Positive social comparative feedback indicates to the learner that they are performing better than others. While this type feedback supports motor skill learning in some tasks, the effect of social comparative feedback on implicit motor sequence learning remains unknown. The aim of this study was to determine the effect of positive social comparative feedback on the learning of and expectancies for a motor sequence task.Forty-eight individuals practiced a joystick-based sequence task and were divided into three feedback groups: CONTROL (no performance feedback), RT ONLY (response time only feedback), and RT+POS . Participants attended sessions on two consecutive days: Day 1 for repetitive motor practice/skill acquisition and Day 2 for retention testing. Performance related expectancies, like perceived competence, were measured before and after motor practice on Day 1 and at retention on Day 2.While all groups improved with practice, the CONTROL group showed better overall performance/learning (faster response times) compared with the RT ONLY group. Despite similar response times, the RT+POS showed higher peak velocities than the RT ONLY group. Overall, the RT+POS and CONTROL demonstrated increases in perceived competence while the RT ONLY group did not.The results of this study suggest that feedback content is an important consideration during motor practice sessions since feedback without context (RT ONLY) may be detrimental to motor sequence learning. The results also suggest that, if providing performance related feedback during practice of a skill that relies on implicit sequence learning processes, comparative context may be necessary for enhancing expectancies and supporting. According to the OPTIMAL (Optimizing Performance Through Intrinsic Motivation and Attention for Learning) theory, positive social comparative feedback during practice  enhances a learner’s expectancies about their performance, thereby benefitting motor performance and learning . PositivPositive social comparative feedback has been shown to support motor skill learning in a range of motor tasks, such as overhead throwing , balanciMotor sequence learning can occur through both explicit processes, with knowledge of the sequence, and implicit processes, without explicit knowledge or awareness of the sequence . Serial Another benefit of the STT task is that it can allow for tracking of spatial and temporal aspects of performance across motor practice. With practice of an STT, improvements in overall performance can be achieved through changes in both spatial  and temporal  components of movement . These vTherefore, the purpose of this study was to determine the effects of positive social comparative feedback on the learning of a joystick-based implicit motor sequence task and related performance expectancies. It was hypothesized that the group who received positive social comparative feedback would show greater improvements in performance (faster response times) and greater increases in task-related confidence (task specific self-efficacy and perceived competence) reflecting enhanced expectancies, at retention testing than groups that did not receive positive social comparative feedback. A secondary aim of this study was to determine the effect of social comparative feedback on spatial and temporal components of motor performance, such as hand path distance and peak velocity, in order to better characterize how performance changed over practice as a result of feedback type.2.2.1.f = 0.25, alpha = 0.05, 1-beta = 0.80; number of measurements = 2; corr among rep measures = 0.5; nonsphericity correction = 1; G*Power 3.9.1.2). To account for the possible loss of data, 48 participants (16 per group) was the target recruitment number. All participants provided written informed consent prior to enrollment in the study. The university’s Institutional Review Board approved all procedures. Participants were provided a $10 cash card at the end of each session.Fifty-four non-disabled adults between age 18 and 40 years were recruited from the university and local community. Individuals were included in the study if they were right-hand dominant as measured by the Edinburgh Handedness Questionnaire  and deni2.2.Participants completed two experimental sessions on consecutive days  was modified from previous studies  such thaThe two sequence types were matched for difficulty based on Fitts’ Law, which considers the distance between the targets and the diameter of the target . In thisParticipants completed the STT in blocks that contained 41 targets (a “start” target plus five 8-target sequences per block) and sequence types alternated within a block. Movement to the first target was not included in data analysis, as this target served to initiate movement away from the joystick’s automatic center before beginning the sequenced movements. At the beginning of Day 1, participants completed an exposure block that included 5 random sequences but no feedback to ensure understanding of the task and to provide a baseline measure of performance. After the exposure block, participants completed 28 blocks of practice for a total of 70 repeated sequence repetitions and 70 random sequence repetitions. Group-specific feedback (see below) was provided in written format on the laptop screen after each of the 28 blocks practice. Participants returned for the second session on the following day (Day 2), which measured retention performance  of the STT, and completed 12 blocks of motor practice. These blocks of retention testing were structured the same as the Day 1 practice blocks but did not include any feedback.Position data from joystick was collected at a rate of 60 Hz using E-Prime 2.0 . Position data was used for calculation of response time, path distance, and peak velocity. The primary measure of STT performance was response time (time to complete one 8-target sequence). Path distance, a spatial measure of performance, was defined as the total distance traveled to complete all 8 targets in a sequence, where shorter distances indicated straighter hand paths. Peak velocity, a temporal measure of performance, was defined as the peak of velocity for each movement between two targets which was then averaged across all movements in each 8-target sequence. Performance data were separated by sequence type (repeated or random) and averaged across five trials of the same sequence type for statistical analysis.2.4.During practice on Day 1, all participants received feedback after each block of five sequences. The control group (CONTROL) received feedback that they completed the block . The response time only group (RT ONLY) received feedback on their response time to complete all of the targets in the block  where the feedback provided their actual response time to “hit” all 41 targets in the block. The response time plus positive feedback group (RT + POS) received feedback about their response time with the additional information that their response time was faster than others . The social comparative difference  was a set percentage of the individual participant’s response time on that block . The per2.5.At the end of Session 2, participants were tested to evaluate explicit awareness of the repeated sequence pattern. The aim of this testing was to confirm that the task paradigm engaged implicit sequence learning processes without promoting explicit knowledge of the sequence order. Subjective awareness was determined by asking participants if they noticed anything about the motor task. Subjective awareness was defined as the ability to explicitly state that there was a pattern or repeated combinations in the targets. Participants with subjective awareness were tested on their recall awareness whereby the participant was asked to reproduce the sequence by tracing the repeated pattern on a printed paper with the 12-target layout . ParticiAll participants were then tested for recognition awareness of the repeated sequence. Participants were first informed of the presence of a repeating pattern and then asked to complete six recognition tests. Each test required participants to view three 8-target sequences play on the laptop, where targets were displayed one at a time. At the end of each test, the participants were asked whether the repeated sequence was present at the “beginning,” “middle,” “end,” or “not at all.” Recognition awareness was defined as the ability to correctly identify two out three positive tests and correctly reject two out three negative tests .2.6.All surveys were collected by subject direct input into RedCap. Prior to STT practice on Day 1, participants completed the Rosenberg Self-Esteem Scale (RSES)  and the After the exposure block, participants completed three surveys. The Task-Specific Self-Efficacy Scale (TSSE) measured participants’ self-efficacy related to STT performance . The scaA modified version of the Intrinsic Motivation Inventory (IMI) was utilized to survey perceived competence and task interest/enjoyment . The modThe Positive and Negative Affect Scale (PANAS-X) was used to measure positive affect . This as2.7.All analyses were conducted in SPSS version 27 . Normality was assessed by Shapiro–Wilk test and visual inspection of histograms. Reciprocal transformations were applied to non-normal data before statistical analysis. To examine differences between groups at baseline, a one-way analysis of variance (ANOVA) was run on age, state anxiety scores, trait anxiety scores, self-esteem scores, baseline psychosocial measure scores  and baseline performance measures from the exposure block . To confirm that sequence-specific learning was present, a repeated measures ANOVA with within-subject factors for block  and sequence (random and repeated) and a between-subject factor for group  was run with response time as the dependent variable. All further analyses were conducted using the repeated sequence data only since the repeated sequence performance reflects implicit sequence learning.As the primary motor learning analysis, a repeated measures ANOVA with a within-subject factor for block  and a between-subject factor for group  was used for the primary variable (response time) and the secondary performance variables . This middle block of retention performance was selected to represent retention ability while minimizing the effects of warmup and online learning . To explp < 0.05. Greenhouse–Geisser correction was utilized when the assumption of sphericity was violated. Post hoc analyses were performed to further assess any significant effects. Main effects of group were followed with a Tukey’s HSD to determine the location of differences between groups. Significant group by time interactions were followed with a repeated measures ANOVA separately for each group; paired comparisons between groups at each timepoint were also assessed. Partial eta squared (ηp2) estimated the effect size where a value 0.01–0.059 indicates a small effect, 0.06–0.139 indicates a medium effect, and ≥ 0.14 indicates a large effect  and a within-subject variable for time  was used to examine task-specific self-efficacy, perceived competence, interest/enjoyment, and general positive affect. The primary outcomes for performance expectancies were perceived competence and task-specific self-efficacy. For all analyses, significance was set at e effect .3.3.1.Participants were on average 25.4 ± 5.2 years old with 11 females and 5 males in each group. There was no significant difference between groups in age, Rosenberg Self-Esteem scores, or State Trait Anxiety Scale scores . In addi3.2.3.2.1.F = 121.67, p < 0.001, ηp2 = 0.73). Response times decreased from the start of Day 1 to the middle of Day 2  = 584.93, p < 0.001, ηp2 = 0.93). Similar to the primary retention analysis below (Section 3.2.2 Retention), the type feedback participants received impacted response times  = 4.07, p = 0.24, ηp2 = 0.15), but there was no group by sequence interaction F = 2.96, p = 0.062, ηp2 = 0.12).Sequence specific learning was present as expected; response times were lower for the repeated sequence compared to the random sequence  = 127.14, p < 0.001, ηp2 = 0.74) demonstrating improved task performance across groups. The type of feedback participants received did not impact response times  = 1.97, p = 0.152, ηp2 = 0.08; group by block interaction F = 0.78, p = 0.706, ηp2 = 0.03). Path distance also decreased over practice on Day 1  = 111.17, p < 0.001, ηp2 = 0.712). The type of feedback participants received did not impact path distance  = 0.91, p = 0.411, ηp2 = 0.04; group by block interaction F = 0.44, p = 0.931, ηp2 = 0.02). Finally, peak velocity increased over practice on Day 1  = 16.93, p < 0.001, ηp2 = 0.27). The type of feedback participants received did not impact peak velocity  = 1.75, p = 0.186, ηp2 = 0.07; group by block