Ameloblastoma is a benign, locally aggressive odontogenic tumor with high recurrence rates. Matrix metalloproteinases (MMPs) mediate extracellular integrity in normal and pathological conditions, and exert multiple functions coordinating inflammation and tumor progression. E‐cadherin and beta‐catenin are adherence junction molecules in cell‐to‐cell connections. We investigated the involvement of MMP‐7, ‐8, ‐9, E‐cadherin, and beta‐catenin in ameloblastoma and the surrounding extracellular matrix.Our material consisted of 30–34 tissue samples from ameloblastoma patients of Helsinki University Hospital. We used immunohistochemistry to detect the expression of the biomarkers. Two oral pathologists independently scored the immunoexpression intensities and statistical calculations were made based on the results.E‐cadherin expression was weaker in the maxillary than in mandibular ameloblastomas. Beta‐catenin was expressed in the ameloblastoma cell membranes. We detected MMP‐8 and ‐9 expression in polymorphonuclear neutrophils in the extracellular area and these MMPs correlated positively with each other. Osteoclasts lining bone margins and multinuclear giant cells expressed MMP‐9. Neither MMP‐8 nor MMP‐9 immunoexpression could be detected in ameloblastoma cells. MMP‐7 expression was seen in some apoptotic cells.The fact that E‐cadherin immunoexpression was weaker in maxillary compared to mandibular ameloblastomas might associate to earlier recurrences. It promotes the idea of mandibular and maxillary ameloblastoma exerting differences in their biologies. We detected MMP‐8 and ‐9 in polymorphonuclear neutrophils which relates to these MMPs participating in extracellular remodeling through a mild inflammatory process. Bone degradation around ameloblastoma may be due to MMP‐9 in osteoclasts but this phenomenon might be an independent process and needs further investigations. They are benign but locally aggressive odontogenic epithelial tumors located to the dentoalveolar region presenting as an intraosseous or peripheral lesion. Patients are typically 30–40 years old, though tumors occur in all age groups  are a heterogeneous group of zinc‐dependent, genetically distinct but structurally related proteinases responsible for the degradation and synthesis control of the extracellular matrix (ECM) and the basement membrane (BM). MMP's also participate by processing nonmatrix bioactive substrates involved in the membrane shedding, chemokine, or growth factor modification, and in regulating the activity of other proteases. They play an important role as the effective regulators of cell proliferation and differentiation, tissue homeostasis, and immune response . E‐cadherin is a Ca‐dependent transmembrane protein which is linked intracellularly to p120‐, In this study, we explored the expression of MMP‐7, ‐8, ‐9, beta‐catenin, E‐cadherin in the ECM and ameloblastoma tumor cells and evaluated the role of those markers combined with clinical factors in predicting recurrence of ameloblastoma.22.1Our series consisted of 34 ameloblastoma patients treated at the Helsinki University Hospital, Department of Oral and Maxillofacial Diseases (HUCH). The Department of Pathology (HUSLAB) archives provided us with the formalin‐fixed paraffin‐embedded tissue samples. We have described the patient material in more detail in our previous study  specific for each antibody functioned as a heat induced epitope retrieval. For staining, we used Autostainer 480  with Dako REAL EnVision Detection System, Peroxidase, Rabbit/Mouse . The primary incubation of each antibody was for 1 hr in +4°C and a secondary HRP‐coupled antibody for half an hour. To visualize results we used either a DAB (brown) or magenta (pink) chromogen. A hematoxylin incubation for 2 minutes counterstained the nuclei. A graded alcohol series dehydrated the tissue. The samples were finally mounted. Primary antibodies were: anti‐MMP‐7 , anti‐MMP‐8 (1:400), anti‐ MMP‐9 , antibeta‐catenin , and ant‐E‐cadherin (1:100 Thermo Fisher Scientific MA). Colon and oral squamous cell cancer tissues functioned as positive controls. For the negative control, we did not add the primary antibody.2.3Two oral pathologists (J.K. and J.H.) scored independently the staining expressions without the knowledge of clinical data. All samples were preliminarily screened to get an overview of intensity differences in expression. We used a semiquantitative scoring system with the following guidelines: 0 when no expression was present, 1 when we saw weak reaction or only focal intense reaction, 2 when moderate diffuse reaction was seen, and 3 when intense diffuse reaction was seen. In case of disagreement, we agreed upon a consensus. MMP‐8 and MMP‐9 were scored as 0 = negative, 1 = mild positivity, 2 = strong positivity. We scored MMP7 expression negative or positive since positive cells were scarce. All tumors had a similar beta‐catenin staining pattern and were scored either 1 = mild positivity, 2 = moderately positive, or 3 = strongly positive. We scored E‐cadherin likewise as either mild or strong. Positivity less than 10% was considered as weak expression. Figure 2.4p‐value equal or less than .05 significant.We sought correlations between MMP‐7, ‐8, ‐9, beta‐catenin, E‐cadherin, age, gender, location, and recurrence. We calculated odds ratios for MMP‐8 and ‐9, MMP‐8/ ‐9/beta‐catenin/and gender, recurrence, and location, MMP‐8/beta‐catenin and age. Scoring results 0 or 1 were relabeled as mild (0) and 2 or 3, were relabeled as strong (1). We used logistic regression, chi‐square tests, and when relevant, 2 by 2 table functions. We conducted the analyses using R 3.4.2 and RStudio 1.1.383 and considered a 3The cohort consisted of 34 patients of which 19 were men and 15 women. The age distribution among men was 13–87 and among women 18–71. Of 34 cases, 24 were mandibular and 10 were maxillary tumors or from the sinonasal area. The tumor size varied from 7 to 110 mm. Table 3.1MMP‐7 was expressed only in apoptotic or mitotic cells in the basal layer of ameloblastoma tumor tissue which otherwise was negative. There was also a mild membranous staining. ECM was negative Figure .3.2p = .026 chi 2x‐test, but when adjusted for gender and age the correlation was lost (p = .112).Polymorphonuclear neutrophils and plasma cells showed MMP‐8 immunopositivity but ameloblastoma cells were negative Figure . MMP‐8 p3.3p = .015), but the confidence interval (CI) was wide indicating a small number of cases .MMP‐9 positivity was detected in inflammatory cells, multinuclear giant cells among inflammatory infiltration, and osteoclasts lining the bone. Ameloblastoma cells were negative Figure . In logi3.4p = .015), male patients having stronger expression, but the CI was once again wide .Cell membrane expression of beta‐catenin was seen in all ameloblastoma samples, without nuclear expression. Beta‐catenin expression in ameloblastomas correlated with gender . With logistic regression E‐cadherin correlated positively with the beta‐catenin expression . Unfortunately, the CI was wide. Although we did not find statistical differences, the often‐recurring maxillary tumors had weak E‐cadherin expression in 4 of 6 recurring cases, whereas in recurring mandibular tumors the proportion was 1 out of 5.Of 34 cases, we were able to score 30 samples for this study. Ameloblastomas expressed E‐cadherin in most of mandibular ameloblastomas 66.7%; 20/30) especially in stellate reticulum‐like areas and in peripheral columnal cells where the expression was weak or negative. Of maxillary tumors 60% (6/10) remained E‐cadherin negative or showed only weak expression (Figure 0/30 espe4In this study, we used immunohistochemistry to investigate the MMP‐7, ‐8, ‐9, beta‐catenin, and E‐cadherin immunoexpression in primary and recurrent ameloblastoma tissue samples from 34 patients. In contrast to most previous studies (Anne et al., MMPs are tissue destructing proteolytic enzymes taking part in the normal and pathological growth and tissue remodeling (Uitto, Overall, & McCulloch, Kumamoto et al.  found stAmeloblastoma remodels jawbone and thins the cortical plates. Osteoclasts are known to express MMP‐9, and these cells take part in bone remodeling (Andersen, del Carmen Ovejero, Kirkegaard, Lenhard, & Foged, Thiolloy et al.  showed tIn normal epithelial tissue, E‐cadherin/beta‐catenin structures provides a steady and adherent cell‐to‐cell junction and normal cell polarity. The loss of E‐cadherin is a principal event in metastatic progression and invasive behavior in gastric cancer (Wu, Zhuang, Jiang, et al., It has been shown that when ameloblastomas lose E‐cadherin expression they gain Snail, Slug, and Twist expression and this shift might allow tumors to gain EMT proprieties (Kurioka, Wato, Iseki, Tanaka, & Morita, N‐cadherin to exclude the possibility minor EMT‐like changes in maxillary tumors. Further research is also needed to solve the mechanism behind the weaker expression of E‐cadherin in maxillary ameloblastomas and its possible role in tumor recurrence.We found that 60% of the maxillary tumors and 20% of the mandibular tumors had only mild E‐cadherin immunoexpression. This might reflect the fact that maxillary tumors recur more often than mandibular ones. These findings could be further investigated by staining for Vimentin, Snail, Twist, and In our material, ameloblastoma tissue showed solely cell membranous expression of beta‐catenin without cytoplasmic or nuclear expression. This might reflect a protective role inhibiting invasion, as nuclear beta‐catenin expression is connected to the metastatic potential (Brabletz et al., This study would have benefited from a larger case cohort especially of maxillary tumors. Another limiting factor in this study is the semiquantitative scoring method which provides approximate estimates of the exact clinical situation. With a larger cohort and compute scoring program more precise results could be obtained.In conclusion, to our estimate, inflammatory cells expressing MMP‐8 and ‐9 might promote tumor growth by providing extracellular degradation or cytokine activation. In maxillary tumors, the weaker expression of E‐cadherin might also facilitate tumor growth and promote recurrence.The authors do not have conflict of interest concerning this article.


