diesel and crude oil contamination could be enhanced by applying a magnetic field. This review provides a theoretical basis and practical guidelines for developing functional NP-SF to improve the remediation of petroleum-contaminated soils. Future research should focus on the structural design of photocatalytic NPs and the application of catalytic NP-SF in soil remediation.

Ti-Mn hydrogen storage alloys: from properties to applications.

Efficient and safe storage of hydrogen is an important link in the process of hydrogen energy utilization. Hydrogen storage with hydrogen storage materials as the medium has the characteristics of high volumetric hydrogen storage density and good safety. Among many hydrogen storage materials, only rare earth-based and titanium-based hydrogen storage alloys have been applied thus far. In this work, current state-of-the-art research and applications of Ti-Mn hydrogen storage alloys are reviewed. Firstly, the hydrogen storage properties and regulation methods of binary to multicomponent Ti-Mn alloys are introduced. Then, the applications of Ti-Mn alloys in hydrogen storage, hydrogen compression and catalysis are discussed. Finally, the future research and development of Ti-Mn hydrogen storage alloys is proposed.

A non-fluorinated superhydrophobic composite coating with excellent anticorrosion and wear-resistant performance.

The facile and low-cost fabrication of fluorine-free superhydrophobic metal surfaces for anticorrosion remains a challenging issue. Here, we report a superhydrophobic coating based on polyacrylate/SiO2 nanoparticles/graphene oxide sheets through a simple yet environmentally friendly method. The as-prepared composite coating sprayed on metal surfaces exhibits excellent superhydrophobic and corrosion-resistant properties. Furthermore, the coating surface possesses good anti-wear performance and remains superhydrophobic after harsh abrasion tests. Prospectively, the developed non-fluorinated superhydrophobic coating opens up opportunities for the application in industrial anticorrosion field.

Innate immune signaling in trophoblast and decidua organoids defines differential antiviral defenses at the maternal-fetal interface.

Infections at the maternal-fetal interface can directly harm the fetus and induce complications that adversely impact pregnancy outcomes. Innate immune signaling by both fetal-derived placental trophoblasts and the maternal decidua must provide antimicrobial defenses at this critical interface without compromising its integrity. Here, we developed matched trophoblast (TO) and decidua organoids (DO) from human placentas to define the relative contributions of these cells to antiviral defenses at the maternal-fetal interface. We demonstrate that TO and DO basally secrete distinct immunomodulatory factors, including the constitutive release of the antiviral type III interferon IFN-λ2 from TOs, and differentially respond to viral infections through the induction of organoid-specific factors. Finally, we define the differential susceptibility and innate immune signaling of TO and DO to human cytomegalovirus (HCMV) and develop a co-culture model of TO and DO which showed that trophoblast-derived factors protect decidual cells from HCMV infection. Our findings establish matched TO and DO as ex vivo models to study vertically transmitted infections and highlight differences in innate immune signaling by fetal-derived trophoblasts and the maternal decidua.

Combination of biochar and AMF promotes phosphorus utilization by stimulating rhizosphere microbial co-occurrence networks and lipid metabolites of Phragmites.

Agricultural biochar and arbuscular mycorrhizal fungi were used to promote the growth of Phragmites in the structural damaged and nutritional imbalanced littoral zone soils. Wheat straw biochar played a significant role in improving soil porosity and supplementing available phosphorus to 79.20 ± 3.20 mg/kg, compared with CK at 17.50 ± 0.88 mg/kg. The addition of Diversispora versiformis improved the plant net photosynthetic rate reaching up to 25.66 ± 0.65 µmol·m-2·s-1, which was 36.60 % higher than CK. The combination of biochar and fungi contributed to the whole plant dry weight biomass of 32.30 % and 234.00 % higher than the single biochar or AMF amendment groups, respectively. Meanwhile, the analysis of microbial co-occurrence networks showed the most relevant networks node species were mainly Talaromyces, Chaetomiacea and Gemmatimonadetes etc. Root lipid metabolite of Glycerophospholines further proved that phosphorus utilization was also enhanced endogenously in the rhizosphere soil. These results indicate that the combination of biochar and arbuscular mycorrhizal fungi play synergic role in enhancing phosphorus utilization endogenously and exogenously.

