Tomato and cucumber are two of the most important and frequently produced and consumed fresh produce. Both of them are highly perishable with various postharvest sanitation techniques to be applied that reduce postharvest losses and extend the shelf life of vegetables and fruits. Chemical sanitizers are limited in the postharvest industry and are subjected to consumer constraints. Essential oils derived from medicinal and aromatic plants are attracting increased interest as natural sanitizers due to their well-known antimicrobial and antioxidant properties.Origanum dubium), present a plethora of properties that can be utilized by the fruit and vegetable sectors of the food industry. The purpose of the present study was to assess the effects of O. dubium EO and hydrosol (at different concentrations and durations of dipping application) for the preservation of tomato and cucumber fruit quality, and their effectiveness as sanitizing agents against two foodborne pathogens . The results of this study indicated that increased concentrations of EO, combined with a longer duration of application, resulted in less marketable fruit compared to hydrosol application. Interestingly, EO application at lower concentrations and shorter durations of application  increased fruit antioxidant, ascorbic acid and carotenoid levels (for tomato fruit), suggesting an increase in the nutritional value of the treated fruit, compared to the control. EO and hydrosol were able to decrease the bacterial populations (both bacteria) on fruits. Both products were especially effective against L. monocytogenes, even seven days after their application and storage at 11 °C (up to an approx. 3 log reduction with the EO application). Overall, the results of this study suggest that the use of O. dubium EO and hydrosol could be considered as alternative sanitation means for tomatoes and cucumbers. In recent years, the use of natural products such as essential oils (EOs) and other plant extracts for the preservation of fresh produce has attracted much interest from the food industry. Many endemic medicinal and aromatic plants, such as Cypriot oregano ( Origanum dubium Boiss.) is a perennial shrub of the Origanum genus belonging to the Lamiaceae family, and grows around the Mediterranean area. This plant, as well as its essential oil, infusion and other forms, has been used as remedy for many centuries due to its antioxidant and antiseptic/antimicrobial  properties [O. dubium has been used as an appetizer and a curative means for many health problems such as gastrointestinal ailments , influenza, headache, toothache and respiration ailments  [O. dubium has also been used in aromatherapy, perfumery and the food industry  [Origanum dubium has only recently been commercially cultivated by farmers in Cyprus, and approximately 20 ha are planned annually in open fields, with an estimated total production of 50 tons of dried product [Interest in the investigation of unexploited, indigenous medicinal and aromatic plants (MAPs) and their properties is currently increasing ,2,3. Cypoperties ,5,6,7. Iverages) . Origanu product . HoweverThe increased need for and consumption of fresh produce as a part of a healthy lifestyle have been linked with increased numbers of foodborne illnesses . OutbreaIn recent years, there has been a turn towards the investigation of natural products as alternative sanitizing agents in fresh produce washing steps. This need derived from consumers’ demands for decreased use of synthetic chemical substances during food processing and preparation ,12. MoreMany EOs  and other natural extracts have been previously used for the preservation of fresh produce and minimally processed fruits and vegetables with encouraging results ,21,22,23O. dubium EO against a plethora of pathogenic bacteria including Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, Salmonella Enteritidis, as well as the opportunistic pathogenic yeast Candida albicans [O. dubium EO and hydrosol on tomato and cucumber fruit quality attributes as well as (ii) the efficacy of these products against two main foodborne pathogens  inoculated on those fruits during storage.Cypriot oregano EO has been shown in previous reports to exhibit antimicrobial and antioxidant activities ,7. Previalbicans ,31. HoweSolanum lycopersicum cv. Torry