Curcuma phaeocaulis Radix (Lüsiyujin) is a mainstream variety of Curcumae Radix cultivated in Sichuan for more than 900 years, but its broader utility is limited by a lack of quality control and pharmacodynamic research. We used the Chinese Pharmacopoeia, 2015 edition, to guide the determination of germacrone and furanodienone content in extracts. We established an animal model of Qi stagnation and blood stasis in a clinical context. Pathological changes in liver function indexes were evaluated to investigate the hepatoprotective effect of Lüsiyujin. In 20 extraction batches of Lüsiyujin, ethanol extracts yielded 9.22%–15.01%, average 12.03%. The germacrone content was 0.003%–0.011% (average 0.0069%), and the furanodienone content was 0.090%–0.478% (average 0.201%). Compared with the control group, the model rats exhibited functional liver damage. Serum markers of liver function varied after treatment with Lüsiyujin, but significant effects were observed with alanine aminotransferase and total bile acid. This study demonstrates a simple method of quality control for Lüsiyujin. The study also demonstrated that Lüsiyujin inhibits hepatocyte damage and regulates the excretion and secretion of hepatic bile. Our findings provide a theoretical basis for the formulation of quality standards, clinical application, and resource development for the utilisation of Lüsiyujin. Curcuma wenyujin (Wenyujin), Curcuma longa (Huangsiyujin), Curcuma kwangsiensis (Guiyujin), or Curcuma phaeocaulis (Lüsiyujin). Yujin has long been used to treat Qi stagnation due to liver depression (LDQS) in traditional Chinese medicine (TCM) [Curcumae Radix (Yujin) is derived from the dried Radix of ne (TCM) .Curcuma phaeocaulis Radix  is a common TCM that has been cultivated for more than 900 years in Sichuan [Curcuma phaeocaulis rhizome [ Sichuan . Its ori Sichuan , 4, Weny Sichuan , and Gui Sichuan  or Curcu rhizome , 8, but Quality standards provided in the Chinese Pharmacopoeia, 2015 edition, only contain quality control items such as characteristics, identification, and physical characteristics . The standards do not yet define methods for extraction and content determination, thus preventing effective quality control. There is also a significant lack of pharmacodynamics research.This study aimed to develop a standardised method for establishing quality control and guiding clinical use of Lüsiyujin. Germacrone and furanodienone content in the Lüsiyujin extract was determined by HPLC. We also evaluated the effect of Lüsiyujin on liver function to provide a reference for clinical application.The germacrone reference standard was purchased from the National Institute for Food and Drug Control . The furanodienone reference standard was purchased from the Chengdu Chroma-Biotechnology . Methanol and acetonitrile  were of HPLC grade. Other reagents were of analytical purity. Water was glass-distilled and filtered through a Milli-Q water purification system  before use. Aspirin enteric-coated tablets were purchased from Yunnan Baiyao Group . Xuefu Zhuyu Pian (Lot no. 170409) was purchased from Weifang Zhongshi Pharmaceutical .Twenty batches of Lüsiyujin were obtained from Shuangliu, Chongzhou, Wenjiang, and other producing areas of Sichuan. These samples were authenticated by Professor Ming Li . Information regarding the sample materials is shown in Ethanol extracts were prepared according to standard 2201 of the 2015 Chinese Pharmacopoeia, Volume IV. Homeopathic alcohol was used as the extraction solvent.μm pore size) before HPLC injection.Lüsiyujin powder was precisely weighed (5 g) and immersed in 25 mL methanol. Additional methanol was added to make up the loss after ultrasonic extraction for 30 min. The material was filtered .A mixed stock solution containing reference standards was prepared by dissolving weighed samples of each compound in methanol, yielding germacrone 54.20 μm) column. The mobile phase consisted of A (acetonitrile) and B (water) (V/V). Optimum separation occurred at 60%A. The flow rate was 0.8 mL·min−1 and injection volume was 10 μL. The column temperature was set at 35°C, and elution was monitored at 210 nm.HPLC determinations were performed using a Shimadzu LC-2030C 3D instrument , equipped with a DAD detector, auto sampler, column heater, and Shimadzu Shim-pack GIST C18  was used to evaluate precision; repeatability; stability; and recovery.T ≤ 50°C). The rats were dosed at 0.9 g·kg−1, a conversion of the human clinical dosage (dose = 10 g/70 kg × 6.3 = 0.9 g/kg).Lüsiyujin decoction was prepared according to the Standard for Management of a TCM Decocting Room in Medical Institutions and Technical Requirements for Quality Control and Standard Formulation of TCM Granules. Lüsiyujin was boiled for 30 min after soaking 30 min with a 9-fold volume of water and then filtered. The dregs were boiled twice for 30 min with a 7-fold volume of water and then filtered and mixed with the previous filtrate. The mixed decoction was concentrated by vacuum concentration  were obtained from Chengdu Dasuo Experimental Animal Co., Ltd. (licence key: SCXK(川) 2015–030, Chengdu, China). Animals were housed in polypropylene cages and left for 5 days to acclimate to the animal room , maintained under controlled conditions (12 h light-dark cycle at 22 ± 2°C) on a standard pellet diet and water ad libitum. Animal experiments were approved by the Committee of Scientific Research and the Committee of Animal Care of the Chengdu University of TCM . Animals were randomly and equally divided into four groups : control group (CG), model group (MG), Lüsiyujin group (LG), and positive group (PoG).−1). PoG was given Xuefu Zhuyu suspension intragastrically (dose = 0.432 g·kg−1). Except for the CG, LDQS blood stasis was induced in the remaining groups as described elsewhere [CG and MG were given normal saline intragastrically. LG was given Lüsiyujin decoction intragastrically dose = 0.9 g·kg g·kg−1. The liver was stained with hematoxylin-eosin staining (H&E). Gross lesions were observed by BA400 Digital microscopy  at 40× magnification. Images of specific lesions were captured at 100× and 400× magnifications.γ-glutamyl transpeptidase (γ-GT), direct bilirubin (DBiL), total bilirubin (TBiL), and total bile acid (TBA) were evaluated by Chemray 240 Automatic Biochemical Analyser  [γ-GT, and TBA were assayed by the performance rate method.We evaluated several markers of liver function to understand the impact of different Lüsiyujin processing methods. Serum levels of albumin (ALB), alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), , China) , 11. ALBP-values <0.05 were considered significant.All data were analysed with SPSS 19.0 software and expressed as mean ± SD. Significance was determined by using one-way ANOVA. The Mann–Whitney test was used for rank data comparison. As described in the aforementioned section, ethanol extracts of the 20 batches of Lüsiyujin yielded 9.22%–15.01% (average 12.03%). The results are shown in The chromatograms of mixed standards and samples are shown in As described in the aforementioned section, the calibration curves of germacrone and furanodienone exhibited good linear regressions .Precision was obtained by six replicate determinations of independent standard solutions, and RSD was calculated. Repeatability was determined by performing six repeat measurements of a single sample (L14). Stability studies were performed at room temperature for 0, 2, 4, 8, 12, and 24 h after preparation. Germacrone and furanodienone were stable for 24 h (RSD <3%). In the recovery test, six samples were prepared by spiking a known quantity of each standard into a Lüsiyujin sample measured and then extracted according to the sample preparation method. All data are provided in Samples and standards were prepared as described above and the germacrone and furanodienone content was determined by HPLC. The germacrone content in the Lüsiyujin samples was 0.003%–0.011% (average 0.0069%), and the furanodienone content was 0.090%–0.478% (average 0.201%) .As compared with the CG of rats , CG, theThe liver damage was graded as follows: “−” expressed no visible cell damage, “+” slight damage, “++” moderate damage, and “+++” moderate/severe damage. γ-GT, DBiL, TBiL, and TBA in each experimental group. Compared with the CG, serum ALB levels were significantly lower in the MG rats (P < 0.01), and serum ALP, ALT, AST, γ-GT, DBiL, TBiL, and TBA were significantly increased (P < 0.01). These results indicate functional hepatic damage in the MG rats. After treatment with Lüsiyujin, the serum indexes of liver function showed varying degrees of change, but only ALT and TBA differed significantly.Curcuma phaeocaulis Valeton [Traditional Chinese medicines prepared in ready-to-use forms (Zhongyaoyinpian) are necessary traditional weapons for clinical differentiation and the important raw materials of Chinese patent drugs. Therefore, the quality of Zhongyaoyinpian is related to the curative effect of TCM. An important reference for quality standards is the Chinese Pharmacopoeia (Part I) and the processing standards of TCM in various provinces. Despite its common use in Chinese herbal medicine, studies of Lüsiyujin are relatively sparse. Most quality indicators depend on germacrone, which is neither a high content component nor its exclusive component. Therefore, it is necessary to find other characteristic components of Lüsiyujin for quality control. Based on the 2015 Chinese Pharmacopoeia, relevant literature , 13, and Valeton . Germacr Valeton , 18. Che Valeton . We defiγ-GT is mainly expressed in the liver and an increase reflects hyperactivity or obstruction of bile discharge [In order to better study the pharmacodynamic effect of Lüsiyujin in the clinical practice of TCM, we established a previously described syndrome model by clamping the tail and repeatedly giving small doses of adrenaline to cause chronic anxiety in rats, who exhibited irritability, anger, and other emotions according to the theories of TCM. Biochemical serum indexes closely related to liver function were used as an indicator of liver injury , 21. ALTischarge . PatholoIn conclusion, this study provides a basis for the quality control of Lüsiyujin and proves its effect on improving liver injury. However, the chemical composition of TCM is complex, and its functions and indications are extensive. In the follow-up study, we will use LC-MS, GC-MS, and other technologies to characterize and identify the main chemical components of Lüsiyujin, establish spectrum effect correlation combined with functional indications, and screen out the effective substance basis. Then, quantitative analysis of multicomponents with a single marker and fingerprint, combined with the pharmacodynamic component group, was used to develop a more perfect quality evaluation method system of Lüsiyujin. At the same time, we should strengthen the research on the pharmacokinetics and pharmacological mechanism of the main compounds (such as germacrone and furanodienone) of Lüsiyujin and tap their clinical application potential.This study improved the quality standard of Lüsiyujin by proving the described method is simple, accurate, reliable, and reproducible. It can be used as a quality control method for other preparations. Pharmacodynamic studies showed that the Lüsiyujin inhibits hepatocyte injury and regulates hepatic bile excretion and secretion. We thus established a quality control method and preliminary pharmacodynamic data for Lüsiyujin. Further studies are needed to identify bioactive compounds and related molecular mechanisms, improve the quality standards, and provide more evidence for quality assurance and a scientific basis for clinical application.


