The cohort consisted of 803 patients with AKI. We proposed a new classification of KeGFR stages, from 1 to 5, and assessed the predictive value of KeGFR stages for AKD development and MAKE30. AKI severity was associated with lower KeGFRs. KeGFR1 and KeGFR2 predicted AKD with AUC values between 0.777 and 0.841 respectively, p < 0.001. KeGFR2 had the best performance in predicting MAKE30 (AUC of 0.819) with a sensitivity of 66.67% and specificity 87.7%. KeGFR1 stage 3, 4 and 5 increased the risk of AKD by 3.07, 6.56 and 28.07 times, respectively, while KeGFR2 stage 2, 3, 4 and 5 increased the risk of AKD 2.79, 3.58, 32.75 and 80.14 times. Stage 5 KeGFR1 and KeGFR2 stages 3, 4 and 5 increased the risk of MAKE30 by 7.77, 4.23. 5.89 and 69.42 times in the adjusted models. KeGFR proved to be a useful tool in AKI settings. KeGFR dynamics can predict AKI severity, duration and outcomes.Kinetic estimation of glomerular filtration rate (KeGFR) has proved its utility in predicting acute kidney injury (AKI) in both adults and children. Our objective is to assess the clinical utility of KeGFR in predicting AKI severity and progression to acute kidney disease (AKD) in patients already diagnosed with AKI and to examine major adverse kidney events at 30 days (MAKE30). We retrospectively calculated the KeGFR within the first 24 h of identified AKI (KeGFR Acute kidney injury (AKI) is a global health problem with a reported incidence of 26% in hospitalized children . AKI is Kinetic estimated glomerular filtration rate (KeGFR) has been used in acute settings as part of a multidimensional approach for AKI prediction ,10,11,12KeGFR is an adequate tool in assessing the risk of AKI in children, as the formula derives from the initial serum creatinine level, the distribution volume, the creatinine production rate and the given time differences of the two serum creatinine values . Based oA retrospective observational study was conducted in a tertiary care teaching and research hospital in western Romania from 1 of July 2014 to 31 December 2022. All patients under 18 years of age were screened based on changes in serum creatinine (SCr) via The Laboratory Information System and Hospital Information System. SCr measurement was performed using the Jaffe Abbott method. AKI was defined and staged using the 2012 Kidney Disease Improving Global Outcomes (KDIGO) SCr criteria . AKD wask = 0.33 in preterm infants, k = 0.45 in infants at term to 1 year old, k = 0.55 in children over 1 year and under 13 years old, k = 0.55 for adolescent females 13–18 years old, and k = 0.7 for adolescent males 13–18 years old. KeGFR was calculated using Chen’s formula [Estimated glomerular filtration rate (eGFR) was calculated using the Schwartz formula  as folloBaseline SCr was defined as the lowest SCr in the 3 months prior to AKI diagnosis, or the minimum inpatient SCr value during follow-up. Mean SCr was calculated from two consecutive SCr measurements. ΔSCr was the difference between the two SCr values, and Δt (h) was the interval in hours between two SCr measurements (maximum of 24 h). The maximum ΔSCr/day was defined as the change (increase) in SCr that occurred in a state of no kidney function dependent on volume of distribution (VD). The VD of creatinine is close to total body water, and it was estimated using Morgenstern et al.’s recalculation of Mellits and Cheek’s equation  based on1 was calculated using the SCr levels on days 1 and 2 of identified AKI, and KeGFR2 was calculated from two SCr values in days 6 and 7, before progression to AKD. The cut-off values of KeGFR were chosen based on KDIGO CKD classification [After adjusting all data for age and sex, KeGFR was calculated twice, using two separate SCr set of values. KeGFRfication  as stageOutcomes of AKI were evaluated via MAKE30 (major adverse kidney events within 30 days). MAKE was defined as death, necessity of RRT or the presence of AKD at day 30 after AKI documentation. The study was approved by the hospital’s Medical Ethics Committee in accordance with the Ethics Code of the World Medical Association and informed consent was waived.t-test or ANOVA. For non-normally distributed continuous variables, the median and interquartile ranges (IQR) were reported, and groups were compared using the Wilcoxon Signed Ranks test. Discrete variables were analyzed with the chi-square test. Odds ratio (OR) and 95% confidence interval (95% CI) were calculated. In order to assess the independent factors that predict the risk of AKD and MAKE30 in our cohort, we employed a backward multivariable logistic regression model. An Akaike information criterion (AIC) was used in order to determine the best model. Receiver-operating characteristic curves (ROCs) were plotted to determine the prognostic values of KeGFR, and area under the curve (AUC) values were generated to determine the predictive values of KeGFR1 and KeGFR2. The following values were used to describe AUC-ROCs: 0.6–0.69, poor; 0.7–0.79, fair; and 0.8–0.89, good. In this study, a p-value of 0.05 was considered the threshold for statistical significance. Data were analyzed using MedCalc Statistical software version 22.009. MedCalc® Statistical Software version 22.009 Data are presented as median and percentage for non-normally distributed continuous variables and categorical ones, respectively. All continuous variables were tested for normality using the Shapiro–Wilk test. For normally distributed variables, we used independent The final cohort consisted of 803 patients with AKI that met the inclusion criteria. We divided the cases into two groups: the AKD group (219 patients) and the non-AKD group (585 patients). Baseline characteristics are presented in p < 0.0001). The prevalence of severe AKI was higher in the AKD group (88.5%) as compared to the no AKD group. Patients that developed AKD maintained the same trend, with severe AKD in 72.8% of the patients (stage 2 or 3 AKD). Prerenal AKI was the main cause of AKI. Patients with intrinsic AKI were more prone to developing AKD as compared to other AKI etiologies. Intrinsic AKI could be traced in 28% of AKD patients and only in 15.6% of the non-AKD ones. As expected, baseline SCr was higher and eGFR lower in the AKD group (p < 0.0001). KeGFR1 and KeGFR2 were 3.57 times and 4.99 times lower, respectively, in the AKD group—see There were no differences between sexes. Patients that progressed to AKD were younger, namely, 3 days versus 365 days (1 staging and AKI severity and causes—see p < 0.0001). KeGFR was classified in KeGFR stages as described in Methods. Within the first 24 h of identified AKI, almost half the cases (45%) were stage 1 or 2 (KeGFR > 60 mL/min/1.73 sm). Regarding AKI stages, AKI stage 1 had the highest KeGFR (stages 1 and 2) as compared to severe AKI (stages 2 and 3). As severity of AKI increased, KeGFR stage increased. In patients that progressed to AKD (217 patients out of 803), severe AKD was also associated with higher KeGFR stages.We identified a strong correlation between KeGFR2 on day 7 using SCr levels from days 6 and 7 in 2 was calculated for 310 patients out of whom 151 children developed AKD (48.7%). The KeGFR2 distribution was similar to KeGFR1, with half the patients having a KeGFR > 60 mL/min/1.73 sm (stages 1 and 2). This analysis once again confirms that AKI severity is associated with higher stages of KeGFR2. Also, AKD severity is associated with decreased levels of KeGFR2. In the subgroup of patients with KeGFR2, we evaluated the distribution of AKI causes. As previously mentioned, a prerenal cause of AKI was the leading one in all KeGFR groups. The results from KeGFR1 and KeGFR2 showed that more than 60% of patients with intrinsic AKI had a KeGFR > 60 mL/min/1.73 sm.After evaluating KeGFR within the first 24 h of identified AKI, we performed the second analysis of KeGFR1 stages as independent ones (2 = 0.27), with an AUC of 0.763. KeGFR1 stages 3, 4 and 5 increased the risk of AKD development by 2.76, 5.33 and 27.23 times, respectively. After adjusting the regression model for sex, AKI stage and AKI causes, the model improved , with KeGFR1 increasing the incidence of AKD by 3.07, 6.56 and 28.07 times in stages 3, 4 and 5, respectively.We performed a logistic regression model with AKD-dependent variables and KeGFRent ones . The una2 stages as independent ones proved to be a good fit in both unadjusted and adjusted . In the unadjusted model, KeGFR2 stages 2, 3, 4 and 5 increased the risk of AKD by 2.65, 3.03, 28.72 and 70.09 times, respectively, and in the adjusted one by 2.79, 3.58, 32.75 and 80.14, respectively . Only stage 5 KeGFR1 increased the risk of MAKE30 by 10.42 times in the unadjusted model and by 7.77 times in the adjusted one  : 53 deaths, 11 patients requiring RRT and 47 children with AKD. Logistic regression with MAKE30 as a dependent variable and KeGFRsted one . KeGFR2 ctively) .1 and KeGFR2 predicted AKD with AUC values between 0.777 (95% CI 0.747–0.806) and 0.841 (95% CI 0.795–0.88), p < 0.001. KeGFR2 had the best performance in predicting AKD, with 66.45% and specificity 91.14% with associated criterion ≤ 40.41 mL.min/1.73 sm, as well as in predicting MAKE30 with an AUC of 0.819 (95% CI 0.772–0.861) with a sensitivity of 66.67% and specificity 87.7% with associated criterion ≤ 25.69 mL/min/1.73 sm, p < 0.001. It should be mentioned that the ROC-AUC of KeGFR2 included 310 patients. KeGFR1 had a fair performance in predicting AKD AUC of 0.777 with a sensitivity of 76.15% and specificity of 68.55%, with associated criterion ≤ 39.18 mL/min/1.73 sm. KeGFR1 included all patients (N = 803). KeGFR1 had an AUC of 0.7 (95% CI 0.667–0.731) with an associated criterion of ≤21.28 mL/min/1.73 sm (p < 0.001), a 55.86% sensitivity and 81.65% specificity in predicting MAKE 30.KeGFR calculation within the first 24 h of documented AKI, as well as 24 h prior to AKD, predicted AKD development and MAKE30—see In this study, KeGFR was analyzed for the first time as a predictor of AKD in children. To best of our knowledge, there are no studies that used KeGFR for AKD prediction in pediatric or adult settings. KeGFR has been used in predicting AKI in high-risk populations ,19,20,211 calculation as a predictor of AKI persistence, as 70% of the children that developed AKD had a KeGFR below 60 mL/min/1.73 sm. AKI evolution is dependent on medical intervention  that in most cases leads to renal recovery. However, more than 25% of our patients had a prolonged AKI episode that further contributed to kidney injury. KeGFR1 proved there is a link between reduced day 1 and 2 renal function and AKD development as an independent variable. As expected, KeGFR2 had a higher prediction rate of AKD compared to KeGFR1. Given the medical intervention during the timeframe between the first 24 h of identified AKI and the 24 h prior to AKD development, KeGFR2 proved once again to be an independent risk factor for AKD. For example, a patient with KeGFR1 stage 5 (<15 mL/min/1.73 sm) has a 28-fold higher risk of progressing to AKD; hence, one could use KeGFR2 in dynamic for predicting the severity of AKD as well as for the risk of MAKE30. KeGFR2 is a better predictor for AKD and MAKE30 as a result of prolonged kidney injury. More than 70% of the patients with AKD had a KeGFR2 below 60 mL/min/1.73 sm, reflecting the transition from AKI state to AKD. The risk of AKD and MAKE30 starts from KeGFR2 stage 3 (<60 mL/min/1.73 sm) as opposed to stage 5 KeGFR1 (<15 mL/min/1.73 sm). With these results, we highlight the utility of repeated kinetic measurements. We suggest careful renal function monitoring in all AKI patients, especially in those with KeGFR1 stage 5 (<15 mL/min/1.73 sm) and KeGFR2 stages 3, 4 and 5 (<60 mL/min/1.73 sm), using repeated SCr measurements.Our results showed that 1 in 4 children progressed to AKD 27.14%), hence the importance of predicting AKD. Progression to AKD is a cumulative result of medical intervention and underlying disease severity. As previously reported by KDIGO guidelines in 2012 and the ADQI consensus report, AKD is a sequel of AKI with increased morbidity and mortality with or without progression to CKD 7.14%, he. With a In clinical settings, several markers proved to be effective in predicting AKI, including KeGFR. For instance, Dewitte et al.  showed t2 model proved to be