CA5A. These cases are in line with 15 cases previously described in the literature, making the phenotypic presentation pathognomonic for this ultrarare  inborn error of metabolism with a good prognosis.The combination of neonatal hyperammonemia, lactic acidosis, ketonuria, and hypoglycemia is pathognomonic for carbonic anhydrase VA (CA‐VA) deficiency. We present two cases of this rare inborn error of metabolism. Both newborns with South Asian ancestry presented with a metabolic decompensation characterized by hyperammonemia, lactic acidosis and ketonuria; one also had hypoglycemia. Standard metabolic investigations  were not indicative of a specific organic aciduria or fatty acid oxidation defect but had some overlapping features with a urea cycle disorder . Hyperammonemia was treated initially with nitrogen scavenger therapy and carglumic acid. One patient required hemodialysis. Both have had a favorable long‐term prognosis after their initial metabolic decompensation. Genetic testing confirmed the diagnosis of carbonic anhydrase VA (CA‐VA) deficiency due to biallelic pathogenic variants in  Patients with this condition have metabolic crises, which are characterized by encephalopathy, hyperammonemia, lactic acidosis, ketonuria, and hypoglycemia. The first report of CA‐VA deficiency identified four patients from two unrelated families.Carbonic anhydrases catalyze the reversible hydration of carbon dioxide and produce bicarbonate. Human carbonic anhydrase VA (CA‐VA) is a mitochondrial enzyme present in the liver, kidney, and skeletal muscle. CA‐VA supplies bicarbonate as a substrate of four mitochondrial enzymes: carbamoyl phosphate synthetase, 1,3‐methylcrotonyl‐CoA carboxylase 1, propionyl‐CoA carboxylase, and pyruvate carboxylase .The first case is a male infant who was born to nonconsanguineous parents originally from Punjab, India. The baby was delivered at term by caesarian section after a failed trial of induction of labor and presence of maternal fever. He was born with APGAR scores 92 < 18 mmHg (35‐45), HCO3− of 13.2 mmol/L (22‐28) with base excess of −5.1 (−2 to +3) indicating mixed metabolic acidosis and respiratory alkalosis. Blood lactate was 7.5 mmol/L (0.9‐2.4) and ammonia was 254 μmol/L (15‐55). He was started on intravenous fluids, antibiotics (ampicillin and gentamycin), sedated, intubated, and transferred to a tertiary care center with a suspicion of an inborn error of metabolism. Metabolic investigations, as shown in Table At day 1 of life, he was noted to be jittery and had two episodes of hypoglycemia recorded at 1.7 and 1.9 mmol/L (>2.4 mmol/L). These episodes corrected promptly with feeds. He became very irritable the following day and developed tachypnea and tachycardia. Blood gas analysis showed pH of 7.57 (7.35‐7.45), PCOAt 56 hours of age, the hyperammonemia was initially managed with intravenous nitrogen scavengers (sodium benzoate/sodium phenylacetate), L‐arginine, dextrose and lipids. After a slight initial decline, his ammonia level increased to 361 μmol/L within 4 hours and he became nonresponsive. Hemodialysis was initiated which reduced the ammonia level to 64 μmol/L. Post hemodialysis, he was given carglumic acid 100 mg OD and managed with biotin 5 mg OD until biotinidase deficiency was ruled out.CA5A: c.721G>A, p.(Glu241Lys), and c.619‐?_774+?del. The two variants were confirmed by Sanger sequencing and qPCR, respectively. Parental follow‐up testing showed the variants were in trans.A brain MRI at 4 days of life was unremarkable. The blood ammonia level remained <100 μmol/L and the baby was discharged at 9 days of life with no dietary restrictions. Subsequent ammonia levels, growth and development have remained normal. He is currently 19 months old, growing well, and meeting all developmental milestones without receiving medications. The family has been provided with a medical care plan in event of any decompensation. At 45d of age, a hyperammonemia targeted gene panel identified two likely pathogenic heterozygous variants in 31 and 95 and his birth weight was 3065 g (25th centile). The pregnancy was complicated only by gestational diabetes.The second case is a 9‐year‐old boy who was born at term to consanguineous parents (first cousins) of Sri‐Lankan descent. He was delivered at term by spontaneous vaginal delivery. He was born with APGAR scores 82 mmHg 13 (35‐45), HCO3− of 5 mmol/L (22‐28) with base excess of −21 (−2 to +3), and an anion gap of 33 (<15). He also had an elevated lactate at 6.6 mmol/L (0.9‐2.4) and ammonia at 363 μmol/L (15‐55). He was resuscitated with fluid boluses, given a bicarbonate correction, started on antibiotics and transferred to a tertiary center intensive care unit for ongoing management. His initial metabolic investigations are shown in Table ETFA, ETFB, and ETFDH genes was negative and fibroblast analysis revealed a normal palmitate oxidation acylcarnitine profile . Mitochondrial fibroblast studies showed normal results for pyruvate dehydrogenase, pyruvate carboxylase, 2‐oxoglutarate dehydrogenase, cytochrome c oxidase, succinate cytochrome c reductase, mitochondrial NADH cytochrome c reductase, oligomycin sensitive ATPase, citrate synthase, and cellular lactate/pyruvate ratio . We therefore cannot explain the multiple elevations on the acylcarnitine profile, which may represent the consequence of intravenous carnitine supplementation.After initial discharge home on day 2, he was readmitted to the neonatal unit at 72 hours of age due to poor feeding, jaundice, tachycardia, tachypnoea, and lethargy. Laboratory investigations revealed a significant metabolic acidosis pH of 7.16 (7.35‐7.45), PCOl‐carnitine, carglumic acid, l‐arginine, and dextrose. His ammonia returned to normal levels within 24 hours and he did not require hemodialysis. He was discharged on oral carnitine supplementation that was discontinued when he was 3 months old, and riboflavin 100 mg per day that was later increased to 150 mg per day and eventually discontinued at 3½ years of age. He underwent an MRI of the brain, which showed laminar subdural hematomas in the parietooccipital regions, posterior fossa, and posterior falx. There was also some nonspecific hyperintensity of the deep white matter regions in the frontal, parietal, and occipital lobes. He also had an abdominal ultrasound that showed small dysplastic and multicystic kidneys bilaterally.Hyperammonaemia was managed with Ammonul , CA5A, which showed he was homozygous for the likely pathogenic variant c.721G>A, p.(Glu241Lys). His parents were confirmed to be heterozygous carriers for the variant.Currently he is 9 years‐old and doing well clinically with no developmental concerns. He was issued with an emergency care plan to perform a blood gas, lactate, urinalysis for ketones, CK, glucose, transaminase, urea, creatinine, and electrolytes during any acute illness. However, he has not had any further decompensations. He eventually underwent targeted genetic sequencing of 4Neonatal hyperammonemia with or without lactic acidosis has a wide differential diagnosis and often initial evaluation and management is targeted to a potential urea cycle disorder or organic aciduria. CA‐VA deficiency is an extremely rare, or perhaps underdiagnosed cause of hyperammonemia, which has the potential to lead to diagnostic confusion with other inborn errors of metabolism. The differential diagnosis of CA‐VA deficiency includes transient hyperammonemia of the newborn, pyruvate carboxylase deficiency, multiple carboxylase deficiency, CPS1 deficiency, and NAGS deficiency. The results of the metabolic investigations allow the differentiation of CA‐VA deficiency from above disorders. In transient hyperammonemia of the newborn, there is isolated hyperammonemia with all other metabolites often being normal . In pyruvate carboxylase deficiency there is an elevated citrulline and lysine, and proximal early infantile onset urea cycle defects typically have normal lactate and ketone levels and low plasma citrulline concentrations. In our patients, other diagnoses that were initially considered included multiple carboxylase deficiencies, multiple acyl‐CoA dehydrogenase deficiency, and mitochondrial disorders. The overlap with metabolites identified in multiple carboxylase deficiency  occurs as biotin is an obligatory cofactor for the three carboxylases that also require bicarbonate as a substrate. However, multiple carboxylase deficiency does not often present with hyperammonemia, and biotinidase deficiency was ruled out enzymatically in patient 1. Multiple acyl‐CoA dehydrogenase deficiency was considered because patient 2 had multicystic kidneys and a suggestive acylcarnitine profile after carnitine supplementation.3− deficiency caused by CA‐VA deficiency and propionyl CoA is a potent inhibitor of NAGS. Carbamoyl phosphate synthetase CPS1 does not function because of the NAG and HCO3− deficiency. Carglumic acid has been shown to be beneficial in treating hyperammonemia in 53% of the published cases of CA‐VA deficiency.The two cases we describe here showcase the major presentation of CA‐VA deficiency that has been described previously.CA5A is 50Kb long with seven exons and six introns. Most pathogenic variants occur in exons 4 and 6. The genetic variants in our cases have both been previously described. The c.721G>A, p.(Glu241Lys) (rs563971993) (NM_001739.2) variant was present in both cases and falls within exon 6. It has an overall population minor allele frequency of 3.09e−4 and has not been observed as homozygous before. This variant is observed in 0.27% of alleles in individuals from a south Asian background in the gnomAD database.Our patients were both from the Indian subcontinent as were 71% of the patients with CA‐VA deficiency previously identified. This propensity to identify cases from the same ethnic background raises the possibility of a founder effect. The gene In summary, we present two cases which add to the limited previous reports of CA‐VA deficiency. CA‐VA deficiency is a recently described ultrarare inborn error of metabolism with most patients being from the Indian subcontinent. It presents early in life with a hyperammonemia crisis accompanied by respiratory alkalosis/metabolic acidosis, lactic acidosis, ketonuria, and hypoglycemia. The outcome is often favorable with normal neurodevelopment and no further crises following prompt and temporary treatment of hyperammonemia with carglumic acid.All authors have no conflict of interest to declare.