Spinal infection (SI) is a life-threatening condition and treatment remains challenging. Numerous factors influence the outcome of SI and both conservative and operative care can be applied. As SI is associated with mortality rates between 2 and 20% even in developed countries, the purpose of the present study was to investigate the occurrence and causes of death in patients suffering from SI.A retrospective analysis was performed on 197 patients, categorized into two groups according to their outcome: D (death) and S . The diagnosis was based on clinical and imaging (MRI) findings. Data collected included demographics, clinical characteristics, comorbidities, infection parameters, treatment details, outcomes, and causes of death.n = 9/51, 18%) compared with the operative counterpart . Death caused by septic multiorgan failure was the major cause of fatalities  followed by death due to cardiopulmonary reasons . The most frequent indication for conservative treatment in patients of group D included “highest perioperative risk” .The number of deaths was significantly higher in the conservative group (We could demonstrate a significantly higher mortality rate in patients solely receiving conservative treatment. Mortality is associated with number and type of comorbidities, but also tends to be correlated with primarily acquired infection. As causes of death are predominantly associated with a septic patient state or progression of disease, our data may call for an earlier and more aggressive treatment. Nevertheless, prospective clinical trials will be mandatory to better understand the pathogenesis and course of spinal infection, and to develop high quality, evidence-based treatment recommendations. Spinal infection (SI) is a life-threatening condition and defined as an infectious disease affecting the spine and/or the paravertebral tissues . SI may We performed a retrospective analysis of all patients presented to our department with an SI between 2010 and 2017. Patients were categorized into two groups according to their outcome: D (death) and S . The diagnosis was based on clinical magnetic resonance imaging (MRI) findings and changes in infection parameters. Data was collected using the patients’ digital health records  and was documented according to institutional standards and the general standards according to the principles of good clinical practice (GCP). Data included demographics, ASA scores, clinical and neurological characteristics measured by the muscle force assessment (0–5) according to the Medical Research Council (MRC), occurrence of comorbidities, age-adjusted Charlson comorbidity index (ACCI), infection parameters, such as C-reactive protein (CRP), treatment details and indications, respectively (operative vs. conservative), and treatment outcomes as well as causes of death. Sepsis was defined by the presence of two or more systemic inflammation response syndrome (SIRS) criteria. Patients suffering from (1) neurological deficits, (2) progressive or intractable pain, and/or (3) radiological progression due to MRI findings despite maximum conservative treatment qualified for surgical treatment, after being medically cleared for surgery by an interdisciplinary team. The operative procedure was determined individually for each patient, depending on present comorbidities, the extent and location of the infection, and the grade of vertebral destruction. All patients were additionally treated with intravenous broad-spectrum antibiotics  .t test and Mann-Whitney U test were performed to analyze differences in clinical and demographic characteristics and in clinical outcome variables. Frequencies were compared by the Chi-square and Fisher’s exact tests. Spearman’s rho correlation (r) was determined to assess the relationship between clinical outcome and demographics. A p value < 0.05 was considered statistically significant. All statistical evaluations were performed with SPSS version 21.0 . Figures were designed using Microsoft Excel .All patients with complete initial data were considered for inclusion in the retrospective analysis. Values are expressed by mean ± standard deviation (SD). The Kolmogorov-Smirnov test was used for testing normal distribution. The unpaired Student’s n = 17/197). Demographic details and patients’ characteristics are outlined in Table n = 12/197) of patients showed an isolated SEA without affection of the discs or vertebral bodies, whereas 5 patients (2.5%) presented with an isolated paravertebral abscess.One hundred ninety-seven patients with a sufficient data set were identified and evaluated retrospectively. Overall mortality in our cohort was 8.6% n = 7/197. DeStaphylococcus aureus . An antibiogram-adjusted antibiotic treatment due to a positive pathogen detection was conducted in 41.2% (n = 7/17) of patients in group D and in 28.8% (n = 52/180) of patients in group S (p > 0.05)  were treated conservatively, and 146 patients (74.1%) were managed surgically. Depending on the extent of infection and bony destruction, surgical cases were only decompressed or decompressed and instrumented with or without  corpectomy (Table 5.9% weren = 10/17), followed by death due to cardiopulmonary reasons . Death by septic multiorgan failure was significantly more frequent in the conservatively treated group  when compared with the surgically treated patients . The individual causes of death for both treatment groups are depicted in detail in Fig. n = 5/17, 29%), “no neurological deficit” , and “healing of abscesses before intervention” . These indications justifying conservative treatment differed significantly between groups D and S (p ≤ 0.01). When rated as “highest perioperative risk” and treated conservatively, a patient’s chance to survive was 50% (n = 5/10). When treated conservatively due to missing neurologic symptoms, a survival rate of 92.3% was observed (n = 36/39). Indications for operatively treated patients in group D solely included “progression of symptoms” . Individual treatment indications in both groups are shown in detail in Table The majority of patients (59%) died from septic multiorgan failure  compared with surgically treated patients . Overall, patients in group S demonstrated a significantly lower ASA score (mean: 2.6 ± 0.7) when compared with group D . Duration of surgery differed significantly between group S (188 ± 89 min) and group D . The overall time interval from diagnosis to death in group D was 110 ± 294 days, whereas the time from surgery to death was 43 ± 60 days.A higher mortality was observed in patients treated conservatively n = 9/5, 18% comp > 0.05). The total number of accompanying illnesses per patient differed significantly between both groups . The ACCI also demonstrated significantly worse scores in group D (6.5 ± 2.3) than in group S . A higher mortality was shown for patients suffering from renal failure  and diabetes mellitus (DM) tended to be associated with a higher mortality rate as well (p = 0.071). Group D largely consisted of patients affected by primary acquired spondylodiscitis  compared with group S  (p > 0.05). Group D showed significantly higher CRP levels  and signs of sepsis at admission . Also, patients in group D were admitted with significantly more pronounced neurological deficits, measured by the weakest muscle group according to the MRC . In group S, neurological deficits as well as infection parameters, improved significantly during the hospital stay (p < 0.05) whereas in group D parameters tended to improve over time, but this failed to reach statistical significance (p > 0.05).The occurrence of an epidural or a paravertebral abscess was not associated with higher mortality , especially in multimorbid patients. Although further prospective studies are mandatory, early surgery seems to be beneficial in severely affected SI patients.Spinal infection is a serious and life-threatening disease requiring urgent treatment. Our retrospective analysis demonstrates a significantly higher mortality rate in patients receiving solely conservative treatment. Mortality is frequently associated with number and type of comorbidities, but also trends to be correlated with primarily acquired infection. As causes of death are predominantly associated with a septic patient state or progression of disease, our data may call for an earlier and more aggressive treatment. Nevertheless, prospective clinical trials will be mandatory to better understand the pathogenesis and course of spinal infection and to develop high quality, evidence-based treatment recommendations.


