More than five decades have been invested in understanding glucose biosensors. Yet, this immensely versatile field has continued to gain attention from the scientific world to better understand and diagnose diabetes. However, such extensive work done to improve glucose sensing devices has still not yielded desirable results. Drawbacks like the necessity of the invasive finger‐pricking step and the lack of optimization of diagnostic interventions still need to be considered to improve the testing process of diabetic patients. To upgrade the glucose‐sensing devices and reduce the number of intermediary steps during glucose measurement, fourth‐generation glucose sensors (FGGS) have been introduced. These sensors, made using robust electrocatalytic copper nanostructures, improve diagnostic efficiency and cost‐effectiveness. This review aims to present the essential scientific progress in copper nanostructure‐based FGGS in the past 10 years (2010 to present). After a short introduction, we presented the working principles of these sensors. We then highlighted the importance of copper nanostructures as advanced electrode materials to develop reliable real‐time FGGS. Finally, we cover the advantages, shortcomings, and prospects for developing highly sensitive, stable, and specific FGGS. Diabetes can result in elevated blood glucose levels that pose a severe hazard to human health.Electrochemical sensors are used to monitor blood glucose levels rapidly.Enzymes‐based glucose sensors are divided into three significant generations.2Among the electrochemical detection techniques, two basic methods, amperometry and potentiometry, have been widely used.The previous decade has seen extensive advancements in the working mechanisms and principles of FGGS.2+ cations present in CuO get oxidized to Cu3+, and CuOOH is formed 2.The mechanism of this reaction is based on the electrochemical function of copper oxide that changes its oxidation states during the reaction.3O4, MnO2, CuO, Cu2O have almost similar glucose‐sensing mechanisms  and modified with CuO nanowires electrode (CuO NWs) gave a linear range of 0.5 μM to 5.9 mM and sensitivity of 4398.8 μA mMCu(III) catalyzes glucose's oxidation into gluconolactone and hydrolyzed into gluconic acid, as shown in Figure The sensitivity, detection range, detection limit, and response time of FGGS composed of copper and copper oxide nanostructures are given in Table 33O4, NiO, CuO, Cu2O, ZnO, and so on) or bimetallic electrodes and carbon‐based nanomaterials have been extensively explored for their excellentA variety of nanostructured electrocatalysts are being investigated to develop advanced FGGS, as simple electrodes cannot compete with their level of glucose detection.3O4, are widely used for glucose biosensors due to their high electrochemical activity, low cost, and the low potential requirement for electron transfer reactions.In addition, metallic,2O) are particularly significant among transition metal oxides because of their excellent thermal, mechanical, and chemical stability. Much attention has been paid to developing copper oxide electrode materials for FGGS with high electrocatalytic activities.2O NPs), or CoNiCu alloy nanotubes (NTs) arrays transferred on indium tin oxide, helps to determine their crystal structure, orientation, shape, and size as well as other structural parameters such as average grain size, strain and crystal defects, characteristics that are important for FGGS applicationsCopper oxides −1 cm−2.Various CuO nanostructures have been extensively researched and synthesized into multiple shapes with individual properties and performance through the development of nanotechnology, such as NPs, nanorods, nanofibers, nanospheres, flower‐like structures, and so on.−1·cm−2, and broad linear range from 2.0 M to 2.5 mM.A simple, cost‐effective microwave‐based method for synthesizing a sensitive FGGS with CuO nanodisks was investigated, which maintained its remarkable selectivity, a high sensitivity of 627.3 μA·mMOcimum tenuiflorum.−1 cm−2, with a detection limit of 0.038 μM (S/N = 3), and linear response ranges from 1 to 7.2 mM with a fast response of 3 s.Dayakar et al. fabricated FGGS with pristine CuNPs on glassy carbon electrode (GCE). They prepared this sensor by the simple green method using leaf extract of −1 cm−2, and a low detection limit of about 0.41 μM.−1 cm−2.CuO porous nanostructure (CuO PN) electrodes have been shown to enhance glucose detection capabilities, showing a linear range of 0.005–0.225 mM, a high sensitivity of about 3072 μA mM4 as a reducing agent producing the best homogeneous phase of CuO NPs (Cu‐colloids).−1 cm−2 for glucose, in a wide linear range of 1–850 μM. The Cu‐colloid particles' excellent electrocatalytic activity is related to their unique blossomed flower‐shaped morphology and the pointed tips of opened mesoporous or microporous petals.Ashok and colleagues synthesized CuNPs using three methods, the colloidal method with NaBH2O) have also been investigated to study their electrocatalytic properties to fabricate FGGS. Zhang et al. synthesized a self‐supported Cu2O/Cu/CC (carbon cloth) using a single step, simple potentiostatic electrochemical deposition on CC.2O/Cu/CC) demonstrated a superior sensitivity of 6952 μA mM−1 cm−2, reproducibility (relative standard difference [RSD] = 2.74%) with an extremely low detection limit of 0.6 μM with a fast response time of less than 2 s. Moreover, 90.2% of the original sensitivity of the electrode was maintained during a 1‐month stability test.Most Cu or Ni‐based NEGS are synthesized by modifying the substrate with NPs, scattered structures, or metal‐carbon hybrids.−1 cm−2, a more comprehensive linear range of 0.5 μM–11.84 mM, with a low LOD of 0.4 μM and was free of interference. Researchers found that the hybrid composite's enhanced catalytic properties were due to its large surface area, multiple active sites, accounting for its excellent electrical conductivity of MWNTs and good selectivity of Cu‐MOF. The glucose detection efficiency of the developed sensor was tested in actual blood samples, yielding satisfactory and feasible results. However, due to the high alkaline conditions, its practical application was hindered.The sensitivity and conductivity of the purest Cu electrode can be easily contaminated by oxidation; thus, researchers are focused on improving their efficiency by incorporating other components.3.2FGGS have received widespread attention in recent times because of their ability to deliver reproducible results with higher stability than traditional EGS. This, therefore, increases the practicability of FGGS in clinical applications and several recent studies support this advantage.Hence, recently the scientific focus has shifted toward developing nanomaterials‐based NEGS that provide better linear range and ease in operation. Nanomaterials also possess sizes equivalent to enzyme molecules that aid in their functionalization. Highly conductive carbon‐based nanomaterials are the best choice for electro‐oxidation of glucose; however, their stability is a significant concern. As a result, researchers have concluded that copper and its bimetallic nanomaterials have a promising potential for fostering and promoting FGGS in mass production. Because of its unusual electrocatalytic activity and use in many electrochemical devices, copper‐based FGGS have gained widespread popularity in recent decades. Copper is abundantly available in nature, low cost, and environmentally friendly and shows high catalytic activity.Despite the innumerable research done on FGGS and the use of nanomaterials in their construction, there are still a few challenges that need to be tackled before these sensors can be availed. The major obstacles that need to be addressed include miniaturization of the sensor, reduction in the sample required during sensing, and quick delivery of results. Furthermore, more work is necessary to improve the shelf life and reduce the cost of such test strips based on NEGS. The application of nanomaterials in the development of FGGS has also gained widespread attention, especially to create sweat based platforms and in vivo implantable glucose sensors for glucose measurements. However, such sensors to detect glucose concentrations in these fluids would require greater sensitivity of copper‐based FGGS. Also, these sensors show a highly accurate correlation between glucose levels measured in interstitial fluids and blood when measured using the commercially available blood‐glucose meter. This correlation has been observed in several recent studies,In addition, the biocompatibility and shelf life of copper‐based FGGS depend on the morphology of the copper architectures and the attached functional groups.Furthermore, there is no sophisticated control over the protective sheath, thickness, and pore size of the nanoporous layer that would allow FGGS to work on plasma, human serum, and blood when undiluted. Moreover, disturbances caused by various electro‐active and electro‐inactive chemical species must still be adjusted.3.3−1 cm−2, and a LOD of 1.37 M. Several studies have shown that combining graphene with CuO NPs will produce more synergistic results and hence improve glucose detection. For instance, Qian et al. suggested a simple and straightforward method for depositing Cu2O NPs on graphene sheets (Cu2O@CRG) using sodium citrate as a reluctant agent,2O or CRG. However, these sensors possess several drawbacks related to the inherent nature of the enzymes, like their minimal reproducibility and decreased stability when used for long durations. Also, the catalytic function of enzymes is easily affected by the external pH, temperature, absence or presence of humid conditions, and other chemicals in the vicinity.The current glucose‐sensing devices available are based on EGS. A few studies have also demonstrated the catalytic effect of copper oxide in enzymatic glucose oxidation and hydrogen peroxide detection with good stability and ultra‐sensitive response. Umar et al., for example, established a reproducible glucose biosensor based on well‐crystallized flower‐shaped CuO nanostructures formed of thin nanosheets.To reduce the drawbacks incurred by these EGS and the volatile nature of enzymes, the NEGS were introduced Figure . As discNanozymes have also gained popularity in recent decades. These nanozymes are nanomaterials that possess properties akin to enzymes and have been extensively studied for sensing purposes.4Recent advances in the fabrication of FGGS have significantly improved. However, the practical application of these devices continues to face significant challenges and hurdles. Efforts are being made to investigate Cu as a competing electrode for FGGS by improving the surface area, shape, and size to volume ratio, enhancing catalytic properties and stability, and detection capability. Reduced stability, shorter shelf life, and enzyme denaturation have limited the application of EGS, focusing researchers toward the tremendously growing field of FGGS. Even though numerous articles have been published demonstrating the efficacy of transition elements as electrocatalytic nanostructures for FGGS advancement, enzyme‐based glucose sensors still outperform the former category for their sensitivity and biocompatibility. To commercially enlist the FGGS, copper‐based characteristics such as low cost, stability, simplicity, and natural abundance can be leveraged to achieve the central goal. When exposed to air, Cu‐based biosensors are easily oxidized, reducing their stability. This can be improved by incorporating other nanomaterials within them, but this complicates FGGS fabrication.Cu‐based electrodes perform best in alkaline media that operate in a synergistic environment, though the exact mechanism remains unknown. The researchers hope to develop FGGS to detect low glucose levels in blood samples and other bodily fluids. These significant challenges in making Cu‐based glucose sensors stable, reproducible, competitive, and commercially available with EGS are within reach, but the field remains exciting. Cu and its oxides are among the best electrocatalytic nanostructures for manufacturing glucose biosensors, but complete dedication is required to eliminate the shortcomings mentioned above. These efforts should be taken seriously to overcome the difficulties associated with maintaining optimal glucose levels in the blood. These findings contribute to the investigation of future research for the development of advanced versions of Cu‐based FGGS.The authors declare no potential conflict of interest.Tasbiha Awan: Data curation ; methodology . Gowhar Naikoo: Conceptualization ; investigation ; writing–original draft . Hiba Salim: Formal analysis ; methodology . Fareeha Arshed: Formal analysis ; methodology . Israr Hassan: Data curation ; formal analysis ; methodology . Mona Pedram: Formal analysis ; methodology . Waqar Ahmed: Formal analysis ; methodology . Hakkim Faruck: Data curation ; investigation ; methodology . Alaa Aljabali: Investigation ; writing–original draft ; writing–review and editing . Vijay Mishra: Investigation . Ángel Serrano‐Aroca: Formal analysis ; investigation ; methodology . Rohit Goyal: Formal analysis ; investigation ; methodology . Poonam Negi: Investigation . Martin Birkett: Investigation ; writing–review and editing . Mohamed Nasef: Writing–review and editing . Nitin Charbe: Writing–review and editing . Hamid A. Bakshi: Conceptualization ; investigation ; project administration ; supervision ; writing–original draft ; writing–review and editing . Murtaza Tambuwala: Conceptualization ; investigation ; project administration ; supervision ; writing–original draft ; writing–review and editing . https://publons.com/publon/10.1002/btm2.10248.The peer review history for this article is available at