interaction F = 0.75, p = 0.653, ηp2 = 0.32).For acquisition performance of the repeated sequence, response time decreased over task practice on Day 1  = 635.63, p < 0.001, ηp2 = 0.93) demonstrating implicit learning across groups. The type of feedback participants received impacted response times  = 4.442, p = 0.017, ηp2 = 0.17), where the CONTROL group showed lower response times than the RT ONLY group (p = 0.024). No other pairwise comparisons were significant, and the group by block interaction was not significant  = 1.14, p = 0.328, ηp2 = 0.05). Additionally, path distance got shorter from baseline to the middle of Day 2  = 347.11, p < 0.001, ηp2 = 0.89). However, the type of feedback participants received did not impact path distance  = 0.20, p = 0.820, ηp2 = 0.01; group by block interaction F = 0.94, p = 0.910, ηp2 < 0.01). Finally, peak velocity increased from baseline to the middle of Day 2  = 55.63; p < 0.001, ηp2 = 0.55). The type of feedback participants received impacted peak velocity  = 3.25, p = 0.58, ηp2 = 0.13), where the RT + POS group showed higher peak velocities than the RT ONLY group (p = 0.046). Peak velocity in the CONTROL group was not significantly different from either of the other two groups. The group by block interaction was not significant  = 0.01, p = 0.991, ηp2 < 0.01).For retention performance of the repeated sequence on Day 2, response times decreased from baseline (3.3.Ten participants reported recognizing a pattern during practice (subjective awareness), however, seven of the ten participants could not reproduce any part of the repeated sequence. Two participants from the CONTROL group and one participant from the RT + POS were able to reproduce part of the repeated sequence in the correct sequential order. None were able to reproduce the whole sequence. Nine participants were identified as having recognition awareness of the repeated sequence . Only two participants had recognition awareness and were able to recall part of the repeated sequence in the correct sequential order (one each from CONTROL and RT + POS group). The similar distribution of explicit awareness across groups suggests that the provision of performance related feedback did not impact explicit awareness of the repeated sequence.3.4.F = 28.18, p < 0.001, ηp2 = 0.39). Post hoc paired t-tests between time points  revealed that, for all groups, TSSE scores increased from pre-practice to retention . Only the CONTROL and RT ONLY groups showed increases in TSSE scores from pre to post on Day 1 . For all groups, scores were maintained at retention and changes that occurred between post and retention were not significant . The type of feedback provided did not impact task-specific self-efficacy ratings .Task-Specific Self-Efficacy scores for each group were assessed at pre-practice, post-practice and retention . One parp = 0.628), but changed differently over time, as indicated by a significant group by time interaction  = 4.21; p = 0.011, ηp2 = 0.16). The CONTROL group  = 19.42, p < 0.001, ηp2 = 0.56) and RT + POS  = 29.89, p < 0.001, ηp2 = 0.67) group showed a significant increase in perceived competence over time while the RT ONLY group did not . The CONTROL group’s perceived competence scores changed by 3.5 ± 3.4 points from pre-practice to post-practice (p < 0.001) and 1.1 ± 2.0 from post-practice to retention (p = 0.049). The RT + POS group’s perceived competence scores changed by 6.1 ± 4.0 from pre-practice to post-practice (p < 0.001) and −0.31 ± 2.1 from post-practice to retention (p = 0.558). Comparing between group at each timepoint, the RT + POS group showed significantly higher perceived competence scores than the RT ONLY group at post-practice and retention (p < 0.01). No other pairwise comparisons between groups at each timepoint were significant.Perceived competence was assessed for each group at pre-practice, post-practice and retention . The grop = 0.463) and positive affect  did not change over time.The type of feedback provided had no impact on positive affect, as measured with the General Positive Affect score from the PANAS-X, or task interest/enjoyment, as measured with the interest/enjoyment subscale of the IMI . Interes4.This study examined the effect of positive social comparative feedback on the learning of a joystick-based motor sequence task that allowed for the examination of implicit sequence learning. As expected, and regardless of feedback group, overall performance on the task improved over practice and at retention as seen by faster response times. The expected sequence-specific effect, where learners were faster at performing the repeated sequence than the random sequence, was also present signifying that implicit sequence learning occurred. However, the primary hypothesis, which was that the group who received positive social comparative feedback (RT + POS) would show greater improvements in performance and greater increases in task-related confidence than groups that did not receive this feedback, was not confirmed in the current study. There was no difference between the feedback groups on response time during acquisition and the CONTROL group had faster response times than the RT ONLY group on retention; no other between group differences on response time were identified. Expectancies as measured by perceived competence scores increased over practice in the CONTROL and RT + POS group, but not for the RT ONLY group. The RT + POS group showed higher peak velocities than the other groups during acquisition and at retention, a potential behavioral reflection of higher intrinsic motivation in the RT + POS group. Overall, these results showed that RT + POS feedback did not promote motor skill acquisition or learning more than the other feedback types, and RT + POS was not superior to CONTROL feedback for enhancing expectancies as measured by self-report surveys.Our results are in conflict with several previous studies that found that performance feedback with positive social comparison benefits learning more than performance feedback without social comparison . ImportaResponse time feedback without context (RT ONLY) appeared to be detrimental for motor sequence learning compared to no feedback (CONTROL) and positive social comparative feedback (RT + POS). A possible explanation for this effect is that the RT ONLY group was given performance information without an easily accessible means for assessing whether their performance was good or bad. Knowledge of results feedback, such as response time, encourages learning through cognitive processes rather than conditioning responses . TherefoThe RT + POS and RT ONLY groups achieved similar response times over practice and at retention. However, the underlying components of the movement were different with the RT + POS showing higher peak velocities. Hand path distance and peak velocity are kinematic variables that contribute to the resulting response time . ShorterThe results of the current study suggest that positive social comparative feedback was not effective in enhancing expectancies beyond that which was achieved in a CONTROL no feedback condition. According to the OPTIMAL theory, positive social comparative is a tool to enhance a learners’ expectancies about future performance, thereby increasing motivation toward the task leading to better motor performance and learning. The feedback provided impacted some measures of expectancies (perceived competence) but not others . All groups showed gains in task-specific self-efficacy, which was expected given that all groups improved performance over practice and previous performance level predicts self-efficacy . HoweverThe joystick-based motor sequence task allowed for the investigation of the spatial and temporal aspects of motor performance as well as examination of general sensorimotor learning and implicit sequence learning. However, this task does not represent all types of motor skill learning, and our results may be specific to this task paradigm. In addition, positive social comparative feedback is a type of feedback manipulation intended to enhance the learners’ expectancies; however, there are many potential feedback manipulations that might enhance a learners’ expectancies and benefit motor learning . The fee5.Positive social comparative feedback indicates to the learner that they are performing better than others. Contrary to our hypothesis, this type of feedback did not result in better overall performance  at retention than no feedback or performance feedback without social context. While the response time only and positive social comparative feedback group showed similar response times, the underlying components of the movement were different, where the group that received positive social comparison demonstrated higher peak velocities between targets. Also contrary to our hypothesis, expectancies, as measured by self-report surveys, were enhanced similarly in the no feedback and positive social comparative feedback groups. Response time feedback without social context was detrimental to both learning and expectancies as compared to a no feedback condition. If providing performance related feedback during practice of a skill that relies on implicit sequence learning, comparative context, which removes the need for historical recollection of performance on a previous block, may be necessary to enhance expectancies and support learning.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the University of South Carolina’s Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.AL and JS contributed to conception and design of the study. AL collected data, performed statistical analysis, and wrote the first draft of the manuscript. RB and LJ assisted with data collection. AL, JS, DO, SW, and SF assisted with interpretation of data. All authors contributed to the article and approved the submitted version.This work was supported by the American Heart Association Predoctoral Fellowship (20PRE35180106), and the University of South Carolina’s Presidential Fellowship, and the University of South Carolina’s Office of the Vice President for Research SPARC Graduate Research Grant.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Blood gas analysis is integral to assessing emergency department (ED) patients with acute respiratory or metabolic disease. Arterial blood gas (ABG) is the gold standard for oxygenation, ventilation, and acid–base status but is painful to obtain. Peripheral venous blood gas (VBG) is a valuable alternative as it is less painful and easy to collect. The comparability of ABG and VBG was studied in various conditions. But in hypotension, previous findings were inconsistent. So, we studied the correlation and agreement between ABG and VBG in hypotensive patients.The study was conducted at the emergency department of a tertiary healthcare center in Northern India. Patients with hypotension above 18 years who satisfied the inclusion criteria were clinically evaluated. Patients who require ABG as a part of routine care were sampled. ABG was collected from the radial artery. VBG was obtained from the cubital or dorsal hand veins. Both samples were collected within 10 min and were analyzed. All ABG and VBG variables were entered in premade proforma. The patient was then treated and disposed of according to institutional protocol.A total of 250 patients were enrolled. The mean age was 53.25 ± 15.71 years. 