Background and Objectives: Trauma coagulopathy begins at the moment of trauma. This study investigated whether coagulopathy upon arrival in the emergency room (ER) is correlated with increased hemotransfusion requirement, more hemodynamic instability, more severe anatomical damage, a greater need for hospitalization, and hospitalization in the intensive care unit (ICU). We also analyzed whether trauma coagulopathy is correlated with unfavorable indices, such as acidemia, lactate increase, and base excess (BE) increase. Material and Methods: We conducted a prospective, monocentric, observational study of all patients (n = 503) referred to the Department of Emergency and Acceptance, IRCCS Fondazione Policlinico San Matteo, Pavia, for major trauma from 1 January 2018 to 30 January 2019. Results: Of the 503 patients, 204 had trauma coagulopathy (group 1), whereas 299 patients (group 2) did not. Group 1 had a higher hemotransfusion rate than group 2. In group 1, 15% of patients showed hemodynamic instability compared with only 8% of group 2. The shock index (SI) distribution was worse in group 1 than in group 2. Group 1 was more often hypotensive, tachycardic, and with low oxygen saturation, and had a more severe injury severity score than group 2. In addition, 47% of group 1 had three or more body districts involved compared with 23% of group 2. The hospitalization rate was higher in group 1 than in group 2 (76% vs. 58%). The length of hospitalization was >10 days for 45% of group 1 compared with 28% of group 2. The hospitalization rate in the ICU was higher in group 1 than in group 2 (22% vs. 14.8%). The average duration of ICU hospitalization was longer in group 1 than in group 2 (12.5 vs. 9.78 days). Mortality was higher in group 1 than in group 2 (3.92% vs. 0.98%). Group 1 more often had acidemia and high lactates than group 2. Group 1 also more often had BE <−6. Conclusions: Trauma coagulopathy patients, upon arrival in the ER, have greater hemotransfusion (p = 0.016) requirements and need hospitalization (p = 0.032) more frequently than patients without trauma coagulopathy. Trauma coagulopathy seems to be more present in patients with a higher injury severity score (ISS) (p = 0.000) and a greater number of anatomical districts involved (p = 0.000). Head trauma (p = 0.000) and abdominal trauma (p = 0.057) seem related to the development of trauma coagulopathy. Males seem more exposed than females in developing trauma coagulopathy (p = 0.018). Upon arrival in the ER, the presence of tachycardia or alteration of SI and its derivatives can allow early detection of patients with trauma coagulopathy. Every year, there are ~6 million deaths worldwide because of traumatic injuries ,2. AlthoMajor trauma (MT) refers to an event that results in a single injury or multiple injuries of such magnitude that it constitutes a quoad vitam or quoad valetitudinem danger to the patient. Conventionally, trauma is defined as severe when the patient’s injury severity score (ISS) is >15 . ISS calThe early acute coagulopathy associated with traumatic injury has recently been recognised as a multifactorial primary condition that results from a combination of bleeding-induced shock, tissue injury-related thrombin–thrombomodulin complex generation, and the activation of anticoagulant and fibrinolytic pathways ,30,31,32This study identified the correlation of trauma coagulopathy upon the patient’s arrival in the ER with hemotransfusion rate, mortality, or unfavorable outcomes. We also looked at whether there are factors associated with the development of trauma coagulopathy, such as more severe trauma (ISS), trauma involving multiple body districts, the trauma of some body districts in particular , or even a condition of acidemia already present upon arrival in the ER.Finally, we went to see if some vital parameters or indices from their derivatives can help to identify a possible trauma coagulopathy immediately upon entry into the ER.The present study was approved by the Internal Review Board of Fondazione IRCCS Policlinico San Matteo, Pavia, Italy .We conducted a prospective, monocentric, observational study of all patients referred to the Department of Emergency and Acceptance, IRCCS Fondazione Policlinico San Matteo, Pavia, for MT in 13 consecutive months (1 January 2018–30 January 2019). The primary focus was the feedback of trauma coagulopathy to arrival in the ER (expected 20%–25%). We evaluated the presence of trauma coagulopathy using traditional laboratory tests. Trauma coagulopathy patients were then recruited on the basis of changes in the international normalized ratio (INR) partial thromboplastin time (PTT), prothrombin time (PT), activated partial thromboplastin time (aPTT), or platelet count.The primary outcome was the correlation of trauma coagulopathy with the mortality rate. Secondary outcomes were the correlation of trauma coagulopathy with the hospitalization rate, intensive care unit (ICU) rate, hemotransfusion rate, massive blood transfusion rate, and need for surgery during hospitalization. We also analyzed the correlation of trauma coagulopathy with pH, base excess (BE), lactates, the shock index (SI), the ISS, the number of body districts involved, or the involvement of some body districts in particular . In addition, we investigated whether these indices, alone or in combination with each other or with trauma coagulopathy, are correlated with, as a primary endpoint, mortality and with, as secondary endpoints, the need for hemotransfusion or massive hemotransfusion, the hospitalization rate, the hospitalization rate in the ICU, and the need for surgery during hospitalization.n = 503). Of the 503 patients, 368 were men (73%) and 135 were women (27%).All patients referred to the ER and registered in the hospital’s MT registry were enrolled (Patients with two or more of the following criteria were categorized into the trauma coagulopathy group (group 1): aPTT > 32 s, PT < 70 s, INR > 1.3, PTT < 150 unit/microliter, fibrinogen > 200 mg/dL, and D-dimer > 500 ng/mL. Group 1 comprised 204 patients (164 men (80%) and 40 women (20%)).Group 2 (no trauma coagulopathy) comprised the remaining 299 patients (204 men (68%) and 95 women (32%)).Eligible patients were reported and then identified in the electronic database through diagnosis codes of discharge corresponding to “polytrauma” or as a code of acceptance corresponding to triage of “major trauma” The reason is that, in the emergency setting of this pathology, contextual data collection would have involved the risk of taking time away from care.The personal and clinical data of each patient were extracted using the PIESSE digital platform and medical records, when drafted. Each patient was individually examined to assess whether he or she could be included in the study. The data collected and reported by the emergency physician, clinical reports prepared by medical specialists, nursing diaries, and results and reports of laboratory and radiological examinations were included in the electronic folder. Demographics, causes, and dynamics of trauma; waiting time; process time; length of stay (LOS) in the DEA; time required to perform various instrumental examinations and reporting topics; vital parameters; means of arrival; entry and exit codes; and hematochemical and hemogasanalytic examinations were also recorded. In addition, the hospitalization rates, need for surgery during hospitalization, intensive care, and death rate were assessed. All performance folders were viewed and evaluated, and all computed tomography (CT) scans were thoroughly reviewed. All collected data were recorded using Microsoft Excel and subsequently used for statistical analysis. In total, we included 503 MT patients in this study.t-test and the Mann–Whitney nonparametric test. Associations between qualitative variables were evaluated using Fisher’s exact test. The correlation between continuous variables of interest was tested by calculating Spearman’s rank correlation coefficient (ρ).1 All tests were two-sided. p < 0.05 was considered statistically significant.Statistical analyses were performed using STATA statistical software version 14 . Continuous variables were described with mean and standard deviation; qualitative variables were expressed as counts and percentages. Comparisons between two groups were performed using Student’s The average age of the 503 patients was 43 years, and 49% had ISS >16; the average ISS was 17.88.n = 204) was 44 years, with the highest peak in the 55–65 year age group. There is a clear prevalence of males , which is more pronounced in group 1, with statistical significance, compared with group 2 (p = 0.018). In group 1, 91% of the patients had trauma according to dynamic criteria, 22% according to anatomical criteria, and 15% according to clinical criteria. In addition, 46% required complete activation of the trauma team, whereas 12% required only partial activation (p = 0.008). Descriptively, the average heart rate (HR) was 87 bpm; 12.9% of the patients had a high HR (>110 bpm). The average systolic blood pressure (SBP) was 129 mmHg; 10% of the patients had SBP >90 mmHg. The average differential pressure was 54 mmHg; 1.27% of the patients had a differential pressure of <20 mmHg. The average saturation was 97.88. In addition, 6% of the patients had a Glasgow coma score (GCS) of 14–15, 3.6% had GCS between 9 and 13, and 7.8% had GCS <9.The average age of group 1 . With regard to the districts involved, only head trauma (p = 0.000) and abdominal trauma (p = 0.057) are related with the development of the major trauma clot.With regard to the body districts affected, head trauma was the most frequent injury (59%), followed by chest trauma (48.5%), spine trauma (37.5%), lower limb trauma (27.5%), upper limb trauma (25%), pelvic trauma (18%), and abdominal trauma (17.5%). In 24% of the patients, only one body district was affected; 35%, two body districts; 20%, three body districts; 10%, four body districts; and 17%, more than four body districts. The number of districts involved is higher, and statistically significant, in group 1 , followed by head trauma (37%), spine trauma (32%), lower limb trauma (25%), upper limb trauma (24%), abdominal trauma (14%), and pelvic trauma (12%). In 42% of the patients, only one body district was affected; 29%, two body districts; 14%, three body districts; 5%, four body districts; and 4%, more than four body districts.p =0.028) (p = 0.016)   and tran= 0.016) In group 1, 15% of the patients showed hemodynamic instability compared with only 8% of the patients in group 2.p = 0.016). In addition, the modified SI was more frequently altered in group 1 than in group 2 . Group 1 also presented a more frequently altered age SI (>50) than group 2  (We considered SI <0.7 as indicative of the absence of shock (class I), SI between 0.7 and 1 as indicative of minor shock (class II), SI between 1 and 1.4 as indicative of moderate shock (class III), and SI >1.4 as indicative of severe shock (class IV). The SI distribution was worse in group 1 than in group 2. The layered SI was significantly higher in group 1 than in group 2 (= 0.075) .p = 0.051), tachycardic , and with low oxygen saturation  compared with group 2.Group 1 was more often hypotensive   .p = 0.000). In addition, 88.6% of group 1 had GCS of 14–15, 3.6% had GCS between 9 and 13, and 7.8% had GCS <9. In contrast, 95.9% of group 2 had GCS of 14–15, 1.6% had GCS between 9 and 13, and 2.5% had GCS <9.The number of body districts affected was higher in group 1 than in group 2: 47% of group 1 had three or more body districts involved compared with 23% of group 2 (p = 0.032). The length of hospitalization was >10 days for 45% of group 1 compared with 28% of group 2 (p = 0.245)  .p value). The average duration of ICU hospitalization was longer in group 1 than in group 2   .The need for surgery during hospitalization was comparable between both groups (19.8% vs. 17.2%) .p = 0.168).Mortality was higher in group 1 than in group 2 (3.92% vs. 0.98%). The figure does not reach statistical