Imatinib is the gold standard for the treatment of all phases of Philadelphia positive Chronic Myeloid Leukemia (CML). During treatment, patients may develop cytopenia. We aimed to study the baseline characteristics and factors associated with cytopenia at a Nairobi Hospital.p values.This was a retrospective case-control study of patients aged ≥18 years on follow-up at the Glivec International Patient Access Program (GIPAP) clinic from 2007 to 2015. The cases consisted of CML patients on imatinib who developed cytopenia. The controls were CML patients on imatinib who did not develop cytopenia. Baseline socio – demographic, clinical, hematologic, and molecular data were retrieved from patients’ files. Chi square or fishers’ exact tests were used to analyze for differences between cytopenia and no cytopenia. Binary logistic regressions were employed to identify relationships. Univariate and multivariate analyses were done to identify independent predictors of cytopenia. Odds ratios (OR) were presented including the 95% confidence intervals and respective A total of 201 patients were studied consisting of ninety-four (94) patients with cytopenia and 107 with no cytopenia. Among the entire population, males were 52, and 42% were aged 36–50 years. Sex, age, marital status, occupation and education level were similar between the cytopenia and no cytopenia groups.Among the 201 patients, 70% had symptoms for > 12 months before diagnosis, 78.6% had B symptoms at baseline, 80% had a moderate splenomegaly at baseline.p = 0.002), neutropenia (p = 0.001), neutrophilia > 100,000/mm3 (p = 0.002) and thrombocytopenia (p = 0.001) increased the odds of developing cytopenia. On multivariable analysis, baseline anaemia , neutropenia , thrombocytopenia  and thrombocytosis  increased the odds of developing cytopenia.Among patients with cytopenia, 40 and 37.4% developed cytopenia within 3 months and 3–6 months respectively after imatinib initiation. Baseline neutrophilia, neutropenia, anaemia, thrombocytosis, thrombocytopenia was found in 68, 11, 11, 23.5 and 11% respectively. Baseline hemoglobin, neutrophil and platelet level were significantly different between the cytopenia and the no cytopenia group. On univariable analysis, baseline anemia with hb < 7.9 g/dL (Odds of cytopenia were higher in presence of baseline cytopenia and thrombocytosis. Clinicians should have a high index of suspicion for these patients.The online version contains supplementary material available at 10.1186/s12885-021-09162-z. CML is a Philadelphia/BCR-ABL1-positive chronic neoplastic disease with an increase in blood granulocytes and bone marrow myeloid precursors, bone marrow hypercellularity composed of mature granulocytes and their precursors. Chronic myeloid leukaemia (CML) is due to a clonal disorder that cause granulocyte cell line proliferation .The fusion protein resulting from this translocation, the BCR-ABL1, is a tyrosine kinase which acts independently of any stimulation and results in the development of CML . TyrosinCML may be diagnosed in any of the three phases. Chronic phase which is the initial phase of CML characterized by increased neutrophils with various early-stage granulocytic precursors; accelerated phase which is characterized by 10–19% blasts in the bone marrow or peripheral blood, genomic evolution, persistent or increasing abnormal blood counts despite TKI treatment, (leukocytosis (> 10 ×  109/L), thrombocytosis (> 1000 × 109/L), or thrombocytopenia (< 100 × 109/L) unrelated to therapy, 20% or more basophils and splenomegaly; blastic phase which is characterized by more than 20% blasts in blood or bone marrow or extramedullary blastic infiltration, genomic evolution, splenomegaly  MyelosupAvailable data reported that longer time from diagnosis to treatment, prior interferon or imatinib therapy, and a lower white blood cell count at the initiation of TKI therapy were associated with an increased risk of grade II to IV cytopenia . GuillotCytopenia is a recognized problem at the Glivec International Patients’ Assistance Program (GIPAP) clinic in Nairobi. Its presence may be associated with poorer response to treatment . UnderstThis was a retrospective case-control study of patients, ≥ 18 years of age, on imatinib, enrolled between 2007 and 2015. All data was retrospective and all charts were reviewed for both populations over a 36-month period for blood parameters, which for our patient population, was tested every 1–3 months during clinic review visits. It aimed to analyze the sociodemographic as well as the clinical and laboratory characteristics associated with increased odds of development of cytopenia among CML patients on imatinib. The Max access program provides imatinib therapy for patients enrolled in the GIPAP (CML) clinic at the Nairobi Hospital. Cumulatively, the clinic has 1200 patients. An average of 150 patients attend the clinic bi-weekly. The age range of patients seen in the clinic is 6 years to 75 years. Males in the clinic are in similar proportion to females and almost 90% present in chronic phase. Patients who initiate treatment are compliant with treatment with adherence rates of approximately 80% [CML patients aged ≥18 years, attending GIPAP clinic from 2007 to 2015 and on imatinib 400 mg daily who developed cytopenia ≥ grade 2 were enrolled. The definitions of cytopenia are included in a publication by the same group of a study preceding this one . CytopenThe estimated required sample size for cases and controls was 76 each using a simple approximation for calculating sample sizes for comparing independent proportions by Fleiss (1980) . ConsecuSociodemographic variables included age, sex, marital status, level of education and occupation.Clinical variables included symptom duration prior to diagnosis, determined by diagnosis of CML less than or more than 12 months after onset of symptoms. Presence of B symptoms was defined as unintentional weight loss of ≥10 kg in the preceding 6 months, fevers, and night sweats. Time to development of cytopenia was defined as less than 3 months, 3–6 months and 6–12 months after imatinib initiation. Laboratory characteristics included the CBC with grade of cytopenia determined as per National Cancer Institute Common Terminology Criteria for Adverse Events v.3 . BaselinData from excel was imported into the statistical analysis software for data management and analysis. Continuous data was presented using means and respective standard deviations (SD). Counts and corresponding percentages were used for categorical variables such as gender of participants and cytopenia group. Bivariate comparisons such as comparisons of cytopenia versus no cytopenia was done using chi square or fishers’ exact tests for categorical variables as deemed appropriate. Univariable logistic regression analysis was employed for demographic, clinical and laboratory variables associated with cytopenia. The odds ratio (OR) and 95% Confidence Intervals was also reported. Stata package, version 15.1 was used during statistical analysis. There were some (50 out of 201 records) BCR-ABL1 reports that were missing. To mitigate for this during the regression modeling, a category for missing data was created to ensure that the multivariable model included all the observations as available for all the covariates. Tables were used to display results. All methods were carried out in accordance with relevant guidelines and regulations.Data on types, grades and time course of cytopenia has been analyzed and published .9/L in 68% (134) and < 1.5 × 10 9/L in 22 patients while the rest had normal levels. Baseline platelets count > 450 × 109/L was found in 23.5% (47) and < 150 × 109/L in 11% (22). There was similar distribution among cytopenia and no cytopenia groups.Ninety four (94) patients with cytopenia and 107 controls were included. Females were 97 and males were 104 of the total number of patients, 42% (85) of the 211 were aged 36–50 years, 30% (61) between 18 and 35 years and 27% (55) > 50 years, 73.1% (147) were married, 75.6% (152) were employed and 47.8% (96) and 46.8% (94) had secondary and tertiary education respectively. Clinically, 70% (142) had symptoms for ≥12 months before diagnosis, and 78.6% (152) had B symptoms at diagnosis. BCR-ABL was 0–25% for 35.8% (72), 26–75% for 27.9% (56) and > 75% for 11.5% (23) from 151 results available, baseline Hb was < 8 g/dl in 11% (22), 8–10 g/dl in 36.7% (73) and > 10 g /dl in 52.3% (104). Baseline neutrophil was > 7.5 to > 100 × 10p values > 0.05.Sex, age, marital status, occupation and education level were similar between the cytopenia and no cytopenia groups, Sixty-six patients (63.6%) among the 94 studied had a monocytopenia. Anemia developed in 32 (34%), neutropenia in 26 (27.6%) and thrombocytopenia in 8 (8%) of the 94 patients. Among patients with bicytopenia, the most common type was anemia plus neutropenia in 12 (12.7%) patients, followed by neutropenia plus thrombocytopenia in 8 (8%) patients and anemia and thrombocytopenia in 3 (3%) patients. Pancytopenia developed in 5 patients among the 94 studied  . LikewisSex, age, marital status, occupation and education level were similar between the cytopenia and no cytopenia groups and they did not increase the odds of developing cytopenia. A study carried out in Iraqi reported that females on imatinib had a predilection for anemia compared to males . This hiClinical symptoms such as time duration to diagnosis, spleen size and positive B symptoms are markers of advanced disease and were similar between the cytopenia group and the no cytopenia group. These factors did not however, increase the odds of cytopenia. Splenomegaly is a marker of advanced disease and is known to be significantly linked to poor outcomes . CytopenBlood counts and BCR-ABL1 differed significantly between the cytopenia and no cytopenia groups with more anemia, neutrophilia, thrombocytosis and thrombocytopenia in the cytopenia than the no cytopenia groups. Baseline anemia is known to accompany a higher baseline white blood cell counts, more frequent splenomegaly, and more CML related deaths . FurtherA few studies have reported that higher BCR-ABL1 levels are associated with poor outcomes. One study demonstrated that patients who experienced very severe myelotoxicity had a significantly higher BCR-ABL1 value after conducting FISH studies . In our The study had a few limitations. Being retrospective, there was missing data that could have affected the outcomes of our study. Further, the study results can only be applied to patients with grade 2–4 cytopenia. It was not possible to risk score the patients fully and correlate prognostic score with cytopenia development due to inadequate numbers of patients with percent myeloblast reports. The Sokal and Hasford (Euro) prognostic scoring systems have been reported to predict outcomes such as overall survival in imatinib treated patients, such that patients with a high Sokal score had a lower OS at 10 years than those with intermediate or low scores .However, the role of the risk scores in predicting development of cytopenia remains controversial.High-risk patients who develop recurrent cytopenias on treatment may be more prone to develop aplasia. But, other risk scoring tools besides sokal have not definitively shown a correlation between high risk disease and development of myelosuppression, implying that myelosuppression is not merely a reflection of more advanced disease. Conversely, whether intermediate or low risk score patients have lower risk of developing myelosuppression remains a subject of active investigation.Our findings are similar to those of studies conducted both in sub-Saharan Africa and in the developed world. We recommend that physicians should have a high index of suspicion to recognize patients at risk of developing cytopenia. This includes patients with low baseline cytopenia as well as patients with baseline thrombocytosis.Additional file 1.