56.8% were male. The study included 45.6% septic, 34.4% hypovolemic, 18% cardiogenic, and 2% obstructive shock patients. The study found a strong correlation and agreement for ABG and VBG pH, pCO2, HCO3, lactate, sodium, potassium, chloride, ionized calcium, blood urea nitrogen, base excess, and arterial/alveolar oxygen ratio. Hence, regression equations were made for the aforementioned. There was no correlation observed between ABG and VBG pO2 and SpO2. Our study concluded that VBG could be a reasonable alternative for ABG in hypotensive patients. We can also mathematically predict values of ABG from VBG using regression equations derived.ABG sampling causes most unpleasant experiences to patients and is associated with complications like arterial injury, thrombosis, air or clotted-blood embolism, arterial occlusion, hematoma, aneurysm formation, and reflex sympathetic dystrophy. The study has shown strong correlations and agreements for most ABG and VBG parameters and can predict ABG mathematically using regression formulas formulated from VBG. This will decrease needle stick injury, consume less time, and make blood gas evaluation easy in hypotensive settings. The first examination of gas content in blood dates back to the 1670 s when Magnus, Hooke, and Boyle obtained gas from the blood by employing a vacuum pump , 3.The clinical use of blood gas analysis originated from the poliomyelitis epidemic in the early 1950s, which showed unprecedented mortality rates in Denmark .In emergency departments (ED), blood gas analysis is used for three primary purposes: establishing acid–base state , assessing ventilation function , and obtaining lactic acid levels in sepsis. These parameters are measured by blood gas analysis. Historically, analyses were performed on arterial blood . Since tThe parameters commonly measured by modern blood gas analyzers include pH; PCO2; partial pressure of O2 (PO2); concentration of hemoglobin (Hb); dyshemoglobin—COHb (carboxyhemoglobin) and MetHb (methemoglobin); lactate; glucose; and electrolytes . At the same time, HCO3 and base excess are calculated from measured values .Arterial blood gas analysis is the gold standard to obtain information about oxygenation, ventilation, and acid–base status. Parameters like pH, pO2, pCO2, HCO3, lactate, and base excess obtained from ABG are considered the gold standard. Peripheral venous blood gas (VBG) sampling is a valuable alternative to arterial blood gas (ABG) sampling in the emergency department evaluating metabolic and acid–base disorders. It is easier to obtain venous blood, so obtaining venous blood gas (VBG) is less painful, and samples may be drawn along with sampling for other laboratory tests. Venous blood sampling reduces the risk of arterial hematoma, dissection, and thrombosis. So, it is increasingly performed these days in the emergency department , 2.Peripheral, mixed, and central venous blood can also be sampled. Venous blood gas (VBG) measurements obtained from peripheral, mixed, or central venous blood can be used interchangeably with ABGs to assess acid–base status in hemodynamically stable critically ill patients . AdrogueThe main complications of arterial blood gas measurements include arterial injury, thrombosis, air or clotted-blood embolism, arterial occlusion, hematoma, aneurysm formation, and reflex sympathetic dystrophy .Turner et al. evaluated recall of patients’ collective experience in their ICU stay. He found that ABG sampling was rated by 48% of the patients as the most unpleasant experience during admission, followed by tracheal suction in 44% of the patients .Till 2006, only 22 cases of radial artery aneurysms were reported in the literature . Less seMany studies have found a strong correlation between arterial pH, partial pressure of CO2 (PCO2), and calculated bicarbonate and corresponding venous values in different clinical conditions . In patiHypotension is one condition where findings of ABG and VBG comparability are inconsistent. Few studies tried to study the correlation between arterial and venous samples in patients with hypotension, but their study findings are not uniform and vary widely. The various studies done on comparability between ABG and VBG are shown in Table ABG sampling is technically challenging and time-consuming, is necessitating sampling skill, and is occasionally associated by the risk of staff needle stick exposure. Because venous blood sample requires fewer punctures, the danger of needle stick injury in medical staff is reduced .Therefore, we intend to do correlation and agreement between ABG and VBG in hypotensive patients. Also, there were no studies done correlating values of ABG and VBG in hypotensive patients in academic emergency medicine settings in India to our knowledge.Our cross-sectional study aimed to determine the relationship and agreement between arterial and venous blood gas analysis for the parameters pH, pCO2, HCO3, lactate, and base excess in hypotensive patients in the emergency department and also to develop prediction models in measuring parameters like pH, pCO2, HCO3, lactate, and base excess in arterial and venous samples.This cross-sectional study was conducted in the Emergency Department of All India Institute of Medical Sciences, Rishikesh, Uttarakhand, between January 2021 and June 2022 (patient recruitment period from March 2021 to March 2022).Patients with systolic blood pressure less than 90 mmHg or MAP less than 65 mmHg in the emergency department who require ABG as a part of routine carePatients more than 18 years of ageThose who did not give consentExistence of contraindications for arterial blood sampling, including impalpable or negative Allen’s test in the upper extremities, infection or fistula at the desired site of puncture, or having severe coagulation disordersInterval of more than 10 min between arterial and venous sampling and inappropriate sample transfer to the laboratoryPostcardiac arrest patientsPatients with hypotension above 18 years of age in the emergency department who satisfied the inclusion criteria were clinically evaluated. The minimum sample size was found to be 14 . BecausePatients with systolic blood pressure less than 90 mmHg or mean arterial blood pressure less than 65 mmHg.Clinical evaluations were performed on emergency room patients with hypotension who were older than 18 years and met the inclusion criteria. After explaining the study to the patient or relative, written consent was obtained. The patient’s demographic details, vitals, clinical details, and diagnosis were entered in the data collection proforma. Patients who required ABG as a part of routine care per treating physician were sampled. An arterial sample (0.5–1 mL) was collected using a heparinized syringe from the radial artery at the wrist level. The venous blood sample was obtained from the cubital or dorsal hand veins. Both samples were collected with minimum delay (less than 10 min). Both samples were analyzed as soon as possible using a blood gas analyzer Nova Biomedicals Stat profile pHOX ultra.All variables of ABG and VBG were entered in premade data collection proforma. The patient was then treated and disposed of according to institutional protocol. The study flowchart is attached Fig. .Fig. 1FlAll data were entered into an Excel sheet and analyzed using SPSS 23.0 version. Descriptive statistics for numerical variables were calculated as the mean and standard deviation for normal distribution and median (IQR) for non-normal distribution, whereas percentages for qualitative variables. Agreement between arterial and venous blood gas analysis parameters was done using the Bland–Altman plot. Pearson correlation coefficients were applied to estimate the correlation between arterial and venous blood gas analysis parameters for Gaussian distribution and the Spearman correlation coefficient for non-Gaussian distribution. Arterial parameters were predicted from venous samples using linear regression.Clinical evaluations were performed on emergency room patients with hypotension who were older than 18 and met the aforementioned inclusion criteria. We obtained their consent and enrolled them in our research. Of all the patients, 250 patients were finally analyzed in the study.The study population’s main baseline characteristics and comorbidities are shown in Table The main examination findings are shown in Table p-value is shown in Table The assessment of various parameters of ABG and VBG with mean, standard difference, and Correlation and agreement of various parameters studied are shown in Table Our study enrolled 250 patients with hypotension and required ABG as a part of routine care and satisfied inclusion criteria.Our study population comprised 250 patients with a mean (standard deviation) years of 53.25 (± 15.71). The study included 56.8% (142) males and 43.2% (108) females. A study by Kim et al. done on 34 patients had a mean age of 65.57 ± 12.4 years, and males were 58.8% (20) and females 41.2% (14) . In a st50.8% were residents of Uttarakhand, 46.8% were residents of Uttar Pradesh, and 2.4% were from other states. 45.6% of patients were septic, 34.4% hypovolemic, 18% cardiogenic, and 2% obstructive shock.For ABG, 24G needles were used in all 250 patients, whereas for VBG, 18G was used for sampling in 59.6% of cases, and in 40.4% of cases, a 20G needle was used. The radial artery obtained all ABGs in our study, while VBG was obtained from forearm veins. In the study by White et al., ABG was collected by either needle puncture or withdrawal from an arterial catheter. The VBG was collected from the upper extremity, and a tourniquet could be left in place for no more than 1 min .p ≤ 0.001) in our study, with 94.0% of the observations having a difference which was within the limits of agreement (± 0.07). The r-value was 0.91 and the formula for ABG pH was devised as ABG:pH = 0.42 + 0.95 × VBG:pH. In the study by Yildizdas et al., pH showed a good interclass correlation of 0.907 with a p-value < 0.001. The r-value for pH for that study was 0.994 , whereas in the study by Shin et al., mean (SD) for potassium was 4.42 (1.18) with 95% CI  and LOA ± 0.82  in our study, whereas in the study by Shin et al., the mean (SD) for ionized calcium was 1.21 (0.08) with 95% CI  and LOA as ± 0.18 [Ionized calcium was found to have a strong correlation between ABG and VBG with an interclass correlation coefficient = 0.70 with s ± 0.18 .p-value ≤ 0.001. 96.0% of the observations had a difference which was within the limits of agreement (± 9.59). The regression equation derived for BUN (mg/dL) was ABG:BUN (mg/dL) = 0.65 + 0.99 × VBG:BUN (mg/dL) [R2 = 0.95] in our study. We found no other study which correlates ABG:BUN and VBG:BUN.Blood urea nitrogen was found to have a very strong correlation between ABG and VBG with an interclass correlation coefficient = 0.98 and p ≤ 0.001 in our study. 94.8% of the observations had a difference within the limits of agreement (± 2.84). The regression equation derived for base excess (mmol/L) was ABG:base excess (mmol/L) =  − 0.55 + 0.95 × VBG:base excess (mmol/L) [R2 = 0.94]. The study by Yildizdas et al. found a good correlation with a Pearson correlation coefficient of 0.972 with a p-value < 0.001. R2 was found to have 0.945 for base excess [R = 0.96, p < 0.001, and 95% LOAs of − 2.2 to 1.8 in their study [d 0.25 (− 3.73 to 4.23) vs. 0.79 (− 2.51 to 4.09) for BE (p = 0.036) [There was a very strong correlation between ABG:base excess (mmol/L) and VBG:base excess (mmol/L) with an interclass correlation coefficient = 0.97 and e excess . Malinosir study . The ave= 0.036) . In a st= 0.036) .p ≤ 0.001). 98.4% of the observations had a difference within the limits of agreement (± 0.52). The regression equation was derived with R2 = 0.58 for a/A as ABG:a/A = 0.67 + 0.55 × VBG:a/A. Our study is the first to evaluate and find a correlation for arterial/alveolar oxygen ratio between ABG and VBG.Our study found a strong correlation between ABG:a/A and VBG:a/A, and this correlation was statistically significant . All other studies comparing ABG and VBG found weak or no correlation for oxygen saturation.Our study found a weak correlation between ABG:SO2 (%) and VBG:SO2 (%), and this correlation was not statistically significant (interclass correlation coefficient = 0.01, In our study, patients were recruited using convenience sampling as study investigators will not be available in all shifts. The study involved collecting single pair of arterial and peripheral venous samples from each patient. So, the homogeneity of ABG and peripheral VBG was not studied as multiple samples at different intervals were not done. We also had many cases where one patient had multiple diagnoses making it challenging to characterize into various subgroups. Subgroups of shock were defined at the time of “working diagnosis” when enrolling the patient and not the final diagnosis. The study design and setting did not allow for a follow-up on the mortality of the patients studied. Patients differed according to many demographic factors, which were not all the same.ABG and VBG assessments are essential tests for assessing ventilation, acid–base disturbances, and other metabolic parameters of patients. Obtaining ABG or VBG in hypotension is challenging as many previous studies have shown conflicting results. Our study has shown either strong or very strong correlations and agreements for most ABG and VBG parameters except pO2 and SO2. We can also predict an ABG mathematically using regression formulas devised from a VBG sample. This will decrease needle stick injury, consume less time, and make blood gas evaluation easy in hypotensive settings. Further studies are required to find the correlation between ABG and central, peripheral, and mixed VBGs and capillary blood gas. Our study is the first to incorporate all four types of shock in ABG and VBG analysis. Also, this is the first one to incorporate all the parameters of ABG and VBG. Also, this is the largest single-center study in ABG and VBG comparison on hypotensive patients. Our study is the first to incorporate details of the point-of-care ultrasound in hypotensive ABG v VBG studies. We have a standardized site and size of the needle to be used for ABG and VBG in this study.