F1) and cucumber (Cucumis sativus cv. PS-64) fruits were obtained from a local producer . Fresh produce was homogenously selected so that fruits presented uniformity in size and appearance, with no physical defects or injuries. After their transfer to the laboratory, the fruits were washed with chlorinated water (using 0.05% v/v sodium hypochlorite-NaOCl), and then, rinsed three times with sterile water, in order to remove/eliminate their native microflora.Fresh tomato (Origanum dubium) plants were collected from Cyprus University of Technology’s experimental farm/greenhouse, where they were grown in soil. The plants used in the present study originated from the Cypriot National Center of Aromatic Plants . The plant material was dried in an oven (air-dried at 42 °C). The EO was obtained via hydrodistillation using Clevenger apparatus for 3 h, and stored in umber glass bottles at −20 °C until use. The hydrosol (water remaining after hydrodistillation) was also collected, filtered (using cheese cloth for removing any solid residues) and stored at 4 °C until use. The composition of O. dubium EO was determined via Gas Chromatography–Mass Spectrometry  according to Chrysargyris et al. [Fresh Cypriot oregano  and for different durations , while for the control (0%), distilled water was used. To assist in the dilution of EO in water, 0.1% v/v Tween 20 was added. After the application, the fruits were removed from the solution and left to dry in air for 1 h at room temperature. Each treatment consisted of four fruits , which were placed in a 5 L polypropylene (PP) plastic container. The containers were placed in an experimental refrigerator at 11 °C and 90% relative humidity (RH) (achieved by placing wet paper inside each box) for appropriate durations of 9 and 12 days for cucumber and tomato, respectively.Preliminary screening was performed as described below for the determination of optimum doses (combination of concentration and duration of application) for each commodity that did not negatively affect their quality. After washing with chlorinated water (0.05% NaOCl), the fruits were air-dried and labeled. The fruits were dipped in treatment solutions of different EO or hydrosol concentrations  was measured after hermetically enclosing each fruit at room temperature (RT) in a 1 L plastic container. The air from the container was sucked for 40 s using a dual gas analyzer . After recording the weight and volume of each fruit, the results were expressed as mL of CO2 produced per kg per h (mL CO2/kg/h).During storage, the fruits’ weight loss and respiration rate were monitored, and sensory evaluation  was also performed for each commodity after an appropriate duration . Fruit weight was recorded on each of the aforementioned days and the percentage of total weight loss was calculated for each day. The effects on each commodity’s respiration rate were determined as previously described by Xylia et al. . BrieflyFor the sensory evaluation, at least six panelists were employed to assess the aroma, appearance and marketability of the fruits on appropriate days  . Aroma eOn the initial (day 0) and last days of storage  quality parameters were also assessed. Fruit firmness was measured at two points on the shoulder of each fruit, using a texture analyzer  equipped with a probe 3 mm in diameter travelling at a speed of 2 mm/s and with a penetration depth of 12 mm . The amo−1(b*/a*), if a* < 0 and h = tan−1(b*/a*), if a* > 0 and b* ≥ 0  [1/2 [The fruits’ surface color was evaluated by recording the L* , a* (−a*: greenness and +a*: redness) and b* (−b*: blueness and +b*: yellowness) values (CIELAB uniform color space) with the use of a colorimeter . Hue (h) was determined in degrees (°) using the following equations: h = 180 + tanctively) ,34. The ly) [1/2 . The colly) [1/2 . The yelly) [1/2 .For the determination of total soluble solids (TSS), titratable acidity (TA) and sweetness (ripening index), tomato and cucumber tissue were milled using a domestic blender, and then, pressed in a cheesecloth to extract the fruits’ juice. TSS were estimated with the use of a digital portable refractometer , while the results were expressed in °Brix. The fruits’ TA was determined via titration with 0.1 N NaOH using the method previously mentioned , and resv/v), as previously described by