The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland..Alport syndrome (AS) is a genetic disorder involving mutations in the genes encoding collagen IV α3, α4 or α5 chains, resulting in the impairment of glomerular basement membrane. Podocytes are responsible for production and correct assembly of collagen IV isoforms; however, data on the phenotypic characteristics of human AS podocytes and their functional alterations are currently limited. The evident loss of viable podocytes into the urine of patients with active glomerular disease enables their isolation in a non‐invasive way. Here we isolated, immortalized, and subcloned podocytes from the urine of three different AS patients for molecular and functional characterization. AS podocytes expressed a typical podocyte signature and showed a collagen IV profile reflecting each patient's mutation. Furthermore, RNA‐sequencing analysis revealed 348 genes differentially expressed in AS podocytes compared with control podocytes. Gene Ontology analysis underlined the enrichment in genes involved in cell motility, adhesion, survival, and angiogenesis. In parallel, AS podocytes displayed reduced motility. Finally, a functional permeability assay, using a podocyte–glomerular endothelial cell co‐culture system, was established and AS podocyte co‐cultures showed a significantly higher permeability of albumin compared to control podocyte co‐cultures, in both static and dynamic conditions under continuous perfusion. In conclusion, our data provide a molecular characterization of immortalized AS podocytes, highlighting alterations in several biological processes related to extracellular matrix remodelling. Moreover, we have established an  COL4A5 gene, while the others have autosomal recessive, or less commonly autosomal dominant, disease, caused by mutations in COL4A3 or COL4A4 genes [Alport syndrome (AS) is a genetic disorder that affects one in every 50 000 newborns. Around 80% of AS families have X‐linked inheritance caused by mutations in the A4 genes . These gA4 genes , 3. CollA4 genes .Col4a3+/− and Col4a3−/− mice), podocytes appear with specific morphological alterations characterized by long filamentous and round shaped projections as compared to the podocytes of wild‐type mice [In particular, the absence of a correct collagen IV α3α4α5 network impairs the functional properties of the glomerular filtration barrier . During ype mice .Since in glomeruli, the production of the collagen IV α3α4α5 heterotrimer is restricted to podocytes , their iin vitro model necessary for the characterization of their morphological, molecular, and functional profile.Several studies demonstrated that podocyte excretion is a natural phenomenon which precedes proteinuria , 16 and in vitro model to evaluate possible functional and molecular alterations in human AS podocytes. Urine‐derived podocytes from AS patients were isolated, immortalized, and cloned, and their gene expression profile was characterized by RNA sequencing, in comparison with normal urine‐derived podocytes. Moreover, a three‐dimensional system of podocyte–glomerular endothelial cell (GEC) co‐culture was established to analyse the selective filtration of AS podocytes, compared with control podocytes. Permeability was measured in both static and dynamic co‐culture conditions, confirming the defective filtration observed in patients with AS.The goal of our study was to set up a novel human A total of three patients diagnosed with AS were recruited in this study. All parents of the AS patients provided informed signed consent for urine collection and subsequent experiments, and the Ethics Committee of the University Hospital Leuven approved the research protocol (S54695). The diagnosis was based on measuring creatinine levels and estimated glomerular filtration rate (eGFR) and was confirmed by the characterization of the mutated Alport syndrome genes Table . Patientg for 10 min and the pellet was resuspended in DMEM/F‐12  supplemented with 10% FCS , 50 IU/ml penicillin, 50 g/ml streptomycin, 5 mm glutamine, 5 g/ml insulin, 5 g/ml transferrin, and 5 mg/ml selenium . Cells (AS and control podocytes) were immortalized and subcloned using a temperature‐sensitive Simian virus 40 large T (SV40T) and human telomerase reverse transcriptase vectors, as described previously [Freshly collected urine was centrifuged at 200 × eviously . AB kidneviously .Control and AS podocytes were grown at 33 °C and transferred to 37 °C for 10–14 days to obtain fully differentiated podocytes. Details are provided in supplementary material, Supplementary materials and methods.Primary normal glomerular microvascular endothelial cells were previously obtained from cell outgrowths of human glomeruli and CD31 sorting, and characterized by morphology and expression of a panel of endothelial antigens  see sup.m of each primer , and 1× SYBR Green PCR Master Mix (Applied Biosystems), and assembled into a 96‐well StepOne Real Time System (Applied Biosystems). Negative cDNA controls were cycled in parallel in each run. Data are shown as relative quantification (2−ΔΔCt). GAPDH expression was used to normalize cDNA inputs. Sample similarity plots were generated using Morpheus (https://software.broadinstitute.org/morpheus/).RNA was extracted using Trizol (Life Technologies) according to the manufacturer's protocol. Aliquots of total RNA (200 ng) were reverse‐transcribed using a High Capacity cDNA Reverse Transcription Kit . Levels of mRNA were assessed by qPCR, using a mix containing 5 ng of cDNA, 100 nCell pellets were lysed at 4 °C for 15 min in RIPA buffer (Sigma) supplemented with protease and phosphatase inhibitors. Details are provided in supplementary material, Supplementary materials and methods.n = 3 experiments in duplicate). Details may be found in supplementary material, Supplementary materials and methods.The concentrations of human VEGFA, Col4α3, and Col4α5 in protein lysate and supernatant of differentiated podocytes were measured using ELISA kits according to the manufacturer's instructions (http://www.ncbi.nlm.nih.gov/projects/geo/) under the GEO accession number GSE134011.Details are presented in supplementary material, Supplementary materials and methods. RNA‐seq data have been deposited in the GEO database . Details are provided in supplementary material, Supplementary materials and methods.4 cells per 12‐well insert  and, after 6 h, podocytes were seeded on the upper side at the same density. Each cell type was cultured in its growth medium for 48 h before the permeability assay and medium were changed once the day after cell plating.For all co‐culture experiments, GECs were seeded first on the lower PET membrane side at a density of 8 × 10−5 dyn/cm2. To roughly calculate this value, the following equation was used: τ = 6μQ/bh2, where μ is the medium viscosity (g/cm per s), Q is the volumetric flow rate (cm3/s), b is the channel width, and h is the channel height [For dynamic experiments, we used a millifluidic device, fabricated by IVTech Srl , consisting of two independent circuits that work in parallel. During permeability tests, the medium was maintained with a flow rate of 100 μl/min and cells in the chamber were subjected to a shear stress of 8 × 10l height , 25, 26.Permeability assays were performed after 48 h of co‐culture by measuring BSA filtration. Complete medium (1 ml) containing or not FITC‐BSA  was placed in the lower endothelial and upper podocyte compartments, respectively. To measure the podocyte filtration ability in basal to apical direction, 100 μl of medium was taken after 6 h from the podocyte compartment and the passage of FITC‐BSA was determined by fluorimetry in triplicate. For the dynamic system, podocyte medium enriched with FITC‐BSA (1 mg/ml) was circulated into the endothelial compartment, while normal culture medium circulated into the upper compartment. After 3 h of perfusion, the passage of BSA‐FITC across the barrier was determined by sampling of fluid from the upper channel. FITC signal was measured in triplicates using a fluorimeter.t‐tests were used for analysis when two groups of data were compared, while two‐way ANOVA with Dunnett's multiple comparison test was applied when comparing more than two groups of data. All statistical analyses were performed using GraphPad Prism software version 6.0 . p < 0.05 was considered significant.Data are shown as mean ± SD. At least three replicates were performed for each experiment. Two‐tailed Student's COL4A3 gene, while AS patients 2 and 3 had mutations in the COL4A5 gene in heterozygosity and in hemizygosity, respectively  and from a normal subject (aged 11 years). AS patient 1 showed compound heterozygous mutations in the Primary urine‐derived podocytes were immortalized by inducing the expression of temperature‐sensitive SV40T and telomerase reverse transcriptase allowing growth at 33 °C and differentiation at 37 °C . Nine clVEGFA transcript levels were also significantly increased in AS patient 2 compared with controls. AS podocytes also expressed lower levels of SYNPO mRNA, but not of PODXL  and 1613 , resulting in alterations of the conformation of C‐terminal C4 residues as shown in Figure COL4A5 in AS patient 2 resulted in a truncated amino‐acid sequence at residue 994, causing the protein to be truncated and unfolded . The models of Col4α3 and Col4α5 represent the normal 3D aspect of the protein C4 terminal domains. AS patient 1 presented frameshift mutations in d Figure  from oneCOL4A3 gene‐mutated podocytes from AS patient 1 showed a significant reduction of COL4α3 protein in both the cell lysate and the supernatant compared with control  out of 17 948 , MMP2, extracellular matrix–actin interactors , and adhesion molecules  was confirmed by RT‐qPCR analysis  and molecules involved in cell survival  and angiogenesis  were also confirmed as differentially expressed in AS podocytes by RT‐qPCR  with respect to control podocytes and detected a total of 348 deregulated genes . In particular, podocytes alone showed a higher resistance to albumin transit through the membrane than GECs alone. Interestingly, the presence of AS podocytes alone significantly increased albumin permeability after 6 h, compared with control podocytes alone (p < 0.0001). Finally, the same significantly increased permeability was obtained when GEC–AS podocyte co‐cultures were compared with GEC–control podocyte co‐cultures (p < 0.0001), reproducing the defective permeability typical in AS patients. Cell counts of the plated cells showed no significant difference between control and AS podocytes, excluding that the altered filtration of AS podocytes was due to an increased cell detachment.A filtration assay was performed by measuring the transit of FITC‐BSA from the lower GEC compartment to the upper podocyte compartment in different experimental conditions Figure . Albumin−5dyn/cm2 shear stress , confirming the increased permeability in AS conditions. The permeability assays were therefore able to recapitulate the AS alterations and confirm from a functional point of view the altered podocyte phenotype demonstrated by molecular analysis.To analyse the permeability of AS podocytes in dynamic conditions, we adopted a millifluidic system that allows continuous perfusion in co‐culture under 8 × 10s Figure . Cells ps Figure . The albCOL4A3 or COL4A5, to assess common pathological features due to collagen IV mutations. AS podocytes showed specific changes in the transcript levels of genes involved in cell motility, adhesion, proliferation, and angiogenesis, with related alterations in their functional properties. In order to study their permeability in vitro, we set up a co‐culture system that reproduced the functional aberrations typical of AS.Increasing evidence indicates that AS podocytes possess an altered phenotype, beyond their altered collagen IV synthesis, which can be involved in the pathogenesis and progression of the disease. In the present study, we isolated and characterized podocytes derived from the urine of three patients with AS, with genetic alterations of either The availability of human AS podocytes in culture is at present limited. Podocyte‐like cells have been recently obtained from induced pluripotent stem cells (iPS) of AS patients , 30 and The evaluation of a podocyte signature, using a panel of 68 previously described genes , demonstMMP2, whose altered expression was previously described in an AS canine model [LAMA5, whose mRNA and protein up‐regulation were shown in AS‐mouse glomeruli [IGFBP5 has been described as a promoter of epithelial and fibroblast responses in fibrosis [Literature data describing the AS podocyte phenotype are quite scarce. Reduced podocyte number per glomerulus and podocyte nuclear density  are commne model , and LAMlomeruli . Among tlomeruli , 38, whifibrosis .Taken together, the data indicate a general alteration in AS podocytes of matrix interaction and cytoskeletal organization, both necessary to prevent podocyte effacement and maintain permeability control. For instance, reduction of synaptopodin, which in turn controls RhoA activity , as wellin vivo AS permeability alteration by assembling a co‐culture system of AS podocytes and GECs. In our co‐culture model, we preferred to avoid the addition of an exogenous collagen IV coating, as this GBM component is defective in AS [The observed alterations were reflected by altered podocyte functions, mainly related to cell motility and adhesion. Furthermore, we could reproduce the ve in AS . In thisve in AS , 43. Simve in AS , AS podoin vitro model that molecularly and functionally reproduces the defective AS podocytes. Using urine‐derived AS podocyte cell lines, we characterized molecular and morphological defects common to collagen IV mutation and related to cell adhesion, motility, survival, and angiogenesis. Moreover, altered permeability measured in AS podocyte–GEC co‐culture underlines the potentiality of this model. In fact, this in vitro model could also be used for the screening of pharmacological compounds, which might restore functional properties to AS podocytes.In conclusion, we describe here a new human in vitro experiments. MA, LA and RC performed RNA sequencing and data analysis. FA, LVDH and EL generated immortalized podocytes and contributed to the study design. BB contributed to the study design, study coordination, and interpretation of the data. All the authors were involved in writing the paper and had final approval of the submitted and published versions.CI performed characterization and functional experiments, statistical analysis, interpretation of results, and prepared the manuscript and all the figures. EC performed the 3D modelling. LB, FA, YG and EP performed Supplementary materials and methodsClick here for additional data file.Figure S1. Glomerular endothelial cell (GEC) characterizationFigure S2. Immunofluorescence microscopy for COL4α5 proteinFigure S3. RT‐PCR for COL4A3 and COL4A5 transcriptsFigure S4. Connectome of differentially expressed genes in AS podocytesClick here for additional data file.Video S1. 3D reconstruction of a podocyte–GEC co‐cultureClick here for additional data file.


We investigated the effects of the interaction between the body and gravitational axes on vection  in school-age children and adults. Experiment 1 was a pilot study of adults that was conducted to determine the appropriate experimental settings for the main experiment that included children and adults. The adult participants experienced vection in four different directions in the head-centered coordinate  under two postural conditions: standing  and supine . The adults reported more rapid and longer lasting vection when standing than when supine. In the main experiment (Experiment 2), we tested adults and school-age children under conditions similar to those of Experiment 1 and found that the reported vection was more rapid and longer lasting in children than in adults, whereas the reported vection tended to be more rapid and longer lasting under the standing condition than the supine condition for both age groups. Based on the similarities and differences between children and adults found in the present and previous vection studies, child-specific features of vection are discussed. Although visual information provides some of the most important cues about the surrounding environment, the mechanisms for processing visual information sometimes result in false recognition. When observing a visual pattern that covers most of the visual field and moves uniformly, individuals generally perceive a subjective self-motion that is opposite the direction of the pattern movement, even when the body remains still . In addiPrevious research has shown that even young children experience vection. For example, one of the earliest studies investigating vection during childhood  showed tThe effects of the relationship between the orientation of an observer’s body axis and that of the gravitational axis on vection have attracted the interest of researchers. Although a number of previous studies have indicated that differences in an observer’s body angle relative to the gravitational axis can result in different experiences of vection, the findings have been inconsistent. For example, On the other hand, Tovee (1999) showed inconsistent results with Several studies have reported findings that differ from the aforementioned previous studies. These inconsistencies among previous studies might stem from differences in experimental settings . For example, Despite the inconsistencies among previous studies, the interaction between an observer’s body (or head) orientation and the gravitational axis appears to have significant effects on vection. Therefore, we investigated the effect of the interaction between the body axis and the gravitational axis on vection by directly comparing children and adults under the same experimental conditions. Previous developmental research implies that there are commonalities as well as differences in the vection experience between children and adults. For example, both children and adults commonly experience more rapid vection during contracting optic flow than during expanding optic flow . HoweverIn the current study, we examined the effect of body orientation relative to the gravitational axis on vection by following the experimental setting used by This study included two experiments assessing vection. Experiment 1 was a pilot study of adult observers based on Experiment 1 was a replication of This study was approved by the Ethics Committee for Psychological Research at Niigata University, and all experiments were performed in accordance with the principles of the Declaration of Helsinki.N = 10, 6 females, mean age: 21.14 years, SD: ± 1.06 years, range: 19.70–22.41 years) and supine . All participants had normal or corrected-to-normal vision, and none had a history of visual or vestibular disease. Participants with a mean latency (or duration and magnitude) shorter (or larger) than the mean latency of each experimental group and/or than the group mean ± 3 SD for any of the three measurements  were to be excluded from the analyses, but no participants met these criteria. Two of the adult observers who participated in the initial experiment were excluded from the final sample due to apparatus failure.The final sample for Experiment 1 consisted of data obtained from 20 adult participants who were divided into 2 experimental groups: standing  that consisted of rigid iron frames covered with an opaque black fabric. In the standing condition, participants stood inside the experimental chamber and observed visual stimuli on two 27-inch LCD monitors  that were attached inside the experimental chamber . The twoThe visual stimuli were generated and controlled by PsychoPy 2 software  running Each visual stimulus was composed of 500 random white dots  moving against a black background on each monitor. There were four conditions for the direction of the moving dots that corresponded to each participant’s head-centered coordinate: backward, forward, downward, and upward. Thus, the possible directions of induced vection in the head-centered coordinate based on the four directions of moving dots were forward, backward, upward, and downward. There were three speed conditions for the dots: low speed (4.44 cm/s), middle speed (6.52 cm/s), and high speed (17.44 cm/s). Each of the speed values corresponded to 10.5 deg/s, 15.4 deg/s, and 41.2 deg/s, respectively, from the midpoint between the surfaces of the two monitors (24.25 cm from each display). It should be noted that each of the speed conditions did not simulate a particular speed of self-motion in a geometrical space but simply replicated the speed conditions of All participants completed a total of 36 trials  with a short break every 12 trials. Each participant was instructed to look at the frontal plane of the experimental booth and to try not to look at the LCD monitors during each trial. They were also instructed to hold the computer mouse in their dominant hand and to press the left button of the mouse when they experienced self-motion during each trial. After 30 s of stimulus presentation, each participant was asked to estimate the magnitude of self-motion during the stimulus presentation by drawing a short orthogonal line using a visual analogue scale . Each participant was instructed that if he/she felt no self-motion at all, then he/she should draw a vertical line at the left edge of the VAS. However, if he/she felt self-motion similar to real locomotion, then he/she should draw a line at the right edge of the VAS as a benchmark for the estimation. The distance from the left edge of the