Circadian rhythm and clinical characteristics in patients with acute myocardial infarction combined with obstructive sleep apnea.

OBJECTIVE: The present study aimed to investigate the circadian rhythm and clinical characteristics of patients with acute myocardial infarction (AMI) combined with obstructive sleep apnea (OSA). METHODS: Patients with AMI combined with OSA were enrolled in the study, and those that met the inclusion criteria were divided into three time-period groups based on their sleep-wake rhythm (22:00-5:59, 6:00-13:59, and 14:00-21:59). The differences between the three groups of patients in sleep-monitoring data, blood routine, biochemical indicators, and coronary angiographic parameters were analyzed and compared. Count data were expressed as the number of cases, and the chi-square test was used for statistical analysis. Continuous data were expressed as mean ± standard deviation, and analysis of variance was used for the statistical analysis of these data. The characteristics of circadian rhythm and clinical features in patients with AMI combined with OSA were analyzed. RESULTS: Of the 148 patients, 90/148 (61%) had chest pain and 58/148 (39%) had non-chest pain symptoms. In the 22:00-05:59 group, there were 70/148 (47%) patients with AMI (of these, 46/70 [66%] had chest pain). In the 06:00-13:59 period group, there were 44/148 (30%) patients with AMI (of these, 26/44 [60%] had chest pain). In the 14:00-21:59 period group, there were 34/148 (23%) patients with AMI (of these, 17/34 [50%] had chest pain). There was no statistically significant difference in the apnea-hypopnea index (AHI) and SYNTAX score between patients in the 22:00-5:59 and 6:00-13:59 groups. However, the AHI and SYNTAX scores in the 22:00-5:59 and 6:00-13:59 groups were higher than those in the 14:00-21:59 group, and the differences were statistically significant. In patients in the 22:00-5:59 group, the levels of serum D-dimer (DD), hemoglobin (Hb), and oxygen desaturation index (ODI3) were higher, the sleep mean oxygen saturation (MeanSaO2 ) was lower and the percentage of nighttime spent with oxygen saturation of less than 90% (Tsat90 ) and less than 85% (Tsat85 ) was longer. CONCLUSION: The peak period for the onset of AMI in patients with OSA was 22:00-5:59, and the incidence of chest pain was high. During this period, patients had higher DD and Hb, higher ODI3, lower MeanSaO2 during sleep, and longer TSat90 and TSat85 . During the 22:00-5:59 and 6:00-13:59 periods, patients had higher AHI and a higher SYNTAX score.

Functional coupling between TRPV4 channel and TMEM16F modulates human trophoblast fusion.

TMEM16F, a Ca2+-activated phospholipid scramblase (CaPLSase), is critical for placental trophoblast syncytialization, HIV infection, and SARS-CoV2-mediated syncytialization, however, how TMEM16F is activated during cell fusion is unclear. Here, using trophoblasts as a model for cell fusion, we demonstrate that Ca2+ influx through the Ca2+ permeable transient receptor potential vanilloid channel TRPV4 is critical for TMEM16F activation and plays a role in subsequent human trophoblast fusion. GSK1016790A, a TRPV4 specific agonist, robustly activates TMEM16F in trophoblasts. We also show that TRPV4 and TMEM16F are functionally coupled within Ca2+ microdomains in a human trophoblast cell line using patch-clamp electrophysiology. Pharmacological inhibition or gene silencing of TRPV4 hinders TMEM16F activation and subsequent trophoblast syncytialization. Our study uncovers the functional expression of TRPV4 and one of the physiological activation mechanisms of TMEM16F in human trophoblasts, thus providing us with novel strategies to regulate CaPLSase activity as a critical checkpoint of physiologically and disease-relevant cell fusion events.