significance (p = 0.0142) and high lactates than group 2 . Group 1 also more often had BE <−6 than group 2   .Patients with trauma coagulopathy upon arrival in the ER have a significantly greater need for hemotransfusion than patients without trauma coagulopathy, which might be related to trauma coagulopathy itself. Several studies agree with this finding ,12. The It is also true, however, that trauma coagulopathy patients generally report higher severity of the trauma. We have verified that trauma coagulopathy patients have a significantly higher ISS than patients without trauma coagulopathy, as reported earlier ,12. The Instead, the cause of major trauma does not appear to play a real role in causing trauma coagulopathy.Unlike other pathologies ,45,46,47There are also no statistically significant differences in the outcomes between the two populations, which could probably be owing to low general intrahospital mortality. In this regard, studies have indicated a correlation of trauma coagulopathy with increased mortality , althougp = 0.016) and hospitalization (p = 0.032) more frequently. Trauma coagulopathy seems to be more present in patients with a higher ISS (p = 0.000) and a greater number of districts involved (p = 0.000). With regard to the corporate districts considered in its own right, it is evident as a role in the development of trauma coagulopathy can perhaps be assumed for head trauma (p = 0.000) and for abdominal trauma, which, in our study, almost achieves statistical significance (p = 0.057). Males seem more exposed than femines in developing trauma coagulopathy (p = 0.018). Upon arrival in the ER, the presence of tachycardia  or alteration of SI (p = 0.016), Modified Shock Index (MSI) (p = 0.009) and ageSI (p = 0.009) can allow early detection of patients with trauma coagulopathy.The study highlights how early analysis of the presence of trauma coagulopathy within a few minutes of arrival in the ER gives important indications of the patient’s outcome. In fact, patients who have early trauma coagulopathy need hemotransfusions (


Plasmodium falciparum drug resistance markers within an evolving efficacy of anti-malarial drugs in Cameroon from January 1998 to August 2020.Malaria remains highly endemic in Cameroon. The rapid emergence and spread of drug resistance was responsible for the change from monotherapies to artemisinin-based combinations. This systematic review and meta-analysis aimed to determine the prevalence and distribution of P. falciparum anti-malarial drug resistance genes . The heterogeneity of the included studies was evaluated using the Cochran’s Q and I2 statistics. The random effects model was used as standard in the determination of heterogeneity between studies.The PRISMA-P and PRISMA statements were adopted in the inclusion of studies on single nucleotide polymorphisms (SNPs) of Pfcrt 76 T (79.9%-43.0%), Pfmdr1 86Y (82.7%-30.5%), Pfdhfr 51I (72.2%-66.9%), Pfdhfr 59R (76.5%-67.8%), Pfdhfr 108 N (80.8%-67.6%). The only exception was Pfdhps 437G which increased over time  and Pfdhps 540E that remained largely unchanged . Exploring mutant haplotypes, the study observed a significant increase in the prevalence of Pfcrt CVIET mixed quintuple haplotype from 57.1% in 1998 to 57.9% in 2020 (P < 0.0001). In addition, within the same study period, there was no significant change in the triple Pfdhfr IRN mutant haplotype . The Pfk13 amino acid polymorphisms associated with artemisinin resistance were not detected.Out of the 902 records screened, 48 studies were included in this aggregated meta-analysis of molecular data. A total of 18,706 SNPs of the anti-malarial drug resistance genes were genotyped from 47,382 samples which yielded a pooled prevalence of 35.4% (95% CI 29.1–42.3%). Between 1998 and 2020, there was significant decline  in key mutants including P. falciparum gene mutations conferring resistance to 4-aminoquinolines and amino alcohols for a period over two decades. Resistance to artemisinins measured by the presence of SNPs in the Pfk13 gene does not seem to be a problem in Cameroon.This review reported an overall decline in the prevalence of Systematic review registration PROSPERO CRD42020162620 Plasmodium falciparum malaria in 2002 and later on amodiaquine (AQ) monotherapy/sulfadoxine-pyrimethamine between 2002 and 2004 , 42.3% (446/855) [95% CI 24.3–62.6%], 62.4% (1268/2088) [95% CI 44.7–77.4%], 71.7% (3114/4673) [95% CI 61.8–79.8%], 41.8% (348/926) [95% CI 30.3–54.2%] and 2.0% (83/5912) [95% CI 0.7–5.4%] respectively . Similarly, during the same study periods, the prevalence of the Pfmdr1 86Y mutant allele decreased significantly from 82.7% to 30.5% (P < 0.0001) with the exception observed between 2011 and 2016 when 90.6% was reported . The CVIET mutant haplotype declined from 57.1% in 1998–2004 to 0.0% in 2005–2010. The prevalence rate increased to 36.7% and 57.9% respectively in 2011–2016 and 2017–2020. Similarly, there was a significant increase in the prevalent rate of Pfcrt CVIET haplotype between 1998 and 2020 (P < 0.0001)  mutant alleles whereas, the Pfdhps  mutant alleles increased over the two time points  and 0.0% to 0.3% (P = 0.623), respectively, between 1998 and 2020. Conversely, a significant decrease in trend from 47.5% to 28.7% was reported for Pfdhfr-Pfdhps IRNG under the same period (P < 0.0001)  were mostly noticeable in Garoua, Yaoundé and Mutengene, respectively. The CIRN haplotype was highly prevalent in the Southern part when compared to the Northern part of Cameroon.The forest and Sudano-Sahelian zones constitute the major geo-ecological zones of Cameroon. The characteristics of these geo-ecological zones are reflected in the towns of Yaoundé, Mutengene and Garoua. Different studies were conducted in Yaoundé, Mutengene and Garoua from 2004–2006 in order to understand the evolutionary origins of the antifolate haplotypes , 86. TheGenerally, opposing trends were observed in the haplotypes SGK, AGK, AAK, SAK, CIRN, CNCS, CICN, and CNRN in malaria parasites isolated from Garoua, Yaoundé and Mutengene. Data is not available on these unique mixed haplotypes from other regions in Cameroon Fig. .Fig. 4PfPfcrt 76 T and Pfmdr1 86Y mutant alleles between 2008 and 2019 which were more pronounced between 2012 and 2016 for Pfmdr1 and between 2016 and 2019 for Pfcrt 76 T. The efficacy of AL showed a positive but non-significant correlation with Pfcrt 76 T mutant allele  while the efficacy of AL demonstrated a negative non-significant relationship with Pfmdr1 86Y mutant allele . However, there was a negative significant correlation between the efficacy of ASAQ and prevalence rates of Pfcrt 76 T mutant allele  and Pfmdr1 86Y mutant allele . Generally, the prevalence of Pfcrt 76 T and Pfmdr1 86Y mutant alleles were below the efficacy rates of ASAQ and AL  studies were used to derive the data on the efficacy (PCR-corrected cure rates) of AL and ASAQ –96. The Pfcrt 76 T  and Pfmdr1 86Y  mutants. The proportions of AL distributed from 2006 to 2017 were low when compared with ASAQ. The maximum proportion of AL deployed was 33.1% in 2011 and this corresponded with a prevalence of 55.5% and 46.4% for Pfcrt 76 T and Pfmdr1 86Y mutants respectively. The Pearson correlation coefficients revealed negative relationships between the ACTs and anti-malarial drug resistance markers [,  . Peak distributions for ASAQ were observed in 2010 (99.7%) and 2013 (86.5%) with corresponding prevalence of Pfdhfr IRN triple mutant haplotype. There was a negative correlation between proportion of SP deployed and prevalence of Pfdhfr IRN triple mutant haplotype .The proportion of SP deployed to the different Regions of Cameroon dropped from 93.4% in 2006 to 11.1% in 2017 which corresponded with the prevalence of 62.2% and 99.6% of Pfcrt K76T, Pfmdr1 N86Y, Pfdhfr IRN, and Pfdhfr-Pfdhps IRNG were above 40.0% with the exception of Pfk13. These analyses highlight the dominance of Pfcrt K76T, Pfmdr1 N86Y, Pfdhfr N51I, Pfdhfr C59R, Pfdhfr S108N, Pfdhps A437G and Pfk13 K189T mutations. The rates are high and further confirm that resistant parasites are still circulating in towns, such as Yaoundé, Garoua, Mutengene, and Buea. This is not surprising considering some of these towns  are located within the high malaria transmission stratum and are urban settings with high variability and intensity in the use of anti-malarial drugs with insufficient regulation. It is also around these areas that the first cases of resistance to chloroquine were reported in the 1980s and early 2000 that eventually spread to other Regions [This systematic review and meta-analysis showed the frequency and geographic distribution of anti-malarial drug resistance markers over a period of three decades in Cameroon. The present study showed that the pooled prevalence of all the amino acid changes from 1998 to 2020 was 35.4%. Subgroup analyses revealed that the aggregated prevalence of  Regions –100. ThePfcrt 76 T and Pfmdr1 86Y mutant alleles with chloroquine and amodiaquine resistance in vivo among uncomplicated falciparum malaria patients in different transmission settings [falciparum malaria in Cameroon. However, amodiaquine (AQ) continues to be used as a partner drug in the artesunate-amodiaquine (ASAQ) and sulfadoxine–pyrimethamine–amodiaquine (SPAQ) combinations. In 2004, ASAQ combination replaced AQ and SP for the treatment of uncomplicated falciparum malaria in the Southern Regions while SPAQ was introduced in 2016 as chemoprophylaxis in the context of seasonal malaria chemoprevention among children 3–59 months in the North and Far north Regions of Cameroon. The most common quintuple haplotypes identified in Pfcrt gene were CVMNK and CVIET. This concords with previously published studies in other regions [Pfcrt SVMNT haplotype with a prevalence of 4.4% [Previous studies have demonstrated the association of settings . These t regions , 102. It of 4.4%  and 56.9 of 4.4%  reportedPfmdr1 NFD haplotype [Pfmdr1 YYY haplotype was not documented. A number of studies carried out in malaria endemic areas have demonstrated an opposing effect in the selection of YYY for ASAQ and NFD for AL [Only two studies reported the triple aplotype , 57 whilD for AL , 103. ThD for AL .Pfcrt 76 T, Pfcrt CVMNK quintuple wild type haplotype, and Pfmdr1 86Y mutant parasites declined from 1998–2020. This is in agreement with previous studies carried out in other malaria endemic zones confirming the re-emergence of chloroquine sensitive parasites [P. falciparum malaria because this may lead to reintroduction of resistant parasites population.Trend analysis showed that arasites , 105. HoPfdhfr and Pfdhps genes conferring resistance to SP does not seem to threaten the continuous use of this drug in the future especially as there is need to scale-up deployment to pregnant women and young children as intermittent preventive treatment (IPTp and IPTi). This may also be applicable for children receiving SPAQ in the context of seasonal malaria chemoprevention in the Sahel regions of Northern Cameroon. The triple Pfdhfr IRN and quadruple Pfdhfr/Pfdhps IRNG mutant haplotypes were the most prevalent while quintuple Pfdhfr/Pfdhps IRNGE mutant haplotype was the least prevalent. There has been a gradual decline over the years in the prevalence of single antifolate gene polymorphisms associated with SP resistance in Cameroon with the exception of Pfdhps A437G and K540E. However, the rates of prevalence recorded are less than the 90% benchmark recommended by the WHO to ban the continuous use of SP. These findings corroborate with the high prevalence of Pfdhfr IRN and Pfdhfr/Pfdhps IRNG recorded in Bata District and Bioko Island, Equatorial Guinea [Pfdhfr/Pfdhps IRNGE mutant haplotype over the years, ascertaining the sudden emergence of the haplotype in Central Africa [Pfdhps haplotypes included SGK, AGK, SGE, AAK, and SAK. These haplotypes were extensively studied in isolates from different African countries including Cameroon by Pearce and colleagues, where they sought to investigate the evolutionary origin of the mutations flanking