VAS to the intersection with the drawn line was adopted as the measurement of magnitude.Two experimenters were involved in this procedure: the main experimenter, who selected an appropriate experimental trial and ran the relevant computer program to begin the experimental trial, and an assistant, who gave instructions to the participants and confirmed that each participant was looking at the front plane of the chamber and holding the computer mouse properly before the start of each trial. After each trial, the assistant gave the participant a pen and the VAS and confirmed that the participant marked the scale as instructed. The assistant was naïve to the properties of the visual stimuli in each trial.F = 5.814, p = .0268, F = 3.657, p = .0179, F = 30.494, p < .0001, F = 2.304, p = .0393, F = 3.474, p = .0175, F = 5.665, p = .0010, t tests with a Bonferroni correction) indicated that the mean latencies were shorter for the upward direction than for the forward direction and for the downward direction than for the forward direction . For the high-speed condition, multiple comparison analyses indicated that mean latencies were shorter for the upward direction than for the forward direction and for the downward direction than for the forward direction .A three-way mixed analysis of variance  revealed that all three main effects were significant: posture,  = 0.629 . In addiF = 18.831, p < .0001, F = 16.117, p < .0001, F = 11.342, p < .0001, p values < .05/3). The other interactions did not reach significance: Posture × Direction, F = 0.355, p = .7856, F = 0.305, p = .7391, F = 0.972, p = .4479, The simple main effects of speed on direction of vection were significant for upward, downward, and backward vections: upward, F = 14.305, p = .0014, F = 4.971, p = .0041, F = 28.534, p < .0001, F = 4.728, p = .0003, F = 6.347, p < .0001, F = 8.293, p < .0001, t tests with a Bonferroni correction) indicated that mean durations were longer for the upward direction than for the forward direction, for the upward direction than for the backward direction, and for the downward direction than for the forward direction . For the high-speed condition, multiple comparison analyses indicated that mean durations were longer for the upward direction than for the forward direction, for the upward direction than for the backward direction, for the downward direction than for the forward direction, and for the downward direction than for the backward direction .A three-way mixed ANOVA (2 posture × 2 direction of vection × 3 dot speed conditions) revealed that all three main effects were significant: posture,  = 0.613 . The intF = 27.483, p < .0001, F = 23.277, p < .0001, F = 7.690, p < .0007, p values < .05/3). For backward vection, multiple comparison analyses indicated that mean duration was longer in the high-speed condition than in the low-speed condition . The other interactions did not reach significance: Posture × Direction, F = 0.426, p = .7349, F = 1.150, p = .3279, F = 1.034, p = .4079, The simple main effects of speed on direction of vection were significant for upward, downward, and backward vections: upward, F = 25.700, p < .0001, F = 6.977, p = .0005, F = 60.041, p < .0001,  = 0.769  = 4.393, p = .0005, F = 7.963, p < .0001, F = 10.113, p < .0001, t tests with a Bonferroni correction) indicated that mean magnitudes were greater for the upward direction than for the forward direction, for the upward direction than for the backward direction, for the downward direction than for the forward direction, and for the downward direction than for the backward direction .A three-way mixed ANOVA (2 posture × 4 direction of vection × 3 dot speed conditions) revealed that all three main effects were significant: posture,  = 0.769 . The intF = 39.606, p < .0001, F = 30.778, p < .0001, F = 3.535, p = 0.0317, F = 14.430, p < .0007, p values < .05/3). For forward vection, multiple comparison analyses indicated that mean magnitude was greater in the high-speed condition than in the low-speed condition . The other interactions did not reach significance: Posture × Direction, F = 0.943, p = .4262, F = 0.590, p = .5596, F = 0.516, p = .7955, The simple main effects of speed on direction of vection were significant for all directions: upward, For all three measurements , there was a significant main effect of posture but no interaction effect. These results imply that the adult participants consistently reported more rapid and stronger vection in the standing condition than in the supine condition. In addition, for all three measurements, there was a significant interaction between direction and speed as well as significant results for the multiple comparison analyses of the simple main effects of vection direction in each speed condition. Taken together, these findings indicate that the participants tended to report more rapid and stronger vection for the vertical directions (upward and downward) than for the longitudinal directions (forward and backward) in the head-centered coordinate. Thus, two main conclusions were obtained from the results of Experiment 1. First, the adult participants reported more rapid and stronger vection in the standing condition in which the body axis was congruent with the gravitational axis compared with the supine condition in which the body and the gravitational axes were orthogonal. This finding is consistent with previous research reporting stronger vection in upright postures than in lying-down postures . Second,The present findings are inconsistent with those of On the other hand, the results of Experiment 1 seem to be consistent with the previous studies that reported more rapid vection in upright postures than supine postures  than when these axes were orthogonal (supine condition). Moreover, vection tended to be more rapid and stronger for the vertical directions than for the longitudinal directions in the head-centered coordinate. The aims of Experiment 2 were to investigate whether these two characteristics of vection in adults would be observed in younger individuals (6- to 11-year-old children) and to compare results directly between children and adults within an identical experimental setting.N = 20, 9 females, mean age: 9.20 years, SD = ± 1.81 years, range: 6.15–11.97 years), children in the supine condition , adults in the standing condition , and adults in the supine condition . All participants had normal or corrected-to-normal vision, and none had a history of visual or vestibular disease. The exclusion criteria applied in Experiment 1 were also applied in Experiment 2, but no participants met these criteria.The final sample for Experiment 2 consisted of data obtained from 40 children and 40 adults who were each divided into two experimental groups : children in the standing condition  was used. Because the younger children seemed to find it difficult to maintain motivation and concentration for a long period, it was necessary to shorten the number of trials as much as possible. The results of Experiment 1 indicated that the reported vection was most remarkable in the high-speed condition; thus, only the high-speed condition was adopted in Experiment 2 to shorten each set of experimental trials.F = 7.158, p = .0091, F = 3.771, p = .0114, F = 2.826, p = .0969, F = 2.799, p = .0404, F = 4.679, p = .0313, F = 4.606, p = .0326,  = 0.015, indicating that latency was significantly shorter in the standing condition than in the supine condition when the visual stimuli represented downward and forward self-motion. The simple main effect of direction of vection on posture was significant for both the standing, F = 3.512, p < .0160, F = 3.058, p < .0291, t tests with a Bonferroni correction) indicated that mean latency was shorter for downward vection than for backward vection . The other interactions did not reach significance: Age × Posture, F = 0.079, p = .7793, F = 0.377, p = .7699, F = 0.962, p = .4114, A three-way mixed ANOVA (2 age × 2 posture × 4 direction conditions) revealed significant main effects of age,  = 0.036 . There wF = 7.662, p = .0001, F = 1.391, p = .2419, F = 1.683, p = .1984, F = 3.130, p = .0265, F = 4.103, p = .0437, A three-way mixed ANOVA (2 age × 2 posture × 4 direction conditions) revealed a significant main effect of direction, ificance . There wF = 6.499, p < .0003, F = 4.292, p < .0057, t tests with a Bonferroni correction) indicated that the mean duration was longer for the downward direction than for the forward direction and for the downward direction than for the backward direction . In the supine condition, multiple comparison analyses indicated that the mean duration was longer for the upward direction than for the forward direction, for the downward direction than for the forward direction, and the forward direction than for the backward direction . The other interactions did not reach significance: Age × Posture, F = 0.149, p = .7009, F = 1.511, p = .2125, F = 1.481, p = .2206, The simple main effect of direction of vection on posture was significant in both the standing, F = 4.728, p = .0328, F = 7.050, p = .0001, F = 1.311, p = .2558,  = 0.017 (t tests with a Bonferroni correction) of the main effect of direction indicated that the mean magnitude was greater for upward vection than for forward vection, for downward vection than for forward vection, and for forward vection than for backward vection . None of the interactions reached significance: Age × Posture, F = 0.086, p = .7700, F = 1.703, p = .1672, F = 1.927, p = .1261, F = 0.243, p = .8663, A three-way mixed ANOVA (2 age × 2 posture × 4 direction conditions) revealed significant main effects of age,  = 0.017 . MultiplIn Experiment 2, vection tended to be more rapid and stronger in children than in adults such that latency and magnitude were significantly shorter and greater, respectively, in children than in adults. This trend is consistent with the findings of previous studies that reported significantly more rapid and stronger vection in school-age children than in adults , 2018.Experiment 2 also showed that vection seemed to be more rapid and lasted longer in the standing condition than in the supine condition in both children and adults. Although there was no significant main effect of posture in any of the three measurements , the interaction between posture and direction was significant for both latency and duration. The interaction and relevant multiple comparison analyses for the simple main effects of posture on vection direction indicated that reported vection was more rapid and longer lasting in the standing condition than in the supine condition in some vection directions . In conjunction with the lack of any significant interactions relevant to age, these results imply that both the children and the adults had a tendency to experience more rapid and longer lasting vection in