Coupling surfactants with ISCO for remediating of NAPLs: Recent progress and application challenges.

Non-aqueous phase liquids (NAPLs) pose a serious risk to the soil-groundwater environment. Coupling surfactants with in situ chemical oxidation (ISCO) technology is a promising strategy, which is attributed to the enhanced desorption and solubilization efficiency of NAPL contaminants. However, the complex interactions among surfactants, oxidation systems, and NAPL contaminants have not been fully revealed. This review provides a comprehensive overview on the development of surfactant-coupled ISCO technology focusing on the effects of surfactants on oxidation systems and NAPLs degradation behavior. Specifically, we discussed the compatibility between surfactants and oxidation systems, including the non-productive consumption of oxidants by surfactants, the role of surfactants in catalytic oxidation systems, and the loss of surfactants solubilization capacity during oxidation process. The effect of surfactants on the degradation behavior of NAPL contaminants is then thoroughly summarized in terms of degradation kinetics, byproducts and degradation mechanisms. This review demonstrates that it is crucial to minimize the negative effects of surfactants on NAPL contaminants oxidation process by fully understanding the interaction between surfactants and oxidation systems, which would promote the successful implementation of surfactant-coupled ISCO technology in remediation of NAPLs-contaminated sites.

Fast plasmoid-mediated reconnection in a solar flare.

Magnetic reconnection is a multi-faceted process of energy conversion in astrophysical, space and laboratory plasmas that operates at microscopic scales but has macroscopic drivers and consequences. Solar flares present a key laboratory for its study, leaving imprints of the microscopic physics in radiation spectra and allowing the macroscopic evolution to be imaged, yet a full observational characterization remains elusive. Here we combine high resolution imaging and spectral observations of a confined solar flare at multiple wavelengths with data-constrained magnetohydrodynamic modeling to study the dynamics of the flare plasma from the current sheet to the plasmoid scale. The analysis suggests that the flare resulted from the interaction of a twisted magnetic flux rope surrounding a filament with nearby magnetic loops whose feet are anchored in chromospheric fibrils. Bright cusp-shaped structures represent the region around a reconnecting separator or quasi-separator (hyperbolic flux tube). The fast reconnection, which is relevant for other astrophysical environments, revealed plasmoids in the current sheet and separatrices and associated unresolved turbulent motions.

The combined effect of Diversispora versiformis and sodium bentonite contributes on the colonization of Phragmites in cadmium-contaminated soil.

To promote the colonization of Phragmites in Cd polluted, nutrient deprived and structural damaged soil, the combined remediation using chemical and microbial modifiers were carried out in potting experiments. The co-application of Diversispora versiformis and sodium bentonite significantly improved the soil structure and phosphorus utilization of the plant, while decreasing the content of cadmium bound by diethylenetriaminepentaacetic acid by 77.72%. As a result, the Phragmites height, tillers, and photosynthetic capacity were increased by 71.60%, 38.37%, and 17.54%, respectively. Further analysis suggested the co-application increased the abundance of phosphorus-releasing microbial communities like Pseudomonassp. and Gemmatimonadetes. Results of rhizosphere metabolites also proved that the signal molecule of lysophosphatidylcholine regulated the phosphorus fixation and utilization by the plant. This work finds composite modifiers are effective in the colonization of Phragmites in Cd contaminated soil by decreasing the bioavailable Cd, increasing the abundance of functional microbial communities and regulating the phosphorus fixation.

Respiratory and intestinal epithelial cells exhibit differential susceptibility and innate immune responses to contemporary EV-D68 isolates.