superior compared to KeGFR1, proving the utility of KeGFR calculation once again in predicting worse renal outcomes. AKI evolution is marked by several outcomes: rapid renal recovery with return to baseline SCr, delayed recovery (up to 90 days), and progression towards CKD or death. When renal recovery does not occur during hospitalization, with progression to AKD, the second KeGFR calculation (days 6 and 7 after AKI diagnosis) proved to be a better predictor of worse renal outcome .Current studies have failed to find a significant relationship between reduced KeGFR and 30-day mortality ,24, whil1 model proved to be fair in predicting MAKE30, with an AUC of 0.7, while the KeGFR2 model proved to be good, with an AUC of 0.819. For instance, Dewitte found a similar predictive value of KeGFR for MAKE in the adult population, with an AUC of 0.81 [The KeGFR of 0.81 .In our opinion, when SCr increases rapidly, kinetic modeling of GFR proves to be a better predictor of AKI outcomes, AKD development and worst renal outcomes at 30 days. One should mention the clinical usefulness of KeGFR, regardless the time of calculation, in both AKI-identified patients and in at-risk AKI patients, as previously reported  ,12,14.The strength of this study is supported by the high number of AKI cases from a mixed pediatric population, both critically ill and non-critically ill, including neonates. Our electronic data system allowed us to identify baseline SCr, making it the first study to include baseline SCr and baseline eGFR in kinetic estimation formula in children, and to include all patients with consecutive SCr measurements within the first 24 h of identified AKI and the 24 h prior to AKD. In addition, we were able to adjust the formula of KeGFR to the maximum daily creatinine production using Morgenstern et al.’s recalculation of Mellits and Cheek’s equation based on height and sex. The strongest point was the use of this tool in order to predict AKD and MAKE30. The limitations were the lack of urine output criteria, single center and retrospective design.Kinetic modeling of eGFR can be used as a complementary tool in AKI settings. KeGFR has already been validated as a severe AKI predictor providing a good prognostic and diagnostic approach. There is an imperative need for prospective studies in the pediatric population in order to validate our results. We suggest that KeGFR measurements could be employed in pediatric intensive care units for risk stratification in patients with or without AKI.


Triple metronomic chemotherapy is one of the options of treatment in platinum-refractory/early failure oral cancer. However, long term outcomes with this regimen are unknown.2 & 9 mg/m2 in phase 2), all taken orally till progression of disease or development of intolerable adverse events. The primary objective was to estimate the long-term overall survival and factors impacting it. The Kaplan Meier method was used for time-to-event analysis. Cox proportional hazard model was used to identify factors impacting overall survival (OS) and progression-free survival (PFS). The factors included in the model were age, sex, Eastern Cooperative Oncology Group - performance status (ECOG PS), tobacco exposure and a subsite of primary and circulating endothelial cell levels at baseline. A p-value of 0.05 was considered significant. Clinical trials information: CTRI/2016/04/006834.Adult patients with platinum-refractory/early-failure oral cancer were enrolled in the study. Patients were administered triple metronomic chemotherapy ie erlotinib 150 mg once daily celecoxib 200 mg twice daily and methotrexate weekly , the median follow-up was 41 months and 84 events of death had occurred. The median OS was 6.7 months (95% CI 5.4–7.4). The 1-year, 2-years and 3-year OS’ were 14.1% (95% CI 7.8–22.2), 5.9% (95% CI 2.2–12.2) and 5.9% (95% CI 2.2–12.2) respectively. The only factor favorably impacting OS was the detection of circulating endothelial cells at baseline . The median PFS was 4.3 months (95% CI 4.1–5.1) and the 1-year PFS was 13.0% (95% CI 6.8–21.2). The factors with statistically significant impact on PFS were detection of circulating endothelial cells at baseline  and no tobacco exposure at baseline .The long-term outcomes with triple oral metronomic chemotherapy ie erlotinib, methotrexate and celecoxib are unsatisfactory. Detection of circulating endothelial cells at baseline is a biomarker predicting efficacy of this therapy.Tata Memorial Center Research Administration Council (TRAC) and Terry Fox foundation.The study was funded by an intramural grant from  We searched the PubMed database for keywords ‘platinum refractory’, ‘oral cancer’ and ‘long term’ and only found 1 paper by Ferris et al. titled “Nivolumab vs investigator's choice in recurrent or metastatic squamous cell carcinoma of the head and neck: 2-year long-term survival update of CheckMate 141 with analyses by tumor PD-L1 expression.” Published in Oral Oncology in 2018. Given that Nivolumab and Pembrolizumab have robust data in treatment of platinum refractory oral cancer and long-term survival data only exists for Nivolumab, we decided to do this study for triple metronomic chemotherapy. Triple metronomic chemotherapy is one of the options of treatment in platinum-refractory/early failure oral cancer. However, long term outcomes with this regimen are currently lacking evidence.A total of 91 patients were recruited. The median OS was 6.7 months (95% CI 5.4–7.4).The 1-year, 2-years and 3-year OS’ were 14.1% (95% CI 7.8–22.2), 5.9% (95% CI 2.2–12.2) and 5.9% (95% CI 2.2–12.2) respectively. The median PFS was 4.3 months (95% CI 4.1–5.1) and the 1-year PFS was 13.0% (95% CI 6.8–21.2). . The only factor favorably impacting OS was the detection of circulating endothelial cells at baseline. The median PFS was 4.3 months. The factors with statistically significant impact on PFS were detection of circulating endothelial cells at baseline and no tobacco exposure at baseline. Per the aforementioned study by Ferris et all, Nivolumab had a 24-month OS rate of 16.9% and demonstrated OS benefit across patients with tumor PD-L1 expression ≥1% (HR [95% CI] = 0.55 [0.39–0.78]) and <1% (HR [95% CI] = 0.73 [0.49–1.09]), and regardless of tumor HPV status. The 24-month OS rate of 16.9% was similar to the 14.1% from our study.Currently reported systemic treatment options in platinum refractory oral cancer are Nivolumab and Pembrolizumab. However, due to the hurdles in access to these options in low and middle-income countries, we opted to study long-term survival data for triple metronomic chemotherapy in these patients. This study was from a single-center and hence can't provide a definitive conclusion however it shows us real-world data on an accessible therapy in platinum-refractory/early failure oral cancer in an LMIC. The factors with statistically significant impact on PFS were detection of circulating endothelial cells at baseline and no tobacco exposure at baseline. These results as well as other such studies performed from around the world will give us robust survival data from this clinical scenario and hence advise decisions regarding its utility in the future.,2 and an oral tyrosine kinase inhibitor (Erlotinib 150 mg) had shown a response in platinum refractory or early failure oral cavity cancers but there is sparse data regarding its efficacy on long term overall survival.Oral cavity cancers presenting at an advanced stage are a major burden in India.This was investigator-initiated, phase I-II, open label, single arm study which was approved by the institutional ethics committee of Tata Memorial Centre and was registered with the Clinical trial registry of India (CTRI/2016/04/006834). All patients provided written informed consent prior to participation in the study. The study was conducted in accordance with good clinical practice guidelines and the principles of declaration of Helsinki. The study was monitored periodically by the institute's data safety and monitoring board.Recruitment of the study was from April 26, 2017 to October 1, 2018. Cut-off date for data analysis was 7th Feb 2022.The study participants include histologically-confirmed squamous cell cancers of the oral cavity with at least one measurable lesion that had either progressed within 6 months of prior platinum based therapy or within 1 month of local therapy (surgery or radiation). The additional inclusion criteria were adult patients (Age ≥ 18 years), Eastern Cooperative Oncology Group performance status score of 0, 1, or 2 , life expectancy of less than 6 months and normal organ functions as per the protocol . Patient1.CD 146 2.CD 45 3.CD 34 4.CD 31 5.CD 133 (progenitor cell marker)6.Viability stain (7 AAD) (apoptosis marker)Patients received erlotinib 150 mg (fixed dose) per oral once daily, capsule celecoxib 200 mg (fixed dose) per oral twice daily and oral weekly methotrexate. Patients on this metronomic chemotherapy regimen were monitored for response and toxicity at C1D8, D30 and subsequently monthly till progression. The response assessment scan was done on day 30 and then monthly till progression. Response assessment was done in accordance with the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.1 The adverse events were recorded in accordance with the Common Terminology Criteria for Adverse Events (CTCAE) version 4.03. The criteria for dose reduction and dose delay provided in the study protocol . The cheFACS Calibur was used for the flow cytometry analysis. The population of EC and Endothelial progenitor cells (EPC) were identified as; CECs: CD 146 (+), CD 45 (-/dim), CD 34 (+), CD 31 (+) and CD 133 (−) and Endothelial progenitor cells: CD 146 (+), CD 45 (-/dim), CD 34 (+), CD 31 (+) and CD 133 (+).This analysis focused on long term outcomes for patients. Hence, we opted to measure OS at 1, 2 and 3 year timepoints along with progression-free survival (PFS) at the same time points. The intention-to-treat (ITT) analysis was applicable for estimating PFS and OS. The progression-free survival (PFS) was defined as the time interval between the date of enrollment on the study to the date of progression or death, whichever was earlier. Patients who did not have any of these events were censored at last follow up. The overall survival (OS) was defined as the time interval between date of enrollment on the study to the date of death. Patients who did not have this event were censored at last follow up.Statistical Package for the Social Sciences IBM SPSS Statistics for Windows, version 20  SPSS version 20 and Rstudio version 1.1.03 were used for analysis. PFS and OS curves were created using the Kaplan–Meier Product-limit method. The median PFS and OS were obtained with a 95% CI. Cox proportional hazard model was used for the identifying factors affecting PFS and OS. A p-value of 0.05 or below was considered as significant. The factors considered were age, sex, subsite, ECOG PS, tobacco exposure and circulating endothelial cells.Flexible-finite sample-based approach was adopted to select the circulating endothelial cells (CEC) interval boundaries and further to use optimum interval design. During the trial, we continuously updated the posterior estimates of the decline in CEC and clinical benefit rate and assigned patients to the most appropriate dose combination). The Bayesian adaptive screening design was used to simultaneously select among possible treatment dose combinations. The design is based on formulating the selection procedure as a Bayesian hypothesis testing problem in which the superiority of each treatment combination is equated to a single hypothesis. During the trial conduct, we used the current values of the posterior probabilities of all hypotheses to adaptively allocate patients to treatment combinations. The dose-finding decision was decided on the twin endpoints: the clinical benefit rate at 2 months and proportional decline in CEC at D8 of first cycle.It was assumed that the 3-month progression-free survival (PFS) rate of a standard cancer therapy was 0.50 (H0). An improvement to 0.60 was considered clinically significant (H1). Assuming both the null and alternative PFS distributions follow an exponential distribution, the 1-sided type I error rate will be of 0.05 and type II error rate of 