Study group, i.e., O + C received five alternate day sessions of ozone therapy by bagging method for 30 minutes each session. Both groups were observed for 30 days for wound healing parameters like reduction of wound surface area, wound diameter, presence and character of discharge, granulation tissue, healing wound edges, microbial negativity, and requirement of revision (re-debridement and/or amputation) surgery. Mean baseline ulcer surface area is 17.43 ± 8.6 cm2for C and 17.87 ± 9.2 cm2(range 1–50 cm2) in O + C group. Percentage change in ulcer surface after 21 days in O + C group is 32.37% compared with 17.15% in C group, which is statistically significant (p = 0.01). Rates of microbial negativity and ulcer healing were significantly faster in ozone group. There was a statistically significant decrease in hospital stay, number of revision surgeries required, and mortality in ozone group. Topical ozone gas was well tolerated. Our study supports the efficacy of ozone therapy in DFU healing and reduction in the chances of infection and revision (re-debridement and/or amputation) surgery. More research is needed for dose, duration, and exposure time standardization.The prevalence of diabetic foot ulcers (DFUs) in India is 11.6%. DFU accounts for major cost expenditure, morbidity, and mortality. One in four diabetes mellitus (DM) patients are reported to develop diabetic foot ulcer (DFU).The aim of the study is to assess the efficacy and safety of topical ozone gas therapy for healing of DFUs.Primary objective:To assess the rate of wound healing in diabetic ulcers.To assess the adverse effects of ozone gas therapy.Secondary objective:To assess the rate of achieving local microbial negativity of wound swabs.To assess the reduction in hospital stay.To assess the rate of formation of healthy granulation tissue.Study design: Prospective comparative cohort observational study.Study site: Study conducted in tertiary care teaching hospital at developing country.Study duration: Until the estimated sample size is achieved (81 in each arm).All the patients, men or women, with either type-1 or type-2 DM with a Wagner classification stages 2, 3 or post debridement stage 4 without venous insufficiency or lymphatic obstruction and without spreading cellulitis.Age above 18 years.2, gangrenous foot ulcers, active osteomyelitis, history of hypo or hyperthyroidism, hemoglobin A1c (HbA1c) >10%, ankle-brachial index <0.8, hemoglobin level <8 g%, serum creatinine level >2.5 mg/dL or patient on dialysis, serum albumin level <2 g/dL, liver function tests  elevated to more than three times the upper normal limit, patients with collagen vascular diseases, patients on steroid therapy, immunosuppressed host, known cancer patient, pregnant females, and post-partum females.Wound size of >50 cmThe criteria include patients withdrawing consent for further participation in due course of study at any point of time due any of the adverse effects like pungent smell of ozone gas, etc.N = (Zα/2 + Zβ)2/(p1 − p2)2 × P × (1 − P)N = size per group;p1 = % of ulcers healed in Ozone plus C Group 24%p2 = % of ulcers healed in C Group 12%P = pooled prevalencep1 + p2/2 = 24 + 12/2 = 18p = 18Zα/2 = Z0.1/2 = Z0.05 = 1.96 — FromZtable at type I error of 10%Zβ = Z0. 20 = 0.842—at 80% powerSample size 81 patients in each group.Study was conducted after institutional ethical approval. All eligible patients were enrolled in the study after informed consent. Treatment arm allocation was done as per treating surgeons' preference and since it was an observational study, investigators had no control over it. All the patients of DFU received conventional wound treatment which consisted of thorough surgical wound debridement followed by daily wound cleaning with desloughing (EUSOL) and antiseptic solution like povidone iodine and application of sterile bandage dressing. Surgical debridement is repeated as and when needed. Once wound turns healthy without any visible slough use of desloughing and irritant antiseptic agent was discontinued and wounds were dressed with emollient agents like paraffin tulle to avoid overgrowth of granulation tissue and sterile bandage. Wound care was performed by surgical resident doctor assisted by the faculty of Department of General Surgery.Multimodal glycemic control plan with dietary modifications and oral hypoglycemic drugs, and insulin if needed was utilized with aggressive sugar monitoring for all patients.In addition to above conventional management; study group also received topical ozone gas treatment as follows.Day 1 of ozone therapy: wound is cleansed with saline and wound swab collected for microbial testing. Topical ozone gas therapy was given by bagging technique.2 + 68.400 cal → 2O3.Ozone gas is generated by medical ozone gas generator . Pure oWound is cleaned thoroughly with normal saline. A piece of saline soaked sterile gauze is placed over the wound to avoid direct exposure of wound to ozone. A bag is formed as per the size of the wound with use of sterile polythene sheet and adhesive sticking. Bag is placed over the wound and ozone gas outlet pipe is inserted in the bag. Mouth of this bag is sealed by roller bandage to avoid gas leakage . Ozone Five such sessions of ozone therapy are given on alternate day.Wound swab was taken on day 1 and every fourth day until microbial negativity and then weekly thereafter for all patients.Wound assessment done on day—1, 4, 8, 14, and 21 days for both the groups and each time following outcome parameters were measured.Wound size: Sterile transparent polyethylene dressing placed over the wound which was already covered partially with a sterile gauze in such a way that edges of wound were exposed. A transparent acetate sheet with grid lines tracing is then placed over this sterile polyethylene transparent sheet through which underlying ulcer boundaries could be seen and marked on grid sheet  surgery and to know the outcome of the patient.All the relevant data were entered in predesigned case record form and compared between two groups for each of the outcome parameter to find out statistical significance.In our study we had total of 162 patients, 81 each in C and O + C therapy group.Wound size: In our studyn = 162, median values of wound surface and maximum wound diameter of C (n = 81) and O + C (n = 81) are calculated on day 1, 4, 8, 14, and 21  and that of largest ulcer diameter for two interventions were significantly different Thus, percent change in ulcer surface area after 21 days was higher 32.37% in O + C group compared with O alone group. And this change or reduction was statistically significant (p = 0.01) (Similarly mean reduction in largest ulcer diameter after 21 days was higher for O + C group (18.62%) compared with C group (14.02%) which was statistically significant (= 0.01) Association of character of wound exudate with C and O + C group: Character of exudate can be purulent, seropurulent, serosanguinous, or serous and they were respectively given scores as 4, 3, 2, and 1.2.p-value <0.05  for two interventions were not significantly different . At any given time point, healing granulation tissue score is estimated to be 20% more for patients receiving O + C therapy compared with patient receiving C therapy. This difference was statistically significant.]4. Association of rate of formation of healing wound edges with C and O + C therapy: To assess the rate of formation of healing wound edges scores were given as follow: <25% = 1, 25–50% = 2, 50–75% = 3, >75% = 4.p-value <0.05  for two interventions were significantly different , methicillin-resistant Staphylococcus aureus (MRSA),Escherichia coli,andPseudomonasin O + C group than C group  surgery required in C and O + C group: Patients were followed up for 30 days for outcomes of requirement of revision surgery and mortality.p-value of 0.04 . Among PP patients with wound size ≤5 cm2, the rate of total wound closure was 100 versus 50% in the sham treatment group (p = 0.006).p-Value in this study (p = 0.006) is more significant than our study (p = 0.01); this might be because of increased sessions of ozone gas therapy.In double blind randomized control trial (RCT) by Wainstein et al in 2011p< 0.05). The wound size reduction was significantly more in O + C group than in control group (p < 0.001).p-Value in this study (p = 0.001) is more significant than our study (p = 0.01) and again this might be because of increased sessions of ozone gas therapy.In Zhang et alNumber of sessions ozone to be given and rate of wound healing might be related as seen in Wainstein et al and Zhang et al but large scale RCT is needed to prove this hypothesis.2O2). They interact with cellular DNA and cysteine residue and release second messengers, they activate enzymes, such as chemical and immune-response mediators in controlled manner to bring about therapeutic effect of ozone on healing.Ozone is capable of reacting to wide range of organic and inorganic biological substances to cause oxidation. Some of these substrates are proteins, amino acids, and unsaturated fatty acids, which form part of the lipoprotein complexes of plasma and of the double layers of the cellular membranes. Ozone reacts with membrane phospholipid bilayer to form some elements like ozonides, aldehydes, peroxides, and hydrogen peroxide . Hence character of ulcer exudate is one of the good assessment parameter for healing of ulcers. No studies are present in the current scenario to study this parameter.The character of ulcer exudate changes from purulent to seropurulent after debridement and as ulcer heals it converts to serosanguinous then finally to serous. This change is faster in O + C group compared with C group  compared with patient receiving C treatment. This difference was statistically significant. And disappearance of signs of inflammation in surrounding skin was much faster in O + C group. Hence ozone might help in disappearance of signs of inflammation and faster induction of healing of wound edges. This might be because of immune modulation function of ozone.On day 21, healing wound edges score was estimated to be 27% more for patients receiving O + C therapy .E. coliandPseudomonasamongst gram-negative organisms. In a study by Fontes et alPseudomonaswas cleared on day 8 in O + C group while it required 14 days to clear in C group.Ozone is specifically effective against MSSA and MRSA S. aureusand MRSA were greater when compared with the control oil group. Almost 100% ofS. aureuswere eliminated by ozonated oil in 5 minutes and MRSA in 15 minutes. In addition, 100%S. aureusand 100% MRSA were eliminated by ozonated water in 1 minute.In Song et al,Gulmen et alEscherichia