the standing condition than in the supine condition.In addition, multiple comparison analyses of the simple main effect of vection direction on posture for latency and duration revealed that vection seemed to be more rapid and longer lasting in the vertical directions than in the longitudinal directions in the head-centered coordinate for both children and adults. More specifically, latency was significantly shorter in downward vection than in backward vection in both the standing and supine conditions, whereas duration was significantly longer in downward vection than in forward vection and in downward vection than in backward vection in the standing condition and significantly longer in upward vection than in forward vection and in downward vection than in forward vection in the supine condition. Similar results were observed for magnitude. The significant main effect of vection direction and multiple comparison analyses for the main effect revealed that magnitude was significantly greater in upward vection than in forward vection and in downward vection than in forward vection.Taken together, the results of Experiment 2 indicate that vection seemed to be induced more rapidly and strongly in children than in adults, as shown in previous studies. However, regarding the relationship between an observer’s body and gravitational axes, the characteristics of vection were comparable between the two age groups.The primary aim of this study was to investigate the development of the effects of the interaction between the body axis and gravitational axis on vection when viewing visual stimuli. Experiment 1 examined the effects of congruency/incongruency between the body and gravitational axes on vection in adults to determine the appropriate experimental conditions for the subsequent experiment that also included child observers (Experiment 2).The results of Experiment 1 indicated that adult participants experienced vection more rapidly and strongly when their body axis and the gravitational axis were consistent (standing condition) compared with when their body axis was orthogonal to the gravitational axis (supine condition). Moreover, adult participants showed more rapid and stronger vection in the vertical directions than in the longitudinal directions in the head-centered coordinate, independent of the congruency/incongruency between the orientation of the body and gravitational axes.Experiment 2 further investigated the effects of the relationship between the body and gravitational axes on vection that were observed in Experiment 1 using both children and adults to assess the development of this relationship. The results of Experiment 2 share similarities with the results of Experiment 1 for both children and adults. Specifically, both children and adults tended to show more rapid and longer lasting vection in the standing condition than in the supine condition and for the vertical directions than for the longitudinal directions in the head-centered coordinate. In addition, as previously reported , 2018, vIn other words, patterns of differences in induced vection among different experimental conditions are similar between school-age children and adults , but the entire effect of vection  is very different between these two age groups. These results are consistent with previous findings. For example, One may claim that the results of Experiment 1 and Experiment 2 seem to be inconsistent because of the lack of the significant main effect of posture in Experiment 2. This inconsistency between Experiments 1 and 2 might stem from the difference in the experimental setting; Experiment 1 contained three speed conditions, whereas Experiment 2 had only one speed condition. Thus, each participant in Experiment 1 had to engage in more experimental trials than the participants in Experiment 2. Such difference(s) in experimental procedure could be critical for producing the inconsistent results between Experiments 1 and 2. However, the results of Experiment 2 indicated significant interaction between posture and direction in both latency and duration, which seems to be partially consistent with the main effect of posture observed in Experiment 1; the interaction showed that both children and adults experienced more rapid and longer lasting vection in the standing condition than in the supine condition in several vection directions . In addition, it should be noted that there were no results showing that vection was more rapid and longer lasting in the supine posture than in the standing posture in Experiment 2. This means that, although the main effect of posture was not significant, the participants of Experiment 2 tended to show more rapid and longer lasting vection in the standing condition than in the supine condition.This study found that reported vection was more rapid and longer lasting when the body and gravitational axes were congruent than when the body and gravitational axes were orthogonal to each other. It is possible that vection can be induced more rapidly and lasts longer when nonvisual information such as vestibular and proprioceptive inputs and/or the recognition of the observer’s own postural state  signals that the orientation of the observer’s body is congruent with the gravitational axis. In the present experiments, although the visual stimuli in the two posture conditions (standing and supine) were identical, the relevant nonvisual information, such as vestibular and proprioceptive inputs and/or higher cognitive information about the observer’s own postural state, differed markedly between the two posture conditions. These findings seem to be consistent with several previous studies  than when these axes were orthogonal to each other (supine condition). On the other hand, school-age children exhibited significantly more rapid and longer lasting vection than adults, as previously reported , 2018. T


We reviewed the literature on 18F‐FDG PET/CT features in gastrointestinal metastasis of PSC patients since 1992, and further analyzed the imaging features. According to the literature review, 23 eligible cases were identified from eight studies, and no cases underwent 18F‐FDG PET/CT imaging. In this study, clinical and PET/CT imaging data of two patients are reported. In our cases, clinical and the CT images of lung masses were not typical, but the uptake of 18F‐FDG was remarkably high, with SUVmax exceeding 30. Small intestinal metastases may not be related to obstruction, or even the local intestinal cavity may be dilated. Therefore, in PSC patients with mild or without abdominal symptoms, 18F‐FDG PET/CT imaging could identify intestinal metastasis at a relatively early stage and may be used to determine the preferred biopsy site, or early intervention by surgery.We herein report two cases of small intestinal metastasis from pulmonary sarcomatoid carcinoma (PSC) detected by 18F‐FDG PET/CT imaging of small intestinal metastasis of PSC has not been previously reported in the literature and here we report the 18F‐FDG PET/CT features of two cases.18F‐FDG was remarkably high in both the primary tumor and metastatic intestinal lesion. 18F‐FDG PET/CT imaging may therefore be used to determine the preferred biopsy site or early intervention by surgery.The uptake of  Both patients underwent a Biograph TruePoint 64 PET/CT Scan . The 18F was produced in Sumitomo HM‐20 cyclotron system . The 18F‐FDG was automatically synthesized in a chemical synthesis module  with a radiochemical purity >95%. After fasting for more than six hours in a calm state, the patients were intravenously injected with 0.12 mCi/kg of 18F‐FDG which was followed by lying in a dark room for approximately one hour. PET and nonenhanced CT imaging was performed after the patients emptied their bladders. Scanning was performed from the middle femur to the cranial vault. The PET images were reconstructed according to an iterative ordered subset expectation maximization method. The CT scan data were collected with 120 kV (with the current adjusted to the patient's bodyweight) and a gantry rotation speed of 0.8 seconds. The reconstruction thicknesses of the CT images were 3.27 mm, and the PET and CT images were individually transferred to Syngo MMWP (Siemens) workstations, respectively, to display frame‐on‐frame fusion images.Physical examination, laboratory analysis, 18F‐Fluorodeoxyglucose and positron emission tomography/computed tomography (18F‐FDG PET/CT). Keywords used included gastrointestinal metastases and pulmonary sarcomatoid carcinoma.We then performed a comprehensive MEDLINE, PubMed and EMBASE search to identify all reported cases of gastrointestinal metastases of PSC since 1992 when the pathological subtype PSC was named, especially cases with 9/L), while other laboratory results were almost normal, including electrolytes, blood sugar, tumor markers, liver and renal function. A previous CT scan from another hospital had demonstrated a mass in the left upper lobe.Case 1 was a 55‐year‐old male heavy smoker with a history of epigastric pain and melena for about one month. Physical examination showed conjunctival pallor but no palpable mass. Laboratory analysis demonstrated anemia (Hct 24.9%) and leukocytosis  was calculated to be 33.2, which indicated a considerable high possibility of malignancy. The CT images of the lung mass showed both carcinomatous features including lobulation, irregular cavity, spiculation and pleural retraction, and sarcomatoid features including increased size, obvious necrosis unmatched with size, pleural involvement, and cavitation within the tumor. The mediastinal lymph node next to the aortic arch was mildly enlarged, measuring 1.5 × 0.9 cm with a SUVmax of 3.4. It is unusual for an enlarged lymph node to be palpated in the area beside the aortic arch and several mediastinal lymph nodes with this metabolic pattern have been proven by surgery to be metastasic in clinical practice, and this lymph node was therefore considered as suspect mediastinal lymph node metastasis.A gastroscopy was performed to investigate the cause of melena and anemia, which detected erosive gastritis, dodecadactylitis and mild esophagitis. PET/CT images revealed a peripheral mass with intensely increased A left adrenal gland mass with obvious necrosis and remarkably increased FDG uptake was detected , which was suspected to be metastases. Circumferential thickening of the small intestinal wall (up to 2.5 cm thickness) was found incidentally in the right middle abdomen  (73 g/L), total protein (51.1 g/L), albumin (27.5 g/L), prealbumin (39 mg/L), serum iron (2.3 umol/L) and total iron binding capacity (35.44 umol/L) level. The other laboratory results were normal, including electrolytes, blood sugar, tumor markers, hepatic and renal function.18F‐FDG PET/CT showed an irregular large mass about 4.7 × 3.3 × 3.5 cm, with an SUVmax