Limited comparative effectiveness data for rituximab (RTX) versus natalizumab (NTZ), fingolimod (FTY), and dimethyl fumarate (DMF) for the treatment of multiple sclerosis (MS) exist.Clinician‐reported data on patients prescribed RTX, NTZ, FTY, or DMF for the treatment of MS at the Rocky Mountain MS Center at the University of Colorado were retrospectively collected. Outcomes included a composite effectiveness measure consisting of clinical relapse, contrast‐enhancing lesions, and/or new T2 lesions, individual effectiveness outcomes, and discontinuation. Logistic regression was used on patients matched by propensity scores and using average treatment effect on treated doubly robust weighting estimator.P < 0.001].and DMF , and similar for NTZ  versus RTX. When examining months 6–24, NTZ demonstrated higher odds of disease activity compared to RTX . Similar odds of discontinuation were seen between NTZ and RTX ; however, FTY  and DMF  had greater odds of discontinuation than RTX.A total of 182, 451, 271, and 342 patients initiated RTX, NTZ, FTY, and DMF and were followed for 2 years. Before and after adjustment, the odds of experiencing disease activity was significantly higher for FTY [adjusted OR (aOR) = 3.17 (95% CI: 1.81–5.55), RTX demonstrated superior effectiveness and discontinuation outcomes compared to FTY and DMF. Although RTX demonstrated similar effectiveness and discontinuation compared to NTZ, RTX had superior effectiveness during months 6–24 and fewer discontinuations when excluding discontinuations due to insurance issues. Results suggest superiority of RTX in reducing disease activity and maintaining long‐term treatment in a real‐world MS cohort. Multiple sclerosis (MS) is a chronic inflammatory disease resulting in demyelination and axonal damage in the central nervous system. Current evidence suggests B cells play a role in the pathogenesis, leading to increasing use of anti‐CD20 B‐cell depleting agents in the treatment of MS.Phase 2, double‐blind, clinical trials for rituximab demonstrated a reduction in contrast‐enhancing lesions (CELs) and clinical relapses at 48 weeks in RRMS patientsWhile these studies have provided valuable data for the comparative effectiveness of RTX in RRMS patients, sample size limitations have resulted in conflicting or nonmeaningful results. Furthermore, previous studies were largely conducted in Swedish RRMS populations, limiting generalizability. Our retrospective study aims to address these gaps through achieving a large sample size for investigation of the comparative effectiveness and discontinuation patterns of RTX‐treated patients compared to those treated with NTZ, FTY, and DMF at a large academic center in the United States.This retrospective observational study included all participants who (a) had an MS diagnosis; (b) initiated RTX, NTZ, FTY, or DMF at the Rocky Mountain MS Center at the University of Colorado (RMMSC at CU) between January 2010 and October 2013; and (c) for NTZ patients only, had a negative JCV serology test at baseline. Some JCV positive patients were prescribed NTZ while they transitioned to another DMT. As NTZ was not intended for long‐term care in these cases, we believed they would obscure results and were, therefore, not included. To avoid potential biases resulting from changing documentation practices over time, we limited the data collection for RTX patients to be identical to those of previously collected NTZ, FTY, and DMF cohorts. During the time frame of this study, standard dosing of RTX for the treatment of MS at our center was an induction dose of 2000 mg (1000 mg at day 1 and day 14) and 500 mg every 6 months thereafter in most (77.4%) patients. To be representative of the real‐world experience of MS patients seen in clinical practice, progressive forms of MS were included in this study. However, a subgroup analysis of RRMS patients was completed.A chart review of electronic medical records was conducted for patients who met inclusion criteria. BV reviewed all RMMSC at CU encounters following each study participant’s start date, defined as date of first administration of RTX, NTZ, FTY, or DMF, for up to 24 months after or until study DMT discontinuation. Baseline characteristics were collected from records at the time of DMT start date. Baseline MRI data were collected from the closest MRI prior to DMT initiation. To confirm accuracy of outliers and consistency of data collection, quality checks were conducted through a second review of a subgroup of charts.The primary outcome was a composite effectiveness measure defined as the patient experiencing a clinical relapse, CEL, or new T2 lesion on follow‐up MRI. Clinical relapses were, for the purpose of this study, defined as clinician‐reported per patient chart notes as new or worsening neurological symptoms lasting greater than 24 h in the absence of fever or infection. MRI data were obtained from neuroradiology reports and clinical reports. At RMMSC at CU, electronic medical records did not consistently capture disability during the time range of this study; therefore, disability was not included in this study.Secondary outcome measures included (1) individual effectiveness outcomes, including clinical relapse, CELs, and new T2 lesions; (2) discontinuation of therapy, defined as no longer on drug at 24 months after start date, or initiation of any other MS DMT during the 24‐month follow‐up period; (3) primary reason for discontinuation, categorized as disease activity, JCV positivity, AE/tolerability, insurance issues, loss to follow‐up, or any other reason. Some patients withheld therapy for a period of time, for example to alleviate tolerability issues or for travel. However, it was not considered a discontinuation if the patient reinitiated the medication without interruption by any other DMT for the treatment of MS. Patients who developed neutralizing antibodies or had extended dosing intervals were not excluded from analyses as we believe these are characteristics of treatment that affect real‐world effectiveness and ability to achieve long‐term care.P‐values < 0.05 were considered statistically significant. Differences in baseline characteristics and secondary outcomes were assessed using t‐tests or Wilcoxon ranks sum tests for continuous variables, and chi‐squared or Fischer’s exact tests for categorical data. For the primary outcome and select secondary outcomes, odds ratios (ORs) were calculated using logistic regression. Multiple methods were used to account for imbalances between groups, including simple logistic regression, adjusted logistic regression, logistic regression on sample group 1:2 nearest neighbor matched by propensity scores (PS) with replacement, and average treatment effect on treated (ATT) doubly robust weighting estimator.Statistical analyses used SAS Version 9.4 and STATA Version 13.1. R Version 3.1.0 generated Cohen’s D effect size plots.Propensity scores generated through logistic regression modeled the probability of receiving RTX treatment using the preselected covariates of age, sex, disease duration, diagnosis, and CEL on baseline MRI. Adjusted logistic regression applied identical covariates as were used in propensity score creation. Kaplan–Meier failure curves assessed cumulative probability of experiencing disease activity, and discontinuation over time. All ORs presented are RTX‐treated patients compared to those treated with NTZ, FTY, or DMF, individually. Comparisons between NTZ, FTY, and DMF have been previously published.A total of 1,246 participants met inclusion criteria for this study: 182 RTX, 451 NTZ, 271 FTY, and 342 DMF. Figure Cohen’s D values for effect sizes comparing baseline covariates between RTX and NTZ/FTY/DMF Figure  demonstrP < 0.001]. After adjustment, results for DMF versus RTX demonstrate greater odds of DMF patients experiencing a clinical relapse, CEL, and/or new T2 lesion .Figure Figure Figure P = 0.005; DMF: OR = 3.27, 95% CI (2.15–4.97), P < 0.001 using ATT doubly robust weighting]. RRMS‐only patients demonstrate results consistent with the overall cohort as seen in Table Table Tables In this retrospective, real‐world study, we investigated the comparative effectiveness and discontinuation patterns for MS patients treated with RTX in comparison with those treated with NTZ, FTY, and DMF, individually. We achieved large sample sizes, and additionally, were able to create well‐balanced groups for comparisons through the utilization of PS adjustment. Results demonstrated improved effectiveness outcomes and decreased odds of discontinuation for RTX compared with FTY and DMF. While similar effectiveness and odds of discontinuation were observed for RTX compared with NTZ in the overall cohort for months 0‐24, we saw increased effectiveness of RTX when examining months 6‐24.Our results suggest improved effectiveness of RTX over NTZ when accounting for time to therapeutic effect. Potential explanations for this may be missed or delayed NTZ doses and/or neutralizing antibodies may result in increased disease activity after 6 months for those treated with NTZ. While previous studies took time to therapeutic effect into account, including effectiveness outcomes occurring at least 3 months after the first DMT dose, they have struggled with investigating comparative effectiveness of NTZ compared with RTX in a meaningful way due to smaller sample sizes.n = 17.When comparing FTY to RTX, our results were consistent with previous studies showing improved effectiveness of RTX. Alping et al and Boremalm et al demonstrated superiority of RTX over FTY in RRMS for clinical relapse and CEL outcomes after adjustment.Currently, to our knowledge, Granqvist et al has conducted the only other comparison of DMF versus RTX using real‐world data and found those treated with RTX had fewer new CELs, but clinical relapses were similar between the two therapies.Additionally, while these studies conducted by Granqvist et al, Boremalm et al, and Alping et al include both clinical relapses and MRI outcomes, a composite measures may be required when investigating efficacy among highly effective DMTs, allowing for increased power needed to detect smaller differences through observation of more events.When investigating discontinuation outcomes, we found lower odds of discontinuation of RTX compared to FTY and DMF, consistent with previous studies.Meanwhile, FTY and, particularly, DMF are known to have issues with tolerability and AEs. This, in combination with the daily administration required of these oral therapies has a probable effect on adherence.n = 822), of which 32.6% received an induction dose of 2000mg, included both relapsing and progressive patients with a mean age of 42.6 and demonstrated discontinuations due to AEs to be 5.2% (mean follow‐up time 21.8 months), similar to the 6.6% in our study.In addition, due to the off‐label use of RTX in the treatment of MS, dosing strategies have varied, which may affect likelihood of AEs and potential benefit. Previous Swedish comparative studies investigated cohorts who similarly received 500‐mg every 6 months, but with few receiving an initial dose of 2000 mg (1000 mg at day 1 and day 14), as was common at our center during the time frame of this study. However, another Swedish study investigating exclusively RTX patients , outcomes for the relapsing‐remitting multiple sclerosis patients only (Table S1‐S3), disease activity during months 6‐24 (Table S4), time to event analyses for effectiveness (Table S5), discontinuations overall excluding insurance issues , discontinuations due to adverse events , and types of adverse events (Table S8).Click here for additional data file.