0.1. Prior assumption included a fixed enrollment rate of 3 patients per month. We made a stop at 3 months at the end of Stage 1. The library (“OptInterim”) was used to calculate the sample size. A 20% extra patient was taken into account for lost to follow up data. Hence a total of 76 (63 patients + 13 patients) sample size was found suitable to carry out the study for stage II with single arm drug therapy.The sponsors had no role in design, conduct, data collection, analysis, interpretation or on the decision to submit the manuscript for publication.A total of 91 patients were recruited (15 in phase 1 & 76 in phase 2). The baseline characteristics among the whole study population is shown in The median follow-up was 41 months and 84 events of death had occurred. The median OS was 6.7 months (95% CI 5.4–7.4). The 1-year, 2-years and 3-year OS’ were 14.1% (95% CI 7.8–22.2), 5.9% (95% CI 2.2–12.2) and 5.9% (95% CI 2.2–12.2) respectively . The onlThe median PFS was 4.3 months (95% CI 4.1–5.1) and the 1-year PFS was 13.0% (95% CI 6.8–21.2). The 2 and 3 year PFS was 6.5% (95% CI 2.3–13.9) and 4.9% (95% CI 1.4–11.9) . The facOverall survival by phase is depicted in Data on outcomes and adverse events have been published in the early study.In our Phase I/II study, the long-term outcomes with the use of triple metronomic chemotherapy (TMC) at 1 year and 2 years was disappointing. In a study by Ferris RL et al.,Metronomic chemotherapy has been a boon for low and middle income countries especially in head and neck cancers. Post the pivotal phase III study by Patil V et al.,In our study, we tried to identify factors that impact progression-free survival and overall survival in patients with early-failure oral cancer on triple metronomic chemotherapy. The factors with a statistically significant impact on PFS were detection of circulating endothelial cells and no tobacco exposure at baseline. The factor that had an impact on OS was detection of circulating endothelial cells at baseline. Thus suggesting that detection of circulating endothelial cells can be a biomarker for prediction of outcomes with metronomic chemotherapy. This is also a hypothesis assuring finding, as the action of metronomic chemotherapy is postulated to be on circulating endothelial cells,There are certain limitations to our study. This is a single center, non-randomized study and only oral cavity cancer patients were included in this study while the other sites of head and neck cancer were excluded. A strength of our study is that by focussing on patients with cancer of the oral cavity, we've accrued data on a highly prevalent site of cancer for the Indian population. Relative to other sites, oral cavity cancer patients have poor outcomes amongst head and neck cancers.There is a need in the future to have a randomized study comparing the low dose immunotherapy alone versus combination of triple metronomic chemotherapy with low dose immunotherapy in platinum-refractory head and neck cancer.The long-term outcomes with triple oral metronomic chemotherapy with erlotinib, methotrexate and celecoxib are unsatisfactory. Detection of circulating endothelial cells at baseline is a biomarker predicting efficacy of this therapy. The factors with a statistically significant impact on PFS were detection of circulating endothelial cells and no tobacco exposure at baseline. The factor that had an impact on OS was detection of circulating endothelial cells at baseline.The authors confirm contribution to the paper as follows:Study conception and design: VP, KP.Data collection: All authors.Analysis and interpretation of results: All authors.Draft manuscript preparation: All authors.All authors reviewed the results and approved the final version of the manuscript. All authors vouch for the accuracy and completeness of the data, analyses and for the fidelity of the study to the study protocol.De-identified data may be shared on a case-by-case basis upon reasonable requests to the corresponding author for a period of 5 years.Vijay Maruti Patil receivedfundingfrom10.13039/100004325AstraZeneca (Inst); 10.13039/501100003769Eisai Germany (Inst); INTAS (Inst); 10.13039/100004331Johnson & Johnson/Janssen (Inst); NATCO Pharma (Inst); 10.13039/100004336Novartis (Inst).Vanita Noronha receivedfundingfrom10.13039/100002429Amgen (Inst); 10.13039/100004325AstraZeneca (Inst); Dr. Reddy's Laboratories (Inst); INTAS (Inst); 10.13039/100004339Sanofi/Aventis (Inst).Kumar Prabhash receivedfundingfromAlkem Laboratories (Inst); BDR Pharmaceutics (Inst); 10.13039/100007777Biocon (Inst); Dr. Reddy's Laboratories (Inst); 10.13039/100017530Fresenius Kabi (Inst); NATCO Pharma (Inst); 10.13039/100004337Roche (Inst).


Interpretation of patient-reported outcome scores such as the Hip Disability and Osteoarthritis Outcome Score (HOOS) can be improved with use of reference values. The aim of the study was to establish population-based reference values for the HOOS’ five subscales and its short-form HOOS-12.A representative sample of 9997 Danish citizens 18 years and older were identified. The population record-based sample was based on seven predefined age groups and an equal sex distribution within each age group. A national secure electronic system was used to send the HOOS questionnaire and one supplementary question regarding previous hip complaints to all participants.2277 participants completed the HOOS, 947 women (42%) and 1330 men (58%). The mean HOOS subscale scores were: pain 86.9 (95% CI 86.1–87.7), symptoms 83.7 (95% CI 82.9–84.5), ADL 88.2 (95% CI 87.5–89.0), sport and recreation function 83.1 (95% CI 82.0–84.1), QOL 82.7 (95% CI 81.8–83.6). The youngest age group reported better mean scores in four subscales compared to the oldest age group , , , . Participants with a self-reported hip complaint had worse HOOS scores across all subscales (mean difference range 22.1–34.6). Super obese patients (BMI > 40) had > 12.5 points worse scores across the five HOOS subscales. Results were similar for the HOOS-12.This study provides reference values for the HOOS and its short form HOOS-12. Results show that older patients and patients with a BMI over 40 have worse HOOS and HOOS-12 scores that may be of clinical importance in the interpretation of scores both when evaluating potential for improvement and post-treatment results. During the last decades, patient-reported outcomes have become central in reporting the treatment effect and patients’ satisfaction following treatment of joint disorders . Large-sIn contrast to generic patient-reported measurement outcomes, body region-specific patient-reported outcome measurements can capture the patient perceived ability to perform specific activities indicatory for body regions such as the hip. This is often combined with questions covering health related quality of lifeThe Hip Disability and Osteoarthritis Outcome Score (HOOS) is widely used body region-specific score used to investigate the effect following treatments of osteoarthritis and other hip related disabilities and is one of several internationally recommended patient-reported instruments to be used following hip replacement . In 2019The interpretation of results from patient-reported outcome measurements such as the HOOS and HOOS-12 can be improved using large-scale normative data from randomly selected reference populations. Patient-reported outcomes scores are frequently reported to be influenced by age, sex, weight, social status, and comorbidity –10. At pThe aim of the present study was to establish reference values for the Hip Disability and Osteoarthritis Outcome Score (HOOS) five subscales and its short form HOOS-12 based on a randomly selected population-based sample of adult Danes.The study was designed as a population record-based sample, including a national representative sample of all citizens of Denmark.At birth or emigration to Denmark, a Civil Registration Number (CPR) is given to all residents and registered in the Civil Registration System. The CPR number is mandatory by law for all citizens in Denmark. Prospective information regarding emigration and death is recorded in this registry . The CivThe Danish Data Protection Agency approved the study (J. nr. 2021 Id: 114). The reporting of the study complies with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement .Included were Danish citizens 18 years and older. Excluded were those without online contact information (E-boks). An invitation to participate in the project was mailed to all participants using the mandatory online system E-boks. The invitation included an online link to the HOOS questionnaire and contact information for the research group in case of questions. Before the study started, the invitation letter, HOOS, and the E-boks system were piloted on a small group of 10 participants. After finishing the HOOS questionnaire, participants were also asked to submit their height and weight. Furthermore, one supplemental question was asked: Within the last 5 years, have you been in contact with a health professional due to a hip problem? Answer: yes/no.In case of no response within 14 days, participants received a second request to participate.A representative sample of 10,000 citizens of Denmark was derived from the Danish Civil Registration System. By 2021, the population of Denmark consisted of 5.8 million citizens.The sample was selected based on seven predefined age groups  and an equal sex distribution across all groups. A sample of 10,000 citizens was defined and contacted to allow adequate power for subgroup analyses based on both age and gender. We expected a response rate of about 30% yielding approximately 200 citizens in each age and gender group.www.koos.nu.The Hip Disability and Osteoarthritis Outcome Score (HOOS) is a patient-reported and body region-specific questionnaire that was introduced in 2003 with the aim of assessing patients’ experiences regarding their hip and associated problems . It is aThe short form HOOS-12 was developed using item response analysis and is calculated based on 12 items from the full HOOS questionnaire . The outHOOS and HOOS-12 scores are calculated based on standardized scoring algorithms and presented as a score between 0 and 100 for each respective subscale . A scorewww.koos.nu.The two scoring manuals are available at The HOOS and HOOS-12 scores are given as mean, median, standard deviation (SD), 95% confidence intervals (CI), minimum, maximum, and number for the overall group and for each age and gender group. In accordance with the HOOS scoring manual , scores Continuous variables are reported by mean and standard deviation (SD) and categorical variables by frequencies. A two-way analysis of variance (ANOVA) was used to test the difference between predefined age and gender groups. If significant ANOVA factors or interactions were found, multiple pairwise analyses with post hoc test (Bonferroni) corrections were used.One-way ANOVA was used to test the difference between subscales scores and reporting of hip problems (yes/no) and between subscales scores and BMI groups , where BMI > 40 indicate the super obese. If a significant ANOVA factor was found, multiple pairwise analyses with post hoc test (Bonferroni) corrections were used.t test and for gender difference by the Chi-square test.Responders and non-responders were checked for age difference by the unpaired P value of < 0.05 was considered significant. The statistical analysis was performed by STATA (version 27).A Thresholds suggested to represent a clinically relevant improvement range from 7 to 36 for the HOOS subscales, and from 15 to 28 for the HOOS-12 subscales . In thisOf the 9997 nationally representative persons identified, 1093 did not have a valid E-boks and could not be contacted. A total of 2277/8904 (26%) contacted participants completed the HOOS questionnaire, 947 women (41.6%) and 1330 men (58.4%). Detailed information regarding the full study population is presented in Fig. The HOOS and HOOS-12 subscale scores for the total sample and for the seven predefined age- and gender groups are presented in Tables The age- and gender specific HOOS and HOOS-12 subscale scores are presented in Fig. Comparing the youngest and oldest age groups a significant difference were observed in four of the five HOOS subscales (pain mean difference 7.2 95% CI 0.4–14.0), (ADL mean difference 11.4 95% CI 4.9–17.8), (sport and recreation function mean difference 17.7 95% CI 9.0–26.4), (QOL mean difference 10.1 points 95% CI 2.0–18.2) and for the HOOS-12 (pain mean difference 7.3 95% CI 0.1–14.5), (ADL mean difference 12.9 95% CI 6.0–19.8), (QOL mean difference 10.1 95% CI 2.0–18.1) and (impact score mean difference 10.2 95% CI 3.1–17.4).Excluding patients reporting a hip complaint reduced the difference between age groups in three of the five HOOS (ADL mean difference 8.6 95% CI 3.1–14.1), (sport and recreation function mean difference 13.6 95% CI 5.7–21.5),  reported a hip complaint within the last 5 years. Of the 377 participants reporting a hip complaint, most were 50 years of age or older (75%), and most were women (67%). Reporting a hip complaint within the past 5 years was associated with worse HOOS scores compared to participants without reporting hip complaints: (pain mean difference 25.4 95% CI 23.6–27.3), (symptoms mean difference 25.2 95% CI 23.3–27.1), (ADL mean difference 22.1 95% CI 20.3–23.9), (sport mean difference 29.0 95% CI 26.5–31.5) and (QOL mean difference 34.6 95% CI 32.5–36.7). Similar differences between groups were found when using the HOOS-12 subscales and the impact score: (pain mean difference 27.3 95% CI 25.4–29.3), (function mean difference 23.3 95% CI 21.3–25.2), (QOL mean difference 34.6 95% CI 32.5–36.7) and (impact score mean difference 28.4 95% CI 26.1–30.8).N = 428) of participants reported a BMI of 30 or higher. Markedly worse scores were found in participants reporting a BMI over 40, Table The mean self-reported BMI was 26.8 (± 11.5). Nineteen percent  was associated with substantially worse HOOS and HOOS-12 scores. The difference between normal weight and the super obese were > 12 points on the HOOS/HOOS-12 subscales indicating likely clinically relevant differences between groups that needs to be considered when using HOOS scores for interpreting patient outcomes. These results are in line with Raja et al.  who repoThe use of HOOS reference data in the orthopedic setting is twofold. When used in the clinic for evaluation of a specific treatment, reference data may help indicate the expected improvement and provide a treatment goal. Age specific reference values may be of particular relevance when for example treating an older woman with a hip fracture, and BMI-specific reference values may be of particular relevance to indicate the expected improvement for a superobese or obese patient having total hip replacement. Reference values are also usable when applied to groups of patients in orthopedic research. When HOOS or HOOS-12 is considered as the primary outcome in a future study, reference values support the initial planning of the study by indicating optimal mean scores following treatment.A strength of this study is the randomly selected national age and gender representative sampling base, with more than 2200 responders making this study the largest HOOS/HOOS-12 reference material available. Missing responses were spread across age and gender subgroups minimizing the risk of a strong selection bias. Responders and non-responders did not differ on age and gender, it is not possible to test if non-responders were different on other variables.This study is based on a national randomly selected population and provides sex and age-specific reference values of the Hip Disability and Osteoarthritis Outcome Score (HOOS) and its short form HOOS-12. We found that older patients and patients with a BMI more than 40 have clinically relevant worse HOOS and HOOS-12 scores. Using age- and BMI-specific reference values may therefore be indicated when evaluating potential for improvement and post-treatment results in these patient groups.


The reliable ultrasound (US) measurements of papillary thyroid microcarcinoma (PTMC) are very important during active surveillance. This prospective study was design to investigate the inter-observer reliability and agreement of two- dimensional ultrasound(2DUS) and three-dimensional ultrasound(3DUS) in the measurement of maximum diameter and volume for PTMC.This prospective study included 51 consecutive patients with solitary PTMC confirmed by biopsy. Two independent observers performed measurements of each tumor using a standardized measurement protocol. The maximum diameter was the largest one of the three diameters measured on the largest transverse and longitudinal 2DUS images. 2DUS volume was calculated using ellipsoid formula method. The virtual organ computer aided analysis(VOCAL) was used to determine 3DUS volume. The inter-observer reliability was assessed using intraclass correlation coefficient(ICC) with 95% confidence intervals(CIs). Bland-Altman analysis was used to evaluate agreement, and expressed as a bias with 95% limits of agreement(LOA).3 vs. 0.175 ± 0.078 cm3, P = 0.005). The ICCs of inter-observer reliability of maximum diameter, 2DUS volume and 3DUS volume was 0.922(0.864–0.955), 0.928(0.874–0.959), and 0.974(0.955–0.985), respectively. The ICCs of 2DUS and 3DUS volume was 0.955(0.909–0.976). The inter-observer agreement of maximum diameter, 2DUS volume and 3DUS volume was 1.096(0.7322 to 1.459), 1.008(0.5802–1.435), and 1.011(0.7576–1.265), respectively. The inter-observer agreement of 2DUS and 3DUS volume was 1.096(0.7322 to 1.459).The maximum diameter was 0.78 ± 0.14 cm. Volume measured by 3DUS was significantly smaller than that by 2DUS(0.163 ± 0.074 cmMaximum diameter had the lowest degree of observer variation among all the measurements. Volume measured by 3DUS had lower variability and higher repeatability than that by 2DUS, which might be helpful to provide more reliable estimates of tumor size for PTMC.The online version contains supplementary material available at 10.1186/s40644-023-00613-3. The global incidence of papillary thyroid microcarcinoma(PTMC) has risen substantially worldwide in the past three decades , 2, follTo avoid overtreatment, active surveillance(AS) has been recommended as a new management option to immediate surgery for adult patients with biopsy-proven low-risk PTMC , 5, and Understanding of the inter-observer variations of US was necessary for accurate evaluation , 18. A pTherefore, the purpose of this prospective study was to investigate the inter-observer variations of 2DUS and 3DUS in the measurement of maximum diameter and volume for PTMC.This prospective study was approved by the Institutional Review Board of our hospitalS2020-237-01). All the enrolled patients fulfilled these inclusion criteria: .Prior to the study, the two observers underwent a training session that consisted of 20 unenrolled cases to acquaint themselves with 3D scanning and manually outlined. To obtain objective measurement, the two observers standardized a measurement protocol as followsFig. :(1) Patients were scanned consecutively by the two observers. Only one observer was present in the exanimation room at any time. For each patient, each observer performed a complete new set of scans for the measurement, consisting of 2DUS and 3DUS, without knowledge of the other physician’s results.(2) During the examination, 2DUS was performed first. For each tumor, the location, composition, echogenicity, shape, margin and echogenic foci were evaluated . The ant(3) When 2DUS examinations were finished, 3DUS mode was activated to view the largest longitudinal image of tumor. For the 3D data acquisition, the entire tumor was scanned through a single sweep. Each observer scanned the tumor twice and the 3DUS images was stored in the hard disk of the system for further analysis. The images were reviewed and measured in the same after all examinations were completed. The VOCAL method was used to reconstruct and postprocess the 3DUS images to calculate the volume. With 3 orthogonal slices simultaneously displayed, the longitudinal US image plane was selected as A plane. Select the contour type as the manual and the angel of rotation as 30°. Then 6 slices images were obtained to manually trace the contour lines of the tumor. Once outlining was finished, the 3DUS volume could be obtained automatically. For each tumor, the volume was measured twice to obtain a mean 3DUS volume of each observer.(4) After the two observers finished their measurements, a total of six measurements were obtained for each tumor. The means of volume by each measurement modality were calculated on the means of the two observers. The measurement time of each modality were also recorded. The measurement time of 2DUS measurement was defined from the 2DUS evaluation to the calculation of 2DUS volume.The measurement time of 3DUS measurement was defined from 3DUS mode activation to the 3DUS volume obtained by VOCAL method.P < 0.05 was considered as statistically significant. Normally distributed continuous variables are expressed as mean ± standard deviation and compared using the paired-samples t-test. Categorical variables were presented as numbers with percentages.Statistical analysis was performed using the SPSS statistical software(Version 25.0) and GraphPad Prism(Version 8.0.0) software. A difference with a priori defined clinical criteria [The inter-observer reliability was assessed using ICC with 95% confidence intervals(CIs) based on the absolute agreement and two-way random effects model. Reliability was classified as follows: excellent(ICC > 0.90), good(ICC = 0.75–0.90), moderate(ICC = 0.5–0.74), and poor (ICC < 0.50) . The intcriteria , 36. Acc3 and 0.163 ± 0.074 cm3(P = 0.005). Representative cases are shown in Figs. A total of 51 patients  with solitary PTMC were included in this study(Table P < 0.001). The intra-observer reliability and agreement by each observer are shown in supplement table The measurement time of maximum diameter was 54.7 ± 4.8s. The measurement time of 3DUS volume was significantly longer than that of 2DUS , 0.928(0.874–0.959), and 0.974(0.955–0.985), respectively. The ICC of inter-observer reliability of volume by two modalities was 0.955(0.909–0.976).The inter-observer agreement of PTMC measurements are summarized in Table It was very important to obtain a reliable measurement of PTMC, as it could be the indication of conversion surgery during AS . This prBecause of the indolent nature and favorable outcomes, AS has been recommended as a new management option to immediate surgery for patients with low-risk PTMC , 5. DuriTo our best knowledge, only one study evaluated the inter-observer variation of 2DUS measurement of PTMC, and the results showed that the 95%LOA of maximum diameter was from − 26.6 to 24.5%, and of volume was from − 65.8 to 64.4%, respectively . It suggThis study also evaluated the inter-observer variation of volume measured by 3DUS. The results found that the inter-observer of 3DUS volume were excellent, and the 95%LOA was from 0.7576 to 1.265. It indicated that different observers did not affect the measurement, and 3DUS could be a reliable and reproducible volume measurement of PTMC. Moreover, the bias of volume measured by 2DUS and 3DUS was above one. Compared with 2DUS volume, 3DUS volume were significantly smaller and had a narrower 95% LOA. It suggested that volume measured by 2DUS was overestimated, and volume measured by 3DUS was more reliable than those obtained by 2DUS, which was consistent with previous studies , 25, 26.Although 3DUS could accurately reflect changes in tumor size and identify of tumor enlargement to inform the timing of conversion surgery during AS, there were drawbacks that limit its clinical application in routine evaluation. First, the borders identification by 3DUS could be subject to the errors because not all the slices had high imaging quality as well as 2DUS. Although this study showed that the 95% LOA of 3DUS volume was within the clinical criteria, the measurement still needed to be cautious. Second, 3DUS required additional processing of manually outlining the tumor border after scanning, leading to labor-intensive and time-consuming. Third, compared with maximum diameter, the 95%LOAof 3DUS was still relatively larger. It suggested that maximum diameter was not only a practical and simple method for tumor enlargement, but also had high reproducibility. However, the tumor growth pattern of PTMC was complicated. Some studies reported that PTMC grew rather rapidly in the initial stages of progression, and in many cases the growth decreased or even vanished at certain time points , 37. TheThis study had limitations. First, this study only evaluated the inter-observer measurement variation of PTMC, thus we did not obtain the true volume of tumor. Second, only one US machine has been used in this study. In clinical routine procedure, it was almost impossible to measure the tumor by the same US machine at each follow-up period. Further studies used two different machines are needed to confirm the results. Third, because only 9 patients in this study had Hashimoto thyroiditis, its impact on the measurement variation was not evaluated. Fourth, this study only enrolled patients with solitary PTMC. Further study is needed to investigate whether the results can be applied to multifocal PTMC.The inter-observer reliability of PTMC measurements by 2DUS and 3DUS were excellent. For PTMC, any ratio difference from 0.7322 to 1.459 in maximum diameter, or from 0.5802 to 1.435 in 2DUS volume, or from 0.7576 to 1.265 in 3DUS volume could be considered as the measurement variation for patients with PTMC. Maximum diameter had the lowest degree of observer variation, which was more practical and simple measurement of PTMC. Volume measured by 3DUS had lower variability and higher repeatability than that by 2DUS, which might be helpful to provide more reliable estimates of tumor size for PTMC.Below is the link to the electronic supplementary material.Supplementary Material 1