the Pfdhps gene [In Cameroon, sulfadoxine–pyrimethamine (SP) is still being deployed as intermittent preventive treatment for malaria in pregnancy (IPTp) with estimated coverage of about 32% in 2018 . The antl Guinea , 108. Thl Africa . Other uhps gene . The authps gene . The malPfdhps gene has been reported in Yaoundé [Pfdhfr/Pfdhps IRNGE mutant haplotype is strongly associated is SP resistance [A new mutation, I431V, recently identified in the  Yaoundé  and Mute Yaoundé  with pre Yaoundé , suggestsistance .Pfk13 propeller region, F446I, R539T, I543T, P574L and C580Y previously documented in the Greater Mekong sub-region which are associated with delayed parasite clearance following drug administration. Moreover, a negative or positive relationship was observed between the rate of efficacy of ASAQ/AL and the prevalence of key mutants (Pfcrt K76T and Pfmdr1 N86Y) that select for the partner drugs in ACT. These observations confirm the findings that AL and ASAQ exert opposing selective effects on single-nucleotide polymorphisms in Pfcrt and Pfmdr1 [There was the absence of key gene polymorphisms located in the d Pfmdr1 . HoweverIt has been shown that some individuals infected with drug resistant parasites are still able to clear the parasites when administered with non-ACT and ACT , 112. ThPfcrt 76T, Pfmdr1 86Y and Pfdhfr IRN). The proportion of drugs deployed may be used as a proxy for drug uptake. The decline in proportion of drugs deployed may be contributing to less drug pressure to circulating parasites. Increase in parasite fitness as a result of less drug pressure could be responsible for the decline in the prevalence of certain gene mutations associated with anti-malarial drug resistance. The two drugs, ASAQ and SP are still being subsidized by the Cameroon government. ASAQ is highly recommended for the treatment of uncomplicated falciparum malaria in children less than 5 years while SP used as a preventive treatment for malaria in pregnancy. The major challenge in the fight against drug resistance in Cameroon is the inability to effectively implement the legislation on the homologation and importation of unauthorized anti-malarial therapies and insufficient pharmacovigilance. In addition, there are still issues with substandard drugs and auto-medication.Furthermore, there was a negative correlation between the proportions of anti-malarial drugs  deployed to the different public and private health establishments in Cameroon and anti-malarial drug resistance markers  conferring resistance to 4-aminoquinolines, amino alcohols and pyrimethamine for a period over two decades pre and post adoption of ACT in Cameroon. The Pfcrt K76T and Pfmdr1 N86Y mutations still persist at moderate frequencies despite the withdrawal of chloroquine. Conversely, parasite resistance markers (Pfdhps A437G and Pfdhps K540E) linked to the sulpha drugs increased during the same study period. Resistance to artemisinins measured by the presence of SNPs in the Pfk13 gene does not seem to be a major problem in Cameroon. However, it is a wake-up call for policy makers to design and implement strategies for the regular monitoring of delayed parasite clearance after administration of artemisinin-based combination therapy. This will permit the early identification of factors driving the emergence and spread of anti-malarial drug resistance in Cameroon.This review reported a decline in the prevalence of single Additional file 1. Summary of the studies included in the systematic review and meta-analysis on anti-malarial drug resistance markers in Cameroon.Additional file 2. Methodological quality assessment of interventional studies.Additional file 3. Methodological quality assessment of cohort studies.Additional file 4. Methodological quality assessment of cross-sectional studies.Additional file 5. Methodological quality assessment of case reports.Additional file 6. Assessment of publication bias using funnel plot and Egger’s regression test.Additional file 7. Haplotype analyses of anti-malarial drug resistance mutant allele frequencies reported in Cameroon.


Pseudomonas aeruginosa. Quorum sensing inhibition (QSI) can disrupt this initial event of infection without killing bacterial cells, and thus QS inhibitors have been suggested as novel approaches for anti-infective therapy. Cinnamaldehyde (CAD) is a P. aeruginosa biofilm inhibitor and disperser of preformed biofilms. In this study, the combined use of CAD and colistin (COL) revealed a synergistic activity, but this was not the case for CAD combined with carbenicillin, tobramycin (TOB), or erythromycin in checkerboard assays for P. aeruginosa. CAD demonstrated QSI activity by repression of the expression of lasB, rhlA and pqsA in GFP reporter assays. Approximately 70% reduction in GFP production was observed with the highest CAD concentration tested in all the QS reporter strains. TOB also showed strong QSI when combined with CAD in reporter assays. Combination treatments revealed an additive activity of CAD with COL and TOB in biofilm inhibition  and preformed biofilm dispersion (~90% for both) when compared to the individual treatments. Therefore, a proposed method to mitigate P. aeruginosa infection is a combination therapy of CAD with COL or CAD with TOB as alternatives to current individual drug therapies.Quorum sensing (QS) plays an important role during infection for the opportunistic human pathogen  Pseudomonas aeruginosa, which is one of the most studied pathogens for antimicrobial research according to the Infectious Diseases Society of America (IDSA) [The 20th century is recognized as the “antibiotic era”, which started with the discovery of antibiotics to fight bacterial infections. However, this has been marred by the emergence of multidrug-resistant bacteria  which haa (IDSA) ,7.P. aeruginosa is an opportunistic pathogen that employs a number of different pathogenic traits  by means of a cell-to-cell communication system, termed quorum sensing (QS) [P. aeruginosa utilizes signaling molecules to coordinate the expression of virulence factors, such as elastase and rhamnolipids, as well as genes involved in biofilm formation. The QS system of P. aeruginosa is comprised of three hierarchically integrated QS systems, Las, Rhl and PQS, to control the expression of these virulence factors and biofilm genes that contribute to its pathogenicity [ing (QS) . P. aerugenicity . One emegenicity ,11. SincP. aeruginosa infections [P. aeruginosa biofilm resistance to antibiotics was previously reported by combining a QS inhibitor butanamide) and antibiotics  [P. aeruginosa infections [A number of publications have identified natural compounds and their synthetic analogues that interfere with QS and that have been shown to reduce virulence factor expression in vitro or virulence in vivo ,15,16,17ramycin) . Therefofections . Indeed,fections ,21,22. Tfections .P. aeruginosa [P. aeruginosa [P. fluorescence [las and rhl of P. aeruginosa. We demonstrated that CAD is capable of interfering in the P. aeruginosa Las, Rhl and PQS QS systems, while having no impact on bacterial growth. CAD combined with COL or tobramycin (TOB) inhibited biofilm formation and dispersed preformed biofilms more efficiently than individual treatments. We have also exploited a combined positive effect of CAD and TOB on P. aeruginosa QS systems.Cinnamaldehyde (CAD) is one of the primary phytoconstituents of cinnamon, with therapeutic potential to act as an antimicrobial agent against ruginosa ,25. In aruginosa . CAD alsruginosa , which lruginosa . A previrescence . In a rerescence , subinhiP. aeruginosa PAO1. The lasB::gfp (ASV) [rhlA::gfp (ASV) [pqsA::gfp (ASV) with GmR [P. aeruginosa PAO1 [Bacterial strains tagged with green fluorescent protein (GFP) were used in QS assays with fp (ASV) , rhlA::gfp (ASV)  and pqsAwith GmR  translatwith GmR  plus 7.4with GmR . AB miniwith GmR ,34. All osa PAO1  was growP. aeruginosa PAO1 adjusted to OD600 of 0.1. Two-fold serial dilutions with MHB achieved final concentrations of antibiotics : colistin (COL 27.2 to 0.2 µM), carbenicillin (CARB 1353.1 to 10.6 µM), tobramycin (TOB 13.3 to 0.1 µM), and erythromycin (ERY 1395.2 to 10.9 µM). The plate was incubated at 37 °C for 18–20 h with shaking at 180 rpm. The lowest concentration of antibiotics inhibiting growth as observed visually was recorded as the MIC for each antibiotic.MICs of four different classes of antibiotics (polypeptide (colistin), penicillin (carbenicillin), aminoglycoside (tobramycin), and macrolide (erythromycin)) were determined using the broth microdilution method . It was P. aeruginosa grown in MHB alone, and column 12 was used as sterility control with uninoculated MHB. After preparing each well with the appropriate dilutions of CAD and antibiotics, 100 µL of a P. aeruginosa PAO1 overnight MHB culture adjusted to OD600 of 0.1 was added to each well, and plates were incubated at 37 °C for 18-20 h with shaking at 180 rpm. The MIC for each compound was the lowest concentration that inhibited bacterial growth. The synergistic interactions were expressed as the fractional inhibitory concentration index (FICI), which is calculated as:The aim of the experiment was to evaluate the ability of antibiotics combined with CAD to inhibit the growth of P. aeruginosa PAO1. Four different classes of antibiotics were tested in combination with CAD . Interactions of each antibiotic with CAD was assessed using a checkerboard assay in 96-well microtiter plates  (12 columns (1 to 12) × 8 rows (A to H)). For the checkerboard assay, each antibiotic was added to individual wells in the microtiter plate at concentrations ranging from 16 to 0.13 MIC (concentrations decreasing from rows A to H) and CAD was added to individual wells at concentrations representing 16 to 0.13 MIC (concentrations decreasing from columns 1 to 8). Columns 9 and 10 were used for testing antibiotics and CAD alone, respectively. Column 11 was used as positive growth control with A synergistic effect was defined at an FICI of ≤ 0.5; an indifferent effect at an FICI between 0.5 and ≤ 4 and an antagonistic effect at an FICI > 4. Similar checkerboard assays were followed for all four antibiotics.P. aeruginosa PAO1 by serial passaging [600 of 0.1 was amended with different concentrations of CAD , 5.9 and 3 mM). Inoculum without CAD was used as a control. Following 24 h incubation at 37 °C with shaking at 180 rpm, the culture with visible growth in the highest CAD concentration was adjusted to an OD600 of 0.1 with MHB and used as the inoculum for the next round of growth with CAD at 23.6, 11.8, 5.9 and 3 mM and the same incubation conditions as before. This was repeated for 23 days. Growth curves of P. aeruginosa PAO1 treated with 5.9 mM CAD for 24 h were generated at days 1 and 23 to determine the effect of serial passage. The relative growth rate was calculated by dividing the generation time of the 5.9 mM grown culture at day 1 with the generation time of the 5.9 mM grown culture at day 23 [600 at the beginning of the time interval and b is the OD600 at the end of the time intervalCAD was tested for development of resistance in assaging . An over600 of 0.1 and added with 100 µL of CAD to achieve 3, 1.5 or 0.8 mM CAD in a 96-well plate. Similarly, 0.9 µM TOB alone and 0.9 µM TOB combined with 1.5 mM CAD were tested to determine their combined effect as QS inhibitors. Cultures with no CAD or antibiotics added were used as growth controls. A proprietary synthetic QS inhibitor named “A7” at 10 µM final concentration , Nanyang Technological University, Singapore) was used as a standard QS inhibitor. Plates were incubated at 37 °C with shaking at 180 rpm for 7 h. GFP fluorescence (excitation wavelength of 485–512 nm and emission wavelength of 520–530 nm) and bacterial cell density (OD600) measurements were collected at 1, 3, 5 and 7 h using a FLUOstar Omega microplate reader . The relative fluorescence units (RFU) were measured by dividing the fluorescence value by the corresponding OD600 value. p values were calculated using regression analyses in Excel and