Lung cancer invading outside a lobe centrally or peripherally, or presenting with synchronous or metachronous tumors, requires a special approach. Here, we aimed to evaluate the rate and outcomes of surgery of these patients in a medium‐volume practice using real‐world, population‐based data.n = 269) on whom lung cancer surgery was performed in Central Finland and Ostrobothnia between January 2013 and December 2019 were included. A total of 40 patients with sleeve (n = 18) or other extended resections (n = 9), multifocal diseases (n = 14), and other operated synchronous cancers (n = 3) required an extended or otherwise special surgical approach (extended group). Short‐ and long‐term outcomes were compared to high‐risk (n = 72) and normal patient groups (n = 157).All patients (P = 0.287), respectively.The rate of extended resection was 14.9%. The rates of PET‐CT (95%), invasive staging (35%), and brain imaging (42.5%) were highest in extended group compared to other groups. Extended group had larger and higher rate of stage III tumors than high‐risk and normal groups. All extended group patients underwent anatomic lung resection with better lymph node yield than the other two groups, with a neoadjuvant and/or adjuvant treatment rate of 70.0%. Major complications occurred in 7.5% in the extended group, 19.4% in the high‐risk group, and 6.4% in the normal group; at one year, alive and living at home rates were 88.2%, 83.3%, and 97.8%, and overall five‐year survival rates 75.6%, 62.4%, and 63.9% (After guideline‐based evaluation, a significant rate of these special cases can be resected with a low complication rate and good long‐term survival in real‐world practice.Extended resections for lung cancer include tumors spreading outside the lungThe rate of extended resection was 14.9% in a population‐based settingMajor complications occurred in 7.5% and five‐year survival was 75.6%What this study addsComplication rate and long‐term outcome were similar compared to normal patientsGuideline‐based evaluation results with excellent outcome in real‐world practice Extended resections for lung cancer include tumors spreading outside the lung. In this population‐based study, the rate of extended resection was 14.9% with major complications occurring in 7.5% and five‐year survival was 75.6%. Guideline‐based evaluation results with excellent outcome in real‐world practice. Worldwide, the leading cause of cancer‐related mortality is lung cancer.Based on our previous population‐based study, the adherence to the modern guideline‐based approach had a major impact on outcomes.Sleeve lobectomy, rather than pneumonectomy, is recommended in centrally located tumors.The reported rate of sleeve resections in large databases or in population‐based studies is only 1–2%.In September 2012, a modern guideline‐based lung cancer surgery program was started at Central Finland Central Hospital by an experienced thoracic surgeon (ES).All Finnish residents are listed by their individually unique and immutable 10‐digit national registration numbers in the hospital databases and several national databases. This allows for reliable identification of patients from hospital records and the Finnish Cancer Registry, as well as linkage of data. The Finnish Cancer Registry is population‐based and covers all parts of Finland. Registration includes the municipality and, therefore, the hospital district where the patient lives. According to Finnish health care policy, all hospital districts are responsible for arranging specialized care for their residents in its area. In Central Finland and Ostrobothnia, which had a total population of 456 976 as of 31 December 2017 (8.3% of the Finnish population), the treatment of lung cancer is organized by Central Finland Central Hospital and Vaasa Central Hospital, respectively. Using the histopathological, clinical follow‐up, and discharge registries of the two hospitals, all patients diagnosed with primary lung cancer who underwent lung resection with curative intent between 1 January 2013, and 31 December 2019, were identified. Cross‐linking of Finnish Cancer Registry data and hospital databases confirmed identification of all surgical cases. From 2015, a prospective surgical database established in Central Finland Central Hospital in 2012 provided the surgical cases. This database was not designed for study purposes and, therefore, the data for all study patients were collected from hospital records.2 10–15 mL/kg/minutes, or climbing only two flights of stairs (7.2 m). Complications were graded according to Clavien‐Dindo classification.The eighth edition of the TNM classification was used for staging. This required recoding all surgical patients accordingly. The study group  included patients with extended central or peripheral local resection beyond the lung tissue, synchronous solid lung cancer in a different ipsilateral lobe or contralateral lung, metachronous lung cancer, or other low‐survival synchronous cancer Table . Two patThe main outcomes of this study were differences in short‐term results , ability to live at home one year after surgery, and long‐term and recurrence‐free survival. The ability to live at home was defined as the proportion of patients, out of all operated patients, living at home one year after surgery instead of a nursing facility, hospital, terminal care unit, or death. Only patients who completed one‐year follow up (operated before 31 March 2019) were included in the analysis regarding living at home one year after surgery.t‐test as appropriate. For patients who received neoadjuvant treatment, clinical stage was used instead of pathological stage. All statistical analyses were performed using IBM SPSS 25.0 .We constructed Kaplan‐Meier survival curves according to the life table method to visualize the crude all‐cause and recurrence‐free survival up to five years after surgery. Proportions, means, and median values of other measured variables were compared using the chi‐squared test, Mann‐Whitney U‐test, and Student's Over the seven‐year period, 269 patients underwent surgery for lung cancer in the Central Finland and Ostrobothnia hospital districts in Finland, with a mean age of 69.7 (SD 9.3) years , sleeve resection (n = 18), treatment of multifocal disease (n = 14), and synchronous other poor‐outcome cancer (n = 3), Table In 40 patients, treatment required extended surgical resection outside the lung . Rates of adjuvant therapy after neoadjuvant therapy and surgery were 42.5%, 33.3% and 0%, respectively. In stage IIA or higher tumors, the rate of either neoadjuvant and/or adjuvant therapy was in the extended group 88.5%. This rate was higher compared to the rate of 56.9% (P = 0.004) in the normal group or the rate of 51.9% (P = 0.004) in the high‐risk group.In the extended group, neoadjuvant therapy was given to 37.5%, and neoadjuvant and/or adjuvant treatment to 70.0% (Table P = 0.004). The rate of N2 disease was 15%, 10.2% and 6.9%, respectively, without statistical significance. In N2 patients of the extended group, the nodal burden with a median of one positive node and a ratio of 0.07 was lower than those of in the normal group with a median of two (P = 0.020) and a ratio of 0.19 (P = 0.007) or in the high‐risk group with a median of three (P = 0.035) and a ratio of 0.25 (P = 0.002). In the extended group, all patients underwent anatomic lung resection, and nearly all patients (92.5%) underwent systematic lymph node dissection, with better lymph node yield than the other two groups  and of higher stage (≥stage III in 32.5%) than in the high‐risk (≥stage III in 9.7%) and normal groups , major complications , and 90‐day mortality  than the normal group. In the extended and high‐risk groups, hospital and ICU stays were significantly longer than in the normal group, though the median ICU stay was 0 in all groups. ICU stay ≥1 day was required for 32.5% of patients in the extended group, 11.1% in the high‐risk group, and 4.5% in the normal group.In the whole population‐based cohort, the overall and major complication rates were 33.5% and 10%, including 1.5% 90‐day mortality Table . These rP = 0.001).The rate of being alive and able to live at home one year after surgery in the whole population‐based cohort was 92.6%. After extended resection, this rate was 88.2% Table . CompareOverall survival at 90 days, one year, and five years after surgery for lung cancer at the population level was 98.5%, 94.8%, and 65.4%. Recurrence‐free survival at five years was 70.8%. Survival rates stratified by study group are presented in Table Based on this real‐world experience, at the population level, patients undergoing extended resection or resections due to other special indications create a significant group comprising 15% of surgical lung cancer candidates. Surgery can be offered to these selected patients with excellent short‐ and long‐term outcomes. Complication rates were comparable to low‐risk patients undergoing mainly standard VATS‐lobectomy or segmentectomy. In this extended surgical group, the five‐year survival rate was 75.6%.The population‐based design from two geographic areas in Finland is the major strength of this study. Unlike many other population‐based reports, we were not restricted to only registry‐based data, but had full access to complete patient data from hospital records. This resulted in more accurate collection of patient demographics, risk factors, and the exact surgeries performed. The available surgical reports are particularly important considering extended resection, which can be misleading if based only on surgical codes and registry data. Furthermore, complications based on hospital records provide accurate information without missing morbidity which often occurs in registry data. Complete follow‐up data were also available from multiple sources. However, the study had some weaknesses. The limited sample size, especially in the extended group, can cause confounding results by increasing the possibility of chance in our results. Limiting this possibility, however, is the fact that multiple factors, including complications, surgical quality, recurrence, and overall survival, were analyzed without discrepancies. Our study period included 2013–2019 with follow‐up extending to 31 March 2020. Actual five‐year survival was not available for all patients, therefore, survival rates were based on Kaplan‐Meier analysis.The importance of well‐established guidelines and book chapters on the treatment of lung cancer in these special cases is clear.In this real‐world population‐based evaluation, the overall one‐ and five‐year survival after lung cancer surgery was 94.8% and 65.4%. These rates in the extended group were 91.3% and 75.6%, respectively. In the most recent 2018 Danish annual report, an overall one‐year survival of 91% and five‐year survival of 60% were detected at the population level in Denmark.A low mortality rate and low rate of major morbidity  are prerequisites for advocating surgery over nonsurgical therapies in more extensive surgical cases. An additional argument for surgery is the 91.3% one‐year survival, which is superior compared to high‐risk patients in our study, and similar to Danish national outcomes.Both the overall short‐ and long‐term results at the population level in this study are equivalent or superior to previously published reports,In conclusion, based on the current study, extended resection and resections due to other special indications create a significant group among surgical lung cancer patients (15%) at the population level. Despite more advanced tumors, or otherwise more complex clinical cases, surgery can be offered after thorough staging and risk‐assessment in real‐world practice, with excellent short‐and long‐term outcomes.The authors have no conflicts of interest or financial ties to disclose.


Mage = 13.36, SD = 0.98; 51.3% girls). The results indicated that popularity was consistently positively associated with popularity goal, but popularity goal did not significantly predict subsequent popularity. Popularity positively predicted elevated aggression and alcohol use, but lower levels of prosocial behavior. For the full sample, alcohol use and overt aggression in grade 7 both predicted subsequent popularity in grade 8. However, when considering gender differences, overt aggression no longer was a significant predictor of popularity. These results were discussed in terms of the dynamic interplay between popularity, popularity goal, and behaviors, and in terms of implications for prevention and intervention efforts.Adolescents’ popularity and popularity goal have been shown to be related to their aggression and alcohol use. As intervention efforts increasingly aim to focus on prosocial alternatives for youth to gain status, it is essential to have a comprehensive understanding of how popularity and popularity goal are associated with aggression and substance use as well as prosocial behaviors over time. The current study examined the bidirectional associations of aggression , alcohol use, and prosocial behavior with popularity and popularity goal in adolescence across 3 years using cross-lagged panel analyses. Participants were 839 Dutch adolescents ( A key developmental change in early adolescence is the growing attention for peer relationships  in a 3-year prospective longitudinal design. The longitudinal data allowed us to examine the temporal direction of associations, including bidirectional effects, which can inform future prevention efforts. Popularity was expected to be a stronger predictor of popularity goal, rather than popularity goal predicting subsequent popularity. Strong associations of both popularity and popularity goal with subsequent overt and relational aggression were hypothesized. There is mixed evidence for aggression predicting subsequent popularity or popularity goal, which we aimed to further clarify. Popularity goal was expected to predict alcohol use, and popularity was expected to be both a predictor and outcome of alcohol use. The current study also investigated the longitudinal links of prosociality with popularity and popularity goal, both of which are less established. Potential gender differences were considered when the aforementioned associations were examined.Mage = 13.36, SD = 0.98; nGrade7 = 286, nGrade8 = 260, nGrade9 = 293). At T2 (2015), there were 833 participants . At T3 (2016), there were 812 participants . At each wave, the majority of participants were born in the Netherlands (ranging from 95.2 to 96%) and had parents who were born in The Netherlands (ranging from 81.9 to 85.8%). For the analyses, participants across all three waves were grouped by grade .Participants were recruited as part of the Kandinsky Longitudinal Study (KLS), a longitudinal study that started in 2010 to identify youth at risk for socio-emotional adjustment difficulties .Each year, a combination of peer nominations and self-reports were assessed via a computerized questionnaire  to 6 .To assess alcohol use, participants were asked “in the last 30 days, on how many days did you drink alcohol?”  