of 13.4 in the left upper lobe. The lesion showed malignant features including an irregular margin, lobulation, spiculation, pleural traction, and obvious necrosis of more than 30% without bronchial stricture and occlusion , and were considered as lymphadenitis. Meanwhile, 18F‐FDG PET/CT detected wall‐thickening of the descendant duodenum and part of the jejunum in the left upper quadrant of the peritoneal cavity with SUVmax of 10.4. The local intestinal cavity was dilated, and the surrounding fat gap was clear.Histopathological results from CT‐guided puncture of the pneumonic lesion suggested poorly differentiated NSCLC with massive necrosis, indicating PSC with IHC markers AE1/AE3 (+), vimentin (+), P40 (−), TTF‐1 (−), S‐100 (−), SMA (−), desmin (−), and Ki‐67 (20%+). Subsequent gastroscopy demonstrated nodular eminence at the descendant duodenum with an obscure boundary, erosion and necrosis of the mucosal surface with dirty moss‐like appearance Fig . Biopsy 18F‐FDG PET/CT imaging. The detailed information on cases from included studies is listed in Table PSC is rare, and gastrointestinal metastasis associated with the condition is exceedingly rare, with only 23 cases previously reported in the English‐language literature18F‐FDG PET/CT features of two cases of small intestinal metastases secondary to PSC. Both cases had initial abdominal symptoms whereas no pulmonary symptoms were present. The CT findings of the lung masses were not typical, with both cancerous and sarcomatoid features. Small intestinal metastases may not be related to obstruction and sometimes the local intestinal cavity may also be dilated. Nevertheless, the uptake of 18F‐FDG was remarkably high in both primary tumor and metastatic intestinal lesions, with SUVmax exceeding 30, similar to the study by Zhang et al. which reported a pulmonary sarcomatoid carcinoma with a SUVmax of 35.5.et al. also reported that PSCs often present with an intense uptake on 18F‐FDG PET/CT scan,Herein, we report 18F‐FDG PET/CT images, surgery or biopsy of a lung mass or intestinal lesion was performed, and sarcoma marker vimentin and carcinoma marker cytokeratin were finally found to be positive, which verified intestinal metastasis of PSC. The epithelial to mesenchymal transition pathway may play a key role. In both cases reported here, positive TTF‐1, CK and CK7 indicated lung origin, while negative CK20, CDX2 and villin excluded intestinal origin.A diagnosis of sarcomatoid carcinoma is always dependent on IHC markers. With reference to et al. reported that the mean survival period of patients with gastrointestinal metastasis of lung cancer after bowel resection was 7.7 months, among which, one patient lived for 22 months.et al. reported gastrointestinal metastasis in one case of PSC who achieved long‐term survival of more than five years after lung and intestinal surgery.Early intervention can prevent patients with gastrointestinal metastasis of lung cancer from acute abdominal emergency, such as perforation and obstruction. Nishizawa In conclusion, for PSC patients with mild or without abdominal symptoms, 18F‐FDG PET/CT imaging could identify intestinal metastasis at a relatively early stage and may be used to determine the preferred biopsy site or early intervention by surgery.All the authors declare that they do not have any conflict of interest.


Children with concurrent wasting and stunting (WaSt) and children with severe wasting have a similar risk of death. Existing evidence shows that wasting and stunting share similar causal pathways, but evidence on correlates of WaSt remains limited. Research on correlates of WaSt is needed to inform prevention strategies. We investigated the factors associated with WaSt in children 6–59 months in Karamoja Region, Uganda.p < 0.05.We examined data for 33,054 children aged 6–59 months using June 2015 to July 2018 Food Security and Nutrition Assessment in Karamoja. We defined WaSt as being concurrently wasted (weight‐for‐height z‐scores <−2.0) and stunted (height‐for‐age z‐score <−2.0). We conducted multivariate mixed‐effect logistic regression to assess factors associated with WaSt. Statistical significance was set at 2), short stature (height <160 cm), low mid‐upper arm circumference (MUAC <23 cm) and having ≥4 live‐births. WaSt was prevalent in households without livestock .In multivariate analysis, being male , aged 12–23 months , 36–47 months  and 48–59 months  were associated with WaSt. In addition, acute respiratory infection , diarrhoea  and malaria/fever  episodes were associated with WaSt. WaSt was significantly associated with maternal underweight (body mass index <18.5 kg/mPreventing the occurrence of WaSt through pragmatic and joint approaches are recommended. Future prospective studies on risk factors of WaSt to inform effective prevention strategies are recommended. Concurrent wasting and stunting (WaSt) was significantly associated with child's age, child's sex, acute respiratory infection (ARI) and diarrhoea episodes especially among children of caregivers with low body mass index (BMI), short stature, low mid‐upper arm circumference (MUAC), ≥4 live‐births and living in households without livestockExisting and new programmes designed for wasting and stunting reduction should be deliberate in addressing both conditions, simultaneously, especially in high burden settingsStudies on how integrated packages involving nutrition‐sensitive and nutrition‐specific interventions can be targeted at preventing child undernutrition are needed. Further studies on risk factors of WaSt are recommended1Wasting and stunting are the commonest forms of undernutrition in children under 5 years. Annually, one‐third of all deaths in children under 5 years are attributed to undernutrition  cross‐sectional survey datasets conducted in all the seven districts of the Karamoja Region in North‐Eastern Uganda. Data was pooled from seven FSNA datasets for the current study. These datasets have been described in detail elsewhere  survey methodology  was measured for both pregnant and nonpregnant women with children aged 0–59 months. Weight, height and MUAC measurements were collected from children aged 6–59 months found in the household. Recumbent length was measured for children <24 months old. Bilateral pitting oedema and haemoglobin levels among children aged 6–59 months were also examined. Child age in months was obtained from the child health cards or by maternal recall using a local event calendar.2.2We defined wasted as weight for height z‐score (WHZ) <−2.0, stunted as height for age z‐score (HAZ) <−2.0, and underweight as weight for age z‐score (WAZ) <−2.0 based on z‐scores of the 2006 World Health Organization (WHO) growth standards WHO, .2.3The outcome of our study was WaSt among children aged 6–59 months. We defined WaSt as concurrently having WHZ <−2 and HAZ <−2 , underweight (BMI < 18.5 kg/m2), and overweight/obese (BMI ≥ 25 kg/m2)  and ≥8 years (secondary and above). We used principal component analysis to generate a wealth index based on household assets ownership  and unimproved water sources  . In the multivariate analysis, we used a backward stepwise method to remove the nonsignificant variables (p > 0.05). To identify variables with interaction effects in the model, we assessed the significance (p > 0.05) of each interaction term one at a time in the basic model, but none of the interaction terms was conceptually meaningful. We found no confounding factors in our model after testing for a ≥10% change in the effect measure in the presence of another variable. We retained maternal stature and season of the survey in the final model although they were dropped during the backward stepwise process based on literature   Table . About 42) Table .3.2Of the 33,054 children in the sample, 10.6% (95% CI 10.2–11.0]) had low MUAC, 26.0% (95% CI [25.4–26.5]) were underweight, 12.0% (95% CI [11.6–12.5]) were wasted and 33.5% (95% CI [33.0–34.1]) were stunted. The prevalence of WaSt among the children in the sample was 5.0% (95% CI [4.6–5.3]) (Table –11.0) ha3.3Several child‐level, maternal, household, socioeconomic and seasonal variables were associated with WaSt at bivariate and multivariate analyses Table . At multAt multivariate analysis, caregivers with 4–6 live‐births  and ≥7 live‐births , maternal underweight , maternal short stature  and maternal low MUAC  were significantly associated with WaSt. The odds of WaSt was lower among children of overweight/obese caregivers  compared with underweight caregivers though this was not statistically significant. Caregivers with no formal education , and caregivers with 1–7 years of education  were significantly associated with WaSt. Maternal age showed significant association with WaSt at bivariate analysis but dropped from the model at multivariate analysis (Table 3–1.72) aIn the adjusted analysis, household heads with no formal education  and household heads who had 1–7 years of education  were significantly associated with WaSt. Households with the rich wealth index quintile had 1.29  odds of WaSt compared with the richest households. Children living in households with middle , poorer  and poorest  wealth index quintiles had higher odds of WaSt compared with those that lived in the richest households. The odds of WaSt were 1.30 times higher among children living in households without livestock compared with those that had livestock . Household food consumption scores, latrine ownership, household access to land for cultivation and seasons were not significantly associated with WaSt (Table 7–2.41) a4We found that the child's sex, age, history of ARI, diarrhoea and malaria/fever episode in the last weeks were associated with WaSt at the individual level. Male children were 1.79 times more likely to experience WaSt compared with females. This finding corroborates earlier analyses showing that males were more susceptible to WaSt  designed solely for the treatment of wasting, food and micronutrient supplementation, infant and young child feeding programme, social safety net, and hygiene and sanitation promotion for stunting prevention should be adapted to address both conditions, especially in high burden settings like Karamoja. There is a need to identify and test how integrated packages of nutrition‐sensitive and nutrition‐specific interventions can be targeted at reducing wasting and stunting in children. Future prospective studies on the risk factors of WaSt are needed to improve our understanding of the causality of WaSt.The authors declare no conflicts of interest.GAOO‐A, HW, MM, AB, JNK and CASK conceptualized and designed the research study. GAOO‐A, HW, RA, JN, JO, YK, JNK, MM, AB and CASK analysed and interpreted the data. GAOO‐A drafted the initial manuscript. GAOO‐A, HW, JN, JO, YK, JNK, EM, RA, MM, AB and CASK reviewed and finalized the manuscript.