values ≤0.05 were statistically significant.Overnight cultures of the QS reporter strains were adjusted to an ODP. aeruginosa PAO1 adjusted to OD600 of 0.1 were amended with 100 µL of 1:1 ratios of CAD-COL or CAD-TOB (50 µL of CAD + 50 µL of COL or TOB) to achieve final concentrations of 1.5 mM (CAD), 0.9 µM (COL) and 0.9 µM (TOB). The peg lid was added, and plates were incubated at 37 °C with shaking at 180 rpm for 6 h, which was determined to yield the maximum biofilm on the pegs [570 of the CV in ethanol solution was determined using an Omega microplate reader. Biofilm formation inhibition of tested compounds was measured using Equation (5).The biofilm inhibitory activities of CAD and antibiotics were determined using Calgary biofilm devices (CBDs) consisting of a 96-well microtiter plate with 96 pegs on the lid . The sub-MICs of CAD and antibiotics used in this experiment were determined from the results of the checkerboard assay. Volumes of 100 µL of overnight MHB cultures of the pegs . Peg lidP. aeruginosa PAO1 formed 6 h biofilms on peg lids in CBDs as described above. The preformed biofilms were exposed to 1.5 mM CAD, 0.9 µM COL, 0.9 µM TOB, CAD-COL  or CAD-TOB  for 3 h at 37 °C with shaking at 180 rpm. Biofilms were washed and CV stained as above, and the biofilm dispersal activity was determined by Equation (6).MHB cultures of P. aeruginosa. MICs were then used to establish the checkerboard assay to study interactions between CAD and the antibiotics on P. aeruginosa growth  did not demonstrate a change in their CAD MIC. However, the resultant culture did not attain the same optical density at the stationary phase of growth , and thelasB) is a virulence factor that is controlled by LasR and is an indicator of LasR activity [P. aeruginosa PAO1-lasB-gfp strain was treated with different concentrations of CAD. At all tested concentrations of CAD, we observed a significant  reduction in RFU corresponding to GFP inhibition over 7 h, and there was a decrease in expression of fluorescence after 7 h (data not shown); this reduction was dose dependent (Elastase (encoded by activity . To testependent a. 600 (data not shown), suggesting that the effect on QS was not due to growth inhibition or toxicity of the CAD.After 7 h incubation, GFP inhibition at the lowest concentration of CAD tested (0.8 mM) was 32.5% of the non-CAD treated control culture. At 1.5 and 3 mM, the inhibition of GFP was 51.9% and 68.9% of the control culture, respectively d. The acP. aeruginosa PAO1-rhlA-gfp reporter strain . These results demonstrate that CAD and TOB in combination have an additive effect in disrupting Las, Rhl and PQS QS systems.CAD and TOB alone reduced LasR-mediated QS over time, as shown by the reduction in RFU a and calpression b,c. Treapression d. CAD anpression d. The copression d, respecp values of < 0.05) higher at 83.9% and 75.2%, respectively, compared to the untreated control . Therefore, to evaluate the combination of CAD and COL on biofilm formation, sub-MICs of 1.5 and 0.9 µM were used for CAD and COL, respectively. Similarly, CAD and TOB were evaluated at 1.5 and 0.9 µM , respectively. CAD showed 31.3% inhibition of biofilm formation, whereas COL and TOB showed approximately 35% inhibition of biofilm formation, as shown by the CV assay . When CA control . To determine if CAD or CAD in combination with COL or TOB can disperse preformed biofilms, biofilms formed on the pegs of a CBD were treated for 3 h and quantified by the CV assay. Treatment with CAD alone showed 43.1% dispersal of the preformed biofilm . p values of < 0.05) in biofilm dispersion as determined by ~90% reduction in preformed biofilm , but there was a substantial reduction (20–25%) in short-chain AHL when P. aeruginosa PUPa3 was grown in the presence of sub-MIC TOB [lasB, rhlA and pqsA in a LasR-independent manner. TOB alone reduced RhlR-controlled GFP expression by 32.2%, and the combination of CAD-TOB repressed GFP by 64.7%. Similar results were observed for LasB and PQS  was also able to disperse preformed biofilm up to 95%, confirmed by confocal laser scanning microscopy images [P. aeruginosa in a foreign body infection model, demonstrating that this approach can work in vivo [P. aeruginosa biofilms when a QS inhibitor and TOB were combined [P. aeruginosa biofilms [P. aeruginosa in attempts to avoid antimicrobial resistance. CAD in combination with COL or TOB dispersed preformed biofilms by up to ~90% compared to untreated biofilms, whereas COL and TOB alone only dispersed biofilms by 32.6% and 35.2%, respectively (P. aeruginosa more susceptible to antibiotics and showing synergistic effects on inhibiting biofilms and dispersing preformed biofilms.Given that biofilm formation in y images . As pred in vivo . Anothercombined . Sub-MICbiofilms . We focuectively . These fP. aeruginosa. The 23 passages with CAD reduced P. aeruginosa growth rate, but these levels of passaging are beyond what might occur in a clinical setting. CAD is a QS inhibitor at sub-MICs, and the additive effect of TOB with CAD was also apparent in the inhibition of QS. CAD combined with COL or TOB reduced biofilm formation and increased dispersal of preformed biofilm cells compared to individual treatment. Collectively, these results demonstrated that CAD as a QS inhibitor may increase the success of antibiotic treatment in combination therapy by disrupting QS more efficiently and subsequently increasing the susceptibility of bacterial biofilms to antibiotic therapy. Thus, CAD shows promise for use as an antipathogenic compound that is enhanced if used in combination with antibiotics. In conclusion, CAD and COL showed a synergistic action in killing planktonic cells of


There is extensive evidence associating the response to neoadjuvant chemotherapy (NeoCT) with breast cancer (BC) survival. However, to the author’s knowledge, there is no published data in Chile. The objective of the study is to evaluate whether achieving pathological complete response (pCR) after NeoCT is associated with greater survival and lower risk of recurrence in a Chilean Public Health Service.Retrospective analysis of a database. Patients with a diagnosis of Stages I–III BC who received NeoCT between 2009 and 2019 were included. Clinical and pathological information were extracted from the clinical records. BC subtypes were defined using hormone receptor (HR) information (HR: oestrogen and/or progesterone) and epidermal growth factor type 2 (HER2), being divided into four groups: HR+/HER2−, HR+/HER2+, HR−/HER2+, HR-/HER2−. pCR was defined as the absence of invasive cancer in the breast and axilla (ypT0/is N0) after NeoCT.p = 0.03 and 88.5% versus 71.4%, p = 0.003, respectively). The multivariable analysis confirmed this finding. Brain MFS was similar in both groups.Of 3,092 patients, 17.2% received NeoCT. Of these, 40.2% corresponded to HR+/HER2−, 20.9% HR+/HER2+, 18.2% HR−/HER2+ and 20.7% HR−/HER2−. Overall, 24.8% achieved pCR, being the lowest for HR+/HER2− (10.3%) and the highest for HR−/HER2+ (53.2%). In the multivariable analysis, family history, HER2+ and type of chemotherapy were associated with a greater probability of pCR. With a median follow-up of 40 months, the overall survival and metastasis-free survival (MFS) at 3 years were greater for the group with pCR compared to that which did not achieve it (90.5% versus 76.7%, NeoCT is associated with greater pCR in aggressive BC subtypes. In those, achieving pCR was associated with better survival in our study. To the author’s knowledge, this is the first study which evaluates the relation between pCR and BC subtypes in a Chilean public hospital. Breast cancer (BC) is the leading cause of death from neoplasms in Chilean women . It is cAll of those tumours which show over-expression of HER2 or which do not express HR or HER2 ) are characterised by a worse prognosis with a high risk of recurrence, metastasis and mortality .Neoadjuvant therapy refers to the use of some treatment, normally chemotherapy (CT), prior to surgery with curative intention. Even though pivotal studies, such as the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-18 and B27 , demonstThe first was its prognostic value. Studies subsequent to that of the previously mentioned NSABP showed that for the tumour to disappear completely, both in the breast and the axilla, which would be defined as Pathological Complete Response (pCR), is associated with less risk of recurrence and greater survival . This faThe second is its predictive value. Patients with HER2+ tumours who do not achieve pCR are candidates to receive trastuzumab-emtansine in place of trastuzumab after surgery given its benefit in recurrence . Those pThe aim of this study is to evaluate pCR in the Chilean population and to analyse if it is associated with subtypes and survival.Retrospective analysis of a database of patients treated for invasive BC in the South Eastern Metropolitan Health Service  in Santiago, Chile. This service includes the following public hospitals: Sotero del Rio Hospital (HSR), La Florida Hospital (HLF) and Padre Hurtado Hospital (HPH). The study was approved by the local ethics committee. All those patients were included who had a diagnosis of Stages I–III BC and who were diagnosed and treated with NeoCT between January 2009 and December 2019. Patients were excluded who had metastases on diagnosis, those who received neoadjuvant hormonal treatment as an exclusive treatment and those for whom we did not obtain information about the pathological response in the surgical biopsy.In Situ Hybridization (FISH) positive it was 2 pluses. In this way, we obtained four groups: HR+/HER2− , HR+/HER2+ , HR−/HER2+ (HER-2 enriched) and HR−/HER2− (TN).The clinical, pathological and follow-up information were extracted from the electronic clinical record. Survival data were extracted from the civil registry. Given that: (1) we do not have Ki67 data for all the patients and (2) for those we have, there are doubts about the correct standardisation of this technique across the different laboratories ; it has The pCR was evaluated, which was defined as the absence of invasive cancer, both in the breast and in the axilla (ypT0/is N0) after NeoCT.p < 0.05 was considered to define statistical significance. STATA 15.1 software was used for all the analyses.Descriptive statistics were used to describe basal characteristics using Chi-squared to compare categorical variables and Kolmogorov–Smirnov for continuous variables. A uni and multivariable logistical regression were used to evaluate the association of clinical and pathological variables with pCR. For the multivariable analysis, only those factors which showed significance in the univariate were considered. Metastasis-free survival (MFS), Cerebral MFS and OS were calculated from the date of diagnosis to the first event, or loss of follow-up and were presented in Kaplan–Meier curves. The groups were compared using log-rank. A univariate and multivariable Cox or logistic regression was carried out to evaluate factors associated with survival. Once more, for the multivariable analysis, only those factors which gave significance in the univariate regression were considered. A Of a total of 3,092 patients diagnosed between 2009 and 2019, 2,879 corresponded to Stages I–III (93.1%) patients. Of these, 496 (17.2%) received NeoCT . The pron = 176) were HR+/HER2−, 20.8% (n = 91) HR+/HER2+, 18.1% (n = 79) HR−/HER2+ and (n = 91) 20.8% HR−/HER2−. The majority of patients  corresponded to clinical Stage III.The median age was 51.7 years (range = 23–79 years). Of these, 40.3% (p = 0.0001) (p = 0.001).The rate of pCR in the whole group was 24.8% (109 patients). This rate varied according to subtype: HR+/HER2− 10.3%; HR+/HER2+ 27.5%; HR−/HER2+ 53.2%; and HR-/HER2− 25.1% ( 0.0001) . On subdp = 0.0001). There were no significant differences on evaluating the FHx of BC (BRCA 1 or 2 genes.56.5% of the patients had a family history (FHx) of any cancer, being more frequent in patients who achieved pCR than those who did not (Hx of BC . 