To evaluate the treatment cost and cost effectiveness of a risk‐stratified therapy to treat pediatric acute lymphoblastic leukemia (ALL) in India.The cost of total treatment duration was calculated for a retrospective cohort of ALL children treated at a tertiary care facility. Children were risk stratified into standard (SR), intermediate (IR) and high (HR) for B‐cell precursor ALL, and T‐ALL. Cost of therapy was obtained from the hospital electronic billing systems and details of outpatient (OP) and inpatient (IP) from electronic medical records. Cost effectiveness was calculated in disability‐adjusted life years.p < 0.0001). OP costs were higher than in‐patient costs for SR and IR, while in‐patient costs were higher in T‐ALL. Costs for non‐therapy admissions were significantly higher in HR and T‐ALL (p < 0.0001), representing over 50% of costs of in‐patient therapy. HR and T‐ALL also had longer durations of non‐therapy admissions. Based on WHO‐CHOICE guidelines, the risk‐stratified approach was very cost effective for all categories of patients.One hundred and forty five patients, SR (50), IR (36), HR (39), and T‐ALL (20) were analyzed. Median cost of the entire treatment for SR, IR, HR, and T‐ALL was found to be $3900, $5500, $7400, and $8700, respectively, with chemotherapy contributing to 25%–35% of total cost. Out‐patient costs were significantly lower for SR (Risk‐stratified approach to treat childhood ALL is very cost‐effective for all categories in our setting. The cost for SR and IR patients is significantly reduced through decreased IP admissions for both, chemotherapy and non‐chemotherapy reasons. With the ICiCLe‐ALL‐14 risk stratified approach, ALL treatment cost for low‐risk patients is significantly lower as compared to intermediate and high‐risk groups. Additionally, it is a cost‐effective intervention in a low‐middle income country. The aims of the research study were to (i) standardize therapy for ALL across centers so that patients could be reassured that they need not travel to other centers (ii) decrease intensity of therapy to reduce cost and toxicity. The trial is ongoing and the impact on toxicities and outcomes are awaited. As an implementation outcome associated with the clinical trial, we report the cost and cost effectiveness of the risk‐stratified treatment strategy at a single center—Tata Medical Center (TMC), Kolkata, India.22.1TMC is a charitable not‐for‐profit tertiary care cancer center with a dedicated pediatric cancer unit, inclusive of inpatient (IP), outpatient (OP), day‐care and a free residential stay facility for poor families. Children (1–18 years), who began and completed treatment for ALL at TMC, between August 2013 and March 2019 were included in this study. Those who had an event, defined as death, relapse or treatment abandonment prior to completion of therapy, were excluded from the study.2.29/L in the absence of organomegaly; and as intermediate risk (IR) if age ≥10 to <19 years or presenting white cell count ≥50 × 109/L as well as SR patients with organomegaly. BCP‐ALL with high‐risk cytogenetics or CNS3 or prednisolone poor response  were treated as high risk (HR). T‐ALL was treated separately, but similar to HR. BCP‐ALL SR and IR with minimal residual disease (MRD) of ≥10−4 at the end of induction were subsequently treated as HR. Through induction, consolidation and interim maintenance, SR patients received reduced intensity therapy aimed at decreasing toxicity; moderately increased for IR with full intensity therapy for HR and T‐ALL. All patients received the same delayed intensification and maintenance therapy  after consent.py Table .10All patients were admitted when first diagnosed and discharged as soon as clinically well. Further therapy for SR and IR patients was day‐care/OP‐based while HR and T‐ALL patients were admitted for high dose methotrexate infusions. Patients were admitted for complications of therapy, while blood and blood products were administered in day‐care.2.3The hospital has an electronic medical record (EMR) and billing system. Patients are categorized as general or private and only those in the general category (90% of patients) were included in this analysis. Billing data are available in separate sections for OP, day‐care and IP stays, as well as costs of hospitalization, investigations, drugs, fluids, and consumables. The billing data contain all expenditures incurred by the patient and include charges for interventions and OP pharmacy.2.42, was obtained from the hospital pharmacy. The actual treatment and procedures' cost for each individual was obtained from the itemized billing data and separated into costs for IP and OP/day‐care episodes. Patients' electronic hospital records were analyzed to obtain the duration of IP admissions and to distinguish IP admissions for chemotherapy from those related to management of complications. For non‐chemotherapy‐related IP admissions, IP costs for first admission (induction) and high dose methotrexate infusions were excluded. All other phases of therapy were managed through OP/day‐care. Demographic data and distance traveled to the hospital from their postal address were extracted from the EMR.The predicted cost of chemotherapy alone for each risk category, based on a reference surface area of 1 m2.5Disability‐adjusted life years (DALYs) were calculated using previously published methods.2.6Data were checked for normality visually with Q–Q/density plot and statistically with Shapiro–Wilk test. Kruskal–Wallis and/or Mann–Whitney test were used to test for differences in overall, IP and OP/day‐care costs. Paired risk group analyses were performed using pairwise Wilcoxon test. All statistical analyses were performed using R (version 3.6.1). Costs are represented in United States Dollars ($) with 1$ = ₹65.27. This is the average of the exchange rates from the date of first patient enrolled to the treatment completion date of the last enrolled patient.3Treatment costs for the entire duration of treatment were analyzed in 145 patients—50 SR, 36 IR, 39 HR, and 20 T‐ALL. Patient characteristics are described in Table 2 is estimated to be $1420, $1690, $1985, and $2117 for SR, IR, HR, and T‐ALL, comparable to that previously reported in Delhi.Chemotherapy costs for a patient with body surface area of 1 mp < 0.0001). IR, HR and T‐ALL patients receive infusions of daunorubicin and cyclophosphamide in OP/day care, and OP/day care costs were comparable in all these three categories. OP costs were higher than IP costs for both SR and IR. In HR, IP and OP costs were comparable but IP costs were considerably higher in T‐ALL , with mean costs of HR and T‐ALL almost double and triple of that for SR  and IR $2100) but significantly higher for HR ($3700) and T ($5400) (100 but sLL Table . Neverthp < 0.0001) than that associated with HR and T‐ALL (Table 2 per dose). In consolidation, IR patients receive BFM Ibp = 0.0115), days of hospitalization (p = 0.0008) as well as an increase in the average number of days admitted per admission (p = 0.0308)  Table . Our staThe estimated annual burden of childhood ALL in India is 388,602 DALYs. As shown in Table 4To our knowledge, the study provides the first combined cost and cost‐effectiveness data for children with ALL diagnosed and treated on a prospective clinical trial in an LMIC. Additionally, we sub‐stratify our results to understand how risk‐stratification modulates costs and impacts on cost‐effectiveness ratios. For health policy makers and patient advocates, these data are critical for prioritization discussions and to ensure budgets earmarked for children with ALL are adequately financed.The median cost of treating a child with ALL at our hospital ranged from $3900 to $8700. This is comparable to costs of $3234–$30,000, using a mixture of western and indigenized protocols, reported by other LMIC's. These protocols have mostly been non‐risk stratifiedAlthough the results of our study of treating pediatric ALL in the Indian context is cost‐effective, cost‐effectiveness does not equate to affordability.All framework recommendations,Due to the lack of public financing for childhood cancer services, a number of NGOs have stepped in to bridge this gap. Examples include St Jude India Child Care Centers which provide free of charge care to families of children with cancer throughout India. CanKids also manages “home away from home” facilities and supports poorer families financially as well as providing free medicines. There are other local charities as well as donor programs from pharmaceutical companies. While the results of this study can help advocacy programs align their fundraising goals with existing patient burden projections, these data are also helpful as a mechanism to begin formulating schemes for government budgetary support. As central or state governments demonstrate an interest in supporting childhood cancer through universal health care packages, following the World Health Organization Curel‐Asparaginase). On occasion patients have acquired drugs from outside the hospital. These and OOPE have not been analyzed, making the interventions appear more favorable compared to reality. Furthermore, we have only taken the final post induction risk stratification into account. Costs have not been separately calculated for patients who were initially SR/IR in induction and then treated as HR based on MRD ≥10−4 at the end of induction.There are a number of caveats to our interpretations. When calculating costs of IP admissions related to complications of therapy, we excluded the initial admissions for induction for all patients and for high dose methotrexate infusions in HR and T‐ALL. For a few patients, complications occur whilst on therapy and our analyses may underestimate the actual non‐therapy costs incurred. The study focused on the cost of the entire treatment excluding those who did not complete therapy due to death, relapse or abandonment while on treatment. These comprise <10% of patients and we feel are unlikely to significantly influence the analyses. In childhood ALL, around 5% of patients are eligible for allogeneic stem cell transplantation in first remission (CR1). As reported by us previously,The Lancet Oncology commission on sustainable care for children with cancer recommended the incorporation of childhood cancers into essential benefits packages when expanding universal health coverage.Tushar Mungle: Data curation, formal analysis, methodology, writing‐original draft and writing‐review and editing. Nandana Das: Data acquisition and data curating, formal analysis, writing – original draft and writing‐review and editing. Saikat Pal: Data acquisition and data curating, formal analysis. Manash Pratim Gogoi: Data curating, writing – review and editing. Parag Das: Data curating, writing – review and editing; Niharendu Ghara: Data curating, writing – review and editing; Debjani Ghosh: Data curating, writing – review and editing; Ramandeep Singh Arora: Formal analysis, methodology, writing – review and editing; Nickhill Bhakta: Formal analysis, methodology, writing – original draft and writing – review and editing; Vaskar Saha: Conceptualization, funding acquisition, formal analysis, methodology, writing – original draft and writing – review and editing. Shekhar Krishnan: Conceptualization, funding acquisition, formal analysis, methodology, writing – original draft and writing – review and editing.This study was part funded by grants from the Indian Council of Medical Research (79/159/2015/NCD‐II); National Cancer Grid (2016/001), Tata Consultancy Services Foundation and a Margdarshi Fellowship of the DBT‐Wellcome India‐Alliance (IA/M/12/1/500261). The funding agencies had no role in collection, analyses or interpretation of data.The authors declare that they have no competing interests.All patients provided written consent for treatment and data analyses at the time of recruitment for the study. Approval for the study was obtained from Tata Medical Center's Institutional Review Board (EC/TMC/12/13).Appendix S1Click here for additional data file.