coli, oxacillin-resistantStaphylococcus aureus, oxacillin-susceptibleS. aureus, vancomycin-resistantEnterococcus faecalis, extended-spectrum β-lactamase-producingKlebsiella pneumoniae, carbapenem-resistantAcinetobacter baumannii,A. baumanniisusceptible only to carbapenems, andPseudomonas aeruginosasusceptible to imipenem and meropenem. All isolates were completely inhibited by the ozone–oxygen mixture while growth occurred in the other 2 control groups.Fontes et al,Enas Mohammed AliC. albicanswas reduced by over 99.5% at 3 ppm ozone concentration after 180 minutes' exposure time. Prevention of mycelial growth inA. flavuswas detected with 100% inhibition efficacy at 3 ppm ozone after 210 minutes. The study also determined the efficiency of ozonation in degrading mycotoxins produced by most dominant mycotoxigenic fungal species. The production of aflatoxins and trichothecene toxins was greatly inhibited at 3 ppm ozone after 180 minutes.Spore viability ofWells et alIt has high oxidizing capacity and acts on microbial wall, which acts on bacteria, viruses, and fungi; hence it has broad spectrum activity.It is effective even on highly resistant microbial flora.It improves the delivery of oxygen to the tissues.It improves the red blood cell metabolism, making the metabolism of glucose more efficient.It improves the metabolism of the fatty acids for the activation of antioxidant enzymes in charge of eliminating peroxides and free radicals.The principal metabolic effects attributed to ozone are:Increment of the use of glucose at the cellular level.It improves the protein metabolism.Direct effects on the unsaturated lipids, it oxidizes them and induces at the same time the repair mechanisms.Ozone has a dual action mechanism: analgesic and anti-inflammatory. These effects seem to be due to its way of acting on diverse targets:Decrease the production of mediators of the inflammation.The oxidation (inactivation) of metabolic mediators of pain.It clearly improves local blood microcirculation, with an improvement in the oxygen delivery to the tissues, essential for the regeneration of anatomical structures; the elimination of toxins and in general the resolution of the physiological disturbance that generated the pain.Because of faster rate of ulcer healing and early microbial negativity, hospital stay of patients has significantly reduced in our study in O + C group. Hence ozone gas indirectly helps to decrease the overall cost expenditure for management of DFU. Rosul and Patskan studied RCT for DFU; there was significantly faster rate of wound healing, lipid peroxidation, reduction in hospital stay, greater antioxidant protection, and yielded significant decrease in microbial colonization of wounds.p-value 0.01 by Chi-square test. This suggests statistically significant reduction in requirement of revision surgery in O + C group. Similar study by Izadi et alBecause of effective antimicrobial, antioxidant, and immune modulation property of ozone there was faster rate of microbial negativity and ulcer healing and decreased requirement of revision surgeries. Forty-two percent of patients required revision surgery in C group while O + C group did not require revision surgery withp-Value by Fischer exact test was found to be 0.04 which is statistically significant. Three deaths were seen in patients who required revision surgery and one of them had MRSA infection. These deaths were due to septic complications of diabetic foot and not due to other co-morbid conditions. As we discussed above, because of effective antimicrobial and immune modulation property of ozone there was faster rate of microbial negativity, ulcer healing, and decreased requirement of revision surgeries. Hence ozone has a role in prevention of both DFU morbidity and 30 day mortality.There were no deaths observed in O + C group while percentage mortality in C group was 4.9% on 1 month follow-up.Our study was nonrandomized.Population was heterogenous with having different inherent wound healing capacity due to different age, gender, and co-morbid conditions leading to multiple confounding factors.Smaller duration of follow-up (21 days) due to social or technical issues of the hospital.Our study is prospective.2).Accurate measurement of ulcer surface area and maximum diameter  of topical ozone gas therapy is optimal for DFU. And ozone gas is well tolerated by patients at this concentration without any significant adverse effects.We recommend using ozone gas therapy for reduction in hospital stay and reduction in requirement of revision (re-debridement and amputations) surgeries. It also has a role in reduction of 30 days mortality.Thus, ozone therapy is very effective, cheap, simple, well tolerated, and easily reproducible but underutilized tool. It does not require huge infrastructure or complex equipment. Also, no recurring cost of consumables is involved making it a very suitable tool to promote wound healing in DFUs in resource-constraint regions.


We aimed to assess the correlation between vitamin D serum level and visceral fat tissue during early pregnancy.p < 0.05 to be significant.This cross-sectional study was performed in Pernambuco, Brazil. 190 low risk pregnant women  were eligible. Visceral adipose tissue was measured by ultrasonography following the technique described by Armellini. The 25(OH) D in serum was determined through chemiluminescence. The Spearman correlation test was applied to evaluate the correlation between vitamin D serum level and VAT, considering p = 0.435).Vitamin D insufficiency was present in 129 (67.8 %) of subjects. Pregnant women with or without vitamin D deficiency did not differ in age, gestational age, nutritional status and visceral adipose tissue. No correlation between visceral adipose tissue and 25(OH) D was observed: − 0.057 (Maternal visceral adipose tissue and vitamin D serum level are not correlated during pregnancy. Vitamin D deficiency (VDD) is a major global public health problem in all age groups, even in developed countries and regions with adequate ultraviolet radiation. Exposure to sunlight is the main source of vitamin D (VD) and factors such as season, time of day, latitude, skin phototype, sun exposure duration, type of clothing and the use of sunscreens may influence its synthesis –3. BraziIt is believed that VDD is associated with obesity, and adipose tissue may be responsible for its lower bioavailability. Visceral Adipose Tissue (VAT) easily absorbs VD by chemical affinity. Therefore, volumetric dilution has been proposed as the main mechanism to elucidate its low levels in obesity –12. Two In pregnant women, VDD is also an important health problem with a prevalence ranging from 5 to 84 % , 18. BesThis cross-sectional study was performed at the Hospital Dom Malan located in Petrolina (9°S and 40°W), Pernambuco state, Northeast of Brazil. Hospital Dom Malan registers about 6 000 births per year. This region has an average ultraviolet index of 13 during most of the year.2) and Atalah classification was used [Pregnant women aged 13–39 years and 8–16 weeks of gestational age were eligible. Exclusion criteria were twin pregnancy, diabetes mellitus, previous gestational diabetes or preeclampsia, fetal malformations, maternal mental disease. After screening, 190 pregnant women were included. All participants answered a questionnaire regarding socio-demographic and clinical information were taken from the medical record. Weight and height were measured according to the standardized methodology. Body mass index (BMI) was calculated by the formula: weight (kg) / height (mwas used . VAT waswas used : the conThe 25(OH) D in serum was determined through chemiluminescence, using the Atellica EVA-Siemens device (Erlangen/Germany) with a result expressed in nanograms per Milliliter. Insufficiency and deficiency values were respectively between 20 and 30 ng/mL and < 20 ng/mL, according to the values adopted by the Endocrine Society Practice Guidelines .Data were analyzed descriptively through absolute and percentage frequencies in the categorical variables and the measures: mean, standard deviation (mean ± SD), and median to numerical variables. To assess a significant association between two categorical variables, Pearson’s chi-square test including the likelihood ratio test and confidence interval (CI) was used. For the comparison between categories concerning the numerical variables, the Mann–Whitney test was used. To assess the degree of the relationship between two numerical variables, Spearman’s correlation coefficient and the specific Student’s t-test for the null correlation hypothesis were obtained.The choice of the Mann–Whitney test and Spearman correlation was due to the absence of normality, which was verified by the Shapiro–Wilk test. The margin of error used in deciding the statistical tests was 5 and 95 % CI. The data were entered into the EXCEL spreadsheet, and the program used to obtain the statistical calculations was IMB SPSS in version 25.P value = 0.435). Table 190 pregnant women were studied. The mean age was 26 ± 5.76 years and pregnant women were included in the study with a 12.3 ± 2.5 weeks of gestation. The BMI ranged from 16.6 to 47.0 kg/m² (25.7 ± 4.9 kg/m²); 57 (30 %) were overweight and 27 (14.2 %) obese. 129 (67.8 %) of pregnant women had vitamin D insuficiency, i.e., serum value of 25 (OH) D < 30 ng/mL. The thickness of the VAT varied between 0.9 and 6.1 cm (2.9 ± 0.9 cm). Pregnant women with or without VDD did not differ in age, gestational age, nutritional status and VAT  D could modulate adipogenesis through VD receptors-dependent inhibition of specific components . Other ePregnancy VDD has been described with a prevalence of 18–84 % . In the In the multicenter HAPO study, increased maternal BMI was associated with lower maternal 25(OH) D levels . HoweverOur study has some limitations. At first, a cross-sectional design was performed and we could not determine the causal relationship between VD and VAT. Second, other possible important variables confounding the VD status, like sun light exposition, dietary habits and possible seasonal variations in VD, were not evaluated in our study. However, despite these limitations our study has strengths. The present study is the first to assess the correlation of VD with VAT thickness in pregnant women. A large sample was studied and specific methods to measure VD and VAT were used.Our data demonstrated that maternal visceral adiposity and low concentrations of VD were not associated during pregnancy. However, as this was the first study to assess the association between VAT and VD in pregnant women, further studies are needed to confirm these findings.