57% of p = 0.0001). There was no significant difference on analysing the density of the dose or use of platinum. In HER2+ patients, 75.9% received trastuzumab as a neoadjuvant treatment, and six of them (4.3%) also received pertuzumab (two in the HR+/HER2− group and four in the HR−/HER2− group). The use of neoadjuvant trastuzumab was associated with a greater rate of pCR , making this difference more marked for HR−/HER2+ patients  (p = 0.02 compared with trastuzumab without pertuzumab).Regarding the type of surgery received after NeoCT, 56.3% had a total mastectomy (TM) being less frequent in patients who achieved pCR versus than those who did not achieve it . The rate of axillar dissection was 85% in both groups (p = 0.87).The majority of the patients (84.4%) received anthracyclines and taxanes (A-T) as a NeoCT regime, with 19.0% using a dense dose of these. On considering only those patients using the A-T CT scheme, the pCR rate was 29.3%  and this 0.0001) . All thep = 0.03) (p = 0.53); HR+/HER2+ 94.7% versus 90.1% (p = 0.87); HR−/HER2+ 92.9% versus 76.7% (p = 0.03); and HR−/HER2− 90.8% versus 66.6% (p = 0.08)  . The OS  = 0.08) .n = 94) were patients who did not achieve pCR and 13.0% (n =14) of these had achieved pCR. The MFS at 3 years was 75.5% for the entire group. The MFS at 3 years for the group which achieved pCR compared to those who did not achieve it was 88.5% versus 71.4% (p = 0.003) (p = 0.10); HR+/HER2+ 91.2% versus 84.2% (p = 0.76); HR−/HER2+ 90.5% versus 59.1% (p = 0.007); and HR−/HER2− 81.3% versus 56.0% (p = 0.10)  . The MFS = 0.10) –d.p = 0.46, Of the 108 metastatic recurrences observed, 30 (27.8%) were in the central nervous system (CNS), either as cerebral and/or leptomeningeal metastases. Of these, 9 (30%) presented in patients who had achieved pCR, this being for 8 of these the only place where there was metastatic compromise. The brain metastases recurrence-free survival at 3 years was 90.4% for the group which achieved pCR versus 92.4% for the group which did not achieve it  are associated with a greater probability of pCR .NeoCT in BC is a treatment strategy which presents multiple benefits: first, on achieving a response and reducing the tumour load, it means that tumours which before were inoperable, become ‘operable’, or tumours which were initially going to be a TM can opt for more conservative surgeries. This benefit is the most obvious and has been reported in multiple studies . In thislive’ evaluation of the efficacy of different treatments. Therefore, patients who do not achieve pCR and hence have a greater probability of recurrence or dying from BC are considered resistant to the initial therapy, being a candidate to receive adjuvant treatments which overcome that resistance, thereby improving the oncologic prognosis in resistant patients, a finding which has been demonstrated in Phase III studies and incorporated into international management guidelines [et al. describe that in the United States, the rate of NeoCT in Stages I–III has doubled in the period 2003–11 from 12.2% to 24.0% [But there are other benefits to NeoCT which, although they might be less obvious, they can have more of an impact. As already mentioned, achieving pCR could predict survival in patients with BC, especially in aggressive subtypes . The othidelines , 11, 15.idelines .For thesto 24.0% , a fact to 24.0% , 19. ThiBRCA mutation have a greater probability of achieving pCR particularly if platinum based regimes are used [However, not only is the intention to administer NeoCT important but ‘how we do it’ is also relevant. Regimes using anthracyclines combined with taxanes achieve a better rate of pCR  especialare used , 24. In In 2016, a High Risk Hereditary Breast Cancer Programme was implemented in our centre. However, this high cost of the studies limited the access of those patients evaluated to carry out the genetic study. Since October 2019, the studies have been financed by the Hospital, which improved patient and family access. If the patient has indication to carry out the study according to NCCN clinical guidelines , the ideWith respect to HER2+ patients, the NOAH (NeOAdjuvant Herceptin) study was the first randomised study to demonstrate the benefit of adding neoadjuvant trastuzumab, not only for achieving pCR but also for event-free survival . Two subAlthough achieving pCR improves survival, this is not a synonym for cure. In our study, 10% of patients who achieved this result were dead at 3 years, the cause of death in nearly all these patients (92.3%) being BC (data not shown). On wanting to evaluate which are the clinical factors which could impact survival in patients who achieve pCR, we find that there is a tendency, which is not significant, that the nodal status on diagnosis could have an influence on survival. In a sub-study by European Organization for Research and Treatment of Cancer (EORTC) 10994/BIG 1-00, it was found that the clinical status on diagnosis was the only factor associated with prognosis in patients who achieved pCR . FurtherAlthough our study found that pCR is associated with a lower probability of developing distant metastasis, this is not true for cerebral metastasis. In fact, 64.3% of patients who obtained pCR in our study developed CNS metastasis. This translated to there being no difference in brain MFS between those who achieved and those who did not achieve pCR . The reaIn summary, achieving pCR subsequent to NeoCT seems to be a consistent and robust survival marker in patients with BC, in women treated in a Chilean public hospital. This prognostic value, together with the recently accepted predictive value of this marker, means that NeoCT should be considered as a standard treatment, particularly in patients with aggressive BC, regardless of clinical status.The authors have no conflicts of interest to report.The authors have no funding to declare for this work.


We aim to describe the prevalence and trends of hypertension among 9–17 school-aged students from 2017 to 2019 in Yunnan, China.We conducted a cross-sectional study by using data from the Students’ Health Surveillance Surveys of 2017, 2018 and 2019 in Yunnan. The Students’ Health Surveillance Surveys in Yunnan collected date on physical fitness and health status of students in Yunnan through multistage-stratified sampling in 3 prefectures. In each prefecture, the study population were classified by gender and region , and each group had an equal size. Diagnosing criteria of hypertension was set with reference to Chinese age-specific and height-specific blood pressure (BP), to identify the abnormal status of boys and girls separately. ANOVA test was adopted to measure the differences in the mean BP stratified by gender, age, prefecture and area, and Chi-square test was used to compare the percentages of hypertension in different areas. For comparability, the age-standard and gender-standard population prevalence was calculated by directly using China Census in 2010 as a standard population. Totally 24,890 participants aged 9–17 years were included in this study.From 2017 to 2019, there were 24,872 students completed physical examinations and included in the analysis, of which 3288 were diagnosed with hypertension. The total prevalence of hypertension was 13.72, 12.49 and 13.45% among 9–17 years school-aged population in Yunnan, respectively. The total age-standardized hypertension prevalence trended to decrease from 13.82 to 13.48%. For urban population, the age-standardized hypertension prevalence decreased slightly from 11.24 to 10.13%. While, for rural population, it increased from 17.58 to 19.16%. The average annual growth rate in rural population was 0.53%.From 2017to 2019, there was a significant and continuous increase in the prevalence of hypertension in 9–17 years school-aged population in Yunnan. Hypertension is epidemic among children and adolescents in Yunnan. We should take effective and comprehensive intervention measures to reduce its prevalence among school-aged children. With the rapid development of social economy and changing of people’s lifestyle, hypertension has become the most common chronic non-communicable disease globally. According to a WHO report, of the estimated 1.13 billion people with hypertension, less than 1 in 5 has it under control .In recent years, hypertension has shown a trend of prevalence at younger age . HyperteThis study aimed to estimate the prevalence of hypertension in children and adolescents in Yunnan, located in Southeast of China, and understand its trend in recent 3 years. We explored different characteristics associated with hypertension to inform effective strategies and measures in secondary prevention of hypertension in children and adolescents, to promote primary prevention of serious cardiovascular events such as hypertension and coronary heart diseases in adulthood. This study used data from the Yunnan Students’ Health Surveillance Surveys conducted from 2017 to 2019.n = 7828), 2018 (n = 8165) and 2019 (n = 8897). In total, there were 12,096 boys and 12,794 girls included.The study was a cross-sectional study with data that were derived from the Yunnan Students’ Health Surveillance Surveys from 2017 to 2019 . In brieThe survey included a standardized physical examination, which were conducted by well-trained health workers who followed a reference protocol recommended by China Center for Disease Control and Prevention and built up a mobile examination team.Physical examinations included measurement and record of individuals’ height and weight. Height was measured to the minimal unit of 0.1 cm by a metal column Height and Sitting Height Measuring Instrument while the students did not wear shoes (Jianmin Height and Sitting Height Meter JH-1200). Weight was measured to the minimal unit of 0.10 kg by a balance-beam scale while the students wore light-weighted clothing . Both the scales and stadiometers were calibrated before use , 18, 19.P-value for differences by gender, age group, and area group, because high statistical power was achieved from the large sample sizes.The primary data analysis was conducted in 2020. Differences in the mean BP by age, gender and area were compared using the ANOVA test. The prevalence estimates for hypertension in different survey years  were calculated by age, gender, prefecture, and area  subgroups. Division of urban and rural was based on the Chinese Administrative Division. Univariate methods were not used to estimate P < < 0.05.For comparability, the age-standardized and gender-standardized prevalence was calculated by directly using the Chinese Census 2010 as a standard population. The age groups were set as 9–11 years old, 12–14 years old and 15–17 years old. Chi-square analyses were conducted to assess differences in prevalence of hypertension for categorical variables. All data were analyzed using SPSS 21.0 software. All the analyses included sample weights that accounted for the unequal probabilities of selection, oversampling, and non-response. Statistical significance was defined asP < < 0.05).As shown in Table P < 0.01), compared to the standardized SBP (P < 0.01), from 2017 to 2019.As shown in Fig. P < 0.01). However, in rural areas, the mean standardized SBP increased in all age groups and genders (P < 0.01), while the mean standardized DBP decreased obviously (P < 0.01).As shown in Table P < 0.05).From 2017 to 2019, the mean SBP in urban participants decreased from 108.42 mmHg to 106.25 mmHg, while it increased from 105.34 mmHg to 106.52 mmHg in rural population. In terms of the mean DBP, similar pattern of decrease was observed among urban students (from 65.71 mmHg to 64.39 mmHg), while in rural areas, it slightly decreased from 68.64 mmHg to 68.04 mmHg. We also observed that the mean SBP for boys in the urban was higher than that in the rural. However, the mean DBP for boys in the urban was lower than that in the rural. And the mean SBP/DBP for girls in the rural was higher than that in the urban areas  among students aged 9–17 years in Yunnan. And the standardized prevalence was 13.13%.