In advanced recurrent tumors, a significant reduction in mean scores was detected 3 months after salvage surgery (29.7 ± 22.94) compared to baseline . Up to 12 months, swallowing function was evaluated inferior compared to baseline independent of tumor stage . Conclusion: Improved HRQoL could be obtained in advanced recurrent OSCC after salvage surgery despite reduced swallowing function. In small recurrent tumors, overall, HRQoL was superior to baseline. Salvage surgery positively affected pain burden. For advanced recurrent tumors, important pain relieve could be observed as soon as 3 months after surgery.Background: Patients with recurrent oral squamous cell carcinoma (OSCC) have limited treatment options. Salvage surgery offers potential curative therapy. The need for extensive ablative surgery together with microvascular reconstruction implies invasive and painful treatment with questionable functional outcome. To address the impact of salvage surgery on the health-related quality of life (HRQoL) of patients suffering from recurrent OSCC, a multi-center prospective analysis was initiated. Material and Methods: Patients with recurrent OSCC from 2015 to 2022 at two German cancer centers were included. Interdisciplinary tumor board decisions determined surgery as the only curative treatment modality. HRQoL, was assessed via a EORTC questionnaire (European Organization for Research and Treatment of Cancer—EORTC: QLQ-C30 and QLQ-H&N35) in dependence of the recurrent tumor stage. Patients completed the questionnaires once before surgery (baseline) and then every 3 months during follow-up or up to the end of treatment. Results: In total, 55 patients were included. The mean follow-up period was 26.7 ± 19.3 months. Global health status showed superior mean scores after 12 months (60.83 ± 22.58) compared to baseline (53.33 ± 26.41) in stage 1 and 2 recurrent tumors. In advanced recurrent tumors’ mean scores for global health showed only minor positive differences after 12 months (55.13 ± 22.7) compared to baseline (53.2 ± 25.58). In terms of the mouth pain, mean scores were lower after salvage surgery in small recurrent tumors after 12 months (20.37 ± 17.73) compared to baseline (41.67 ± 33.07; Wilcoxon two-sample signed-rank test  The recurrence of OSCC occurs in up to 50% of patients with advanced primary tumors independent of the initial oncologic therapy ,2,3,4,5.A prospective multi-center study, which was confirmed by the local ethical committees of the participating centers , was conducted. Study registration was implemented  (Reg.-Nr.: DRKS00009255)). Patients were enrolled by the University Department of Maxillofacial Surgery in Heidelberg and the University Department of Maxillofacial Surgery at the Saarland Medical Centre. In total, 55 patients received salvage surgery between 2015 and 2022 .All patients had undergone multiple previous therapeutic approaches, including surgery and or radio-/chemotherapy, due to oral cancer and, thus, were defined as “heavily pre-treated”. Followed by a guideline-based staging-examination, salvage surgery was determined as curative therapy via an interdisciplinary oncological case discussion in the corresponding center. Alternative curative radiochemotherapy was not considered in the tumor board’s decision. Exclusion criteria were the infiltration of the common and/or internal carotid artery, skull base tumors, distant metastasis and an age younger than 18 years.The HRQoL was evaluated using a quality of life (QoL) questionnaire of the EORTC (European Organization for Research and Treatment of Cancer—EORTC: QLQ-C30 and QLQ-H&N35). This is a widely used questionnaire consisting of a basic questionnaire and an associated questionnaire specially adapted for head and neck cancers ,30. Patip-values were reported. Additionally, a 95% confidence interval (CI) for the Hodges–Lehmann estimator was reported for the MWU test. Overall group comparison was performed by means of a linear mixed-effects regression. The models included the change score as the dependent variable and the group, gender and age as independent variables. For the estimated effects, p-values and 95% confidence intervals were reported. Score value differences of 5 to 10 points were considered a small change, 11 to 20 points a moderate change and more than 20 points a major change [Statistical analysis was performed using R version 4.2.2. Clinical and histo-pathological parameters were assessed descriptively. Metric variables were described using mean and standard deviations. Overall survival and disease-specific survival were assessed using Kaplan–Meier estimation. Comparison of overall survival between the small and advanced recurrent tumors groups was performed using the Log-rank test. The QoL dataset was evaluated according to the scoring manual (Third edition from 2001) ,31. Mannr change . Score-vr change . All p-vIn total, 55 intensively pretreated patients with recurrent cancer were enrolled and received salvage surgery in the participating centers from 2015 to 2022. Moreover, 49 patients were treated at the Department of Maxillofacial Surgery in Heidelberg, and 6 patients were treated at the Department of Maxillofacial Surgery at the Saarland Medical Centre. The mean follow-up was 26.7 months SD ± 19.34. The cohort consisted of 24 (43.6%) women and 31 (56.4%) men. The mean age was 65.89 SD ± 10.41 years. The response rate for the QoL Questionnaires was 77.4% after 12 months .All patients received mean 3.2 SD ± 1.25 prior to treatment modalities. In total, 28 (50.9%) patients suffered from a secondary cancer, 23 (41.8%) patients showed a local recurrence and 4 (7.3%) patients presented with regional lymph node metastasis but stable local tumor control. Except for 12 (21.8%) patients, all resected specimens showed clear margins in histopathological examination. Moreover, 50 (90.9%) patients received microvascular reconstruction, while 5 (9.1%) patients received local flap or pedicled flap reconstruction. Two (3.6%) flaps were lost due to venous stasis. In total, 31 (56.4%) patients required a permanent tracheostomy, and 23 (41.8%) patients received a gastric percutaneous endoscopic gastrostomy tube. Of these, 5 (21.7%) patients were at stages 1 and 2, and 18 (78.3%) patients were at stages 3 and 4 .jcm-12-QoL data were analyzed according to the EORTC protocol.n = 14) at baseline, in contrast to advanced tumors (Stage 3–4) (47.31 ± 24.00 n = 31). In early recurrent tumors mean score values decreased three months after salvage surgery . Up to 9 months mean values were stable (n = 10). In contrast, patients with advanced recurrent tumors showed an immediate increase in their mean scores three months after surgery . Over the following 6 months, mean scores showed a minor decrease (n = 13). Observed changes in mean scores in GHS were not significant  showed higher mean score values  (p = 0.003). The mean score was further reduced after 6 months . At 9 months, the score decrease was not so pronounced as in the months before but was still meaningful compared to baseline . After 12 months, we observed a clinically relevant reduction in pain scores compared to baseline . The stage-specific means scores at each time point differed in terms of relevance but were not statistically significant . In small recurrences, a constant decrease from baseline (48.81 ± 30.11) for up to 12 months (21.97 ± 17.19) was detected , Table 3nificant .n = 14) in contrast to stage 3–4 tumors . Three-month postoperative mean scores increased in both groups  (n = 13) in contrast to advanced tumors . After 12 months, mean scores values were still higher than baseline in both groups   . Three-m± 26.21) . The mea± 26.21) .p = 0.054) (Recurrence was observed in 36 (65.5%) patients. In total, 25 (45.5%) patients died during follow-up. The mean follow-up time was 26.7 ± 19.3 months. The median overall survival was 33.9 months . The med= 0.054) . Median = 0.054) . During The treatment of recurrent OSCC remains a major challenge ,26. BothThe HRQoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC), a widely used quality-of-life questionnaire consisting of a basic questionnaire and an associated questionnaire specially adapted for head and neck diseases ,30. In rIn terms of GHS, small recurrent OSCC patients had stable mean scores over time . A comprPain relief has a great influence on the HRQoL, especially in advanced tumors . In bothWhen it comes to swallowing function, there were no significant differences between both groups at any given timepoint. Nevertheless, swallowing function is significantly impaired after salvage surgery compared to baseline in both groups. This observation seems to be constant, as mean scores for swallowing then show only minor changes up to one year. Worth mentioning is the fact that head and neck cancer therapy in general impacts swallowing function. In a study including 109 patients with primary head and neck cancer, treated either with surgery, surgery in combination with radiotherapy or chemoradiation were assessed for their swallowing function. It was found that 75.6% of the patients were affected in their social life after oncological therapy . TherefoIn a previous evaluation, salvage surgery in intensively pretreated patients showed a 1-year and 2-year disease specific survival (DSS) of 68.4% and 59.3%, respectively . In a meSalvage surgery has positive oncological influence on OSCC patients. It is a safe, technical, feasible and proven therapy option in complex oncological cases. The impact of salvage surgery is associated with future advances in the prediction accuracy of immunotherapeutic response rates. The combination of salvage surgery with immunotherapeutic approaches offers promising opportunities.Due to the single-arm study design, the low number of cases and the small number of returned questionnaires, the power of this study is limited. In addition, the subdivision into subgroups led to the problem of unbalanced groups, which further reduced the power of the performed statistical tests. Static power was insufficient for a comparison of quality of life with different primary therapy approaches. The perioperative medical history in terms of pain killers has not been considered in this study. Moreover, it has to be considered that patients with a better QoL tend to be more likely to complete questionnaires.HRQoL can be maintained despite extensive surgery. In particular, salvage surgery seems to have a positive impact on the course of pain. As swallowing function seems impaired after surgery, reconstructive techniques should intensively focus on swallowing anatomy, and functional therapies should be intensively integrated into early rehabilitation.