IDH2) mutation who are ineligible for hematopoietic stem cell transplantation (HSCT).The present study evaluated the relative survival benefits associated with enasidenib and current standard of care (SoC) therapies for patients with relapsed/refractory (R/R) acute myeloid leukemia (AML) and an isocitrate dehydrogenase 2 (Propensity score matching (PSM) analysis compared survival outcomes observed with enasidenib 100 mg daily in the phase I/II AG221‐C‐001 trial and SoC outcomes obtained from a real‐world chart review of patients in France.n = 195) was associated with numerically improved overall survival (OS) relative to SoC . After matching and adjusting for covariates (n = 78 per group), mortality risk was significantly lower with enasidenib than with SoC . The median OS was 9.26 months for enasidenib  and 4.76 months for SoC . Results remained robust across all sensitivity analyses conducted.Before matching, enasidenib (IDH2 mutation who are ineligible for HSCT. Future prospective studies are needed to validate these findings using other data sources and to assess the comparative efficacy of enasidenib for other treatment outcomes.PSM analyses indicate that enasidenib significantly prolongs survival relative to SoC among patients with R/R AML and an  Overall survival was improved with enasidenib compared with SoC. Enasidenib may be an important advance in treatment for patients with R/R acute myeloid leukemia associated with IDH2 mutations who are ineligible for hematopoietic stem cell transplantation. The present study sought to indirectly compare the relative survival benefits associated with enasidenib and current SoC therapies in these patients using propensity score matching (PSM) analyses.Enasidenib is a first‐in‐class, selective inhibitor of mutant isocitrate dehydrogenase 2 (IDH2) proteins that is indicated for the treatment of adult patients with R/R AML with an 22.12.1.1Data were obtained from the AG221‐C‐001 trial of enasidenib monotherapy and the French chart review (FCR) study of patients receiving SoC therapies.IDH2+ hematological malignancies. The trial enrolled 345 patients (280 with R/R AML) aged ≥18 years who were ineligible for hematopoietic stem cell transplantation (HSCT), had a baseline Eastern Cooperative Oncology Group (ECOG) performance status score of 0–2, adequate renal and hepatic function, and a platelet count of ≥20,000/µl.The AG221‐C‐001 trial (NCT01915498) was a phase I/II, multicenter, open‐label, dose escalation, and expansion trial that investigated the efficacy and safety of enasidenib in patients with advanced mn = 113), phase I expansion (n = 126), and phase II expansion (n = 106). Combining the phase I and phase II data sets produced a total of 214 patients with mIDH2+ R/R AML who received enasidenib 100 mg/day .The AG221‐C‐001 trial included three phases: phase I dose escalation (n = 103). The inclusion criteria used in the FCR study aligned with those used in the AG221‐C‐001 trial , as determined from health records or medical charts. The chart review was carried out at nine centers in France that had inpatient diagnostic and treatment facilities for patients diagnosed with AML between 1 September 2011 and 30 September 2016, belonged to a network of oncologists or hematologists treating patients with R/R AML, had been operational and treating patients with AML for ≥24 months, and had clinical records available for review. All patients identified with R/R AML and a mIDH2+ were screened for inclusion until >100 eligible patients were enrolled.The FCR study was a retrospective, observational, multicenter, chart‐review study of patients treated with SoC therapies (The SoC therapies administered included: 5‐azacitidine (37%), cytarabine‐containing regimens (22%), ′7 + 3′ chemotherapy (16%), methotrexate and mercaptopurine (1%), mercaptopurine (1%), decitabine (1%), clofarabine (1%), best supportive care , and other therapies (11%). Data were collected by a trained data reviewer to ensure accuracy, consistency, appropriateness, and completeness. Relevant data were also reviewed by the sponsor’s clinical research scientist and clinical research physician to ensure accurate chronology of patient data, and to confirm that definitions of therapy lines and disease progression aligned with those used in the AG221‐C‐001 trial.Data in the FCR study were collected from the time of initial AML diagnosis. Conversely, patients in the AG221‐C‐001 trial were enrolled at various times after their first diagnosis of R/R AML and data were only collected after enrollment; the date of enasidenib treatment initiation was defined as the baseline date. Since the FCR study was a real‐world evidence study and lacked a clear date of treatment initiation, baseline  was defined as the initiation date of the last treatment line after the initial R/R disease diagnosis Figure . This al2.22.2.1IDH2+ R/R AML were: prior history of HSCT (yes or no), age at baseline (<65 years vs. ≥65 years), number of prior lines of AML therapy (<2 vs. ≥2), cytogenetic risk profile  was lower than the number of patients in the enasidenib group (n = 195), 1:1 optimal matching was considered more appropriate than other 1:1 matching algorithms.After consultation with clinical experts, it was determined that the propensity score (PS) covariates with the greatest impact on treatment response in patients with m2.2.2p value of <0.05 indicated a violation of the assumption).The main outcome of interest was OS, defined as the time from baseline (T0) to death from any cause. Kaplan–Meier plots were generated to summarize OS in the two treatment groups. A robust variance structure was incorporated in subsequent analyses to account for the use of PSM methods.2.2.3Sensitivity analyses were conducted to assess the robustness of the primary analysis against the choice of matching algorithm. These included: using alternative applications of PS , alternate weighting approaches , as well as analyses stratified by matched pairs.p value of <0.05, and all comparisons between groups were reported with the respective HR and associated 95% CI, which incorporated robust variance estimators.All statistical analyses were performed using R software , through the application of the ‘MatchIt’33.1IDH2+ R/R AML. Notably, the AG221‐C‐001 trial excluded patients for whom potentially curative anticancer therapy  was available at the time of enrollment. However, patients could become eligible to undergo HSCT during the course of the trial. In contrast, the FCR study did not have such an exclusion criterion, given its retrospective and observational nature. To ensure a valid estimate of comparative efficacy and alignment between the patient populations, the PSM analysis population excluded patients who underwent HSCT after baseline in both data sources . As the estimation of PS requires complete information for all covariates, the primary analysis population excluded patients with missing data for any of the covariates assessed. After the exclusion of patients with subsequent HSCT or missing data, the primary analysis population consisted of 195 patients treated with enasidenib in the AG221 C‐001 trial and 78 patients treated with SoC therapies in the FCR study.The primary analysis population included patients with m3.2n = 78 for each treatment group). For each covariate, the SMD was compared before and after matching to determine if the PSM methods resulted in sufficient balance between groups  and age ≥65 years . However, considerable differences were observed for the number of prior treatment lines, prior HSCT, and cytogenetic risk profile, as indicated by an SMD of ≥0.10 for each covariate. Fewer patients in the enasidenib group had prior HSCT , and more patients had previously received ≥2 prior lines of therapy . Cytogenetic risk was also more unfavorable in the enasidenib group, with fewer intermediate‐risk patients (enasidenib: 49% vs. SoC: 84%), and more poor‐risk patients (enasidenib: 27% vs. SoC: 6%) or failure/unevaluable patients (enasidenib: 24% vs. SoC: 10%) Table .3.4The enasidenib and SoC groups were well balanced after 1:1 optimal matching, with most SMDs improving after matching Table . Density3.5Before matching, enasidenib was associated with numerically prolonged OS relative to SoC . The results remained robust across a range of sensitivity analyses , suggesting consistent survival benefits for enasidenib beyond those provided by current SoC therapies. The estimated 12‐month probability of survival remained significantly higher in patients receiving enasidenib (37.3%–47.2%) compared with SoC therapies (18%–25.9%) through sensitivity analyses for matching, IPTW, nearest neighbor matching, and ECOG performance status score.In the absence of head‐to‐head randomized clinical trial data, PSM methodsIDH2+ R/R AML, and results suggest that enasidenib significantly prolongs survival relative to SoC therapies. These findings provide evidence in support of enasidenib as an important treatment option for patients with mIDH2+ R/R AML.Current treatment options for patients with R/R AML are limited, and there is a substantial unmet need for effective, well‐tolerated therapies.IDH2+ R/R AML who received treatment before the introduction of IDH2 inhibitors.A recent study by Largeaud and colleagues evaluated real‐world treatment outcomes among patients with mIDH2+ AML eventually develop isocitrate dehydrogenase differentiation syndrome (IDH‐DS).An estimated 12% of enasidenib‐treated patients with mIDH2+ R/R AML.There are several potential limitations to consider when interpreting the findings of this study. First, certain factors could not be included for PS estimation or subsequent statistical adjustments because of limited available data, such as the duration of first response. However, the most comprehensive set of available covariates was included, considering the prognostic significance rankings of the four clinical experts and the availability of patient information from the study data sources. This resulted in the majority of the most highly ranked prognostic factors being included in the analyses. Secondly, criticisms of analyses based on PSM techniques, such as incomplete sampling from the treatment and control groups, have previously been reported.IDH2+ R/R AML who are ineligible for HSCT. Future studies are needed to validate these findings using other data sources, and to assess the comparative efficacy of enasidenib for other treatment outcomes.In conclusion, the present findings suggest that enasidenib offers greater survival benefit than SoC therapies among patients with mSdB has received research funding and served on an advisory board for Agios; participated in speakers’ bureaus and served on advisory boards for AbbVie, Bristol Myers Squibb, and Janssen; served on an advisory board and provided consultancy to Pierre Fabre; and served on advisory boards for Astellas, Bayer, Daiichi‐Sankyo, Forma, Novartis, Pfizer, Servier, and Syros. JMB has served on advisory boards and received honoraria from Bristol Myers Squibb, Jazz Pharmaceuticals, Novartis, Otsuka, Pfizer, and Teva; and received research funding from Bristol Myers Squibb. AHW has received research funding and honoraria and served on advisory boards for AbbVie, Bristol Myers Squibb, Novartis, and Servier. AP has received honoraria from AbbVie, Amgen, Astellas, Bristol Myers Squibb, Daiichi‐Sankyo, Jazz Pharmaceuticals, Novartis, Pfizer, and Roche. BQ has received honoraria from Astellas, Celyad, Novartis, and Sunesis. CR has served on advisory boards for AbbVie, Janssen, MacroGenics, and Pfizer; served on advisory boards for and received research funding from Astellas, Bristol Myers Squibb, Daiichi‐Sankyo, Jazz Pharmaceuticals, Novartis, and Sunesis; and received research funding from Agios, Amgen, Chugai, and MaaT Pharma. MH‐B has interests in AbbVie, Astellas, Daiichi‐Sankyo, and Sunesis. NB has received honoraria from Amgen, Ariad, Jazz Pharmaceuticals, Pfizer, Shire, and Servier; and served on advisory boards for Bristol Myers Squibb. SAN, MGF, AT, RM‐G, and J(J)W are employees of Bristol Myers Squibb. CC is an employee and shareholder of EVERSANA Life Sciences Services Inc. MS is an employee of EVERSANA Life Sciences Services Inc. BH is a methodological advisor for EVERSANA Life Sciences Services Inc. GM has provided consultancy services to Bristol Myers Squibb. EMS has received consulting fees from Agios, Amgen, Astellas, Bristol Myers Squibb, Daiichi‐Sankyo, Genentech, Novartis, PTC Therapeutics, Seattle Genetics, and Syros. XT, OL, and SC have no conflicts of interest to disclose.BMS is the manufacturer of enasidenib and sponsored the trial and chart review that were used in this study. The concept and design for PSM analyses underwent internal BMS approval and EVERSANA was provided access to anonymized data from the AG221‐C‐001 trial and France Chart Review to run the analyses after approval. AG221‐C‐001 was registered with Clinicaltrials.gov (NCT01915498). The AG221‐C‐001 protocol received approval in 24 study locations from their local institutional review board or independent ethics committees. The France Chart Review study protocol did not require any submission or approval since Aixial has a global commitment to follow processes required by the Commission Nationale de l’Informatique et des Libertes (CNIL) called MR003. All patients in the AG221‐C‐001 trial were required to provide written informed consent before any study‐related procedures were performed.IDH2 mutations who are ineligible for HSCT.Results from this PSM analysis indicate that enasidenib significantly prolongs OS relative to the current SoC for patients with relapsed/refractory AML and Supplementary MaterialClick here for additional data file.