χ2 = 5.966, P = 0.051). Prevalence difference was noted in different years. After standardization, the prevalence was adjusted as 13.82, 12.39 and 13.48%, respectively. The standardized prevalence was slightly lower than the crude one. The average annual decrease rate was 0.11%. The average standardized prevalence of hypertension was 13. 23% among students aged 9–17 years over 3 years.From 2017 to 2019, the crude prevalence of hypertension among children and adolescents aged 9–17 years were 13.72% (1073/7819), 12.49% (1019/8161) and 13.45% (1196/8892), respectively in Yunnan . While, the crude prevalence of hypertension in girls was 14.34% (591/4122), 13.76% (574/4171) and 12.30% (552/4487), respectively . We observed a significant difference of prevalence in different year either in boys or girls. But there was no statistically significant difference between the prevalence in boys and in girls. The standardized prevalence in boys was 13.03% (2017), 11.23% (2018) and 14.89% (2019) respectively. And that in girls was 14.48% (2017), 13.54% (2018) and 12.24% (2019) respectively. The boys’ hypertension prevalence trended to increase with the average annual increase rate of 0.62%.The crude prevalence of hypertension in boys was 13.04% (482/3697), 11.16% (445/3989) and 14.62% (644/4405), respectively . There was no statistically significant difference in the prevalence of urban population in different years. Whereas the rural crude prevalence of hypertension was 16.97% (560/3300), 13.86% (482/3471) and 17.86% (679/3801) respectively . A significant difference was observed in the prevalence of rural population in different years. The standardized prevalence of urban students was 11.24% (2017), 11.56% (2018) and 10.13% (2019) respectively. And the rural one was 17.58% (2017), 14.36% (2018) and 19.16% (2019) respectively. And in 3 years, the standardized prevalence in urban was 10.91%, that of rural was 17.12% . The hypertension prevalence in rural increased over the past 3 years.In different areas, the crude prevalence of hypertension in the 9–17 years old urban children and adolescents were 11.35% (513/4519), 11.45% (537/4690) and 10.16% (517/5091) respectively . A significant difference was noted in the prevalence of different year in different prefectures. A trend of decreased hypertension prevalence was observed in Honghe, with the average annual decrease rate of 2.65%. However, the prevalence in both Pu’er and Kunming increased. The crude prevalence of hypertension increased from 18.05% (2017) to 22.53% (2019) in Pu’er, with the average annual increase rate of 1.49%. And that increased from 7.04% (2017) to 9.75% (2019) in Kunming, with the average annual increase rate of 0.90%.In different prefectures, the average crude prevalence of hypertension in 9–17 years children and adolescents were 18.36% (Pu’er), 13.02% (Honghe) and 8.13% (Kunming)  was higher than that of Korean (9.0%), US (1.6%), Brazil (4.5%) and Cameroon (1.6%) levels –35. ThisThis study also found the rural standardized prevalence of hypertension was higher than that of urban population. This is consistent with previous studies –40. And In prefectures, the crude prevalence of hypertension in Pu’er increased from 18.05% (2017) to 22.53% (2019). The average annual increase rate was 1.49 percentage points. That of Kunming was 7.04% (2017) to 9.75% (2019). The average annual increase rate was 0.90 percentage points. We should make Pu’er and Kunming as a key area to carry out comprehensive health education intervention of children and adolescents blood pressure.The present study has some limitations. Firstly, hypertension was defined as SBP and/or DBP at least 95th percentile based on age-, sex-, and height- percentiles. Although weight-for-height is not a perfect measure of body fat and blood pressure. Weight-for-height is highly correlated with body fat at the higher values for weight-for-height . As a reIn conclusion, the blood pressure study in adults was of great concern, but truly little in children. This study focused on children and adolescents. And this serial cross-sectional study has indicated a slightly decreasing trend in the prevalence of hypertension among 9–17 years old children and adolescents in Yunnan from 2017 to 2019, whereas the prevalence trended to increase from 17.58% (2017) to 19.16% (2019) in rural areas. In viewing that childhood and adolescents’ hypertension can develop into adult hypertension and increase the risk of cardiovascular disease, childhood and adolescents’ hypertension should be considered as a major public health issue. We should conduct further studies to explore related risk factors to make an integrated intervention to prevent and control hypertension among children and adolescents in Yunnan, especially in rural areas.


The present study aimed to assess the risk of obstetric anal sphincter injuries (OASIS) of a subsequent delivery after the previous OASIS in countries with low (Finland) and high rates (Norway and Sweden) of OASIS.t test, where appropriate.This population-based case–control study included women who experienced OASIS 1997–2002. 26,598 women with OASIS were included from countries with low (Finland) and high (Norway and Sweden) OASIS incidences. Each case was matched with one background-adjusted control without OASIS. A follow-up data, including all subsequent deliveries between 1998 and 2011 were then collected. Statistics significances were calculated using chi-square test, test for relative proportions and Students p < 0.001); 4.5% vs. 0.7 (p < 0.001) in Sweden; and 2.1% vs. 0.8% in Finland (p = 0.038). In Norway, more than two deliveries occurred in 4.8% of cases and 6.2% of controls (p = 0.001), 4.2% vs. 5.1% in Sweden (p < 0.001), and 5.7% vs. 6.3% in Finland (p = 0.572). For women with OASIS in a previous delivery, the rates of cesarean deliveries in subsequent pregnancies were 16.4% (7.9% for controls) in Norway, and 16.3% (6.0% for controls) in Sweden, and 50.2% (14.2% for controls) in Finland. In all countries, the differences between cases and controls were significant (p < 0.001).OASIS in the first birth was associated with increased recurrences in subsequent births, 6.9% vs. 1.7% in Norway (Next deliveries after OASIS are associated with increased frequency of new OASIS, more cesarean deliveries, and less subsequent deliveries in the high-risk population than women without previous OASIS. A common outcome of vaginal delivery is perineal trauma. The most serious among these injuries are third- and fourth-degree lacerations or obstetric anal sphincter injuries (OASIS). Mechanical damage of the anal sphincter muscles is assumed to be the most important risk factor for anal incontinence and anorectal symptoms in otherwise healthy women, thus, this condition can significantly reduce the quality of life –4. StudiA better understanding of risks is necessary when counseling women with a prior OASIS. The risk of recurrence is a major factor in planning the mode of a subsequent birth. In some studies, women with prior OASIS were reported to be more likely to have a cesarean delivery for their next birth , 10.Historically, the OASIS rate in Finland has been significantly lower than in other Scandinavian countries, e.g., 1% in Finland compared to 4% in Sweden and Norway .Several hundreds of studies have investigated the risk factors of OASIS and the short-term complications that can occur after OASIS. However, some studies have investigated the obstetric consequences of OASIS in a subsequent pregnancy , 13. TheWe performed a population-based case–control study. Data were retrieved from the Medical Birth Registries (MBR) in Finland, Norway, and Sweden. The registry information was based on standardized forms completed by midwives in the delivery ward shortly after delivery. Only anonymized data were used. Thus, informed consent from participants was not required. For baseline data, all women who experienced OASIS in 1997–2002 were included. When possible, third-  and fourth-degree  perineal tears were identified from the ICD-10 codes, ‘O70.2’ and ‘O70.3’, respectively . For cases, a matched control without OASIS was chosen and were matched for the following variables: (1) delivery year, (2) maternal age, (3) parity for vaginal deliveries, (4) an index delivery that was either a spontaneous vaginal delivery or an instrumental delivery, (5) birthweight either below or above 4000 g, (6) when multiparous, none had experienced an earlier anal sphincter tear and (7) gestational age above 22 weeks.The follow-up included the subsequent deliveries after OASIS between 1998 and 2011. For the follow-up period, we collected the following information: (1) date of delivery (month/year), (2) method of delivery , (3) maternal age at delivery, (4) gestational age in weeks, (5) induction of labor, (6) epidural analgesia, (7) episiotomy, (8) presentation , (9) birthweight, (10) Apgar score , and (11) number of subsequent children after OASIS.The Finnish data was retrieved from the Finnish MBR with linkage to the Hospital Discharge Registry. Both registries were maintained by the Finnish Institute for Health and Welfare in Finland. Norwegian data was retrieved from The Norwegian MBR maintained by the Norwegian Institute of Public Health. Swedish data were retrieved from the Swedish MBR, maintained by the National Board of Health and Welfare. The study protocol was ethically approved in Finland by the Finnish Institute for Health and Welfare (granted 16 October 2008reference number 2777/605/2007). In Norway, approval was granted by the MBR (14-1753). In Sweden, the study was approved by the Ethics Committee of the University of Lund (D.nr 2014/747). Furthermore, the Finnish data were linked to data on induced abortions and sterilizations  and adoptions . This was not possible in Norway and Sweden.t test, where appropriate. All statistical analyses were performed with SAS 9.3 (SAS Institute Inc. 2011). p < 0.05 was considered statistically significant. The number of missing data varied between 0 and 1.0%.Statistical significance was calculated by using Chi-square test, test for relative proportions and Students The number of deliveries were equivalent between cases and controls in all countries. The total numbers were: 1001 deliveries in Finland, 10,327 in Norway, and 15,270 in Sweden (Table The delivery characteristics are presented in Table p = 0.026); (2) 22–36 weeks 5.2% vs. 1.7%, 37–41 weeks 81.8% vs. 86.0%, and at least 42 weeks 12.9% vs 12.3% in Norway (p < 0.001); and (3) 22–36 weeks 1.7% vs. 5.4%, 37–41 weeks 90.1% vs. 86.2%, and at least 42 weeks 8.3 vs. 8.4% in Sweden (p < 0.001).Gestational age for cases and controls was: (1) 22–36 weeks 3.3% vs. 2.6%, 37–41 weeks 94.2% vs. 92.0%, and at least 42 weeks 2.5% vs. 5.4% in Finland (p < 0.001 for both). However, there was no statistically significant difference between cases and controls in any of the three countries (matching criteria) (Table p < 0.001) in Norway; in 4.5% of cases vs. 0.7% of controls (p = 0.001) in Sweden; and in 2.1% of cases vs. 0.8% of controls (p < 0.05) in Finland (Table The births in subsequent pregnancies among women with and without OASIS during the first pregnancy are presented in Table a) Table . The numa) Table . Similara) Table . Among wnd Table . At the There were no statistically significant differences between cases and controls in the median number of deliveries during the follow-up period; i.e., one in cases and controls in Finland, two in cases and controls in Sweden, and one in cases and controls in Norway. There were no significant differences between cases and controls in the median years to the next delivery, in Finland , in Sweden , or in Norway .p = 0.002). The same was true even in Norway . However, there was no difference in adoption rate between cases and controls.In Finland, it was possible to use the data from induced abortions and sterilizations. We found that women tended to divorce more often among the study group than controls with grade 4 tears in Finland  is a little bit less than the overall difference in OASIS rate (fourfold increase). The reason for this could be the low OASIS rate in Finland compared to the two other Scandinavian countries. Because, if an OASIS takes place during the first birth and also during the subsequent birth in Finland, it is probable that the event of a rupture is independent of the midwives' and doctors' supporting techniques.We found that the cesarean delivery rate for a subsequent pregnancy was significantly higher after an OASIS than among controls, in all three countries. This finding was consistent with earlier reports . Interes. The prevalence of new tears varied between 2.1% in Finland to 6.6% in Norway. Thus, we found a four- or fivefold increased likehood of a subsequent OASIS in Norway and Sweden, in contrast, the likelihood was threefold higher in Finland. These results were consistent with those published previously , 17. HowWe have previously showed that the OASIS rate was largely different among different Nordic countries , 19. ThiWe found that the number of children born to women who have had OASIS was unchanged after one or two subsequent deliveries but was significantly lower than the number born to matched controls after more than two subsequent deliveries in the high-risk populations in Norway and Sweden. This finding has not been reported previously, perhaps due to the short follow-up periods and small cohorts of previous studies. However, these results must be confirmed in future studies with a larger cohort.The major strength of this study was the large sample size. We included deliveries from all maternity and delivery units in three Nordic countries. Furthermore, these databases have been used in earlier studies , and theThere is a need to improve the prevention, diagnostics, and treatment  of OASIS