Tests of between-group differences indicated that multilingual children evidenced more severe SLDs, had lower school engagement, and had lower reports of flourishing than English monolingual children with SLDs. Further, a greater proportion of multilingual children with SLDs missed more school days than English monolinguals. However, multilinguals were less likely to bully others or have been bullied than monolinguals. While the previous between-group differences were statistically significant, they were small (vs ≤ 0.08). Increased SLD severity predicted an increased number of repeated school grades, increased absenteeism, and decreased school engagement, when age and socioeconomic status were controlled. Increased SLD severity also predicted greater difficulty making and keeping friends and decreased flourishing. The effect of SLD severity on being bullied was statistically significant for the monolinguals but not multilinguals. There was a statistically significant interaction for SLD severity and sex for school engagement and difficulty making and keeping friends for monolinguals but not multilinguals. The interactions indicated that school engagement decreased more for females than for males while difficulties making and keeping friends increased more for males than females as one’s SLD severity increased. While some findings were specific to monolinguals, tests of measurement invariance indicated that the same general pattern of relations among the variables were evident across the groups of multilinguals and monolinguals. These final findings can inform the interpretation of the results from both the current and future studies, while the overall findings can inform the development of intervention programs, thereby improving the long-term academic and socioemotional outcomes of children with SLDs.Research points to negative associations between educational success, socioemotional functioning, and the severity of symptoms in some speech-language disorders (SLDs). Nonetheless, the majority of studies examining SLDs in children have focused on monolinguals. More research is needed to determine whether the scant findings among multilinguals are robust. The present study used parent report data from the U.S. National Survey of Children’s Health (2018 to 2020) to gain a better understanding of the impacts of SLD severity on indicators of academic success and socioemotional functioning among multilingual ( Speech-language disorders (SLDs) interfere with one’s process of normal communication and are one of the most commonly reported disorders in childhood . SymptomIn general, academic achievement has been found to predict college attendance and earnings in adulthood . Lower aChildren with SLDs are at higher risk for socioemotional difficulties compared to children without SLDs e.g., . For exaWhen considering the relations between SLD severity, academic success, and socioemotional functioning, it could be important to consider a child’s biological sex and a family’s socioeconomic status (SES). The findings from several studies indicate that genetics and being male are risk factors for SLDs e.g., . PutativMost studies examining SLDs have focused on monolinguals . Participants 6-years of age and older were chosen because SLD typically become apparent or peak in children between 3-and 5-years of age with some children recovering from SLDs such as stuttering around 6-years of age  “Does not currently have condition,” (2) “Current condition, rated mild,” (3) “Current condition, rated moderate/severe.”Academic success was measured by three variables. One, parents were asked if their child repeated any grades since starting in kindergarten, which was a dichotomous item . Two, school engagement was a composite from two items on the parent survey, reflecting the frequency with which their child, cares about doing well in school and completes all their required homework. Both questions were measured on a 4-point scale: (1) “Always,” (2) “Usually,” (3) “Sometimes,” (4) “Never.” The two items were combined to create an indicator of school engagement measured on a 3-point scale: (1) “Always to both items,” (2) “Always or usually to one item or usually to both items,” (3) “Sometimes or never to both or any item.” Finally, parents were asked “During the past 12 months, about how many days did this child miss school because of illness or injury?” Missed school days were measured on a 5-point scale: (1) “No missed school days,” (2) “1–3 days,” (3) “4–6 days,” (4) “7–10 days,” (5) “11 or more days.”Socioemotional functioning was measured through four variables. One, parents were asked, “Compared to other children his or her age, how much difficulty does this child have making or keeping friends,” which was measured on a 3-point scale: (1) “No difficulty,” (2) “A little difficulty,” (3) “A lot of difficulty.” The second variable, flourishing, was based on three questions that aimed to capture curiosity and discovery about learning, resilience, and self-regulation. The survey questions asked, “How often does this child: (1) show interest and curiosity in learning new things, (2) work to finish tasks they start, and (3) stay calm and in control when faced with a challenge?” The 4-point scale for these three items was (1) “Always,” (2) “Usually,” (3) “Sometimes,” (4) “Never.” Of the 4-point scale, the “Always” or “Usually” responses rather than the “Sometimes” and “Never” responses indicated the child meets the flourishing item criteria. Thus, the responses to the three questions were recoded to create a single variable in the NSCH dataset for flourishing, measured on a 3-point scale: (1) “Meets 0–1 flourishing items,” (2) “Meets 2 flourishing items,” (3) “Meets all 3 flourishing items.” Parents were also asked about two facets of bullying. Specifically, “During the past 12 months, how often was this child bullied, picked on, or excluded by other children?” and “During the past 12 months, how often did this child bully others, pick on them, or exclude them?” The response for both questions was measured on a 5-point scale: (1) “Never (in the past 12 months),” (2) “1–2 times (in the past 12 months),” (3) “1–2 times per month,” (4) “1–2 times per week,” or (5) “Almost every day.”To measure SES, the child’s household poverty level was derived from parent responses about family income. Specifically, parents were asked, “What is the income level of the household that the child lives in? Responses were coded according to federal poverty levels (FPLs), “Household income 0–99% FPL,” “Household income 100–199% FPL,” “Household income 200–399% FPL,” or “Household income 400% FPL or greater/.”To measure the child’s sex, parents were asked, “What is the child’s sex?” The only response categories were “Male” and “Female.”t-test and Hedges g, the chi-square test of independence (χ2) was used to determine if there is statistically significant relationship between the each observed variable and group, while Cramer’s v provided an effect size estimate of the relationship. In contrast to g, which is unbounded, v ranges between 0 and 1, and was interpreted according to the following conventions: <0.10 (negligible association), 0.10 to 0.19 (weak association), 0.20 to 0.39 (moderate association), 0.40 to 0.59 (relatively strong), ≥0.60 (strong)  . Hedges R2, the variance in the outcome accounted for by the set of predictors in Models 1–4, were interpreted according to β, correlations among outcomes, intercepts, and residual variances) from each Model to equality across the two groups. The tenability of the fully constrained Models was judged relative to values for commonly used fit indices  as discussed in p > 0.05) for the χ2 test of model fit indicates acceptable model fit . Because households were randomly selected to participate in the NCHS from across the U.S., a nested structure to account for non-independence of the child outcomes was not needed. After examining main effects, path analyses that examined the interaction of SLD severity by sex were estimated. Model 1 included the three academic outcomes. Model 3 included the four socioemotional outcomes. Models 2 and 4 were extensions of the Models 1 and 3 that included the interaction of SLD severity and sex. Estimates of odel fit , if addiple size . To avoiχ2(1) = 716.59, p < 0.001, v = 0.34χ2(1) = 1.56, p = 0.21, v = 0.02. In contrast to English monolinguals, multilingual children where from homes where English was not the primary language spoken (χ2(2) = 6,207.00, p < 0.001, v = 1.00). A greater proportion of multilingual children were born outside of the U.S., χ2(1) = 159.44, p < 0.001, v = 0.16, and were Hispanic or Asian, χ2(6) = 959.26, p < 0.001, v = 0.39, compared to monolinguals. The groups also differed in age, t(277.17) = 5.41, p < 0.001, g = 0.34, and SES, χ2(3) = 100.08, p < 0.001, v = 0.13. On average, multilingual children were 1.19 years younger than monolinguals and from lower SES backgrounds. Although similar proportions of multilingual and English monolinguals had special education plans (χ2(1) = 2.80, p > 0.05, v = 0.02), the groups differed with regard to some comorbid conditions. Relative to monolinguals, the proportion of multilingual children with Down syndrome (χ2(1) = 18.74, p < 0.001, v = 0.06), intellectual disability (χ2(1) = 15.88, p < 0.001, v = 0.05), learning disability (χ2(1) = 5.97, p < 0.05, v = 0.03), and autism (χ2(1) = 8.09, p < 0.05, v = 0.04) was greater than expected by chance; however, the magnitudes of the differences were small.The sample’s demographic characteristics are displayed in χ2(2) = 35.82, p < 0.001, v = 0.08, their school engagement as lower, χ2(2) = 9.21, p < 0.01, v = 0.04, and they were less likely to be described as flourishing, χ2(2) = 20.57, p < 0.001, v = 0.06. The pattern for missed school days also differed between multilinguals and English monolinguals, χ2(4) = 12.96, p < 0.01, v = 0.05, which may be due to the proportion of multilinguals that did not miss school. Finally, multilinguals were less likely to bully others, χ2(4) = 18.82, p < 0.001, v = 0.06, or have been bullied by others than English monolinguals, χ2(4) = 28.49, p < 0.001, v = 0.07. While statistically significant, it is important to remember that the previous associations were interpreted as negligible according to the conventions posited by There were significant associations between home language status and six of the eight observed variables and responses see . Comparekurtosis = 17.79; see Descriptive analyses and visual inspections of the ordinal data revealed a floor effect for parent report for ‘bullied others’ within the group of multilinguals , increased absenteeism , and decreased school engagement  for multilinguals and English monolinguals, respectively , decreased absenteeism , and increased school engagement  for the English monolinguals; however, these relations were not statistically significant for the multilinguals. The main effect of sex was statistically significant for school engagement  and missed school days  among the English monolinguals, but not