Data on influenza incidence during pregnancy in China are limited.From October 2015 to September 2018, we conducted active surveillance for acute respiratory illness (ARI) among women during pregnancy. Nurses conducted twice weekly phone and text message follow‐up upon enrollment until delivery to identify new episodes of ARI. Nasal and throat swabs were collected ≤10 days from illness onset to detect influenza.In total, we enrolled 18 724 pregnant women median aged 28 years old, 37% in first trimester, 48% in second trimester, and 15% in third trimester, with seven self‐reported influenza vaccination during pregnancy. In the 18‐week epidemic period during October 2015 to September 2016, influenza incidence was 0.7/100 person‐months (95% CI: 0.5–0.9). In the cumulative 29‐week‐long epidemic during October 2016 to September 2017, influenza incidence was 1.0/100 person‐months (95% CI: 0.8–1.2). In the 11‐week epidemic period during October 2017 to September 2018, influenza incidence was 2.1/100 person‐months (95% CI: 1.9–2.4). Influenza incidence was similar by trimester. More than half of the total influenza illnesses had no elevated temperature and cough. Most influenza‐associated ARIs were mild, and <5.1% required hospitalization.Influenza illness in all trimesters of pregnancy was common. These data may help inform decisions regarding the use of influenza vaccine to prevent influenza during pregnancy. We conducted active surveillance among pregnant women in Suzhou, China, to assess influenza incidence in a population at risk for influenza disease.22.1From October 2015 to September 2018, we conducted active surveillance for laboratory‐confirmed influenza‐associated acute respiratory illness (ARI) among pregnant women in Suzhou. Suzhou is a city located in eastern China with an estimated population of approximately 10 million in 2015.The enrollment methodology and description of the cohort profile of the China Respiratory Illness Surveillance among Pregnant women (CRISP) have been published previously.2.2Study nurses enrolled pregnant women into annual cohorts from October to September of each study year that was defined as the influenza season in the national influenza surveillance protocol.Upon enrollment, study nurses conducted face‐to‐face interviews using a structured questionnaire to collect data on the participant's demographics, health conditions, pregnancy‐associated conditions, health behaviors, social behaviors, and self‐reported influenza vaccination status. For health conditions, chronic diseases referred to any medical problem diagnosed by a doctor or other health care provider before pregnancy that lasted for at least 6 months such as diabetes, asthma, heart disease, or cancer. Pregnancy‐associated conditions referred to a newly developed condition identified during pregnancy by enrollment such as gestational diabetes or high blood pressure. Health and social behaviors included dietary supplement intake, smoking, alcohol, and self‐reported changes in working hours and social activities.2.3After enrolling pregnant women in active surveillance, study nurses conducted twice weekly follow‐up starting at the enrollment date until the delivery date or the end of pregnancy/loss of pregnancy with phone call and WeChat text message  alternatively to identify episodes of ARI. An ARI episode was defined as ≥1 respiratory symptom  and ≥1 systemic symptom  or ≥2 respiratory symptoms. When a current illness or recent illness was identified, the study nurse used a standardized questionnaire to collect data on illness onset date, symptoms, and hospital admission. Participants reporting ARI were encouraged to visit the study hospital's respiratory illness department (ambulatory clinics) or offered a house call for testing to ensure specimen collection ideally within 24 h but up to a maximum 10 days from illness onset. Study nurses collected both a nasal and a throat swab with double‐headed disposable virus sampling tube . Respiratory specimens were transported to the Suzhou CDC laboratory within 24 h of collection at 4°C and were analyzed using real‐time reverse transcription polymerase chain reaction to test for influenza virus subtype/lineage.2.4The cohorts were considered open, and eligible participants could be enrolled at any time during the study period. An enrolled participant was considered to have complete data if she completed the enrollment interview, responded to weekly surveillance contacts by study nurses until delivery or termination of pregnancy, and had perinatal records available for review. Those who were lost to follow‐up (no response to any contact for at least two consecutive weeks despite multiple attempts), voluntarily withdrew, or left Suzhou before the end of pregnancy only contributed the person‐time for which there was available data. If a pregnant woman was enrolled in an annual cohort but delivered after the end of the surveillance year, the person‐time was split between the two surveillance years. For example, if a woman was enrolled at week 10 of pregnancy and 15 weeks of her remaining pregnancy occurred in one surveillance year and the other 15 occurred in the following surveillance year, we considered 15 weeks of person‐time to have occurred in surveillance year 1 and 15 weeks of person‐time to have occurred in surveillance year 2. To streamline cohort management and reporting, the full analytic population for each surveillance year included those contributing person‐time from the previous surveillance year if applicable.We calculated incidence rate over the influenza epidemic periods of each influenza surveillance year. The start of each influenza epidemic period was defined as the first day of three consecutive influenza reporting weeks in which the percentage of specimens testing positive for any influenza virus infection was higher than 5%. The end of each influenza epidemic period was defined as the day before the first of three consecutive influenza reporting weeks in which the percentage of specimens testing positive for influenza was below 5%.Our primary outcome was the influenza incidence identified through ARI screening. For secondary outcomes, we evaluated the influenza incidence using influenza‐like illness (ILI) case definitions for screening. ILI was defined as a measured temperature ≥38°C and cough/sore throat.p < 0.05 was considered as statistically significant. R version 3.5.3 was used for statistical analysis.We described demographic, clinical, and knowledge and practices related to influenza vaccination. Chi‐square or Fisher exact tests were used to compare proportions where appropriate. Incidence rate was calculated as the number of new cases per 100 person‐month. Since the total number of missed swabs was minimal, those with missing swabs contributed person time but did not contribute to the total number of influenza positive cases; 95% confidence interval (CI) for person‐month rate was simulated with bootstrapping. Fisher exact test was used to compare person‐month rates. All tests were two sided, and a 33.1Among the women registered for prenatal care or with positive pregnancy tests in study facilities, we had high contact rates (reached) of 97% (6489/6661), 99% (8993/9116), and 98% 6779/6892) over three cohorts, respectively. Among those reached, 84% (18 724/22 261) participated in the prospective cohorts with participation rates of 87% (5636/6489) in year 1 cohort, 80% (7226/8993) in year 2 cohort, and 86% (5862/6779) in year 3 cohort. Among participants, 95% (17 871/18 724) had complete follow‐up information until delivery with minimal variability by cohort year. Most participants who did not complete follow‐up either left Suzhou , voluntarily withdrew , or were lost to follow‐up   who reported not working in the week prior to enrollment, pregnancy was the self‐reported primary reason among 86% for not working. Of all participants, 40% reported decreased working hours during pregnancy, 52% reported a reduction in general social interactions, and 57% reported reduced social activities with friends during pregnancy  reported that they had been vaccinated during pregnancy. Only 0.6% reported influenza vaccination in the prior year and 0.6% reported influenza vaccination among family members in the prior year. The proportion vaccinated during pregnancy did not differ significantly across cohorts  of 2.5 months. In 2015/2016, we collected samples for 83% of the 1429 ARIs reported. Of those, 67 (6%) were influenza positive. The influenza epidemic period for this season was 18 weeks from Week 53, 2015, to Week 17, 2016, with an influenza incidence of 0.7/100 person‐months (95% CI: 0.5–0.9), and A(H1N1)pdm09 virus most frequently detected . In 2016/2017, 98% of 2637 ARIs reported had samples collected. Of those, 185 samples (7%) were influenza positive. The influenza incidence during the total 29‐week long epidemic with two separate periods from Week 47, 2016, to Week 13, 2017, and from Week 30, 2017, to Week 39, 2017, was 1.0/100 person‐months (95% CI: 0.8–1.2), and A(H3N2) virus was most frequently detected . In 2017/2018, of 2402 ARI reported, 96% had samples collected. Of those, 225 samples (10%) were influenza positive. The influenza incidence during the 11‐week epidemic period, from Week 52, 2017, to Week 10, 2018, was 2.1/100 person‐months (95% CI:1.9–2.4), with B virus Yamagata lineage most frequently detected Table .3.3p < 0.001). The findings regarding demographic characteristics' and case definitions' difference in influenza illnesses were consistent over the entire study period (Table No significant difference in influenza incidence was observed by age or education level. Influenza incidence varied significantly when using different surveillance case definitions. Using ILI as the surveillance case definition had significantly lower influenza incidence (0.4 per 100 person‐months) than using ARI (1.2 per 100 person‐months) in overall of the epidemic periods  and in the third trimester (7.6 per 100 person‐months) in comparison with the first trimester (21.0 per 100 person‐months) during the epidemic periods Table . This ob4From 2015 to 2018, influenza incidence during epidemic periods in pregnant women varied by year ranging from 0.7 to 2.1 per 100 person‐months. Influenza vaccination during pregnancy was rare although approximately half of the women enrolled reported social distancing behavioral changes during pregnancy. Influenza incidence was similar across trimesters. Using ILI as a case definition missed more than half of the total influenza illnesses compared with broader ARI criteria. Over the three cohorts, 1.6–5.1% of