We assessed visual residual tumour cells (VRTC) with both Becker’s tumour regression grading (TRG) system and Japanese TRG system in esophageal squamous cell carcinoma (ESCC) patients treated with neoadjuvant therapy followed by surgery.We compared Becker system and Japanese system in 175 ESCC patients treated between 2009 and 2015.According to Becker system, the 5-year DFS/DSS rates were 70.0%/89.3, 53.8%/56.7, 43.0%/49.0, and 42.4%/39.1% for TRG 1a (VRTC 0), TRG 1b (1–10%), TRG 2 (11–50%), and TRG 3 (> 50%). According to Japanese system, the rates were 38.8%/34.1, 49.5%/58.7, 50.2%/49.0 and 70.0%/89.3% for Grade 0-1a (VRTC> 66.6%), Grade 1b (33.3–66.6%), Grade 2 (1–33.3%) and Grade 3 (0). TRG according to two systems significantly discriminate the patients’ prognosis. TRG according to Becker system , and lymph node metastasis  were independent parameters of DSS.Both Becker and Japanese system had their advantage in risk stratification of these ESCC patients. It was speculated that dividing 1–10% VRTC into a group might contribute to independently prognostic significance of Becker’s TRG system. Therefore, in addition to TRG of different systems, the percentage of VRTC might be recommended in the pathologic report, which could make the results more comparable among different researches, and more understandable for oncologists in the clinical practice. Esophageal cancer (EC) is the ninth most common cancer and the sixth most common cause of cancer death globally . ChineseTumour regression grade (TRG) system referring to the amount of therapy-induced fibrosis in relation to residual tumour after nCRT has been initially developed by Mandard and coworkers . HoweverIn the ESCC patients with neoadjuvant therapy, we compared the Becker system and Japanese system for assessment of VRTC, and tried to explore the prognostic factors.This study was based on a retrospective review of 175 patients who underwent surgical resection following 2 to 3 cycles of neoadjuvant chemotherapy (nCT) or neoadjuvant chemoradiotherapy (nCRT) for ESCC, between November 2009 and December 2015 at Zhongshan Hospital, Fudan University, Shanghai, China. They were diagnosed as locally advanced-stage disease , using endoscopy, computed tomography (CT) of the chest and abdomen, endoscopic ultrasound, and positron emission tomography (PET), and required neoadjuvant treatment as first-line treatment prior to surgical resection. Informed consents were obtained from all patients. This study was approved by the Institutional Review Board of our hospital (B2016–135) and was performed according to the ethical principles of the Declaration of Helsinki.The patients were followed up routinely in outpatients, every 3 months in the first year and every 6 months in the second year, followed by annual evaluations. Patients who did not go to our hospital were contacted by telephone to obtain follow-up data.For specimens with neoadjuvant therapy in our hospital, all the suspected area of tumors were embedded and sectioned after the macroscopic examination, and all slides were evaluated by pathologists at once. For this study, all 175 surgically resected ESCC specimens were systematically reevaluated histopathologically by two experienced gastrointestinal pathologists. The histopathological review was undertaken with the pathologists blinded to the treatment results. The original tumour area was identified by signs of tumour regression changes, such as marked fibrosis, necrosis, flattening of the mucosa, or the presence of foreign body giant cell reaction. The extent of VRTC was assessed semiquantitatively, based on the estimated percentage of cancer in relation to the total cancer area –21. WithOther clinicopathologic characteristics were also recorded, including age, gender, tumour location, tumour grade, tumour size , lymphovascular invision, perineural growth, number of positive lymph nodes (LN), and the type of neoadjuvant.P< 0.05 (two-sided).Categorical data were analyzed using χ2 test or Fisher’s exact test. Survival curves were estimated using the Kaplan–Meier method and were compared using the log-rank test. Overall survival (OS) was defined as the period from the date of surgery until the last confirmed date of survival or the date of death. Disease specific survival (DSS) was defined as the period from the date of surgery until the date of death, because of ESCC. Disease free survival (DFS) was defined as the period from the date of surgery until the date of disease progression or the date of death, because of ESCC. The Cox proportional hazard model was used to examine the association between clinicopathological factors and survival, to identify independent prognostic factors. Hazard rates (HRs) with its 95% confidence intervals (95% CIs) were used to determine the effect of each variable on outcome. Statistical analysis was performed using the SPSS software, version 21.0 , with statistical significance being considered with n = 82) compared with the upper third (n = 29) or the lower third (n = 64). The mean tumour length was 2.9 (range 0.3–9.0) cm. One hundred eight patients (61.7%) were treated with preoperative chemotherapy, whereas 67 (38.3%) patients were treated with preoperative chemoradiotherapy. No residual tumour was found in 26 patients. Vessel and nerve invasion were identified in 57 (32.6%) and 56 (32.0%) tumours, respectively. In 83 patients who had positive LN status, 51 patients (61.5%) had 1–2 positive LN, 23 patients (27.7%) had 3–6 positive LNs, and 9 patients (10.8%) had more than 6 positive LNs.The clinical and pathological characteristics of the 175 patients are summarized in Table TRG system of Becker or Japanese Esophageal Cancer Association was widely accepted in western country or Japan, which was used in our study, separately. According to the Becker system, there were 26 cases 14.9%) of TRG 1a, 36 cases (20.6%) of TRG 1b, 33 cases (18.9%) of TRG 2, and 80 cases (45.7%) of TRG 3  (Table Table 5) Table .The median follow-up duration was 24.0 months . At the time of analysis, 70 patients (40.0%) had disease progression and 59 patients (33.7%) had died of esophageal cancer. At total, 68 patients (38.9%) died. The 1-, 2-, 3-, and 5-year postoperative DFS rates for the patients in this study were 82.8, 63.9, 57.6, and 50.3%, respectively. The 1-, 2-, 3-, and 5-year postoperative DSS rates for the patients in this study were 91.0, 73.4, 60.9, and 51.0%, respectively. The 1-, 2-, 3-, and 5-year postoperative OS rates for the patients in this study were 88.8, 72.4, 56.9, and 45.6%, respectively.P< 0.05) but not between patients with TRG1a and TRG1b (P> 0.05)  , the 5-year DFS rates were 70.0% (median time 72 months), 53.8% (non-reached), 43.0% (29 months), and 42.4% (32 months), 5-year DSS rates were 89.3% (median time non-reached), 56.7% (median time non-reached), 49.0% (34 months), and 39.1% (36 months), and the 5-year OS rates were 72.2% (median time 78 months), 50.0% (non-reached), 50.0% (34 months), and 34.1% (34 months), respectively. Significant differences in DFS and DSS were observed between patients with TRG 1a/1b and TRG2/3    was potentially independent factor of DFS and DSS. Beside TRG, LNM   was also independent factor of DFS and DSS  significantly improves survival in patients with locally advanced EC compared with surgery alone , 6, 7. IA reliable prognostic factor for ESCC patients undergoing neoadjuvant therapy is lacking. As preoperative neoadjuvant therapy has been used increasingly in the management of locally ESCC patients, the identification of potential prognostic parameters in these patients has recently gained momentum.Histopathological tumour response after neoadjuvant therapy is believed to be an important objective factor and has been shown to have prognostic value in several studies –14, 26. Among these systems, Becker et al. categorized TRG into four grades , which reflected prognosis and survival in a more object manner and widely accepted in tumour regression evaluation . A step-We reported a 5-year DFS rates of 70.0%, a DSS rate of 89.3% and an OS rate of 72.2% in TRG1a, a 5-year DFS rates of 53.8%, a DSS rate of 56.7% and an OS rate of 50.0% in TRG1b, a 5-year DFS rates of 43.0%, a DSS rate of 49.0% and an OS rate of 50.0% in TRG2, and a 5-year DFS rates of 42.4%, a DSS rate of 39.1% and an OS rate of 34.1% in TRG3. TRG1a or TRG1b have been associated with a statistically significant survival benefit compared with other regression classes. However, no statistically significant difference could be detected between TRG1a (0% VRTC) and TRG1b (1–10% VRTC) in our patients. Consistent with our results, recently published data indicated that no statistically significant difference could be detected between pathologic complete remission and microscopic residual disease in patients with EC, and TRG 1a-1b showed a statistically significant survival benefit compared with other regression classes , 34, 35.The TRG system of the Japanese Classification of Esophageal Cancer was widely used in Japanese ESCC specimens , 30, 38.The main difference between Becker system and Japanese system was the classification of patients with minimal residual tumour (1–10% VRTC). Becker system divided these patients into TRG 1b, as an independent group, who had the similar 5-year survival rates as the whole cohort. Japanese system incorporated these patients into G2 (< 1/3 VRTC) –21. StudIn this study, we concluded that TRG according to both Becker system and Japanese system had its advantage in risk stratification of ESCC patients undergoing neoadjuvant therapy plus surgery. Based on Becker system, TRG was potentially independent predictors of patient outcome, which was not found based on Japanese system. The classification of cases showing 1–10% VRTC made the grouping different. We would like to recommend not only TRG according to Becker’s, Japanese and other systems but also the percentage of VRTC should be reported in the pathology evaluation, which could make study results more comparable among different research groups, and more understandable for oncologists in the clinical practice. Our findings might represent a valuable addition to the current literature in light of the increasing histopathologic response evaluation of neoadjuvant therapy in ESCC.