to +3 (very important).Adolescents were asked Table p < 0.001. Two-sided Fisher’s Z-tests were used to examine whether the correlations were significantly different between boys and girls. The stabilities of most variables were significant for both genders, with a few exceptions. Alcohol use in grade 7 was not significantly associated with grade 8 alcohol use for girls or grade 9 alcohol use for girls and boys. Furthermore, for girls only, grade 7 and 8 overt aggression were not significantly associated with grade 9 overt aggression. Thus, with the exception of alcohol use, most constructs were highly stable across all three grades.Bivariate correlations between all variables are shown in Table rs ranging from 0.22 to 0.36). In grade 7, popularity was positively associated with all grade 7 behaviors, except for alcohol use, for both genders. In grade 8, popularity was positively associated with overt and relational aggression for both genders, and also with alcohol use for boys. In grade 9, popularity was positively correlated with all behaviors for girls, but only with aggression and alcohol use for boys. Popularity goal in grades 7 and 8 were not significantly correlated with any grade 7 or 8 behaviors, respectively, for either gender. In grade 9, popularity goal was positively associated with relational aggression and alcohol use for girls only. Thus, in all grades, popularity was more consistently associated with aggression, alcohol use and prosocial behaviors than popularity goal.In each grade, there was a modest positive association between popularity and popularity goal for both genders  = 50.39, p < 0.001, CFI = 0.98, TLI = 0.90, RMSEA = 0.052 . The constrained model with all stability and predictive paths set equal for boys and girls was significantly worse than the unconstrained model, χ2(18) = 49.03, p < 0.001, CFI = 0.98, TLI = 0.92, RMSEA = 0.032 , indicating gender differences. The stability of overt aggression from grade 8 to 9 and the paths from grade 8 popularity to popularity goal and overt aggression in grade 9 differed significantly by gender.The fit of the model Fig.  was good2(34) = 73.94, p < 0.001, CFI = 0.98, TLI = 0.94, RMSEA = 0.026 . All stability paths for popularity and popularity goal were significant, ps < 0.001. Popularity in grades 7 and 8 was positively associated with popularity goal 1 year later . Popularity in grade 7 positively predicted overt aggression in grade 8 . For boys (but not for girls), grade 8 popularity was positively associated with grade 9 overt aggression . Overt aggression was stable from grade 8 to 9 for boys , but not for girls. Without considering gender differences, overt aggression in grade 7 was positively associated with popularity in grade 8 ; however, this path was no longer significant in the model once accounting for gender differences.Next, a series of models was compared with each combination of these pathways constrained or freely estimated. There was no significant difference in model fit between the unconstrained model and the model with all paths constrained except for the stability of overt aggression from grade 8 to 9 and the predictive path of grade 8 popularity to grade 9 overt aggression, χ2(9) = 31.09, p < 0.001, CFI = 0.99, TLI = 0.95, RMSEA = 0.038 . The fit of the unconstrained model, χ2(18) = 38.26, p = 0.004, CFI = 0.99, TLI = 0.96, RMSEA = 0.026 , was significantly better than the model with all paths constrained, χ2(36) = 101.15, p < 0.001, CFI = 0.97, TLI = 0.93, RMSEA = 0.033 , indicating gender differences. The model with all paths constrained except for the predictive path from grade 7 popularity to grade 8 relational aggression yielded the best fit, χ2(35) = 58.78, p = 0.007, CFI = 0.99, TLI = 0.97, RMSEA = 0.020 . All stability paths were significant, ps < 0.001. Although popularity in grade 7 was positively associated with grade 8 relational aggression for both boys  and girls , the association was significantly stronger for girls. Popularity in grade 8 also positively predicted grade 9 relational aggression for both genders . For boys and girls, grade 7 popularity was positively associated with grade 8 popularity goal . Relational aggression in grade 7 was negatively associated with popularity goal in grade 8 for boys and girls .The model resulted in a similar pattern as the model for overt aggression Fig. . The fit2(9) = 25.06, p = 0.003, CFI = 0.99, TLI = 0.95, RMSEA = 0.033 . The test of gender differences showed that the fit of the fully constrained model, χ2(36) = 57.23, p = 0.014, CFI = 0.99, TLI = 0.97, RMSEA = 0.019 , was not significantly worse than the unconstrained model, χ2(18) = 38.99, p = 0.003, CFI = 0.99, TLI = 0.94, RMSEA = 0.026 , indicating no significant gender differences. All stability paths were significant, ps < 0.001. Popularity in grades 7 and 8 was positively associated with popularity goal  and alcohol use  1 year later. Alcohol use in grade 7 was positively associated with grade 8 popularity . Popularity goal in grade 8 positively predicted grade 9 alcohol use .The fit of the model see Fig.  was good2(9) = 37.75, p < 0.001, CFI = 0.99, TLI = 0.93, RMSEA = 0.044 . No paths were moderated by gender, as the fit of the fully constrained model, χ2(36) = 73.99, p < 0.001, CFI = 0.98, TLI = 0.95, RMSEA = 0.025 , was not worse than the fit of the fully unconstrained model, χ2(18) = 48.19, p < 0.001, CFI = 0.98, TLI = 0.92, RMSEA = 0.032 . In this model, all stability paths were significant, ps < 0.001. Popularity in grade was positively associated with grade 8 popularity goal  and negatively associated with grade 8 prosocial behavior .The model Fig.  had adeqPopularity and popularity goal are deeply intertwined with antisocial behaviors in adolescence . Consistent with Dawes and Xie , popularOf note, the current study sheds light on these processes in a Western, but non-American, sample, which is important as the associations of popularity that have been found predominantly in American samples may not be the same in other areas of world  than grade 9 (Ms > 0.28). It is possible that drinking was not prevalent enough in grade 8, when youth are between the ages of 13 to 15, to be predicted by popularity goal in grade 7. Moreover, when drinking is still relatively uncommon, perhaps only youth with high levels of popularity have opportunities to drink, rather than those with a high popularity goal. However, as youth get older and drinking alcohol becomes more common, those who want to be popular  appear particularly likely to drink alcohol. Despite the relatively low prevalence of alcohol use in this age group, it is particularly important to understand mechanisms that underlie alcohol use in early adolescence, as youth who begin to drink alcohol between ages 11–14 years are more likely to develop alcohol abuse or dependence  in all models tested. Taken together, this suggests that overt aggression was more characteristic of boys, whereas the association between popularity and relational aggression was stronger for girls than boys. Nonetheless, the findings only highlighted a few gender differences, suggesting that the prospective associations between popularity, popularity goal, and aggression and alcohol use are largely the same for boys and girls.There were several mean level gender differences in terms of aggression and alcohol use. Boys scored higher on overt aggression in all grades, and their overt aggression was more stable than that of girls, whereas girls scored higher on relational aggression than boys in grades 8 and 9. In grade 7 only, boys were more likely than girls to drink alcohol. Yet, there were only a few gender differences regarding the associations of aggression and alcohol use with popularity and popularity goal. Popularity in grade 8 predicted elevated overt aggression in grade 9 for boys only, whereas popularity in grade 7 predicted elevated overt aggression in grade 8 for both boys and girls. Furthermore, popularity predicted high levels of relational aggression for both boys and girls. These findings are consistent with past research suggesting that, while overt or physical forms of aggression may be somewhat more common among boys than girls, relational aggression is used by both girls and boys  implement both prosocial and aggressive behaviors to gain resources  that may be differentially related to behaviors and popularity. For example, adolescents with high status goals who also have high communal goals behave differently than adolescents who only care about being popular match between youth’s popularity and popularity goal. In other words, youth who want to be popular  may have different behavioral profiles than youth who want to be popular but are not popular  and aggression. This study adds to previous research indicating that there are risks associated with popularity (e.g., Mayeux et al.


He was undergoing HD thrice a week for seven years. HD was provided 16 h after carboplatin administration. During the first cycle, grade 4 neutropenia (neutrophil count: 74/μL) and leukopenia (white blood cell count: 680/μL) occurred. Therefore, chemotherapy was administered with a reduced dose of carboplatin (AUC = 4) and etoposide (30 mg/m2) from the second to fourth cycles. After four cycles, no severe non‐haematological adverse events occurred, showing a remarkable response. We conclude that the carboplatin, etoposide, and atezolizumab combination can be safely administered to cancer patients undergoing HD.Little is known about the safety of chemotherapy plus atezolizumab for patients with extensive‐stage small cell lung cancer (ES‐SCLC) undergoing haemodialysis (HD). An 80‐year‐old male received carboplatin [area under the concentration‐time curve (AUC) = 5 on day 1], etoposide  undergoing haemodialysis (HD) who received chemotherapy plus atezolizumab. Lung cancer (LC) remains a major cause of cancer incidence and mortality worldwide . Small cPlatinum‐based chemotherapy has long been the first‐line treatment for ES‐SCLC . HoweverToday, >1 million people require long‐term dialysis worldwide . With thWe report an ES‐SCLC patient undergoing HD who received chemotherapy plus atezolizumab.An 80‐year‐old male was diagnosed with relapsed stage IV ES‐SCLC . The patient's performance status was 1. He had been undergoing HD thrice a week for seven years. HD was performed using APS‐21SA  for 4 h every session.2 on days 1, 2, and 3), and atezolizumab (1200 mg/body on day 1) as the first‐line therapy. On day 1 of each cycle, the patient received carboplatin 16 h before dialysis. HD schedule was thrice a week. During the first cycle, thrombocytopenia (grade 1), neutropenia , and leukopenia  were observed. No severe non‐haematological adverse events occurred.We initiated carboplatin , etoposide (40 mg/m2), as grade 4 neutropenia occurred during the first cycle. After the initiation of the second cycle, the patient developed grade 3 neutropenia but did not develop any severe non‐haematological adverse events.The second, third, and fourth chemotherapy cycles were performed with a reduced dose of carboplatin  and etoposide  and brain magnetic resonance imaging (MRI) showed marked tumour shrinkage Fig. . At presThe patient exhibited a remarkable response to carboplatin, etoposide, and atezolizumab despite the dose and schedule adjustment due to HD. No severe adverse reactions were reported.The metabolic and excretion routes of each drug in healthy patients are reported as follows: carboplatin is not the first drug to bind into proteins, but the majority of the drugs bind to proteins within 24 h, whereas 55–70% of the drugs are excreted renally within 24 h . Atezoli2/day to avoid haematological toxicity in patients with renal insufficiency. Furthermore, HD does not primarily remove etoposide; hence, it can be administered before or after HD  16 h before dialysis. The culvert formula has been extensively used to determine carboplatin dosing for fixed AUC and glomerular filtration rate (GFR). This formula can be used in patients with end‐stage renal disease undergoing HD by assuming a zero GFR . If HD iafter HD . Finallyafter HD . TherefoIt is not clear how dialysis affects the blood levels of each drug as the blood concentration was not measured. The patient exhibited a remarkable response and did not develop severe adverse reactions. From Japanese data of the IMpower 133 trial, severe non‐haematological adverse events (grade ≥ 3) occurred in approximately 6% of patients and the response rate was about 75% .In conclusion, we safely administered a combination of carboplatin, etoposide, and atezolizumab to a patient undergoing HD, who demonstrated a remarkable response. This treatment is feasible and effective for SCLC patients undergoing HD.Appropriate written informed consent was obtained for publication of this case report and accompanying images.Dr DF reports personal fees from AstraZeneca KK, Ono Pharmaceutical, Bristol‐Myers Squibb, Taiho Pharmaceutical, Chugai Pharmaceutical, MSD KK, Boehringer Ingelheim Japan, Eli Lilly Japan KK, and Novartis Pharma KK, all outside the submitted work. Dr NY reports grants and personal fees from MSD KK, AstraZeneca, Ono Pharmaceutical, Daiichi Sankyo, Taiho Pharmaceutical, Takeda Pharmaceutical, Chugai Pharmaceutical, Eli Lilly Japan KK, Boehringer‐Ingelheim, Novartis, and Pfizer; personal fees from Thermo Fisher Scientific, Bristol‐Myers Squibb, Life Technologies Japan, Nippon Kayaku, and Merck Biopharma; and grants from Astellas Pharma, Tsumura & Co., Shionogi, AbbVie GK, Amgen, Kyorin Pharmaceutical, Eisai, Terumo, Toppan Printing, and TOSOH, all outside the submitted work. The remaining authors have no conflict of interest.All authors contributed to the study conception. The literature search was performed and the first draft of the manuscript was written by Mihoko Imaji. The manuscript was corrected by Daichi Fujimoto. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.