Chrysargyris et al. [The procedure for the extraction of polyphenols and antioxidants was performed with 50% methanol  and ferric-reducing antioxidant power (FRAP) assays. For the DPPH assay, the procedure was performed as described by Chrysargyris et al. , wherebyv/v diluted in 0.1% oxalic acid) was titrated against standardized DCPIP solution. The results were expressed as mg of ascorbic acid per 100 g of fresh weight (mg AA/100 g).The ascorbic acid (AA) content of tomato and cucumber fruits was determined using the 2,6-dichloroindophenol (DCPIP) titrimetric method, as previously mentioned , wherebylycopene and β-carotene) was also extracted and estimated using the procedure reported by Nagata and Yamashita [v/v) and the absorbance of the upper phase formed after the extraction was read at 453, 505, 645 and 663 nm. The results were quantified using the following equations [For tomato fruit, carotenoid content  per 100 g of fresh weight (mg/100 g).The results were further expressed as mg of carotenoids  and Listeria monocytogenes (ATCC 19111) were obtained from the Department of Nursing, Cyprus University of Technology. Fresh bacterial cultures (8 log cfu/mL) were prepared in brain–heart infusion broth  after overnight (16–18 h) incubation at 37 °C [Bacterial strains of at 37 °C .S. enterica and L. monocytogenes inoculated on tomato and cucumbers fruits. Thus, the following treatments were assessed: (i) sterile distilled water (control), (ii) chlorine (0.02%), (iii) EO Dose A (0.01% for 10 min), (iv) EO Dose B (0.1% for 10 min), (v) hydrosol Dose A (0.1% for 20 min) and (vi) hydrosol Dose B (0.5% for 20 min).The selected doses (concentration duration of application) from the preliminary screening were further investigated for their ability to lower and/or eliminate the populations of The procedures of inoculation and treatment application were performed as previously described , with moS. enterica and L. monocytogenes, respectively. The plates were then incubated at 37 °C for 24–48 h, typical colonies for each bacterium were counted and the results were expressed as log cfu/mL.For the determination of the remaining (surviving) inoculum, an appropriate volume of maximum recovery diluent  was added into each bag (in a 1:10 ratio) . The bagp = 0.05). A paired-samples t-Test was also used for comparing control data on the initial and final days.The experimental setup was a Completely Randomized Design (CRD) with four biological replications in each treatment. IBM SPSS version 25.0 was used, wherein the data were subjected to one-way analysis of variance (one-way ANOVA) comparing the treatment on each day by performing Duncan’s multiple range test (O. dubium EO and hydrosol application on the weight loss and respiration rate of tomato fruit are illustrated in O. dubium hydrosol at 0.5% for 20 min resulted in lower weight loss compared to non-treated (control) fruit after six days of storage at 11 °C (The effects of at 11 °C B. Howeveat 11 °C B.2/kg/h) compared to 0.01% for 10 min, 0.1% for 10 min and 0.5% for 20 min   compared to 0.01% for 5 min and 0.1% for 5 min  on the sixth day (The respiration rate of tomato fruit at 6 days was found to increase with the application of EO at 0.5% for 5 min (4.15 mL COO2/kg/h) C. The apixth day D. On theixth day D.O. dubium EO and hydrosol application on cucumber’s % weight loss and respiration rate. The application of EO at 0.5% for 20 min presented the greatest weight loss on the sixth day , on both sampling days (ixth day A. On theixth day A. When Oing days B.2/kg/h) on the ninth day  of tomato fruit are shown in Tomato’s appearance was found to present lower scores with the application of EO at 0.5% for 5 min, and 0.5% for 10 min and 20 min , while higher scores were found with 0.01% for 5 min (7.13—orange-red) C. The apEssential oil-treated tomatoes revealed that on the last day of storage, all applied treatments resulted in decreased scores, and this was more evident as the concentration and duration of application were increased . All appO. dubium EO and hydrosol application on cucumber’s sensory attributes . All applied EO treatments resulted in decreased aroma scoring values on the sixth day, and this was evident at 9 days of storage (except for applications at 0.01% for 5 min and 0.1% for 5 min) (r 5 min) A. When hr 5 min) B.The