There is limited information of radical radiotherapy (RT) on lymphoepithelial carcinoma of salivary gland (LECSG) regarding to the rarity of the disease. We conducted this retrospective study that evaluated the feasibility and efficacy of radical RT with/without surgery in LECSG.We retrospectively reviewed patients that were pathologically diagnosed of LECSG and had definite or suspicious residual disease. The prescribed dose given to P-GTV and/or P-GTV-LN was 66 to 70.4 Gy. The clinical target volume (CTV) involved ipsilateral salivary gland and corresponding lymph node drainage area.A total of 56 patients were included. With a median follow-up of 60 months (range: 8 to 151 months), the 1-, 5-, and 10-year progression-free survival (PFS) rates were 94.6%, 84.7% and 84.7%; locoregional progression-free survival (LRPFS) rates were 98.2%, 87.4% and 87.4%; distance metastasis-free survival (DMFS) rates were 94.6%, 86.7% and 86.7%; and overall survival (OS) rates were 98.2%, 92.4% and 89.0%, respectively. A total of 7 patients without surgery were included. All patients were alive and only one patient experienced failure of distant metastasis four months after RT. The results of univariate analysis showed that compared with N stage, the number of positive lymph nodes (2 positive lymph nodes) was better prognostic predictor especially in PFS. There were no treatment-related deaths and most toxicities of RT were mild.Radical RT with/without surgery in LECSG for definite or suspicious residual disease is feasibility and efficacy. Most toxicities of RT were mild due to the target volume involved ipsilateral area. Lymphoepithelial carcinoma (LEC) is a rare malignant tumor, which was originally described by Hilderman in 1962 . It is cThe major salivary glands are the most common sites and more than 80% occurs in the parotid gland , 9–11. SThis was a retrospective study that evaluated the feasibility and efficacy of radical RT with/without surgery in LECSG. All patients were pathologically diagnosed by core needle aspiration or surgery. All patients had definite or suspicious residual disease and received dose of RT ≥ 66 Gy. They were all re-staged by the 8th American Joint Committee on Cancer (AJCC) criteria. The patients were staged by pathological  if they had surgery, otherwise by image combined with clinical features.It was difficult to make an accurate diagnosis of LECSG before treatment because there were no typical symptoms or examinations. Initial assessment consisted of medical history and physical examination, enhanced MRI/CT of the salivary gland and/or cervical, ultrasound or lesion site fine needle aspiration biopsy (FNAB). Other assessment included positron emission tomography-CT (PET-CT), or replaced by chest CT, abdominal ultrasound/CT and bone emission CT. To make a correct diagnosis and exclusion of NPC, physical examination of nasopharyngeal combined with nasopharyngoscopy and imaging  examinations was conducted before RT.Before RT, all patients were therapied by core needle aspiration, salivary gland disease biopsy, resection of the primary location alone or resection of both the primary location and cervical lymph nodes. 3D conformal RT (3D-CRT) or intensity-modulated RT (IMRT) was administrated in our hospital for all patients. Platinum-based chemotherapy was used for patients with high risk factors.The gross tumor volume (GTV) included the region of positive margin and residual salivary tumor/cervical lymph nodes, confirmed by physical examination, enhanced MRI/CT and/or PET-CT. The clinical target volume (CTV) was considered as subclinical lesions that included the whole involved ipsilateral salivary gland and corresponding lymph node drainage area. The planning target volume (PTV) would consist of the GTV/CTV with a 3–5 mm margin. The prescribed dose given to P-GTV  and/or P-GTV-LN  were 66 to 70.4 Gy. The PTV covering the high-risk CTV was 57–60 Gy. The PTV covering the low-risk CTV was 50-54.4 Gy.Radiotherapy-related toxicities were assessed according to the Radiation Therapy Oncology Group (RTOG) and determined by a retrospective chart review. Patients were assessed weekly during RT to monitor the treatment response and toxicity. After treatment completion, follow-ups were repeated every 3 months for the first 2 years, every 6 months from the third through the fifth year and annually thereafter. Routine follow-up included medical history and physical examination. Enhanced MRI/CT or ultrasonography of the primary site was performed in the routine follow-up. Chest CT and ultrasonography of the abdomen were conducted once yearly. Bone emission CT was performed when there were clinical indications.SPSS 23.0  was used for statistical analysis in this study. The factors of categorical variables were compared with the chi-square test or Fisher exact test. Overall survival (OS) was calculated from the date of diagnosis to the date of death for any cause or last follow-up. Progression-free survival (PFS) was calculated from the date of diagnosis to the date of tumor progression, death for any cause or last follow-up. Locoregional progression-free survival (LRPFS) was calculated from the date of diagnosis to the date of locoregional failure or the date of death or last follow-up. Distance metastasis-free survival (DMFS) was calculated from the date of diagnosis to the date of metastasis or the date of death or last follow-up. The OS, PFS, LRPFS and DMFS were calculated by the Kaplan–Meier method. Log-rank test was used to examine the differences between groups. A 2-sided P < 0.05 was considered statistically significant.The method descriptions could be referred to our previously published article From Jan 2008 to December 2020, 56 patients pathologically diagnosed with LECSG by core needle aspiration or surgery were enrolled in this study. All patients had definite or suspicious residual disease and received dose of RT ≥ 66 Gy. The median dose of PTV-G was 66 Gy . FNAB was performed preoperatively in 17 patients, and 15 of 17 patients (92.9%) presented with a malignant tumor. They were all re-staged by the 8th AJCC criteria and one patient was M1 (multiple bone metastases) at the initial diagnosis. Platinum-based chemotherapy was used for 20 patients with high risk factors. 13 patients received concurrent chemotherapy and 13 patients received induction or adjuvant chemotherapy. The characteristics of patients and detailed features of treatment were shown in Table With a median follow-up of 60 months (range: 8 to 151 months), 52 of 56 patients (92.9%) were alive, 2 (3.6%) developed locoregional failure, 4 (7.1%) experienced distant metastasis, 7 (12.5%) developed tumor progression or death and 1 (1.8%) had the second primary tumor. At the last follow-up visit, a total of 4 patients died: 3 patients died of distant metastasis and 1 of other disease. For the whole cohort, the 1-, 3-, 5-, and 10-year PFS rates were 94.6%, 90.7%, 84.7% and 84.7%, respectively; LRPFS rates were 98.2%, 96.2%. 87.4% and 87.4%, respectively; DMFS rates were 94.6%, 92.6%, 86.7% and 86.7%, respectively; and OS rates were 98.2%, 98.2%, 92.4% and 89.0%, respectively  presented with stage IV. 5 (71.4%) patients received chemotherapy, consisting of 3 with induction chemotherapy (IC) and 4 with concurrent chemotherapy (CCRT). The median follow-up was 60 months (range: 11 to 151 months), all patients were alive and only one patient experienced failure of distant metastasis four months after RT.2 copy/mL. Examination of the nasopharynx found no lesions. Based on the clinical, radiological and pathological, a final diagnosis  was made. The patient was treated with IC and CCRT. The IC regimen was a combination of 75 mg/m2 docetaxel and 75 mg/m2 nedaplatin q3w. CCRT consisted of nedaplatin 75 mg/m2 q3w. The radiation dose schedule was as follows: the planning gross tumor volume (P-GTV and P-GTV-LN) was prescribed a dose of 70.4 Gy; PCTV1, 57.6 Gy; and PCTV2, 54.4 Gy. A partial response (PR) was achieved after IC and complete response (CR) was achieved after CCRT. No serious adverse events were found. There was no evidence of recurrence or metastasis after 40 months  was positive in the tumor cells. The quantification of EBV-DNA load was 6.17*10Impact of prognostic factors on PFS, LRPFS, DMFS and OS were evaluated using univariate analyse, including age at diagnosis, gender, primary site, T stage, maximum diameter of primary lesion, N stage and number of positive lymph nodes. Table  Age , 15 (26.8%) and 5 (8.9%) had grade 1, 2 and 3 mucositis, respectively. Most skin reactions were grades 0 to 2. A total of 5 patients suffered grade 3 skin toxicity. Overall, most late injuries were assessed as grades 0 to 1. The most common late toxicity was neck fibrosis, which occurred in five patients who underwent both radical neck dissection and whole neck irradiation. One patient had the second primary tumor, of whom was lymphoma.We retrospectively evaluated the feasibility and efficacy of radical RT with/without surgery in LECSG. Although surgery has been considered the standard treatment of LECSG, it is often difficult to remove the tumor completely of LECSG due to the facial nerves protection. Owing to the histologically indistinguishable from NPC, the relationship with EBV and the predilection of both cancers for certain regions and populations, we assume that LECSG is sensitivity to RT as NPC. Meantime, to the patients’ quality of life, RT is supposed to be a vital treatment to the patients’ quality of life.In our study, all patients had definite or suspicious residual disease and received dose of RT ≥ 66 Gy. For the whole cohort, the 1-, 3-, 5-, and 10-year PFS rates were 94.6%, 90.7%, 84.7% and 84.7%, respectively; LRPFS rates were 98.2%, 96.2%. 87.4% and 87.4%, respectively; DMFS rates were 94.6%, 92.6%, 86.7% and 86.7%, respectively; and OS rates were 98.2%, 98.2%, 92.4% and 89.0%, respectively. The results of 3-year LRPFS and OS were higher than the rates reported in the treatment of definitive surgical resection and postoperative RT. The rates of 3-year locoregional control (LRC) and OS in previous studies  in FudanThe treatment failure of our research was that only 2 (3.6%) patients developed locoregional failure and no patient died of it. The critical factor might be that the dose of RT was sufficient and all patients received dose of RT ≥ 66 Gy. RT is one of the most important means to improve locoregional control and protect the organ at risk of LECSG, as the similar conclusion was found in Zhan’s study . Wang anIn our study, the results of univariate analysis showed that compared with N stage, the number of positive lymph nodes (2 positive lymph nodes) was better prognostic predictor especially in PFS. Though the limitation of our study was a retrospective and relatively small sample study, optimizing the tumor-node-metastasis (TNM) staging system of salivary gland might be necessary. In addition, there was lack of information on the EBV status in our cohort. A high prevalence of EBV infection may contribute to the development of LECSG. Determination of EBV status is valuable in diagnosing LECSG and judging the effect of treatment –8. The pRadical RT with/without surgery in LECSG for definite or suspicious residual disease is feasibility and efficacy. The dose of all patients received RT ≥ 66 Gy. The locoregional failure was low and no patient died of it. The results of univariate analysis showed that compared with N stage, the number of positive lymph nodes (2 positive lymph nodes) was better prognostic predictor especially in PFS. Most toxicities of RT were mild due to the target volume involved ipsilateral area. Limitations of the study such as retrospective data, long time span and single center should be considered in the future research.