Robot‐assisted partial nephrectomy (RAPN) is emerging as an effective treatment oncologically and functionally for clinically localized renal tumors. However, RAPN in high‐complexity tumors with a Preoperative Aspects and Dimensions Used for an Anatomical score ≥10 remains challenging. In this study, the feasibility of RAPN for high‐complexity tumors was assessed.The study cohort consisted of 177 cases with clinically localized renal cell carcinoma who had undergone RAPN at our hospital from July 2010 to February 2018. They were assessed for perioperative parameters and trifecta achievement .P = 0.05 and 0.018, respectively). In multivariate analysis, tumor size was the only factor directly associated with trifecta achievement (P = 0.029).Among the 177 cases who had undergone RAPN, 60 had high‐complexity tumors, and 117 had non‐high‐complexity  tumors. There were no significant differences in the operative and console times between the cohorts, but estimated intraoperative blood loss was much lower in the non‐high‐complexity group. Although the average warm ischemia time was less than 25 minutes in both groups, it was significantly shorter in the non‐high‐complexity group. Trifecta achievement rates significantly differed between the high‐ and non‐high‐complexity groups (68.3% vs 86.3%). Comparisons of four operative parameters  using univariate analysis in the 60 high‐complexity tumor cases showed that BMI and tumor size were independent factors . Operative variables including age, gender, BMI, tumor side, operation approach , R.E.N.A.L. nephrometry score, and PADUA score were extracted. Before surgery, all patients underwent 3‐D CT or MRI to define tumors’ clinical stage and anatomical characteristics. Patients were divided into two groups according to PADUA score: the high‐complexity group (PADUA score ≥10) and the non‐high‐complexity group  (PADUA score 6‐9). To assess perioperative parameters, operative time, console time, estimated blood loss (EBL), and warm ischemia time (WIT) were checked. Trifecta achievement was a composite outcome measure for assessing quality of surgery in RAPN that consists of a WIT ≤25 minutes, no complications, and a negative surgical margin. Complications were defined as those that were Clavien‐Dindo ≥grade III.To perform RAPN, tumor depth was assessed with a laparoscopic ultrasound. After the administration of mannitol, the renal artery or its branches were clamped with a bulldog clamp. The tumor was resected with 2‐5 mm of the parenchymal margin. For the inner renorrhaphy layer, the collecting system and large vessels were closed with 3‐0 V‐Loc sutures, and if needed, parenchymal sutures were made with 2‐0 V‐Loc. Seven surgeons who completed the da Vinci certification program approved in Japan performed RAPN. We performed RAPN for the first time on July 29, 2010.The protocol for this study was approved by our institution's ethics committee , and the study was performed in accordance with the ethical standards established in the most recent version of the Declaration of Helsinki.2.2t test, Mann‐Whitney U test, χ2 test, or Fisher's exact test. To assess independent prognostic factors for trifecta achievement in the high‐complexity group, univariate analysis was performed with BMI, size, endophytic properties, and hilar tumor as variables. Significant preoperative variables in the univariate analysis were included in multivariate analysis using a Cox proportional hazards regression model. In all statistical analyzes, P < .05 was considered significant. All data were analyzed using IBM SPSS version 23 .All values are presented as means ± SD, and statistical comparisons of the results were performed with Student's 33.12 in the high cohort and 58.7 years and 23.7 kg/m2 in the non‐high cohort. The transperitoneal approach was used more than the retroperitoneal approach in both groups. The mean R.E.N.A.L. nephrometry score and PADUA score were 8.4 and 10.8 in the high cohort and 6.0 and 7.5 in the non‐high cohort. Among the factors age, gender, BMI, tumor side, approach, R.E.N.A.L. nephrometry score, and PADUA score, only the scores significantly differed between the two cohorts (P < .001).The study cohort consisted of 177 cases with clinically localized renal cell carcinoma who had undergone RAPN at our hospital from July 2010 to February 2018. There were 60 cases in the high‐complexity group (high cohort) and 117 cases in the non‐high‐complexity group (non‐high cohort) (Table 3.2P = .0019). Likewise, the mean WIT significantly differed between the high cohort and the non‐high cohort .Perioperative parameters including operative time, console time, EBL, and WIT are shown in Figure 3.3P < .001). There were no complications classified as Clavien‐Dindo ≥grade III in 53 cases (88.3%) in the high cohort and 106 cases (90.6%) in the non‐high cohort; there was no significant difference between the groups. Complications included urine leak , hemorrhage , and others . Overall, the trifecta was achieved in 41 cases (68.3%) in the high cohort and 101 cases (86.3%) in the non‐high cohort. There was significant difference in the rates of trifecta achievement between the cohorts (P = .009).We assessed trifecta achievement in both cohorts Table . There w3.4P = .03), but in multivariate analysis, none of the four factors was associated with WIT (Table P = .029), but BMI did not  tumor size, (b) endophytic properties, (c) hilar tumor, and (d) BMI. BMI was selected as a substitute for renal toxic fat Figure . In univIT Table . When thot Table . These a4In recent years, an increased number of cases have undergone RAPN because of the advantages on its minimal invasiveness compared to open and laparoscopic techniques. Also, RAPN has the advantages of a lower perioperative complication rate, shorter length of hospital stay, less EBL, shorter WIT, and better renal functional outcome than both open and laparoscopic PN.Regarding perioperative parameters, Abdel Raheem et al. reported that tumor complexity  did not affect operative time.Recent studies have demonstrated varying results with regard to trifecta achievement in high‐complexity tumors. Several have reported that high‐complexity tumors (PADUA score ≥10) could predict an increase in WIT.Our study of trifecta achievement demonstrated that there was significant difference in PADUA score between the high cohort and non‐high cohort. This analysis of trifecta achievement in high‐complexity tumors is consistent with that in previous studies.Our study encountered limitations as a result of the retrospective collection of data, the small sample from a single center, and the lack of well‐designed analyses. Therefore, further studies are required.In conclusion, the trifecta achievement rate for high‐complexity tumors (PADUA score ≥10) was significantly lower than that for non‐high‐complexity tumors. Tumor size was the only important factor that affected trifecta achievement during RAPN for high‐complexity tumors.The authors have no potential conflicts of interest to disclose.


CP gene encoding caeruloplasmin (ferroxidase). Caeruloplasmin is a copper‐containing plasma ferroxidase enzyme with a key role in facilitating cellular iron efflux. We describe a case of a patient with acaeruloplasminemia, confirmed by genetic analysis, treated with combination therapy of monthly fresh‐frozen plasma (FFP) or Octaplas and iron chelation over a 3‐year period. This 19‐year‐old male was diagnosed at the age of 14 after developing issues with social interaction at school prompting investigation. Prior to this, he had been well with a normal childhood. He was found to have an iron deficient picture with a paradoxically high ferritin, with low serum copper and undetectable caeruloplasmin. Genetic testing identified a homozygous splicing mutation, c.(1713 + delG);(c.1713 + delG), in intron 9 of the caeruloplasmin gene. Ferriscan showed a high liver iron concentration of 5.3 mg/g dry tissue (0.17‐1.8). Brain and cardiac T2‐weighted magnetic resonance (MR) imaging did not detect iron deposition of the brain or heart respectively. Treatment with monthly Octaplas infusion was commenced alongside deferasirox (540 mg o.d.) in an attempt to increase caeruloplasmin levels and reduce iron overload, respectively. After 3 years of treatment, there was biochemical improvement with a reduction in ferritin from 1084 (12‐250) to 457 μg/L, ALT from 87 (<50) to 34 U/L together with improvement in his microcytic anaemia. No significant adverse events occurred. This case report adds further evidence of treatment efficacy and safety of combined FFP and iron chelation therapy in acaeruloplasminemia.Acaeruloplasminemia is a rare autosomal recessive condition caused by inactivating mutations of the  CP is a copper‐containing ferroxidase enzyme which has a crucial role in cellular iron homeostasis. It is the disruption of CP ferroxidase activity that leads to systemic iron accumulation which over time can result in clinical manifestations such as diabetes mellitus, progressive neurodegeneration, retinopathy, microcytic anaemia and liver disease.Acaeruloplasminemia (ACP) is a rare, autosomal recessive condition of adult onset, caused by inactivating mutations affecting the In ACP the loss of this important regulatory function is what ultimately results in neurodegeneration as well as causing iron‐mediated damage to other organs such as the liver, pancreas and retina. ACP is the only known iron overload disorder in which both systemic and brain iron overload are present.2A 12‐year‐old male was referred to a community paediatrician after finding interaction with his peers difficult. Prior to this, he had a normal childhood with no significant illness being reported and no delay in the onset of puberty. He was born at 38 weeks of gestation due to maternal gestational cholestasis. Clinical examination was unremarkable apart from the presence of marked leukonychia. As part of his behavioral workup, he went on to have basic biochemical and hematological testing which identified a microcytic anaemia with a haemoglobin of 10.4 g/L (11.5‐15.0) and mean cell volume of 61 fL (78‐100). Serum iron was low at 6 μmol/L (14‐31) with a total iron‐binding capacity of 67 μmol/L (54‐80), iron‐binding saturation of 6% (20‐55) and an elevated ferritin of 534 μg/L (10‐322). His haemoglobin electrophoresis and haemoglobinopathy genetic test were negative. Further evaluation under pediatrics led to copper assessment, prompted by a raised alanine aminotransferase (ALT).in vivo copper metabolism using a protocol based on that of Lyon et al.65Cu/63Cu ratio by inductively coupled plasma mass spectrometry at time points up to 72 hours after administration of a 3 mg oral dose of the stable copper‐65 isotope. The results  with an undetectable CP of <0.02 g/L (0.20‐0.60). Urinary copper excretion was low‐normal at 0.17 μmol/d (<1) ;(c.1713 + delG) in intron 9 of the y Figure ; a cousi2 (77th percentile for age). At that time, assessment of liver iron deposition using Ferriscan identified an elevated liver iron concentration of 5.3 mg/g dry tissue (0.17‐1.8)  to 457 μg/L .Several case reports have described the use of the combination of iron chelation with caeruloplasmin replacement .During the period of follow‐up, we did not encounter any safety issues with this combination therapy and the treatment was well tolerated. Plasma transfusion is not without risk; although rare these include transmission of infective pathogens, allergic reactions and transfusion‐related lung injury.4This case report adds further evidence of treatment efficacy and safety in using combination therapy with FFP and iron chelation in ACP. We were able to demonstrate biochemical improvement in iron overload over a three‐year period with a reduction in ferritin and ALT, together with an improvement in his (iron‐restricted) microcytic anemia. However, owing to different liver imaging modalities before and after treatment, we were unable to quantify this radiologically. We did not encounter any adverse effects using this combination therapy. More studies are needed to assess treatment efficacy over a longer duration, with specific attention being paid to neurological outcomes. Moreover, establishing FFP dosing guidance, perhaps using CP level monitoring in order to titrate the FFP dose, would help to ensure optimal treatment at minimal risk to the patient and cost to the care provider.Andreas Tridimas—conception and design, drafting the manuscript, data extraction; Karolina M. Stepien, Andreas Tridimas, Godfrey T. Gillett, Adrian Williams, Sally Pollard, Nandini Sadasivam, Kirsty Mellor, Anthony Catchpole—conception and design, revising the manuscript critically for important intellectual content. Godfrey T. Gillett suggested initiation of plasma infusion therapy shortly after diagnosis. Anthony Catchpole performed the copper‐65 test and provided us with its interpretation. All authors read and approved the manuscript before submission.Written informed consent to publication has been obtained.AT and KMS.