influenza‐associated ARI cases required hospitalization.Prior to this study, there were limited data on influenza incidence and epidemiology of infection during pregnancy in China.Although we found that the incidence of ARI during pregnancy varied by trimester, in our cohort, influenza incidence was similar across trimesters. Studies from the United States during the 2009 influenza pandemic described a higher frequency of hospitalization among pregnant women with influenza virus illness in the third trimester.Applying the overall cohort influenza incidence rates during pregnancy of our study to a 12‐week‐long epidemic period, our result is comparable with the estimates in unvaccinated adults aged 18–64 years based on a modeling study from the United States, which estimated a cumulative seasonal incidence of symptomatic influenza of 4.3%–7.9% in seasons of moderate severity.Few participants in our cohort reported receiving an influenza vaccination during their pregnancy or in the year prior to their pregnancy. This finding is consistent with other published data from China, which showed that 0.2% of participants reported influenza vaccination within the last 12 months, and none during pregnancy.Our study had several strengths. First, this prospective cohort used laboratory‐confirmed influenza as the outcome allowing us to identify respiratory disease incidence specific to influenza. Second, the study cohort had high participation and sample collection rates compared with similar studies,This study was subject to several limitations. First, our surveillance case definitions do not capture atypical and asymptomatic manifestations of influenza infection. Second, our cohort only describes influenza incidence during pregnancy, so we are unable to compare the findings from this population to other high‐risk populations or healthy women of child‐bearing age. Finally, Suzhou is an economically developed city in China, and the participants in our cohort were older and had higher education levels compared to pregnant women in Suzhou overall5Influenza illnesses in all trimesters of pregnancy were common in Suzhou, China, and we found that non‐febrile influenza illnesses were more frequent than febrile influenza illnesses during pregnancy. Pregnant woman in China are not getting vaccinated for seasonal influenza, and other studies have shown that barriers to vaccination include pregnancy listed as a contraindication in package insert, self‐perceptions that they are not at risk of infection and healthcare worker reluctance to vaccinating this population.No conflict of interest declared.This study was approved by the Institutional Review Board (IRB) of Jiangsu Provincial Center for Disease Control and Prevention and the United States (U.S.) Centers for Disease Control and Prevention relied upon the Jiangsu Provincial IRB.Liling Chen: Data curation; formal analysis; methodology; project administration; software; supervision; visualization. Suizan Zhou: Conceptualization; methodology; project administration; validation; visualization. Lin Bao: Data curation; investigation; project administration; supervision. Alexander J. Millman: Formal analysis; methodology; validation; visualization. Zhongwei Zhang: Data curation; investigation; resources; supervision; visualization. Yan Wang: Data curation; investigation; resources; supervision; visualization. Yayun Tan: Data curation; formal analysis. Ying Song: Methodology; validation; visualization. Pengwei Cui: Data curation; formal analysis. Yuanyuan Pang: Data curation; investigation; supervision. Cheng Liu: Data curation; investigation; supervision. Jiangchun Qin: Data curation; investigation; supervision. Ping Zhang: Data curation; investigation; supervision. Mark G. Thompson: Formal analysis; methodology; visualization. A. Danielle Iuliano: Formal analysis; methodology; visualization. Ran Zhang: Methodology; project administration; validation; visualization. Carolyn M. Greene: Conceptualization; methodology; validation; visualization. Jun Zhang: Funding acquisition; methodology; project administration; software; visualization.The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.https://publons.com/publon/10.1111/irv.12888.The peer review history for this article is available at


To compare the diagnostic accuracy of US shear wave elastography (SWE) and magnetic resonance elastography (MRE) for classifying fibrosis stage in patients with nonalcoholic fatty liver disease (NAFLD).Patients from a prospective single-center cohort with clinical liver biopsy for known or suspected NAFLD underwent contemporaneous SWE and MRE. AUCs for classifying biopsy-determined liver fibrosis stages ≥ 1, ≥ 2, ≥ 3, and = 4, and their respective performance parameters at cutoffs providing ≥ 90% sensitivity or specificity were compared between SWE and MRE.2) with fibrosis stage distribution (stage 0/1/2/3/4) of 43, 36, 5, 10, and 6%, respectively, were included. AUCs (and 95% CIs) for SWE and MRE were 0.65 (0.54–0.76) and 0.81 (0.72–0.89), 0.81 (0.71–0.91) and 0.94 (0.89–1.00), 0.85 (0.74–0.96) and 0.95 (0.89–1.00), and 0.91 (0.79–1.00) and 0.92 (0.83–1.00), for detecting fibrosis stage ≥ 1, ≥ 2, ≥ 3, and = 4, respectively. The differences were significant for detecting fibrosis stage ≥ 1 and ≥ 2 (p < 0.01) but not otherwise. At ≥ 90% sensitivity cutoff, MRE yielded higher specificity than SWE at diagnosing fibrosis stage ≥ 1, ≥ 2, and ≥ 3. At ≥ 90% specificity cutoff, MRE yielded higher sensitivity than SWE at diagnosing fibrosis stage ≥ 1 and ≥ 2.In total, 100 patients (mean age, 51.8 ± 12.9 years; 46% males; mean BMI 31.6 ± 4.7 kg/mIn adults with NAFLD, MRE was more accurate than SWE in diagnosing stage ≥ 1 and ≥ 2 fibrosis, but not stage ≥ 3 or 4 fibrosis.For detecting any fibrosis or mild fibrosis, MR elastography was significantly more accurate than shear wave elastography.• For detecting advanced fibrosis and cirrhosis, MRE and SWE did not differ significantly in accuracy.• For excluding advanced fibrosis and potentially ruling out the need for biopsy, SWE and MRE did not differ significantly in negative predictive value.• Neither SWE nor MRE had sufficiently high positive predictive value to rule in advanced fibrosis.• The online version contains supplementary material available at 10.1007/s00330-021-08369-9. With an estimated global prevalence of 25%, nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide . NAFLD cHistology is the current clinical standard for assessing fibrosis stage but liver biopsy is invasive, costly, and associated with non-negligible complication risk . These dThe purpose of this study is to compare the diagnostic performance of SWE versus MRE for staging fibrosis in a well-characterized cohort of American adults with suspected or known NAFLD using histopathology as the reference standard. Secondarily, we explored the impact of obesity and hepatic steatosis on performance.This is a cross-sectional study of a prospectively recruited cohort of patients with known or suspected NAFLD who underwent liver biopsy for clinical care and contemporaneous SWE and MRE for research within 180 days of liver biopsy between July 2016 and June 2019. Confounder-corrected chemical-shift-encoded (CSE)-MRI was performed as part of the MRE exam in order to estimate proton-density fat fraction (PDFF), which was used to stratify the cohort in the exploratory analyses. This study was approved by the Institutional Review Board and is compliant with the Health Insurance Portability and Accountability Act.Study participants were recruited at the University of California, San Diego (UCSD), NAFLD Research Center. The screening process consisted of a standardized clinical evaluation which included a detailed physical examination, biochemical profiling, and an alcohol history assessment performed using the Alcohol Use Disorders Identification Test and Skinner Lifetime Drinking questionnaires. Eligible participants provided written informed consent to undergo SWE and MRE. Participants were instructed to fast for at least 8 h prior to SWE and MRE exams.For this research, a single experienced hepatopathologist  reviewed the clinically obtained biopsy specimen and scored the histologic features using the NASH Clinical Research Network histologic scoring system . FibrosiDetails of eligibility criteria, clinical assessments, liver biopsy protocol, and histology interpretation are available as Supplemental Methods.SWE exams were performed on a clinical ultrasound system  provided by GE for this research through an equipment loan agreement. The ultrasound system was equipped with the transducer and software required for SWE.One of four certified diagnostic medical sonographers  performed SWE using a convex transducer (C1-6). Sonographers were scheduled for each exam based on availability.For SWE, participants were imaged in the dorsal decubitus position with the right arm fully abducted to facilitate a right intercostal approach. The transducer was oriented perpendicular to the liver capsule to optimize the acoustic window. Then, SWE was activated and, once a real-time colorized stiffness map of the right liver parenchyma had stabilized during an 8–10-s breath hold at shallow expiration, the sonographer recorded the stiffness map with a button press. The sonographer then placed a circular ROI at least 1 cm below the liver capsule but no more than 8 cm from the skin surface that overlaid as much of the homogeneous color map as possible while avoiding large blood vessels, portal tracts, and rib shadowing. The mean and standard deviation of shear wave speed values within the ROI were recorded.The above steps were repeated until 10 sequential shear wave speed (SWS) measurements were acquired per participant (out of a maximum of 20 attempts), as recommended by the manufacturer. A study was considered adequate if the IQR for the 10 measurements was less than 30% of the median (IQR/median < 0.30), 14. TheMR exams were performed using a 3-T research scanner with a 60-cm bore  and a 32-channel torso radiofrequency coil array. The scanner was fitted with MRE hardware and software licensed for research (Resoundant) , 16. TheR2 < 95%) were cross-hatched to exclude them from analysis [An active acoustic driver set to the standard frequency of 60-Hz delivered vibrations via a passive pneumatic driver that was centered over the liver and secured snugly to the abdominal wall by an elastic band. A two-dimensional (2D) gradient-recalled-echo (GRE) MRE sequence modified with bipolar motion encoding gradients synchronized to the applied vibration imaged the shear wave displacement. Four 10-mm contiguous axial slices