multilingualsThe results of the multigroup path analyses, controlling for the child’s sex and SES, indicated that increased SLD severity predicted an increased number of repeated school grades . The inclusion of the interaction term for each academic outcome, minimally improved the predictive utility of Model 2 over Model 1, accounting for an additional 0–1% and 0–7% of the variance for multilinguals and English monolinguals, respectively.Model 2, which included the SLD severity by sex interaction, provided evidence of moderation for one outcome among the English monolinguals, school engagement (β), correlations among the three outcomes, intercepts (or mean level of parent reports for each outcome), residual variances and by extension, variances, were evident across the groups of multilinguals and English monolinguals. These findings have implications for how the results are interpreted, which are discussed below.The results from the tests of measurement invariance for academic success are displayed in β = 0.34, p < 0.001), decreased flourishing , and increased frequency of being bullied  and bullying others  for the English monolinguals  and decreased flourishing  for the multilinguals. Among the English monolinguals, being a female was associated with decreased difficulty making and keeping friends , increased flourishing , and decreased frequency of being bullied . For the multilinguals, neither the child’s sex nor SES was a statistically significant predictor for any of the measures of socioemotional functioning. In contrast, increased SES corresponded increased flourishing  and decreased frequency of being bullied , and bullying others  for the English monolinguals. The group of predictors in the main effects model for socioemotional functioning accounted for 0–18%  and 1–13%  of the variance in the outcomes.The results of multigroup path analyses, controlling for the child’s sex and SES, indicated that increased SLD severity predicted increased difficulty making and keeping friends  but not multilinguals. A closer look at the interaction indicated that it was more difficult for males to make and keep friends than females regardless of their SLD severity  in the general population e.g., . Nonetheχ2∆(1) = 4.56, p = 0.03, suggesting that the association between SES and SLD severity differs for multilingual (r = −0.16) and English monolinguals (r = −0.01). That is, regardless of the mechanism, increased SES appears to be a protective factor against SLD severity for monolinguals but not multilinguals.Finding that SLD severity decreased as SES increased for English monolinguals, but not multilinguals may be due to a combination of socioeconomic, linguistic, and cultural obstacles . Namely,β(SE) = −0.25(0.23), than monolinguals, β(SE) = −0.10(0.05), though the standard errors suggests that there was more variability in the multilinguals, which is a function of sample size. Given the magnitude of the effects, standard errors, and results from the tests of measurement invariance, it is plausible that these relations are similar for multilingual and English monolinguals.The present findings indicated that academic difficulties increase as the severity of a multilingual and English monolingual child’s SLD intensifies; a finding that is consistent with prior studies among monolinguals only . The acaβ = 0.11) and the tests of measurement invariance, suggesting that this relation and inferences drawn from it are equally applicable to multilingual children with SLDs. Lastly, the relation between SLD severity and difficulties making and keeping friends was moderated by sex. Males may find it particularly challenging to make and keep friends as their SLD intensifies.The results of the present study extend the findings of others e.g., , indicatStudies of teachers  and SLPsOur findings that as SLD severity increases, children with SLDs are increasingly likely to repeat a grade, engage in school less, and miss more school should be of assistance to school personnel in charge of school wide applications of behavioral systems and supports. Given the importance of early language development to children’s literacy, math, and science learning e.g.,  and the While the present study was characterized by several strengths, there were a few limitations. To begin with, the current study employed parent reports for all measures. It is unclear whether SLDs were formally diagnosed, or whether parent recall was accurate. The heterogeneity and variability of speech symptoms may increase the risk of misidentification. Relatedly, experiences associated with the different speech-language disorders are also likely to be highly variable. For example, children with specific language disorder may face different academic and social challenges compared to children who stutter. The present study was not able to disentangle these differences. We suggest this as a future area of investigation. Further, parents’ recall of their child’s SLD may not be accurate and as such, children may be disproportionately (over-or under-) identified in this study. Children were identified as multilingual or monolingual based on parent report of a non-English language spoken within the home. However, the total number of languages children were exposed to, and their degree of proficiency were not determined in the survey. Although bilingual  education is uncommon in the U.S., it is possible that there are some emergent bilingual children who use English at home and attend language immersion schooling in another language. These children would be considered monolingual in the current study but would likely have some degree of second language exposure . In addiA second limitation is that there is no way to determine causality of the relations investigated in the present study. In other words, it cannot be concluded that SLD severity interfered with academic success and socioemotional functioning or if the reverse were true. While we technically have temporal precedence , this assumption is weak. It is possible, for example, that decreased school engagement and missing school led to increased severity of a child’s SLD. Similarly, if a child found it difficult to make and keep friends, they may have fewer opportunities to interact with peers; thereby intensifying the severity of their speech and language symptoms. Most likely the relations identified in the present study are bidirectional, e.g., SLD severity leads to decreased school engagement, increased absenteeism, and increased difficulties making and keeping, which in turn, lead to increased SLD severity. While addressing this concern was not possible with the present dataset, it may be beneficial to use longitudinal data and cross lagged panel models to better understand the relations revealed by the present study.A final concern is the external validity of this study–the extent to which the results of this study generalize should be interpreted cautiously for a few reasons. One, parents from cultures where disabilities are highly stigmatized may be less likely to identify their child with a disorder while parents who place a higher value on verbal ability may be more likely to report SLD as a concern . FurtherThe present study is among the first to focus on the intersection of SLDs and multilingualism. The findings suggest more similarities than differences between multilingual and monolingual children who have speech and language impairments. Notably, SLD severity decreased as monolinguals’ SES increased, however this was not the case for multilingual children. Being female was associated with increased school engagement even though females missed more days of school than males for the monolinguals, though the direction and magnitude of these regression effects were similar for multilinguals. Being female was also associated with fewer difficulties making and keeping friends and increased flourishing for the monolinguals. Again, the direction and magnitude of these regression effects were similar for multilinguals. Regarding bullying, being female and monolingual was associated with increased frequency of being bullied but being female and multilingual was not. Thus, there was evidence in support of the putative effects of being female, though the findings were mixed. The results of this study highlight the need for school personnel to consider a child’s SLD severity. Specifically, increased severity in one’s speech and language impairments correspond to increased frequency of repeating a grade, absenteeism, difficulty making and keeping friends, and decreased school engagement and flourishing for both groups of children. Increased severity of one’s speech and language impairment was also associated with increased frequency of being teased and bullied for monolinguals, though we attribute the lack of statistical significance for multilinguals to their smaller sample size. The results of the present study could inform treatment and the development of intervention programs for SLDs.https://www.childhealthdata.org/browse/survey?s=2&y=43&r=1.Publicly available datasets were analyzed in this study. This data can be found here: For the current study ethical review and approval, and written informed consent, were not required in accordance with the local legislation and institutional requirements. The NSCH data on which this study is based were reviewed by the NCHS Research Ethics Review Board (ERB) and the Abt Associates Institutional Review Board (IRB). The patients/participants provided their written informed consent to participate in this study.AC and SS developed the theoretical framework. AC prepared the data. MF and SS planned the data analyses. MF completed the data analyses. All authors discussed the results and wrote the manuscript, which was a collaborative effort and conceived of the presented study and drafted the manuscript, which was led by MF.