KE + CHO induced ANK in all six subjects with median peak βHB concentration of 2.6 mmol/L (range: 1.6‐3.1). Subjects remained normoglycemic in both study arms, but delta glucose concentration was 2‐fold lower in the KE + CHO arm. The respiratory exchange ratio did not increase in the KE + CHO arm when workload was doubled in subjects with overt myopathy. In vivo 31P MR spectra showed a favorable change in quadriceps energetic state during exercise in the KE + CHO arm compared to CHO in subjects with overt myopathy. Effects of ANK during exercise are phenotype‐specific in adult GSDIIIa patients. ANK presents a promising therapy in GSDIIIa patients with a severe myopathic phenotype.Glycogen storage disease type IIIa (GSDIIIa) is an inborn error of carbohydrate metabolism caused by a debranching enzyme deficiency. A subgroup of GSDIIIa patients develops severe myopathy. The purpose of this study was to investigate whether acute nutritional ketosis (ANK) in response to ketone‐ester (KE) ingestion is effective to deliver oxidative substrate to exercising muscle in GSDIIIa patients. This was an investigator‐initiated, researcher‐blinded, randomized, crossover study in six adult GSDIIIa patients. Prior to exercise subjects ingested a carbohydrate drink  or a ketone‐ester  + carbohydrate drink . Subjects performed 15‐minute cycling exercise on an upright ergometer followed by 10‐minute supine cycling in a magnetic resonance (MR) scanner at two submaximal workloads . Blood metabolites, indirect calorimetry data, and in vivo ClinicalTrials.gov identifier: NCT03011203.  P‐MR3131 phosphorus magnetic resonanceβHBbeta‐hydroxybutyrateAcAcacetoacetateANKacute nutritional ketosisCOVcoefficient of variationCPETcardio‐pulmonary exercise testFAOfatty acid oxidationFFAsfree fatty acidsGDEglycogen debranching enzymeGSDglycogen storage diseaseGSDIIIaglycogen storage disease type IIIaHMPshexose‐mono‐phosphatesKEketone‐esterPCrphosphocreatinePiinorganic phosphateRERrespiratory exchange ratioRPErate of perceived exertionRQrespiratory quotient2maxVOmaximum oxygen uptakeWmaxmaximal workload1AGL gene, resulting in impaired glycogen debranching enzyme (GDE) activity in liver, cardiac, nerve, and muscle tissue. According to the International Study on GSDIII (ISGSDIII), most patients present before the age of 1.5 years with various combinations of hepatomegaly, failure to thrive and fasting intolerance.Glycogen storage disease type IIIa  is an inborn error of carbohydrate metabolism caused by pathogenic variants in the Dietary management to maintain normoglycemia and prevent hyperketonemia is the mainstay of treatment in GSDIIIa patients. Specifically, it involves designed dosing and frequency of a high‐protein diet with cornstarch supplementation.The pathophysiology underlying muscle dysfunction in GSDIIIa patients is still incompletely understood. Various disease mechanisms have been proposed. First, the primary GDE deficiency together with high carbohydrate intake could cause excessive storage of an abnormal glycogen structure  in muscle interfering with contractile function.To date, physical training remains the most effective approach to prevent and reverse progressive loss of skeletal muscle mass and muscle quality.Here, this matter was further investigated. Specifically, we investigated if ANK in response to KE ingestion is equally effective in adult patients with GSDIIIa to deliver oxidative substrate to exercising muscle with favorable effects on intramuscular energy balance state during submaximal exercise.22.1The Medical Ethical Committee of the University Medical Center Groningen (UMCG), the Netherlands approved the study protocol (ref. no. METc2016.591). The study was conducted according to the principles of the Helsinki Declaration of 1975 as revised in 1983. All subjects provided written informed consent prior to inclusion in the study.2.2AGL variation analysis, GSDIIIa further specified as GDE deficiency in muscle or clinical and/or biochemical signs of cardiac and/or skeletal muscle involvement, and (b) age from 18 to 65 years. Exclusion criteria included (a) pregnancy or breastfeeding, (b) insulin‐dependent diabetes mellitus, (c) recent cardiac disease , (d) contraindications for magnetic resonance imaging studies, (e) unable to perform bicycle exercise, and (f) intercurrent illness which may influence exercise tolerance. Adults with GSDIIIa were recruited by the center of expertise for hepatic GSD at the UMCG, the Netherlands and the Faroes Hospital, Tórshavn, Faroe Islands. The trial was conducted at the UMCG between February 2017 and March 2018. Inclusion criteria were (a) confirmation of GSDIII with enzyme assay and/or 2.3This was an investigator‐initiated, randomized, researcher‐blinded, comparator‐controlled, two‐way crossover study (NCT03011203). Three consecutive study visits were scheduled at the UMCG, after written informed consent. Foreign subjects stayed in a hotel close to the study site during the whole study period. Other subjects stayed in the hotel the night before study visit 2 and 3.2.42.4.1Z‐scores for muscle ultrasound density of the biceps, quadriceps, calf (gastrocnemius and/or soleus), and tibialis anterior muscles were calculated based on age‐related references values.2max).General history, physical examination, muscle ultrasound, dynamometry and plasma analysis of liver transaminases, total creatine kinase, and NT‐proBNP were performed. The activity level was assessed by the International Physical Activity Questionnaire.2.4.2am, a taxi brought the subject to the study site. Here the subject was transported in a wheelchair to minimize exercise before study procedures. After general instructions and positioning for exercise, the subject was given the study drink at approximately 9:00 am (t = 0). Forty‐five minutes after study drink ingestion, the subject started with a 15‐minute upright bicycle protocol. The target pedaling frequency was 70 rounds per minute (rpm). During the upright bicycle protocol, indirect caloric and heart rate measurements were collected . Ratings of perceived exertion (RPE) were assessed with the Borg scale.Subjects fulfilled an identical exercise protocol during visits 2 and 3, which were separated by 7 days in all subjects. Subjects were asked to refrain from alcohol and caffeine for 24 hours prior to each study visit and to consume a similar breakfast in the morning of both study visits. A 3‐day food diary was collected prior to visit 2 and 3. At 8:00 2.531P‐MR) spectra during exercise and recovery. The 31P‐MR spectroscopy permits continuous and noninvasive monitoring of inorganic phosphate (Pi), phosphocreatine (PCr), and pH, allowing assessment of muscle energy metabolism during exercise.The primary outcome measures were blood βHB and glucose concentrations, exercise performance, as assessed with indirect caloric and heart rate measurements, and 31 phosphorus magnetic resonance  or an isocaloric carbohydrate drink containing only maltodextrin ~66 g (CHO). In both study arms, a minimum of 1.2 g of carbohydrate per minute exercise supply was ensured.2.731P‐MRS data was blinded for study drink randomization. Ingestion and preparation of study drink took place in another study room to guarantee blinding for this researcher. All data sets from 31P‐MR spectra were coded for blinded analysis by one researcher (I. J. H.).Subjects were randomly assigned to a study drink order based on enrollment. The researcher (J. A. L.J.) who analyzed the 2.82.8.131P‐MR spectroscopic data on quadriceps energy and pH balance at rest, during exercise and postexercise were collected using a 3.0 Tesla whole‐body MR‐scanner fitted with a supine cycle ergometer  and analyzed according to methods described elsewhere.31P‐MR spectra during 10‐minute cycling exercise at 70 to 80 rpm was synchronized with motion using custom‐built ergometer‐spectrometer interfacing hardware and software as described elsewhere.In vivo 2.8.231P‐MR spectral properties as described elsewhere  in combination with prior knowledge information on ATP metabolite content and see also .29 Int2.931P‐MRS data. Data were considered statistically significant at P < .05.Data were analyzed using SPSS Statistics version 23.0  and visualized using Prism 5 software . Data from indirect calorimetry were processed using Matlab version 2019a . A linear mixed model was used to analyze the effect of study drink on blood metabolites. Fixed effects in this model were the main effects of study arm, time, workload, and order of the study drinks in the cross‐over design as well as the two‐way interactions between study arm and workload and study arm and time and the three‐way interaction between study arm, time, and workload. Subject ID was included in the model as a random effect. Post hoc contrast analyses were performed to determine the effect of study drink per time point. Descriptive statistics were used for remaining outcome parameters and a two‐tailed paired Student's test was used for statistical differences in 33.1Six GSDIIIa  patients from four different countries were enrolled with a median age of 46 years (range: 36‐63). Table 3.2KE was well tolerated by all subjects. One subject (#2) reported mild headache after ingestion of KE + CHO (maximum βHB concentration in this patient reached 2.8 mmol/L). The other subjects did not report any symptoms of nausea, headache, or stomach pain after ingestion of the KE + CHO drink. No adverse events were reported.3.3t = 0 ranged from 0.0 to 0.4 mmol/L in the CHO arm and from 0.0 to 0.7 mmol/L in the KE + CHO arm. Four hours after ingestion of KE + CHO median βHB concentration was 0.5 mmol/L . All subjects remained normoglycemic in both study arms  completed the supine cycling exercise task inside the MR scanner. Due to technical difficulties, the data of the CHO arm collected during exercise could not be analyzed for subject #5. Of the three subjects with overt myopathy , only subject #1 was able to complete the regular in‐magnet exercise task. Subject #3 performed an adapted exercise task consisting of propelling the ergometer flywheel without any mechanical braking (“idle” resistance of the ergometer) due to insufficient leg muscle power. Subject #2 was unable to perform any form of supine cycling exercise in the MR scanner due to foot flexor paralysis.Pi/PCr ratios are useful measures of muscle mitochondrial function, where a decrease in Pi/PCr ratio reflects improved mitochondrial efficacy. Figure 31P‐MR measurements in quadriceps muscle during in‐magnet cycling exercise for subject #3. In the CHO arm, this subject was able to maintain cycling exercise for 162 seconds  in contracting fibers  musm Figure .3.6tau of Pi recovery toward resting level  comparable to those previously found in healthy adultsThe whole‐body indirect calorimetry results confirmed that subjects performed exercise at submaximal workloads, with peak heart rates around 130 bpm at the highest imposed workload. When stratifying for muscle phenotype, a striking finding was that the COV was 2‐ to 3‐fold lower in the KE + CHO arm compared to the CHO arm in both groups—that is, subjects with overt myopathy (#1‐3) and subjects without overt myopathy (#4‐6) Figure . On a wh31P spectrum at exhaustion recorded in the CHO arm showed large accumulation of phosphorylated glycolytic intermediates as well as mild muscle acidification, both of which were absent in the KE + CHO arm  AGL genotype in subjects #4 to 6 causes truncation of enzyme, which affects both enzymatic functions, namely oligo‐1,4‐1,4‐glucanotransferase and amylo‐1,6‐glucosidase.AGL knock‐out mice demonstrated a reduction in muscle wasting in mice fed a high protein and glucose restricted diet.On basis of these results, we conclude that ANK during exercise induced by prior KE ingestion may be beneficial to GSDIIIa patients when engaging in physical activity. Specifically, the results of this study suggest that such therapeutic approach should principally be focused on patients with a severe muscle phenotype, exemplified by subjects #1 to 3 in this study. Nevertheless, long‐term follow‐up studies are needed in more patients to assess efficacy and safety. Here it may be important to note that subjects #4 to 6 all originated from and resided in the same North‐Atlantic archipelago with a known founder pathogenic variation,The generalizability of our findings is subject to several limitations. Like other clinical studies in patients with ultra‐rare disease, this study was complicated by difficulties of including sufficient subjects. Despite the demanding study protocol, we were able to recruit six patients from four different countries, reflecting the wide spectrum of clinical heterogeneity between adult GSDIIIa patients. The latter prompted the analysis of two n = 3 subgroups rather than one n = 6 population. Due to this small number of subjects and the great heterogeneity between individual GSDIIIa patients, definitive conclusions on the efficacy of ANK cannot be drawn for the whole cohort. The intervention was constrained by the absence of a negative control group because of the requirement of a “sufficient” amount of CHO in both study arms to ensure patient safety. This issue was discussed during a focus group meeting with patients, resulting in a decision to have safety arguments outweigh methodological arguments. Similarly, muscle biopsy was offered as an optional procedure in our protocol, similar to CoxFor decades, several descriptive studies have underlined the importance of investigation of muscle involvement in GSDIIIa patients,The intellectual property and patents covering the uses of ketone bodies and esters are owned by BTG Ltd., The University of Oxford, the NIH and TdeltaS Ltd. Should royalties ever accrue from these patents, Kieran C. Clarke and Pete J. Cox as named inventors may receive a share of royalties as determined by the terms of the respective institutions. Kieran C. Clarke is director of TdeltaS Ltd., a spin out company of the University of Oxford, to develop and commercialize products based on the ketone‐ester. Irene J. Hoogeveen, Foekje de Boer, Willemijn F. Boonstra, Caroline J. van der Schaaf, Riemer J. K. Vegter, Johannes H. van der Hoeven, M. Rebecca Heiner‐Fokkema, Terry G. J. Derks, and Jeroen A. L. Jeneson declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.The Medical Ethical Committee of the University Medical Center Groningen (UMCG), the Netherlands approved the study protocol (ref. no. METc2016.591). The study was conducted according to the principles of the Helsinki Declaration of 1975 as revised in 2000. All subjects provided written informed consent prior to inclusion in the study.Not applicable.Figure S1 Study protocolFigure S2. Participant flow chartFigure S3‐5. AMARES 31P‐MRS fitting details of subject #3.Table S1. Changes in blood metabolites after ingestion of CHO and KE + CHO study drink from all subjects (n = 6).Table S2. Individual data on RER during the upright bicycle protocol in both study arms.Table S3. Individual data on muscle pH at 30% and 60% Wmax equivalents in both study arms.Click here for additional data file.