Enterovirus D68 (EV-D68) has been implicated in outbreaks of severe respiratory illness and is associated with acute flaccid myelitis (AFM). EV-D68 is often detected in patient respiratory samples but has also been detected in stool and wastewater, suggesting the potential for both respiratory and enteric routes of transmission. Here, we used a panel of EV-D68 isolates, including a historical pre-2014 isolate and multiple contemporary isolates from AFM outbreak years, to define the dynamics of viral replication and the host response to infection in primary human airway cells and stem cell-derived enteroids. We show that some recent EV-D68 isolates have decreased sensitivity to acid and temperature compared with earlier isolates and that the respiratory, but not intestinal, epithelium induces a robust type III interferon response that restricts infection. Our findings define the differential responses of the respiratory and intestinal epithelium to contemporary EV-D68 isolates and suggest that a subset of isolates have the potential to target both the human airway and gastrointestinal tracts.

A color turn-on fluorescent probe for real-time detection of hydrogen sulfide and identification of food spoilage.

A color and fluorescence turn-on H2S probe is synthesized, achieving real-time detection of H2S in pure water solution with high selectivity. Importantly, the probe is able to sense H2S gas in air via the probe-deposited test paper, which has been successfully used for food spoilage identification.

Three-Dimensional CuO/TiO2 Hybrid Nanorod Arrays Prepared by Electrodeposition in AAO Membranes as an Excellent Fenton-Like Photocatalyst for Dye Degradation.

Three-dimensional (3D) CuO/TiO2 hybrid heterostructure nanorod arrays (NRs) with noble-metal-free composition, fabricated by template-assisted low-cost processes, were used as the photo-Fenton-like catalyst for dye degradation. Here, CuO NRs were deposited into anodic aluminum oxide templates by electrodeposition method annealed at various temperatures, followed by deposition of TiO2 thin films through E-gun evaporation, resulting in the formation of CuO/TiO2 p-n heterojunction. The distribution of elements and compositions of the CuO/TiO2 p-n heterojunction were analyzed by EDS mapping and EELS profiles, respectively. In the presence of H2O2, CuO/TiO2 hybrid structure performed more efficiently than CuO NRs for Rhodamine B degradation under the irradiation of 500-W mercury-xenon arc lamp. This study demonstrated the effect of length of CuO NRs, on the photo-degradation performance of CuO NRs as well as CuO/TiO2 heterostructure. The optimized CuO/TiO2 hybrid NR array structure exhibited the highest photo-degradation activity, and the mechanism and role of photo-Fenton acting as the catalyst in photo-degradation of dye was also investigated.

Efficacy and tolerability of deep transcranial magnetic stimulation for treatment-resistant depression: A systematic review and meta-analysis.

OBJECTIVES: This study aimed to investigate the efficacy of deep transcranial magnetic stimulation (dTMS) for treatment-resistant depression (TRD). METHODS: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Medline, PsycINFO, Embase, and Cochrane Library were systematically searched from the time of their inception until July 17, 2019. Data were pooled using a random-effects model. Primary outcomes were mean change of depression and anxiety severity. Secondary outcomes were response and remission rate of depression. RESULTS: Fifteen studies including three randomized controlled trials (RCTs) (n = 417, mean age: 50.6 years) and twelve uncontrolled clinical trials (n = 284, mean age: 46.4 years) were included. dTMS significantly improved the depressive (Hedges' g = -1.323, 95% CI = -1.651 to -0.995, p < .001) and anxiety symptoms (Hedges' g = -1.282, 95% CI = -1.514 to -1.051, p < .001) in patients with TRD. Subgroup analysis showed that non-RCTs had a larger effect size than RCTs (-1.461 vs -0.756) on depression severity. Although the response and remission rates of the dTMS group were high, only studies using both dTMS and antidepressant medications achieved significance. The anxiolytic effect of dTMS was more heterogeneous, and the results were obtained mainly from non-RCTs. Importantly, the dTMS group showed favorable tolerability without major adverse events. CONCLUSIONS: dTMS is a safe and effective intervention in patients with TRD. Studies combining dTMS and antidepressant medications seemed to show greater therapeutic effects. Future studies are needed to address the interaction effect of dTMS with different classes of antidepressant medications.