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Endomembrane system compartments are significant elements in virtually all eukaryotic cells, supporting functions including protein synthesis, post‐translational modifications and protein/lipid targeting. In terms of membrane area the endoplasmic reticulum (ER) is the largest intracellular organelle, but the origins of proteins defining the organelle and the nature of lineage‐specific modifications remain poorly studied. To understand the evolution of factors mediating ER morphology and function we report a comparative genomics analysis of experimentally characterized ER‐associated proteins involved in maintaining ER structure. We find that reticulons, REEPs, atlastins, Ufe1p, Use1p, Dsl1p, TBC1D20, Yip3p and VAPs are highly conserved, suggesting an origin at least as early as the last eukaryotic common ancestor (LECA), although many of these proteins possess additional non‐ER functions in modern eukaryotes. Secondary losses are common in individual species and in certain lineages, for example lunapark is missing from the Stramenopiles and the Alveolata. Lineage‐specific innovations include protrudin, Caspr1, Arl6IP1, p180, NogoR, kinectin and CLIMP‐63, which are restricted to the Opisthokonta. Hence, much of the machinery required to build and maintain the ER predates the LECA, but alternative strategies for the maintenance and elaboration of ER shape and function are present in modern eukaryotes. Moreover, experimental investigations for ER maintenance factors in diverse eukaryotes are expected to uncover novel mechanisms. More than 15 proteins have a role in shaping the endoplasmic reticulum (ER) but studies on the evolution of these factors are lacking. Now, a molecular evolutionary analysis indicates that reticulons, REEPs, atlastin, spastin, lunapark, TMEM33, STIM1 and VAPs likely evolved as early as the last eukaryotic common ancestor (LECA). Secondary losses are common, while more recent innovations are evident in the Opisthokonta. Future experimental investigations for these ER maintenance factors in diverse eukaryotes are expected to uncover novel mechanisms. The distribution of these proteins based upon recovered homologs is shown in Figure To reconstruct the evolutionary history of proteins involved in ER morphology, we searched 50 high quality predicted proteomes using protein sequences of ER morphology‐associated proteins from 2.1S. cerevisiae, Allomyces macrogynus), multiple proteins in Cryptophyta (three in G. theta and two in G. avonlea) and many in plants . Phylogenetic reconstruction suggests an early duplication in the Opisthokonta leading to two clades, one with vertebrate REEPs 1–4, and one with REEPs 5–6  are particularly common within the Viridiplantae  which localizes to the tip of dynamic microtubules. STIM1 and EB1 interact with each other directly, allowing ER tubules to elongate or contract.2.5E. histolytica, D. discoideum, Acanthamoeba castellanii) but further analysis showed that REEP homologs are present in certain other species of this lineage .Multiple duplications were observed for many of the proteins considered here, including reticulons, REEP5/Yop1p, atlastin/Sey1p, Yip3p and VAPs, indicating species‐specific and lineage‐specific innovation. Furthermore, secondary losses are common in individual species, and even in certain lineages, for example the reticulons have most likely been lost from the stramenopiles; lunapark from the stramenopiles and alveolata; TMEM33 from the cryptista, haptophyta and metamonada, and STIM from the alveolata, excavata, glaucophyta, haptophyta, rhizaria and rhodophyta. To further check whole‐lineage losses apparent in Figure E. histolytica, and atlastin/Sey1p, spastin, Use1p and TBC1D20 the only proteins recovered in Monocercomonoides exilis , is localized at the plasma membrane of neurons, and binding of RTN4A to NogoR can lead to inhibition of neuronal growth.o Figure . This nao Figure , althouggs Table . Notably3The endomembrane system comprises multiple organelles providing important functions specific to eukaryotic cells. Significantly, many of the ER proteins studied here are widely distributed across eukaryotes, pointing to an origin predating the LECA and diversification of eukaryotic supergroups. Apart from being fully consistent with a highly complex endomembrane system in the LECA, these observations unite the ER with other compartments in terms of an ancient origin.Several central components of the ER have clear antecedents in the Archaea. Use of dolichol‐pyrophosphate as a lipid‐linked oligosaccharide donor in Archaea is in common with eukaryotes as opposed to dolichol phosphate as used by bacteria,44.1Data were collected from 50 species with high quality genome databases and selected to provide a wide sampling of the eukaryotic super‐groups,4.2H. sapiens and S. cerevisiae predicted proteins  and, in some cases, against the NCBI non‐redundant database for confirmation of orthology. For yeast queries, reverse BLAST searches were run manually; for human protein queries, reverse BLAST searches were run automatically  and further inspected manually. A candidate ortholog was considered if reverse BLAST recovered the original query or annotated orthologs from other species, within the top five hits. Additionally, both for initial candidate identification and for validation by reverse BLAST, rather than relying solely on e‐values, sequences were analysed by alignment and parsed through the NCBI conserved domain database for the presence of significant sequence similarity throughout the protein length, conservation of overall protein length and domain architecture. In cases where the initial queries failed to recover a candidate ortholog, the following three strategies were used: Forward BLAST searches were repeated using query sequences  from a taxon more closely related to the target genome (e.g. an Arabidopdis protein used as the query against Chlamydomonas), HMMer v3.1b1 (hmmer.org) was used with a template composed of the entire set of recovered proteins for a given query and with a cut‐off significance parameter of 0.05, or yeast and/or human protein sequences were used as queries for tBLASTn against genomic contigs. Default tBLASTn settings were used, again with an e‐value cut‐off of 0.05. Results from these searches were evaluated for e‐value, predicted protein length, conserved domains, and subjected to reverse BLAST against the original query genome. Furthermore, returned candidate sequences were aligned and subject to phylogenetic analysis to confirm both extensive sequence homology and monophyly. Failure to identify a significant hit with all these methods resulted in assignment of ‘not found’. Detailed results from all searches are shown in Table Tetrahymena thermophila reticulon and the D. discoideum lunapark) extra BLAST searches were done using wider species sampling, the results of which are shown in Table http://evocellbio.com/eukprot/) for each linage of interest were examined by BLAST, using as queries H. sapiens and S. cerevisiae predicted proteins with an e‐value cut‐off of 0.05, and all recovered sequences were subjected to reverse BLAST  on the NCBI server against the Homo sapiens, S. cerevisiae, and the general RefSeq database for confirmation of orthology. Any novel hit identified by this method was also used as a query against the rest of the species of the lineage. Specifically, we used the EukProt server to search for (a) reticulons in the Alveolata, Metamonada, Rhizaria and Stramenopiles, (b) REEP in the Amoebozoa, (c) Lunapark in SAR and Discoba, (d) TMEM33 in Cryptista, Glaucophyta, Haptophyta, Metamonada, Rhizaria and Rhodophyta, and (e) STIM in the Alveolata, Amoebozoa, Cryptista, Excavata (Discoba and Metamonada), Glaucophyta, Haptophyta, Rhizaria and Rhodophyta.Initial queries used s Tables  and S3. 4.37 generations, removing all trees before a plateau established by graphical estimation and checked for convergence. All analyses had an average standard deviation of split frequencies less than 0.01 (indicating convergence), with the exception of the pan‐eukaryotic REEP analysis (0.027) and VAP analysis (0.014). Maximum‐likelihood (ML) analysis was performed using IQ‐TREE v.1.6.10Alignments  analyses are highlighted. The REEP 1–4 and REEP 5–6 clades in vertebartes are also highlighted. The red parentheses ‘)’ indicate species‐specific duplications.Click here for additional data file.Figure S2 Phylogenetic reconstruction of the VAPs. The tree shown is based on MrBayes. Well‐supported nodes in both the MrBayes and Maximum Likelihood (IQ) analyses are highlighted. The red parentheses ‘)’ indicate species‐specific duplications or expansions. The duplication leading to mammalian VAP‐A and VAP‐B likely occurred in the vertebrates. Species names are coloured as in Figure 3. At: Arabidopsis thalianaClick here for additional data file.Figure S3 Phylogenetic reconstruction of spastin and fidgetin. The tree shown is based on MrBayes. Well‐supported nodes in both the MrBayes and Maximum Likelihood (IQ) analyses are highlighted. The tree separates the fidgetin (top) and spastin (bottom) clades. The red parentheses ‘)’ indicate species‐specific duplications. Species names are coloured as in Figure 3.Click here for additional data file.Figure S4 Phylogenetic reconstruction of atlastin and Sey1p. The tree shown is based on MrBayes. Well‐supported nodes in both the MrBayes and Maximum Likelihood (IQ) analyses are highlighted. The tree separates the atlastin (top) and Sey1p (bottom) clades; the inset on the left shows the same tree in star format to highlight the clear separation of the two clades . The length and conserved domains of each query protein are given in the top 10 lines. Grey cells with a ‘−’ sign indicate ‘absence’ as no significant hit was found in a genome for the corresponding protein. Green cells with a ‘+’ sign indicate ‘presence’ based on forward and reverse BLAST hits with significant e‐value (see Table S3); a number in such cells indicates that >1 ortholog was found. Blue cells with a ‘+’ sign indicate possible ‘paralogs’ based on forward BLAST hits with significant e‐value (see Table S3) but where the best reverse BLAST hit was to a different member of the protein family; a number in such cells indicates that >1 homolog was found.Click here for additional data file.Table S3 Detailed results of the comparative genomics analysis. For each result, the accession number of the corresponding protein in each genome is given, as well as the protein length, and the e‐value of the forward BLAST or HMMer analysis. In cases of multiple isoforms, only the accession number of the longest isoform is given. Grey cells indicate ‘absence’ as no significant hit was found in a genome for the corresponding protein (includes notes on ‘neighbour‐BLAST’ results). Coloured cells indicate ‘presence’ based on forward and reverse BLAST or HMMer hits with significant e‐value. Light green: results from BLAST , dark green: results from HMMer, blue: results from ‘neighbour‐BLAST’ , pink: results from tBLASTn against contigs . Notes in red indicate discrepancies in protein size between the query and the hit, hinting at possible mis‐annotations or gene fusions/fissions.Click here for additional data file.Table S4 A comparison of the results of this study with previous analyses in the literature, for the proteins Use1p and Dsl1p. Previous comparative genomic analysis has been conducted for 2 proteins used in the present study: Use1p  and Dsl1p . Grey cells with a ‘−’ sign indicate ‘absence’ of a protein ortholog. Green cells with a ‘+’ sign indicate ‘presence’ of a protein ortholog; a number in such cells indicates that >1 ortholog was found. Dark cells indicate that the organism was not included in the corresponding study.Table S5 List of organisms included in this study. For each species, an abbreviation is given, which was used for the alignments and phylogenetic analyses. The genome source for each organism used for BLAST and Hmmer searches are also indicated.Click here for additional data file.Table S6 Detailed results of the comparative genomics analysis for lineages checked with wider species sampling on the EkProt server.Click here for additional data file.