were acquired through the widest transverse section of the liver, each with a 16-s breath hold performed at relaxed end-expiration. Acquisition parameters are listed in Supplemental Methods. Using MRE reconstruction software, the MR scanner automatically processed the wave images into cross-sectional 2D shear-stiffness maps; unreliable pixels  downloaded the raw and processed MRE data for offline analysis. Using MRE analysis software , the analyst manually drew free-form ROIs on portions of the right hepatic lobe on the wave images while avoiding the liver edge (outer 1 cm), major vessels, and areas of nonplanar or low amplitude wave propagation , 18, 19.A 2D multi-echo spoiled gradient-recalled-echo sequence with magnitude reconstruction was performed through the entire liver. Using a previously described custom algorithm, the MR scanner automatically processed the source images into cross-sectional PDFF maps –24, whicThe pathologist was blinded to imaging data. Sonographers were blinded to clinical, histological, and MRI data. MR analysts were blinded to clinical, histological, and ultrasound data.Statistical analysis was performed by a postdoctoral fellow  under the supervision of a biostatistician  using “R” statistical computing software .Sample size was based on feasibility. The target enrollment was set to ≥ 100 participants who complied with the study protocol and completed SWE and MRE.Analyses of diagnostic performance were performed in participants in whom both SWE and MRE were adequate, as defined earlier. Spearman’s correlation was used to evaluate the relationship between SWE, MRE, and fibrosis stages.p value less than 0.05  was considered statistically significant. We chose a priori not to formally compare additional performance metrics  to reduce the number of comparisons.ROCs and AUCs with DeLong 95% confidence intervals (CIs) were computed for SWE and MRE for classifying each dichotomized fibrosis stage. AUCs were compared using the DeLong test for dependent ROCs. The shear wave speed cutoffs (SWE) or stiffness cutoffs (MRE) providing at least 90% sensitivity or at least 90% specificity for each dichotomization were identified. Performance parameters at those cutoffs were compared using McNemar’s test for paired proportions. The Bonferroni correction was applied to each grouped comparison of AUC, sensitivity at 90% specificity, and specificity at 90% sensitivity. A To evaluate the impact of obesity and steatosis on both techniques, the above analyses were repeated separately in obese (BMI ≥ 30) and nonobese (BMI < 30) participants and in those with none-to-mild and moderate-to-severe steatosis as determined noninvasively by published PDFF cutoffs  .Between July 2016 and June 2019, 118 patients with liver biopsies to evaluate known or suspected NAFLD met inclusion criteria, of whom 18 were excluded , and for stiffness values and fibrosis stages is 0.654 (p < 0.01). Representative SWE and MRE images are shown in Fig. 2, and the mean (± SD) cumulative ROI size over 4 slices of MRE for each participant was 3350 (± 1498) pixels (469 cm2 ± 210 cm2).Mean shear wave speed and stiffness values are shown in Fig. p = 0.005) and stage ≥ 2 fibrosis . The AUC point estimates of MRE were nominally higher than those of SWE for stage ≥ 3 and stage = 4 fibrosis, but the differences were not significant . The point estimate for PPV was higher for MRE than for SWE for all stages of fibrosis among this particular cohort, though formal statistical comparisons were not performed.At sensitivity of at least 90%, the SWE cutoffs were 1.27, 1.49, 1.46, and 1.59 m/s for stage ≥ 1 fibrosis, stage ≥ 2 fibrosis, stage ≥ 3 fibrosis, and stage 4 fibrosis, respectively; the MRE cutoffs were 2.01, 2.77, 2.77, and 2.77 kPa, respectively. MRE had higher specificity than SWE for all stages of fibrosis, and the difference was significant for stage ≥ 1, ≥ 2, and ≥ 3 (p ≤ 0.01). The point estimate for NPV was higher for MRE than for SWE for all stages of fibrosis except cirrhosis (stage 4) among this particular cohort, though formal statistical comparisons were not performed.At specificity of at least 90%, the SWE cutoffs were 1.75, 1.79, 1.78, and 1.81 m/s for stage ≥ 1 fibrosis, stage ≥ 2 fibrosis, stage ≥ 3 fibrosis, and stage 4 fibrosis, respectively; the MRE cutoffs were 2.60, 3.06, 3.17, and 3.42 kPa, respectively. MRE had higher sensitivity than SWE for all stages of fibrosis, and the difference was significant for fibrosis stages ≥ 1 and ≥ 2 (n = 64) and nonobese (n = 36) participants, MRE was superior to SWE at diagnosing stage ≥ 1 fibrosis among obese participants (p = 0.008). In stratified analysis of participants with none-to-mild steatosis using PDFF cutoff < 17.43% (n = 68) and moderate-to-severe steatosis using PDFF cutoff ≥ 17.43% (n = 32), MRE was superior to SWE at diagnosing stage ≥ 2 fibrosis among participants with none-to-mild steatosis (p = 0.009), and at diagnosing stage ≥ 1 fibrosis among participants with moderate-to-severe steatosis (p = 0.024).In stratified analysis of obese  that may impact imaging study performance. Hence, the optimal test or combination of tests has yet to be defined. Our study aimed to compare MRE and SWE against histological reference standard in a NAFLD population. While MRE was significantly more accurate than SWE for diagnosing lower stages of fibrosis (stage ≥ 1 and ≥ 2), the two techniques did not differ significantly at higher stages of fibrosis (stage ≥ 3 and = 4). In exploratory analyses, MRE also showed a trend towards better performance than SWE in all participant subgroups regardless of the presence of obesity or the severity of steatosis, though the differences between subgroups were sometimes significant only in the lower fibrosis stages.Our study is the first to detect a significant difference in performance between SWE and MRE at diagnosing lower stages of fibrosis. A previous study by Furlan et al.on American adults with NAFLD examined the diagnostic performance of SWE and MRE at detecting significant fibrosis (stage ≥ 2) and advanced fibrosis (stage ≥ 3) and did not find a statistically significant difference, while a recent study by Imajo et al. on Japanese adults with NAFLD examined the diagnostic performance of SWE and MRE at detecting the full spectrum of fibrosis and found that MRE offered superior performance at staging cirrhosis only , 11. TheCompared to published studies on the diagnostic performance of SWE for fibrosis staging in NAFLD patients, we found lower diagnostic accuracy as assessed with AUCs , 25–27. The diagnostic performance of MRE across all dichotomized fibrosis stages in our study was consistent with prior studies on NAFLD patients and overweight-to-obese patients, which included patients with similar fibrosis stage distribution , 9, 29. As opposed to ruling out disease, ruling in disease requires high specificity and PPV. Although we identified high-specificity (≥ 90%) cutoffs, our cohort was assembled from an outpatient setting, where the pre-test probability of advanced fibrosis tends to be low. In this situation, despite applying high-specificity cutoffs, the PPVs for ruling in advanced fibrosis  are not sufficient to avoid biopsy altogether. Our results are consistent with those reported by Loomba et al., where an MRE stiffness cutoff of 3.63 kPa yielded a specific result (91%) and a high NPV of 97% for excluding stage ≥ 3 fibrosis in NAFLD patients, but a PPV of only 68% for ruling it in . Furlan Our study has several limitations. First, the small sample sizes of obese and nonobese subsets as well as the nonuniform stratification of steatosis severity by PDFF cutoff values limited our assessment of obesity and steatosis and their confounding effects on SWE and MRE. Future studies are needed to verify our preliminary finding from the exploratory analyses that MRE is superior to SWE regardless of body habitus and steatosis severity. Also, the distribution of liver fibrosis in our cohort is skewed towards the milder end of the spectrum. Although this may increase the applicability of our results to common clinical contexts such as fibrosis screening, the relatively low number of participants with fibrosis stage ≥ 2 compared to fibrosis stage 0–1 limits discrimination between adjacent advanced fibrosis stages. For instance, for a predefined sensitivity ≥ 90%, MRE cutoff is the same for fibrosis stages 2, 3, and 4 (2.77 kPa) while SWE cutoff for fibrosis stage 3 is lower than for fibrosis stage 2. For the purposes of comparing SWE and MRE, fibrosis distribution affects both techniques equally and would not introduce a bias in favor of one method. Second, this study was conducted using US and MRI systems from a single manufacturer at a single subspecialty center focused on NAFLD research, which may limit the generalizability of its results to other settings such as community centers or sites with systems from other vendors. Third, as technology advances rapidly, it is possible that newer technologies would have provided more accurate performance. For SWE, this might include the use of software that provides real-time feedback on the quality of shear wave propagation and the use of time-harmonic elastography techniques in obese patients. For MRE, this might include a spin-echo echo planar imaging sequence rather than a GRE sequence and/or the use of thin flexible blanket-like torso phased array coils. Finally, we did not test the longitudinal reproducibility of the two modalities, a factor that would be important for determining the best test for monitoring treatment response. The comparative performance of SWE and MRE for longitudinal monitoring remains a gap in knowledge for which future research is needed.In conclusion, this prospective study provided direct comparison of SWE versus MRE for staging fibrosis in a cohort of participants with known or suspected NAFLD and clinically indicated liver biopsy. We showed that in patients in whom both methods are adequate, MRE had significantly higher accuracy than SWE for diagnosing earlier (≥ 1 and ≥ 2) fibrosis stages. For purposes of directing biopsy to detect advanced fibrosis, SWE and MRE performed equally well, both demonstrating high NPV for excluding disease. Future studies that aim to evaluate the relative reproducibility of these modalities for longitudinal monitoring and the cost-effectiveness of various diagnostic approaches using combinations of SWE, MRE, biopsy, and clinical decision support will further inform optimal usage of both methods for clinical care and clinical trials.Supplementary file1 (DOCX 1014 KB)Below is the link to the electronic supplementary material.