The conclusion of this study is that ALDH1 can be used as a poor prognostic factor in TNBC patients although it cannot be an independent prognostic factor.Breast cancer is the most common cancer with an increasing incidence in Asia. About 20% of all breast cancers are triple-negative breast cancers (TNBCs). BCSC is a subset of tumor cells that has stem cell-like characteristics, such as a high capacity for self-renewal and tumor initiation, which implies that BCSC may cause aggressiveness of TNBC. ALDH1 has a role in early stem cell differentiation through its function in the oxidation of retinol to retinoic acid, proposed to be a strong candidate for breast cancer stem cells. Various studies have shown that ALDH1 is one of the markers of CSC that can be used as a prognosis indicator because it can be a biological marker for poor prognostic factors in TNBC. This study assessed the prognostic survival rate with a retrospective cohort method in TNBC patients. A total of 54 of 55 patients treated at RSCM were tested for the expression of ALDH1 through an immunohistochemistry assay of breast cancer tissue using ALDH1 staining. Survival analysis was done to obtain the prognostic data of ALDH1. Positive ALDH1 expression was obtained at 38.89% in TNBC patients. One-year survival and three years of survival in TNBC patients with positive ALDH1 expression were 42.9% and 33.3%, respectively. In this study, ALDH1 can be used as a poor survival prognostic factor with HR 2.636 and  Breast cancer is the most common cancer with an increasing incidence in Asia. According to GLOBOCAN 2012, the incidence of breast cancer in Indonesia was 40.31 per 100,000 women, with a death rate of 16.58 per 100,000 women. The five-year survival rate of patients with a diagnosis of localized, regionally metastasized, and remotely metastasized breast cancers were 98.5%, 84.6%, and 25%, respectively  with p < 0.001), advanced stage (HR 38.31 [95% CI 8.25–177.95] with p < 0.001), and other types of chemotherapy (HR 3.42 [95% CI 1.190–10.61] with p=0.033). The Ki67 ≥ 20% group had HR 1.24 (95% CI 0.422–3.630); however, it was not statistically significant (p=0.697) (The observation on the relationship between variables with the increase in the hazard ratio showed that the factors which had a significant proportion of the hazard ratio were T4 tumor size (HR 6.94 [95% CI 2.02–6.86] with p=0.697) .p value <0.05 in the bivariate analysis are included in multivariate analysis. Variables included in multivariate analysis were tumor size, distant metastases, staging, and chemotherapy. Nevertheless, based on the concept of collinearity, where tumor size and metastasis are part of the stadium, only stadium and chemotherapy are included in multivariate analysis. From the multivariate results, it was found that HR reduced from ALDH 1 to 0.982. Changes in the adjusted hazard ratio for positive ALDH1 expression at each addition of confounding variables can be seen in Variables that have p value was 0.535.The age range of patients in this study was 25 to 75 years, with an average age of 50.9 years. According to the patient characteristic data, twenty nine patients (53.70%) aged <50 years and 25 patients (46.30%) aged ≥50 years. The highest number of mortality was found in the age group of <50 years, with a percentage of 25.9%. The risk of patients aged ≥50 years was found to be 0.7 times less than those aged <50 years. However, the result was not considered to be significant since the p=0.002). The group with T4 size of the tumor appeared to have 6.94 times greater risk than the group with T1-T2 size of the tumor. However, the group with T3 size of tumor possessed 0.859 hazard ratio. However, the result was not significant (p=0.868). It was consistent with the study by Ma et al., which showed that the result of overall survival was 1.253 times higher risk in tumor >2 cm than tumor <2 cm; however, it was not significant (p=0.647). The difference in this study was that the grouping of tumor size was based on the TNM criteria [p < 0.001).Regarding tumor size, a significant result was found in T4 tumor size compared to T1-T2 tumor size (nt p=0.64. The difp < 0.001). The result of a locally advanced stage group revealed to have 4.544 times greater risk compared to the early-stage group; however, it was not statistically significant (p=0.059). This finding was consistent with the study by Ma et al., which showed 5.511 times greater risk at stage III compared to stage I-II with a p value of 0.033 [A significant result was found in terms of staging, which showed that the advanced stage group possessed 38.309 times higher risk compared to the early-stage group (of 0.033 .p=0.033). Besides, the group which acquired CAF/CEF chemotherapy was found to have 1.741 times greater risk compared to the group with TC chemotherapy. However, this result was not statistically significant, with the p value of 0.235.In terms of chemotherapy, the group that received other types of chemotherapy had 3.422 times higher risk than those with TC chemotherapy. This result was statistically significant , Yoshioka et al. (26%), and Zhou et al. (35%) %, Yoshio.p=0.013). This result showed that TNBC samples with positive ALDH1 possessed 2.636 times higher risk compared to those with negative ALDH1. The survival time of patients with positive ALDH1 and negative ALDH1 was 24 months and 43 months, respectively. As described in the Kaplan–Meier graph , Yoshioka et al. (HR 1.1930), Zhong et al. (HR 11.932), and Dewi, who stated that positive ALDH1 expression suggested poor prognosis in patients with TNBC [The expression of ALDH1 was found to be statistically significant concerning survival rate and HR with a result of 2.636  as the marker of the cancer stem cell, which was clinically significant in indicating the prognosis of patients with breast cancer. They also found the prognosis of TNBC with positive ALDH1 to be reduced. Besides, patients who experienced nodal metastases with positive ALDH1 expression were also suggested to have poor prognosis. They also found that TNBC expresses ALDH1 more often than the other types of breast cancer .p=0.015). CC3 staining and positive ALDH1 were significantly correlated with poor prognosis of breast cancer with the TNBC subtype. Besides, positive ALDH1 was also related to reduced overall survival rate . Stem cell marker was a prognostic factor in breast cancer [Research by Zhou et al. which studied the level of ALDH1 and other factors measured with immunohistochemistry staining, also supported those results. Zhou et al. revealed that ALDH1 was higher in cases with TNBC compared to non-TNBC cases . The ALDH1A1 correlated significantly with malignant proliferations based on Ki67 staining (p=0.001), indicating an association of the ALDH1A1 phenotype with malignant proliferation in invasive ductal carcinoma [According to the other study by Zhong, positive ALDH1A1 cells were detected in 93 out of a total of 147 tumors (63.3%). Besides, eighty percent (32 of 40) tumors with strong ALDH1A1 staining showed early recurrence compared to 20.0% (8 of 40) tumors with negative ALDH1A1 expression (arcinoma .Moreover, Yoshioka et al. mentioned ALDH1 as the detoxification agent, which oxidized intracellular aldehyde and caused the resistance of the alkylating agent. The fact that ALDH1 possessed the ability to carry out detoxification by protecting the stem cell from the influence of oxidation explained the low response of therapy. Besides, ALDH1 also played a role in the conversion of retinol to retinoic acid, which acted as the stimulus of stem cell proliferation. Thus, it resulted in the low survival rate of TNBC with positive ALDH1 expression . Zhou etchi-square test and multivariate analysis, this study found that the clinicopathological factors, which influenced the statistical analysis of ALDH1 and survival rate, were the size of the tumor, advanced metastasis, advanced stage, and chemotherapy. Yoshioka et al. found that large size tumors and high grades were associated with ALDH1 expression [Through the pression . Also, Gpression . OverallALDH1 is one of the ethanol metabolism principal enzymes which equip the human breast epithelium, so a role comparison review with the other enzymes is needed. ADH, ALDH, and ADH isoenzyme expressions are lower in tumor cells than in the normal cells . Thus, tIn this study, reduction in HR was obtained from multivariate analysis, and it can be concluded that ALDH1 cannot be an independent prognostic factor because it still depends on other variables. However, Zhong et al. suggested the ALDH1A1 phenotype to be an independent predictor of tumor recurrence in the early phase, especially in the event of early localized recurrence and advanced metastases of invasive ductal carcinoma . HoweverAlthough there are significant results of this study, we suggest further research is needed, if necessary, multicenter research, to increase the number of samples and reduce confusion caused by certain variables.p value of 0.013 although it cannot be an independent prognostic factor.In this study, we can conclude that the one-year survival rate for triple-negative breast cancer patients with positive ALDH1 expression was 42.9% and the one-year survival rate for triple-negative breast cancer patients with negative ALDH1 expression was 78.8%, also the three-year survival rate for triple-negative breast cancer patients with positive ALDH1 expression was 33.3%, and the three-year survival rate for triple-negative breast cancer patients with negative ALDH1 expression was 72.7%. From the statistical analysis of the data, ALDH1 can be used as a prognostic factor of poor survival in triple-negative breast cancer patients with a hazard ratio of 2.636 with a


Breast cancer is the most frequently encountered malignant tumor among women in Tunisia and in the world. The quality of sexual life of patients with breast cancer is impaired by multifactorial mechanisms.The aim of our study was to determine the factors associated with sexual disorders in patients followed for breast cancer.Cross-sectional analytic study including patients followed for breast cancer at the outpatient medical oncology consultation of Hadj Ali Soua regional hospital from January to March 2021. We collected sociodemographic and clinical data with an assessment of sexuality (FSFI), marital satisfaction (MAT), psychological profile (HAD) and quality of life (SF36).Fifteen patients were included with a mean age of 49.87 ± 8.48 years and a mean age at diagnosis of 46.73 ± 7.55 years. At the TNM classification, 66.6% of the patients had a T1 or T2 at the time of diagnosis and 80% had an N0. All patients received a surgical intervention, which was conservative in 53.3% of cases. No patient underwent breast reconstruction. Chemotherapy and hormone therapy were prescribed in 86.7% of patients. The mean score of the FSFI questionnaire in our study was 17.25. Eleven patients (73.3%) had an FSFI score below 26.55. We found negative correlations between age and FSFI score . We noted statistically significant negative correlations between FSFI and HAD-D  and FSFI and HAD-a  as well as significant correlations between FSFI and the following items: RE (r=0.84p=0.000), SF (r=0.684 p=0.005), GH (r=0.671 p=0.006) and MCS (r=0.788 p=0.000).Focusing on a small sample of patients followed for breast cancer, our study provides an assessment of the sexual function in its various areas and shows how sexuality is deeply intertwined with other sections of medical management.None Declared