Nivolumab belongs to immune checkpoint inhibitors (ICIs). ICIs‐induced kidney injury is rare and acute interstitial nephritis (AIN) is the majority. A 58‐year‐old woman had gastric cancer treated with nivolumab. Her serum creatinine (Cr) increased to 5.94 mg/dL post 2 cycles of nivolumab and co‐administered with acemetacin. A kidney biopsy showed acute tubular injury (ATI). Nivolumab rechallenge was done and Cr worsened again. The lymphocyte transformation test (LTT) indicated a strong positive for nivolumab. Although rare, ATI due to ICIs could not be ruled out, and LTT is a tool to identify the culprit. Clinical course and management of Nivolumab‐induced ATI. Among many immune‐related adverse events (IRAEs) due to ICIs, IRAE nephritis is around 2–5%.2A 58‐year‐old postmenopausal woman was diagnosed with right breast cancer , ER:, PR:, HER‐2: [1+], KI‐67:15% , and stage I (T1cN0M0) in May 2016. She received partial mastectomy and Sentinel node excision on June 26, 2016. She kept on adjuvant hormone therapy with Tamoxifen after operation. Synchronous stage IV gastric adenocarcinoma with ovarian metastasis and peritoneal carcinomatosis (T3N2M1) was diagnosed in July 2016. Systemic chemotherapy with XELOX and FOLFORI was administrated until September 2017. Ovarian metastatic tumor progression and bone metastasis were noted in September 2017. Laparotomy with bilateral salpingo‐oophorectomy and partial omentectomy was performed on October 17, 2017. Palliative systemic therapy with Nivolumab (3 mg/kg) was initiated on November 24, 2017. The second cycle was given on December 11, 2017, and her Cr level was 0.91 mg/dL, urinalysis showed negative for protein and hemoglobin before nivolumab initiation and Cr level was 0.74 mg/dL on December 27 before the second cycle of immunotherapy.The patient was found to have acute kidney injury (AKI) with a Cr level of 3.11 mg/dL (CTCAE grading 3) on December 22 through prechemotherapy lab survey, after 2 cycles of nivolumab  was applied for suspected IRAE nephritis on December 25, 2017  from 2017 12/20–24 for pain control, which may contribute to her renal impairment as the Cr level showed an increase  and BUN was 31.3 mg/dL on January 1, 2018. We discontinued methylprednisolone on January 2, 2018. Third cycle of immunotherapy with Nivolumab was re‐initiated on January 4, 2018. The patient denied any discomfort after immunotherapy and she was discharged on January 8, 2018.At fourth cycle immunotherapy on January 18, 2018, impaired kidney function was noticed again. The Cr level was 2.0 mg/dL (CTCAE grading 3) on January 17 and BUN was 44.6 mg/dL. She denied urine output decreased, dysuria, or back pain.Besides, interval progression of the right hydronephrosis despite double‐J in place was noted. We consulted Urologist. for progression of the hydronephrosis. Ureteroscopy and change bilateral double‐J tube were performed. We hold the 4th immunotherapy and readmitted the patient for further treatment. Therefore, methylprednisolone 60 mg QD was prescribed from February 1, 2018, to February 7, 2018. The patient's renal function improved gradually  compared to other organs.The types of nephropathies caused by the ICI class vary enormously even when induced by a single agent such as nivolumab. Cortazar et al.The median time from ICI start to AKI is variable. In the patient of our case, the time relapsed from the initial exposure to nivolumab plus longer half‐life acemetacin until the onset of AKI was 30 days. This delayed response is in line with the observations of a case series of 13 patients with ICI‐induced AKI, in which the median time from initiation of an ICI to AKI was 91 days (range: 21–245 days).Our patient had received short‐acting NSAIDs without causing abnormal renal function before this incident. The use of long‐acting acemetacin during nivolumab therapy may result in increased nephrotoxicity according to the longer half‐lives. After our patient had experienced a second treatment of nivolumab (3 mg/kg) 160 mg and acemetacin 90 mg, the serum Cr surged from 0.91 to 5.94 mg/dL compared to nivolumab alone (Naranjo score = 6). According to the severity of nephrotoxicity provided by KDIGO guidelines, our patient belongs to stage 3 AKI .As we know, anti‐PD‐1 therapy may drive an autoimmune variant of interstitial nephritis, similar to the induction of autoimmune diabetes, possibly mediated by the loss of peripheral tolerance to self‐reactive T cells.Our therapeutic approach included the discontinuation of the possible offending agent  and daily administration of systemic corticosteroids for IRAEs according to guidelines. After 5 days of treatment, serum Cr dropped. Current guidelines20 for ICI‐induced AKI are formulated by the Society for Immunotherapy of Cancer per Common Terminology Criteria for Adverse Events (CTCAE version 5.0).In the study from Cortazar et al, only 22% of patients with stage 2 or 3 AKI were rechallenged; only 23% of rechallenged patients occurred in recurrent ICI‐induced AKI; of those with recurrent AKI, all but one responded to the second course of glucocorticoids.In our case, after the third cycle of nivolumab in the condition without NSAIDs involved, renal function relapse occurred, giving a Cr level of 2.0 mg/dL. (Naranjo score = 7) In comparison, the second cycle of nivolumab given with acemetacin showed a Cr level of 5.94 mg/dL. Therefore, we highly suspect that acemetacin might play a role in causing AKI.However, our case report has several limitations. First, LTT for acemetacin was not performed before nivolumab therapy. Thus, it is not known whether nivolumab therapy altered the patient's immunological tolerance against acemetacin. LTT results for suspicious drugs are required to clarify the pathophysiology of AKI. Second, the LTT detection time for nivolumab takes 3 weeks, and IHC staining is not promptly in progress. Therefore, it might delay a better understanding of the pathophysiology and etiology behind the renal disease associated with ICIs. Third, we do lack baseline urinalysis before the use of ICI and, therefore, cannot completely exclude the presence of underlying renal pathologies prior to ICI use. Four, Renal biopsy was performed not promptly after high‐dose steroid therapy and decreased creatinine to near baseline level in this case. Thus, tubulointerstitial inflammation might already disappear at the time of the biopsy, Finally, considering the half‐life of nivolumab in the human body (12 to 20 days) and the decline in renal function appears to be related to the dose and duration of exposure to NSAID, it is uncertain the causal relationship between ICI and concomitant medications known to cause ATN.In summary, acemetacin (an NSAID)‐induced ATI was highly suspected initially. However, according to the LTT and nivolumab rechallenge results, we strongly speculated that nivolumab (an ICI) may contribute to ATI formation. From the literature review, cases of ICIs‐induced ATI had been found as well1. We should give scrupulous attention to nivolumab treatment in a case with co‐administered NSAIDs.4We reported a rare case of nivolumab‐induced ATI. A kidney biopsy is essential to exclude other possibilities such as interstitial nephritis or associated glomerular diseases. LTT is a useful tool to identify the possible culprit in spite of not being able to reveal the result in real time. It is important to note that, in patients with limited choice for ICI reuse, culprit medication associated with ICI‐related nephrotoxicity should be avoided.Hui‐Hsin Yang: Visualization; writing – original draft; writing – review and editing. Chia‐Wen Chang: Data curation. Tai‐Di Chen: Supervision.This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.All authors have no financial or other conflicts of interest.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Basal cell carcinoma (BCC) incidence is steadily increasing but therapeutic solutions remain limited and present a public health challenge.To identify predictive factors of BCC recurrence after primary free margin excision, with automated methods, by evaluating cell proliferation, the Hedgehog pathway activation and primary cilia.This case–control study included 32 patients  who underwent surgery for BCC. Formalin‐fixed paraffin‐embedded cutaneous resections were processed for immunohistochemistry or immunostaining with the following primary antibodies: mouse anti‐MCM6, rabbit anti‐ARL13B and rabbit anti‐GLI1.p < 0.001) and a lower cilia count (p = 0.041) in the primary lesion. No significant differences were observed regarding cilia length (p = 0.39) or GLI1‐positive nuclei.BCC recurrence after free margin excision was significantly linked to a higher proliferative index (The complex interplay between essential signaling pathways, cell proliferation and cilia requires further experimental investigations in the context of BCC recurrence.A higher proliferative index evaluated with MCM6 antibody could be a useful prognosis marker of BCC risk of recurrence. The lower cilia count in the primary lesion unveiled novel perspectives to understand BCC recurrence molecular mechanisms.  Its incidence is steadily increasing, but therapeutic solutions remain limited and present a public health challenge.Different proliferative index markers have been extensively studied in BCC, but analyses remained controversial.Recent advances in the understanding of the Hedgehog signalling pathway , inherently associated with primary cilia, and its role in BCC pathogenesis led to the introduction of new treatments significantly improving clinical outcomes in unresectable, recurrent or metastatic lesions.The present study aimed to identify predictive factors of BCC recurrence after primary free margin excision, with automated methods, by evaluating the proliferative activity, the Hedgehog pathway activation and cilia formation.2On a preliminary screen, we selected 281 patients with more than 2 BCC histories (2009–2015 period). Then, we selected 59 patients with two BCC at the same localization as assessed with the dermatology department photo database. When the primary diagnosis was wrong or when margins and histological subtypes were unclear, the patients were rejected. Moreover, one patient refused to be included in our study. Finally, 16 recurrent BCC were selected for analysis, with strict selective criteria. They were matched with non‐recurrent BCC, selected from the 2010–2015 period, and defined as patients with no recurrence during a follow‐up period of at least 5 years and with an average follow‐up of 8.6 years. Microscopic length, deep and lateral margin were analysed. Formalin‐fixed paraffin‐embedded (FFPE) cutaneous resections were processed for immunohistochemistry or immunostaining with the following primary antibodies: mouse anti‐MCM6 , rabbit anti‐ARL13B  and rabbit anti‐GLI1 . Immunoreactivity was illustrated with Ultra View Universal 3,3’‐diaminobenzidine (DAB) detective kit, using the Ventana Automatic Benchmark Ultra System.For the evaluation of MCM6‐positive cells, five high‐power fields with the highest number of positive nuclei were counted at 400 magnifications.For the evaluation of GLI1 and cilia, five high‐power fields at 1000 magnifications were processed for quantification.Micrographs were acquired by AxioImageur Zeiss (100x Ph) with ZEN software. Data were obtained and processed with the ImageJ software. The percentage of ciliated cells and the average cilia length were automatically quantified with CiliaQ on ImageJ.Comparisons between groups were performed using Student's tests or Wilcoxon–Mann–Witney tests when appropriate.p = 0.05). We found a statistically significant increased proliferative index evaluated with MCM6 ; and a lower percentage of ciliated cells  in recurrent BCC. However, no significant differences were observed regarding cilia length  or GLI1‐positive nuclei .No significant differences were observed between the two groups, regarding clinical and histological characteristics Table , except A subgroup analysis was performed based on the classification of the recurrence risk of BCC (seven low‐risk BCC and nine high‐risk BCC). The results were identical and showed a statistically significant association between recurrence and cell proliferation and the decrease in the number of cilia (except for low‐risk BCC). The results remained inconclusive for GLI1.3In this study, we demonstrated that recurrence of BCC was associated with a higher MCM6 proliferative index, with relative slightly dispersed values. This was an important observation since KI67 assessments were often inconclusive in BCC immunohistochemistry analyses because of a large dispersion of the results. This was further associated with a decrease in ciliated cells.The originality of our approach lies in the evaluation of an additional proliferation‐associated marker (MCM6‐antibody), and in the automated computer‐assisted evaluation of cilia on FFPE tissue sections with ARL13B staining instead of acetylated‐tubulin which provides a more robust evaluation of ciliated cells.In conclusion, we have shown that a higher proliferative index evaluated with MCM6 antibody could be a useful prognosis marker of BCC risk of recurrence. The lower cilia count in the primary lesion  unveiled novel perspectives to understand BCC recurrence molecular mechanisms.Valérian Dormoy reports personal fees from Chiesi outside the submitted work.A. Jacquet: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. V. Dormoy: Conceptualization, Data curation, Formal analysis Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. M. Lorenzato: Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review & editing. A. Durlach: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.