Currently, there is no molecular‐targeted agent that has demonstrated evidence of efficacy in patients with unresectable hepatocellular carcinoma (u‐HCC) who have developed resistance to treatment with lenvatinib (LEN). In this real‐world study, we aimed to investigate the therapeutic effect and safety of sorafenib (SOR) in patients with u‐HCC after progression on treatment with LEN.A total of 13 patients with u‐HCC , who were treated with SOR after progression on LEN, were enrolled in this retrospective study. Therapeutic efficacy was evaluated via contrast‐enhanced computerized tomography at 8 weeks after the initiation of SOR therapy according to modified response evaluation criteria in solid tumors (mRECIST) and RECIST. According to mRECIST, the objective response rate (ORR) and disease control rate (DCR) were 15.3% (2/13) and 69.2% (9/13), respectively. According to RECIST, the ORR and DCR were 0% (0/13) and 69.2% (9/13), respectively. The median progression‐free survival was 4.1 months. The median albumin‐bilirubin scores did not deteriorate significantly at 4, 6, and 8 weeks after initiation of SOR, compared with the scores at the baseline. The most frequent grade 1 or 2 adverse events (AEs) were palmar–plantar erythrodysesthesia, fatigue, diarrhea, and hypertension. There was no incidence of grade 3 AEs.Treatment with SOR may be effective for u‐HCC after failure on LEN and may not worsen the liver reserve. We demonstrated that treatment with sorafenib after lenvatinib failure could be useful for unresectable hepatocellular carcinoma. In addition, this treatment strategy may not worsen the liver reserve. The clinical significance of molecular‐targeted agents (MTAs) in unresectable hepatocellular carcinoma (u‐HCC) has increased drastically since the results from phase III SHARP trial in 2007 were obtained.In the phase III RESORCE trial, regorafenib (REG) demonstrated survival benefit in u‐HCC as a second‐line systemic therapy in patients progressing on SOR.However, there is no evidence of the effectiveness of MTAs in u‐HCC after progression on LEN. Hence, there is an unmet need to search for more effective and less toxic therapeutic approaches as second‐line treatment for u‐HCC after progression on LEN.VEGFR and PDGFR, as well as C‐Raf, wild‐type B‐Raf, and mutant B‐Raf, which are involved in the MAPK pathway.LEN is an MTA that targets vascular endothelial growth factor receptors 1–3, fibroblast growth factor receptors 1–4, platelet‐derived growth factor receptor α, RET, and KIT.Therefore, in this study, we aimed to investigate the therapeutic effect and safety of SOR in patients with u‐HCC after progression on treatment with LEN.,This retrospective, observational study evaluated the efficacy and safety of SOR  monotherapy in patients with unresectable advanced HCC after resistance to treatment with LEN. The study was conducted at the Tokushima University between May 2019 and February 2020. This study was approved by the Ethics Committee of Tokushima University Hospital  and was performed in compliance with the 1975 Declaration of Helsinki. The inclusion criteria were based on those of the SHARP trial. Briefly, the antitumor effect was evaluated using conventional response evaluation criteria in solid tumors (RECIST) for measuring treatment responses based on tumor shrinkage, whereas tumor uptake in the arterial phase of contrast‐enhanced computed tomography (CT) was evaluated using modified RECIST (mRECIST)For patients with no risk factors, we introduced the recommended initial dose of SOR of 400 mg twice daily.10 bilirubin (μmol/L)× 0.66) +  × −0.085)], and defined by the following scores: ≤−2.60 = Grade 1, >−2.60 to ≤−1.39 = Grade 2, and >−1.39 = Grade 3.Hepatic reserve function was assessed according to albumin‐bilirubin (ALBI) grading and Child‐Pugh classification. ALBI grade was calculated based on serum albumin and total bilirubin values, using the following formula: [ALBI score =  were used to estimate progression‐free survival (PFS) and overall survival (OS). All statistical analyses were performed using Easy R (EZR) version 1.29 .Categorical variables were compared using Fisher's exact test, while continuous variables were compared using Mann–Whitney and Kruskal‐Walls tests. All significance tests were two‐tailed, and statistical significance was set at A total of 13 patients  with u‐HCC, who were treated with SOR after progression on LEN, were enrolled in this study. Baseline patient characteristics are shown in Table The median observation period after initiation of SOR was 203 (50–335) days. For all the patients, therapeutic efficacy was evaluated using contrast‐enhanced CT at 8 weeks after the initiation with SOR therapy according to mRECIST and RECIST. As per mRECIST, no patient had complete response (CR), two patients had partial response (PR), seven patients had stable disease (SD), and four patients had progressive disease (PD). The objective response rate (ORR) and disease control rate (DCR) were 15.3% (2/13) and 69.2% (9/13), respectively. As per RECIST, no patients had CR and PR, nine patients had SD, and four patients had PD. The ORR and DCR were 0% (0/13) and 69.2% (9/13), respectively , compared with the baseline scores (−2.19 ± 0.33) . However, contrast‐enhanced CT images, obtained 1 month after cTAE, revealed that lipiodol was washed out from more than half of the HCC nodules. We then started treatment with LEN. After about 12 months of LEN treatment, the patient exhibited PD (according to mRECIST). When the treatment with LEN resulted in PD, the AFP level was ≤400 ng/mL, and hence, RAM could not be used. Therefore, we started treatment with SOR. An enhanced CT examination, performed 8 weeks following SOR initiation, showed decrease in enhanced lesions, and the case was judged as PR by mRECIST Fig. .In the present study, we showed the therapeutic efficacy and safety of SOR as a second‐line treatment option for u‐HCC after resistance to treatment with LEN. We also demonstrated that, over the duration of treatment with SOR, no significant decrease in ALBI score was observed. To our knowledge, this is the first study to report the feasibility and therapeutic efficacy of SOR after progression on LEN in a clinical setting.Recently, LEN has been suggested as the first‐line treatment for u‐HCC, in addition to SOR, as per several guidelines. In addition, the opportunities for the administration of LEN in clinical practice have increased.et al. reported the results of a small cohort study in which patients with u‐HCC with AFP >400 ng/mL were administered RAM treatment after LEN failure and showed promising therapeutic efficacy and safety, with DCR of 80%, median time to treatment progression of 3.1 months, and the incidence of grade 3 AEs of 10%.In the REACH study, RAM was reported to have significantly extended the survival in cases of AFP >400 ng/mL, as a second‐line treatment, after progression on SOR.However, considering the fact that, among the patients who progressed after SOR, only 23.3% of patients were eligible for RAM,n = 13, 48.1%), RAM , and transcatheter arterial embolization (TAE) , while the remaining 9 cases were best supportive care (BSC). Among the 27 cases of radiologic PD, only 29.6% of the patients met the eligibility criteria for the administration of RAM,In our study, among the 45 patients who received LEN as first‐line treatment, 27 cases were identified as radiologic PD; 18 patients (66.7%) received subsequent therapies after LEN treatment, including SOR (n = 5), even in AFP >400 ng/mL, which is the eligibility criterion of RAM, DCR was 80%, with a median PFS of 4.1 months. Therefore, our results were comparable to the results of previous studies that reported sequential therapy of MTAs in patients with resistance to SOR. Interestingly, as shown in Figure In the RESORCE study, treatment with REG as the second‐line sequential therapy resulted in a DCR of 65% and median PFS of 3.1 months. The CELETIAL study showed that treatment with CAB resulted in a DCR of 64% and median PFS of 5.2 months. In our study, treatment with SOR resulted in a DCR of 69.3% and median PFS of 4.1 months. Furthermore, although the number of cases was small (The drug‐related AEs reported in this study were mostly of grade 1 or 2 severity. Moreover, in line with the results of SHARP and the Asia‐Pacific study, the most frequent AEs in this study were grade 1 or 2 palmar‐plantar erythrodysesthesia, fatigue, diarrhea, and hypertension. In addition, treatment with SOR showed a different AE profile than LEN, and thus, SOR treatment could easily be initiated following treatment with LEN, which suggested that treatment with SOR after progression on LEN was well‐tolerated.The hepatic reserve function at the initiation of MTA treatment is essential in the treatment of u‐HCC.The main limitations of our study were its retrospective nature, small sample size, and the short observation period. Therefore, future large‐scale prospective studies are required to confirm the findings of this study.In conclusion, we demonstrated that treatment with SOR after LEN failure could be useful for u‐HCC. In addition, this treatment strategy may not worsen the liver reserve during treatment.Figure S1. Progression‐free survival among patients with unresectable hepatocellular carcinoma treated with sorafenib.Click here for additional data file.