Marked elevations of alanine aminotransferase (ALT) are caused by a limited number of underlying pathologies, including hepatic ischemia, drugs/toxins, viral hepatitis, and—rarely—autoimmune hepatitis. The aim of this study was to determine the relative incidence of pathologies resulting in ALT greater than 1000 IU/L and factors predicting clinical outcomes in an Australian cohort.A retrospective cohort study of all adult patients with ALT levels greater than 1000 IU/L between January 2013 and December 2015 was conducted at a large teaching hospital network in Australia. Multivariable logistic regression analysis was used to determine predictors of etiology and mortality.There were 287 patients identified with ALT levels greater than 1000 IU/L. The most common causes were ischemia (44%), drugs/toxins (19%), biliary obstruction (16%), and viral hepatitis (7%). Independent predictors of a diagnosis of ischemic hepatitis included : hypotension , chronic obstructive pulmonary disease (COPD) , coronary artery disease , congestive cardiac failure , diabetes mellitus , metabolic acidosis , gamma‐glutamyltransferase < 135 IU/L , and albumin <34 g/L . Independent risk factors for all‐cause 28‐day mortality included: septic shock , metabolic acidosis , history of COPD , cardiogenic shock , prothrombin time ≥ 20 s , and age ≥ 65 years .Ischemic hepatitis was the most common cause of ALT levels greater than 1000 IU/L and was associated with high mortality. Common causes of marked alanine aminotransferase derangement include liver ischemia, drugs/toxins, biliary obstruction, and viral hepatitis. Determination of etiology and outcomes of patients with severe liver injury can be guided by clinical and biochemical parameters. Alanine aminotransferase (ALT) is an enzyme found predominantly in the liver and is used as a marker of hepatocellular injury.The various causes of marked ALT derangement differ in their prognoses and treatment requirements: ischemic hepatitis is associated with a high mortality and usually requires admission to the intensive care unit (ICU),The aim of this study was therefore to: (i) determine the incidence of ALT greater than 1000 IU/L, (ii) determine the etiology of ALT concentration greater than 1000 IU/L, (iii) describe the clinical and biochemical profiles of the most common etiologies, and (iv) describe the outcomes and factors predicting 28‐day mortality of patients with ALT greater than 1000 IU/L in a large Australian cohort.We conducted a retrospective cohort study at Eastern Health, a large nontransplant health service that includes three teaching hospitals in Melbourne, Australia, over a 3‐year period between January 2013 and December 2015. The study was approved by the Eastern Health Research Ethics Committee. All cases of serum ALT concentration greater than 1000 IU/L in adult patients aged 18 years and older were retrieved from the hospital pathology database. An ALT cut‐off level of 1000 IU/L has been used in a previous study and is approximately 33 times the ULN.R‐factor as (ALT/ULN of ALT)/(ALP/ULN of ALP). Based on our laboratory's reference range, we used 40 IU/L as the ULN of ALT in males, 30 IU/L as the ULN of ALT in females, and 110 IU/L as the ULN of ALP in all patients.Relevant comorbid conditions were included if they were recorded in hospital medical notes. Clinical signs including hypotension (systolic blood pressure < 90 mmHg), bradycardia (heart rate < 50 bpm), hypoxia (oxygen saturation < 90%), and fever (temperature ≥ 38.0°C) were included if there was a documented episode occurring within the 48 h preceding the ALT measurement. Biochemical markers including prothrombin time, serum levels of platelets, creatinine, albumin, bicarbonate, total bilirubin, gamma‐glutamyltransferase (GGT), and alkaline phosphatase (ALP) were collected at the time of ALT measurement or at the first available instance within the following 12 h. Survival data were collected with censoring at 28 days from the collection date of ALT greater than 1000 IU/L. Aspartate aminotransferase (AST) data were limited as they are not routinely collected as part of the panel of liver function tests at our health service. We calculated the The etiology of marked elevations of ALT was determined according to predetermined criteriaU test. Categorical variables were expressed as frequencies and percentages, and comparisons were made using Fisher's exact test. For inclusion in logistic regression analysis, continuous variables were dichotomized using clinically relevant categories and/or receiver operating characteristic analysisP < 0.1 were included in multivariable logistic regression models that were adjusted for age ≥ 65 years and gender as prespecified covariates. Two models were used: (i) a full model, and (ii) a reduced model using backward stepwise selection with removal criterion P > 0.05. Kaplan–Meier analysis using the log‐rank test was used to estimate and compare survival curves with a serial time of 28 days. A two‐sided P < 0.05 was used to indicate statistical significance. Statistical analysis was performed using Stata/IC 14.1 .Normally distributed continuous variables were expressed as mean ± SD and compared using the two‐sided T test. Non‐normally distributed continuous variables were expressed as median with interquartile range and compared using the Mann–Whitney There were 287 patients with an ALT level greater than 1000 IU/L identified amongst 388 267 acute admissions to our health service between January 2013 and December 2015. The incidence of ALT levels over 1000 IU/L was therefore 7.4 cases per 10 000 admissions per year. Baseline demographic data were obtained , 49 were due to septic shock , 12 were due to hypovolemic shock , and 1 was due to anaphylactic shock.Of the 54 cases of toxic hepatitis, 28 were due to paracetamol toxicity, 7 were attributed to antibiotics , 3 were due to 3,4‐methylenedioxymethamphetamine (Ecstasy), 1 was due to alcohol, and 15 were due to others .Of the 47 obstructive causes, 33 were due to choledocholithiasis (without cholangitis), 8 were due to ascending cholangitis, 4 were due to a pancreatic mass, 1 was due to cholangiocarcinoma, and 1 was due to biliary stricture.Of the 21 viral causes, 8 were due to hepatitis C, 6 were due to hepatitis B, 3 were due to hepatitis A, 2 were due to cytomegalovirus, and 2 were due to Epstein–Barr virus.Of the remaining 19 identifiable causes, 6 were due to direct liver insult , 5 were due to rhabdomyolysis, 3 were due to autoimmune conditions , 3 were due to pregnancy‐related conditions , 1 was due to Wilson's disease, and 1 was due to leptospirosis.P < 0.001) and were more likely to have had a documented episode of hypotension, bradycardia, and hypoxia  compared to patients with all other causes  and biliary obstruction . There was no difference in length of ICU stay across etiologies. No patients received a liver transplant in the study period.The mean length of hospital stay was 6.9 days (SD 6.9), and there was no significant difference in length of stay across etiologies. Eighty‐six (30.0%) patients were admitted to ICU, and the mean length of ICU stay was 3.5 days (SD 3.6). Patients with ischemic hepatitis were more likely to be admitted to ICU compared to patients with toxic hepatitis (54.3 P < 0.001), with a median survival of 11 days (95% CI 5–17) . The overall 28‐day mortality rate was 30.5% (82 of 269), and almost all cases were patients with ischemic hepatitis . The remaining deaths were caused by toxic hepatitis in two cases, obstructive hepatitis in one case, and viral hepatitis in one case. The most common causes of death were cardiogenic shock (43.9%), septic shock (41.5%), and hemorrhagic shock (6.1%). Patients with ischemic hepatitis had a higher mortality compared to all other causes  bias may be present, in part because clinical interpretation of previous events through chart reviews may be subjective. However, this was mitigated through the use of our predefined diagnostic criteria for the etiology of marked ALT derangement. Certainly, the independent variables that emerged from our analysis cannot be considered causative.Marked elevation in ALT reflects severe liver injury and has a high mortality rate. Common causes of marked ALT derangement include liver ischemia, drugs/toxins, biliary obstruction, and viral hepatitis. The relative frequencies of etiology likely reflect the regional incidences of each condition. Ischemic hepatitis is associated with a high mortality and accounts for the vast majority of deaths following marked ALT derangement. A diagnosis of ischemic hepatitis can be predicted by important clinical information and has a distinct biochemical profile. Biliary obstruction is an underrecognized but common cause of marked ALT derangement in an Australian population. Early diagnosis and identification of high‐risk patients are required to mitigate the high mortality associated with severe liver injury.Table S1. Criteria for retrospective diagnosis of etiology of serum alanine aminotransferase (ALT) concentration > 1000 IU/L.Table S2. Comparison of clinical characteristics of patients with alanine aminotransferase >1000 IU/L who died within 28 days of any cause compared with those who survived.Click here for additional data file.