Self-declared awareness of gonorrhea was associated with age (p = 0.001), education (p = 0.031), and ethnicity/race (p = 0.002), with older, more educated, and Black/African Americans having higher awareness. Males (p = 0.001) and those with more sexual partners (p < 0.001) were more likely to enroll in a gonorrhea vaccine trial. Educational intervention had a significant (p < 0.001) impact on hesitancy. Improvement in willingness to enroll in a gonorrhea vaccine trial was greatest in those initially marginally hesitant and lowest in those initially strongly hesitant. Basic educational intervention has the potential to improve recruitment into gonorrhea vaccine trials.Globally, >80 million new gonorrhea infections occur annually. Here, we assessed barriers to and influences on participation in a gonorrhea clinical trial and the impact of educational intervention. The survey was fielded in the US in March 2022. Higher enrollment of Black/African Americans and younger individuals than represented in the US demographic distribution reflected the higher incidence of gonorrhea in these groups. Behavioral characteristics and baseline attitudes toward vaccination were collected. Participants were probed on their knowledge of and likelihood to enroll in general and gonorrhea vaccine trials. Participants hesitant to enroll in a gonorrhea vaccine trial were given nine bullets of basic facts about the disease and asked again to rank their likelihood to enroll. Overall, 450 individuals completed the survey. Fewer participants were willing (quite/very likely) to join a gonorrhea versus a general vaccine trial (38.2% [172/450] vs. 57.8% [260/450]). The likelihood to enroll in any vaccine trial or a gonorrhea vaccine trial was greater with higher self-declared knowledge (Spearman’s ρ = 0.277 [ Neisseria gonorrhoeae, the causative agent of gonorrhea, continues to evolve and acquire resistance to multiple classes of antibiotics, leading to reduced treatment options ) of the eight STDs presented to them. HIV infection was the most commonly known (92.9% [418/450]), followed by genital herpes (85.8% [386/450]) and gonorrhea (84% [376/450]). Overall, awareness of each disease was generally high (ranging from 79.8% [359/450] to 92.9% [418/450]).p = 0.001, p = 0.031, and p = 0.002, respectively; p > 0.05).Age, education, and ethnicity/race were statistically significantly associated with gonorrhea knowledge .Baseline sentiments about general vaccination did not affect awareness of gonorrhea: 84.0% (294/350) of those open to being vaccinated indicated that they had heard of gonorrhea, and 82.0% (82/100) who were not open to vaccination were also aware of gonorrhea . Self-declared knowledge of gonorrhea correlated with willingness to enroll . Black/African American participants had similar overall hesitancy scores  to enroll in a gonorrhea vaccine trial as White participants . Conversely, those who were open to vaccination were approximately twice as likely to enroll in a gonorrhea trial than those who were not open to future vaccination .In contrast to a general vaccine clinical trial, the decision to take part in a gonorrhea vaccine trial did not appear to be affected by whether the participants had had a previous vaccination  did not change their opinion after being shown the educational intervention; 11.0% (n = 13) became more negative (quite or strongly hesitant), and 32.2% (n = 38) became positive (quite likely or very likely to participate).Overall, 278/450 participants indicated that they had some degree of hesitancy  toward enrolling in a gonorrhea vaccine trial. After educational intervention, 32.7% (91/278) of these initially hesitant participants became less hesitant  of MSM versus 32.3% (85/263) of others; 35.0% (42/120) of men versus 30.3% (47/155) of women; 39.4% (50/127) of younger participants versus 29.3% (29/99) and 23.1% (12/52) of older age groups; and 42.2% (27/64) of participants with two or more sexual partners within the previous 6 months versus 29.7% (63/212) with one or none. Conversely, the impact of the educational intervention on Black/African American participants was lower than that on White participants (23.4% [18/77] vs. 39.0% [60/154]). There was a greater impact on hesitancy by the educational intervention among those who were “open” to vaccination at the start of the survey (38.3% [77/201] vs. 18.2% [14/77] for those “not open” to vaccination).p < 0.001). Overall, 59.7% (92/154) of individuals who were very or quite hesitant to take part in a gonorrhea trial expressed anxiety about being judged by society. This compares with 34.5% (29/72) of those who were quite or very hesitant to take part in a general clinical trial.The top trusted sources of healthcare information for all participants were their doctors (76.0% [342/450]), their families (42.4% [191/450]), and healthcare websites (40.9% [184/450]). Only 20.2% [91/450] of participants identified pharmaceutical companies as a trusted source. Social media sources (8.7% [39/450]), community religious/faith leaders (6.4% [29/450]), and members of the church/mosque (4.2% [19/450]) ranked relatively low. Black/African Americans had a lower trust than White participants in their doctor (73.2% [104/142] vs. 78.0% [184/236]) but a higher trust in their family members (50.0% [71/142] vs. 40.7% [96/236]). Overall, the most useful ways to receive information were through the research team and other healthcare professionals, with conversations  marginally preferred over emails  and an informative website about the study (mean rank: 3.77). Of those who were initially strongly or quite hesitant to enroll in any clinical trial, 45.5% (30/66) indicated that information “on how the vaccine can help society” would be essential for decision-making versus 58.5% of those who were quite or very likely to take part (152/260). On the other hand, 56.1% (37/66) and 55.4% (144/260) of the respective groups identified information on “how the vaccine may help me personally” as essential. Those who were open to vaccination had greater trust in the information they received from any source . This difference was highest for “government announcements” and “a conversation with the research team”  of hesitancy to enroll in a gonorrhea clinical trial mistrusted pharmaceutical companies (70.0% [35/50] vs. 51.9% [40/77]) and had concerns about mistreatment and misuse of personal information (70.0% [35/50] vs. 59.7% [46/77]).Of the 61.6% (277/450) of survey participants who had “definitely heard” of gonorrhea and indicated that they knew at least something about the disease, the school/college nurse (34.7% [96/277]) was the most frequently selected source of information, followed by an official medical website (27.4% [76/277]), and then a health information leaflet, brochure, or campaign (26.7% [74/277]). Family, friends, and partners (range 9.0 [25/277]–13.0% [36/277]) were less frequently identified as sources of information about gonorrhea.Gonorrhea is a major public health priority , for whiThe finding that educational intervention had the greatest impact on those who were marginally hesitant and the least impact on those who were strongly hesitant is perhaps not surprising when considering the higher level of mistrust driving greater hesitancy . HoweverAs shown here, the relationship between awareness and willingness to participate in clinical research is complex. Participants with higher levels of education had a higher awareness of clinical research and gonorrhea. However, educational levels statistically significantly correlated only with the willingness to take part in a general vaccine trial but not a gonorrhea clinical trial. Perceivably, some participants with greater levels of gonorrhea health literacy realized that they were at lower risk, and therefore they were less likely to enroll. Nonetheless, a major challenge is that both health literacy and willingness to participate in clinical research are partly driven by socioeconomic status rather than disease risk . VariousIn the US, Black/African Americans have both lower education levels (27.8% vs. 37.5% of the respective ≥25-year-old populations had at least a bachelor’s degree ) and a hA limitation of this survey is that educational intervention was applied only to participants who showed some degree of hesitancy. It cannot be ruled out that for some participants, the improvement in willingness to enroll in a gonorrhea trial was due to chance, irrespective of the educational intervention—a consequence of regression to the mean. This appears to be a contributory factor, as a proportion of those who were borderline hesitant  increased hesitancy after educational intervention, although there was a >3-fold greater shift toward reduced hesitancy in this group after the intervention. The relatively limited sample size of 450 participants meant that only one educational intervention could be assessed. The information was therefore designed to be short and easily digestible, and, aside from informing that gonorrhea is transmitted through unprotected sex, it did not explicitly discuss the demographic and other baseline considerations that lead to higher risk. It should also be noted that, while hypothetical willingness has been shown to be statistically associated with actual enrollment, not all individuals who indicate a willingness to enroll would necessarily do so .Statistical analysis on the effectiveness of the educational intervention on subsets, including those at higher risk, was descriptive in nature due to the limited numbers of participants in these subsets and challenges with multiplicity. The influence of social determinants of health (SDOH) was not investigated for the same reason. Nonetheless, a more profound appreciation of the influence of SDOH on willingness to engage in clinical research would enable more effective content for communicational intervention.Black/African Americans were over-represented versus the US population (32% vs. 14% of the US population), and White participants were under-represented (52% vs. 76% of the US population) , to reflTo our knowledge, this is the first quantitative survey to investigate the relationship between risk, knowledge, and willingness to enroll in a gonorrhea vaccine study. Educational intervention reduced the degree of hesitancy in almost a third of those initially unwilling to enroll in a gonorrhea trial. Strong baseline sentiments, personal perceptions of risk, and attitudes against vaccination may have diluted the impact of the intervention. Nevertheless, a basic educational intervention, delivered through trusted healthcare professionals to high-risk communities, has the potential to significantly improve the recruitment of at-risk individuals into vaccine clinical trials for STDs.


Mycobacterium tuberculosis (MTB). The central nervous system is involved in about 1%-2% of all current tuberculosis (TB) cases and about 7%-8% of all EPTB. if not treated early, TBM leads to a high rate of neurological sequelae and mortality.Introduction: Tuberculous meningitis (TBM) is a manifestation of extrapulmonary tuberculosis (EPTB) caused by Objective: This study aimed to assess the diagnostic performance of the GeneXpert MTB/rifampicin (RIF) assay in patients with TBM.Methods: A total of 100 suspected TBM cases were enrolled from various departments at tertiary care hospital, Bhopal, Madhya Pradesh, India, and classified as definite, possible, or probable TBM. The clinical samples were tested for microbiological and other cerebrospinal fluid (CSF) testing.Results: Out of 100 cases, 14 (14%) were classified as definite TBM, 15 (15%) were having probable TBM, and 71 (71%) were having possible TBM. Out of a total of 100 participants, all were negative for acid-fast bacilli (AFB) staining. Of the 100 cases, 11 (11%) were positive by mycobacterium growth indicator tube (MGIT) culture, of which only four (36.36%) were positive by GeneXpert MTB/RIF. GeneXpert MTB/RIF detected three (3%) cases that were negative by MGIT culture. Ten (90.9%) of the 11 MGIT-positive culture isolates were found to be RIF sensitive while one (9.1%) was found to be RIF resistant. Three cases tested positive/sensitive by the GeneXpert MTB/RIF but negative by MGIT culture. Six (85%) of the seven GeneXpert MTB/RIF positive cases were RIF sensitive while one (15%) was RIF resistant. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were 36.36%  (10.93% to 69.21%)), 96.63% (95% CI (90.46% to 99.30%)), 57.14% (95% CI (25.50% to 83.85%)), 92.47% (95% CI (88.70% to 95.06%)) and 90% (95% CI (82.38% to 95.10%)) for GeneXpert MTB/RIF assay, compared with MGIT culture as the reference standard.Conclusion: Our study found that the sensitivity is lower when compared to culture, so using GeneXpert MTB/RIF alone is not recommended. Overall performance of GeneXpert MTB/RIF assay is noteworthy. The GeneXpert MTB/RIF assay is a potentially accepted test for obtaining an earlier diagnosis, and if it tested positive, the treatment should begin immediately. However, culture must be performed in GeneXpert MTB/RIF negative cases. Mycobacterium tuberculosis (MTB) [Tuberculous meningitis (TBM) is a manifestation of extrapulmonary tuberculosis (EPTB) caused by is (MTB) . The cenis (MTB) ,3. TBM lis (MTB) .The exact prevalence of TBM in India is unknown, but according to India's official guidelines for the treatment of EPTB, TBM may be present in 1% of all TB cases . TBM is Laboratory diagnostic procedures are primarily culture-dependent (using liquid and/or solid culture media). Culture takes several weeks to yield observable bacterial replication, and the sensitivity is low, around 40%-50% ,8. AlthoChanges in TBM diagnosis have occurred over the last few decades. For the rapid onset of TB, genotypic methods have come into play. Genotypic methods are faster and have higher sensitivity and specificity. The GeneXpert MTB/RIF assay  is an automated closed-cartridge system for detecting MTB and rifampicin (RIF) resistance in less than two hours . It was This cross-sectional study was conducted at the Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India, from November 2020 to April 2022. Ethical clearance was obtained from the Institutional Human Ethics Committee-Post Graduate Research (IHEC-PGR) of the AIIMS, Bhopal, Madhya Pradesh, India . The sample size of this study was 100 which was determined as the number of samples required for detecting an estimated prevalence of TBM cases with a relative precision of 5% and 5% of α error and 95% of CI.All the suspected TBM cases presented at AIIMS, Bhopal, Madhya Pradesh, India, were included in the study. Patients who were not willing for the consent were excluded from the study. A total of 100 TBM-suspected cases in the age range 0-80 years were enrolled from the pediatrics, general medicine, and neurology departments of AIIMS, Bhopal. All demographic, clinical, and radiological details have been filled in the request form for all the suspected cases of TBM. In this study, we used Lancet Consensus Case Definition Criteria as per Marais et al. to categorize the TBM cases into three categories . (i) DefCSF samples were collected during lumbar puncture and a volume of 2-6 mL CSF sample was collected into sterile plastic containers with leak-proof screw caps. CSF was centrifuged at 3,000-3,500g for 15-20 minutes, and re-suspended sediments were used for smear preparation, MGIT inoculation, and GeneXpert MTB/RIF assay. The biosafety precautions were taken while handling the samples.Ziehl Neelsen (ZN) stainingThree drops of the specimen were put on the slide with a pipette. The smear was heat fixed and stained with ZN staining method. Stained smears were examined using a bright field microscope with a 100x oil immersion field. In positive smears, MTB appeared straight/slightly curved, long slender, beaded red-colored, uniformly stained AFB. For labeling the smear as negative, a minimum of 100x oil immersion fields were observed .Liquid culture using MGIT 960 TB systemFirstly, 800 µL volume of the antibiotic mixture of Polymyxin-B, Amphotericin-B, Nalidixic acid, Trimethoprim, Azlocillin (PANTA), and growth supplement solution was added to each MGIT tube, followed by 500 µL of CSF sample. After scanning the MGIT tube barcode, all inoculated tubes were loaded into the automated MGIT-960 system in the slot assigned by the instrument. All the positive flagged tubes were taken for further processing and all the negative flagged tubes were removed after the completion of 42 days of incubation. ZN staining was performed on all the flagged positive tubes. All the smears positive for AFB were further confirmed by MPT64 antigen card test as per the manufacturer’s instructions.Confirmation of MTB by rapid MPT64 antigen card testA total of 100 µL of culture broth was added to the well of the Ag MPT64 TB rapid kit cassette. Inoculated immunochromatographic cassettes (ICT) were kept at room temperature for 20 minutes in the Class II biosafety cabinet before being examined for the presence of control and test bands. The band in the “C” region confirmed test validity. An additional band in the “T” region was interpreted as positive for MPT64 Ag. Only one band in the “C” region and no band in the “T” region were considered negative for MPT 64 antigen. No band in the “C” region was interpreted as an invalid test.GeneXpert MTB/RIF assayA volume of 2 mL of sample buffer reagent was added to 1 mL of CSF centrifuged sediment, mixed well, and incubated for 15 min at room temperature. Then 2 mL of the mixture was transferred to the sample chamber in the cartridge. The cartridge was loaded in the GeneXpert instrument, and the results were obtained after about two hours. For MTB, the results were either “MTB detected” or “MTB not detected.” RIF drug results were reported as susceptible, resistant, or indeterminate. The results were classified as high, medium, low, or very low based on the cycle threshold (Ct) value of the MTB target DNA.Drug susceptibility testing (DST) for RIF by MGITFor MGIT-positive culture isolates, a drug susceptibility test for RIF was performed as per the manufacturer's instructions. Susceptibility testing was performed using a 1% proportional method and a drug concentration of 1.0 μg/mL . The BACOther investigationsAll patients underwent routine tests for TBM such as CSF cell count and radiological examination.Data collection and statistical analysisThroughout the study, all data were collected in the request case report form with a written consent form. The Excel sheet contained all of the information, including the demographic profile, clinical and radiological findings, and laboratory and CSF findings. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy with a 95% confidence interval (CI) of the GeneXpert MTB/RIF assay were calculated in comparison to MGIT culture.Over an 18-month period, 100 patients with suspected TBM presented to AIIMS, Bhopal (Madhya Pradesh), India. In correlation between Lancet Consensus Criteria for TBM and clinical parameters, 14 (14%) of the 100 cases were classified as definite TBM, 15 (15%) were having probable TBM and 71 (71%) were having possible TBM.The average age of the definite TBM cases was 31.87 ± 20.22, probable cases were 21.97 ± 12.07 and that of the possible cases was 29.83 ± 22.08. Patients with definite and probable TBM were more likely to be female, whereas men were more likely to have possible TBM. A total of 31 patients were in the pediatric age group. Out of which two had definite TBM, 23 had possible TBM, and six had probable TBM. Fever was the most prominent clinical feature in 14 (100.0%) of the definite, 14 (93.3%) of the probable, and 71 (100.0%) of the possible TBM cases, followed by weight loss in 12 (85.7%) of the definite, 10 (66.7%) of the probable, 53 (74.6%) of the possible TBM cases and loss of appetite in 12 (85.7%) of the definite, 10 (66.7%) of the probable and 52 (73.2%) of the possible cases. As shown in Table The microbiological characteristics of 100 TBM suspected cases by ZN staining, MGIT culture, GeneXpert MTB/RIF and MGIT DST for RIF results summarized were in Table The sensitivity, specificity, PPV, NPV and diagnostic accuracy for GeneXpert MTB/RIF assay was 36.36% (95% CI (10.93% to 69.21%)), 96.63% (95% CI (90.46% to 99.30%)), 57.14% (95% CI (25.50% to 83.85%)), 92.47% (95% CI (88.70% to 95.06%)), and 90% (95% CI (82.38% to 95.10%)) compared with MGIT culture as the reference standard. The results were summarized in Table TB is the world’s most dreadful infectious disease with high morbidity and mortality among people . TBM amoAccording to the Lancet Consensus Criteria by Marais et al., 14 (14%) of the 100 recruited cases were definite, 15 (15%) were probable, and 71 (71%) were possible TBM cases in this study. In clinical research, Lancet Consensus Criteria comes up with strong and practical use of clinical case definition in 2010 .All of the CSF samples in this study tested negative for direct ZN staining. The paucibacillary nature of the bacilli in the CSF samples could be one reason. Previous studies showed a low detection rate of 0%-20% for MTB in CSF specimens . The posCulture methods are time-consuming and have a sensitivity of around 40%-50% . BecauseThe possible reason for the low sensitivity of GeneXpert assay being a molecular test is low genetic material due to less number of bacilli in the sample . AnotherThe specificity of the GeneXpert MTB/RIF assay was 96.63% (95% CI (90.46% to 99.30%)) in this study. The PPV was 57.14% (95% CI (25.50% to 83.85%)), NPV was 92.47% (95% CI (88.70% to 95.06%)), and the diagnostic accuracy was 90% (95% CI (82.38% to 95.10%)). A study by Rufai et al., (2017) observed 55.1%  sensitivity and 94.8%  specificity of GeneXpert MTB/RIF assay in comparison to MGIT culture . Vadvai Seven cases were negative by GeneXpert MTB/RIF assay and direct ZN staining, but positive by MGIT 960 culture system. The very low bacillary load in the CSF sample could be the cause. Previous research has found that the GeneXpert MTB/RIF assay has a low NPV. Therefore, it is recommended by WHO to do further diagnostic test in GeneXpert MTB/RIF negative suspected TBM patients . WHO recThe study's limitations included the use of conventional ZN staining rather than fluorescent staining because the latter has higher sensitivity and specificity, the use of only one drug in MGIT DST, and the inclusion of patients on anti-tubercular drugs.Our study found that the sensitivity of GeneXpert MTB/RIF assay is lower when compared to culture, so using this assay alone is not recommended. The overall performance of GeneXpert MTB/RIF assay is noteworthy. The assay has a median time to results of less than two hours compared to MGIT culture's three to four weeks. In cases where the GeneXpert MTB/RIF assay is negative, culture must still be performed. The GeneXpert MTB/RIF assay is a potentially accepted test for making an earlier diagnosis, and treatment should start right once it detects MTB.