appearance of cucumber was reported to present lower scores with the EO applications and especially at 0.5% for 10 and 0.5% for 20 min  on the sixth day C. DecreaDecreased marketability scores were reported on the sixth day with EO application ), while on the last day, all EO treatments presented lower values, especially at 0.5% for 5 min, 0.5% for 10 min, 0.1% for 20 min and 0.5% for 20 min . HydrosoO. dubium hydrosol resulted in lower firmness in fruit treated with 0.5% for 5 min compared to 0.01% for 20 min . Fruit firmness decreased in control samples during storage. Hydrosol application increased tomato’s TSS on day 12 at 0.5% for 20 min (3.90 °Brix) compared to 0.5% for 10 min and 0.01% for 5 min   .Titratable acidity was not affected by EO use 12 days after application . The appO. dubium EO and hydrosol application on the firmness, TSS, TA and sweetness of cucumber fruit stored at 11 °C for 9 days. When EO was applied at 0.1% for 20 min, 0.5% for 5 min, 0.5% for 10 min and 0.5% for 20 min, it maintained fruit firmness  compared to the control (12.68 N). Interestingly, the application of EO for 10 min , as well as at 0.01% for 20 min and 0.5% for 20 min, decreased the TSS of cucumbers at the end of storage (day 9), whilst hydrosol application did not significantly affect cucumber’s TSS , whereas hydrosol application did not significantly affect tomato’s hue value . Chroma The browning index on tomato fruit increased with EO application at 0.1% for 20 min, while a decreased browning index was reported on tomato fruit when treated with hydrosol at 0.1% for 5 min, 0.5% for 5 min, 0.1% for 10 min, 0.5% for 10 min and 0.01% for 20 min compared to the non-treated fruit. Comparing the control on the initial and last days, an increased browning index was reported during the latter. An increased yellowing index was observed on the last day of tomatoes’ storage with EO application at 0.5% for 10 min and 0.1% for 20 min compared to 0.5% for 20 min, 0.01% for 5 min, 0.1% for 5 min and 0.01% for 10 min . HoweverO. dubium EO and hydrosol are shown in The cucumber color parameters as affected by the applied treatments of lycopene and β-carotene). Total phenols were found to increase with the application of EO at 0.5% for 20 min, followed by 0.5% for 5 min, whereas the application of hydrosol at 0.5% for 10 min increased the phenolic content of tomato fruit compared to the other treatments. The antioxidant activity (assessed via DPPH) of tomato increased with EO at 0.01% for 5 min and 0.5% for 10 min compared to all other treatments (except 0.1% for 10 min) ( 10 min) . The sam 10 min) . The FRA 10 min) .Lycopene was found to increase with EO at 0.1% for 20 min (2.16 mg Lycopene/100 g) compared to 0.01% for 20 min, 0.5% for 20 min, 0.01% for 10 min, 0.5% for 10 min and 0.5% for 5 min  . EO application at 0.01% for 10 min and 0.1% for 20 min resulted in increased β-carotene content compared to all other treatments . Hydrosol increased β-carotene content when applied at 0.5% for 5 min, 0.5% for 10 min and 0.01% for 20 min. Comparing the control on the initial and last days, an increase in carotenoids (Lycopene and β-carotene) was observed during the latter (As shown in e/100 g) . Hydrosoe latter . O. dubium EO and hydrosol application on cucumber’s phenolic content, antioxidant activity  and ascorbic acid content are presented in O. dubium EO at 0.1% for 20 min, 0.1% for 10 min and 0.5% for 10 min compared to the control and 0.01% for 5 min. When hydrosol was applied, decreased phenolic content was obtained at 0.5% for 10 min and 0.5% for 5 min compared to the control. The DPPH assay showed that EO application at 0.5% for 20 min increased tomato’s antioxidants compared to all other treatments , followed by dose A (0.01% for 10 min), with a 3.04 and 2.38 log decrease, respectively, on the first day of storage. The population of S. enterica inoculated on tomato fruit was decreased by all applied treatments on the first day of storage, with a greater decrease being reported with EO. A decrease in S. enterica was observed with chlorine and EO dose A on the last day (day 7)   .L. monocytogenes was decreased on cucumbers with all the applied treatments (except chlorine) on the first day of storage, and all treatments were able to decrease the bacterial population on the last day (day 7) , while no significant difference was observed between hydrosol doses. On the seventh day of storage, the S. enterica population was decreased with all applied treatments  (The population of  (day 7) . Howeverecrease) . InteresTomatoes and cucumbers are among the most widely consumed fresh produce. However, during storage, great losses might occur due to mechanical damage and deterioration (decay), among others. Weight loss due to water loss (via the respiration and transpiration processes) can result in senescing, browning, a loss in fruit texture and flavor, susceptibility to chilling injury and membrane disintegration, among others ,41. In tClimacteric fruits are characterized by increased ethylene production and respiration rates during their ripening stage . Tomato,Among the most important factors shaping consumers’ purchasing decisions, optical/visual quality  and aroma are noticed first. The application of EOs should be carried out with caution as they are products with intense and distinct aromas that could interfere with the fresh produce’s own aroma, resulting in an unpleasant final product. In the present study, it was observed that tomato treated with EO at increased concentrations and for longer durations presented an unpleasant aroma, whereas hydrosol application resulted in a less tomato-like (but acceptable) aroma. Moreover, increased EO and hydrosol levels and longer durations of application caused tissue burning/spotting for both tomato and cucumber fruit . TzortzaLycopene, β-carotene and chlorophylls) as well as prevent undesirable enzymatic activities  [O. dubium EO and hydrosol might have been caused by the EO’s “stronger” chemical profile since EOs tend to be more active than the respective hydrosols [The vibrant color of fruits increases consumers’ interest in purchasing. In our case, EO  and hydrosol application resulted in more orange-red colored tomato fruits and greener cucumbers. Cucumber fruit treated with an eco-product based on eucalyptus and rosemary EOs (via the dipping method) was found not to affect fruit’s appearance (at concentrations of 0.4 and 0.8%) . The finrowning) ,26. A prrowning) . In anotrowning) . The varrowning)  reportedydrosols ,23.Origanum vulgare) (up to 3%) incorporated in packaging film, which maintained firmness even after a week of storage at 4 and 22 °C [Consumers, when purchasing fresh produce, tend to prefer more firm fruits  as they have longer fridge and/or shelf lives. In the present study, firmness was maintained in tomato fruit treated with EO applications at 0.01%, 0.1% and 0.5% for 10 min, 0.5% for 5 min and 0.01% for 20 min. Maintenance of fruit firmness was also observed with the application of 0.1% sage EO, while a higher concentration (0.5%) was found to result in softer fruits . The maind 22 °C .The sweetness of fruits progress during the maturation stage, where fruits’ acids are reduced and sugars are increased. During fruit maturation, the TSS increase and the TA decrease is related to the conversion of starch and acids into sugars . PreviouO. dubium EO and hydrosol application in fresh produce  could result in products with increased nutritional value . However, these observations seem to vary due to different concentration–time combinations. Based on the literature, the antioxidant capacity of oregano extracts is due to both non-phenolic compounds  and phenolic compounds (disrupting the chain of processes that consume oxygen using a mechanism similar to how tocopherols work) [O. dubium EO are associated with carvacrol content, which is the main EO component [As with many fruits and vegetables, tomatoes and cucumbers are an important source of phytonutrients such as antioxidants. In our study, the phenolic content of tomatoes increased with EO at 0.5% for 20 min and 0.5% for 5 min, as well as with hydrosol at 0.5% for 10 min. On the other hand, cucumber’s phenolic content was found to decrease with EO at 0.1% for 20 min, 0.1% for 10 min and 0.5% for 10 min, as well as with the application of hydrosol at 0.5% for 10 min and 0.5% for 5 min. The antioxidant activity of tomato fruit was found to increase with EO at 0.01% for 5 min. Similarly, an increase in antioxidants was observed in tomatoes treated with hydrosol at 0.5% for 10 min compared to the ones treated with 0.1% for 5 min and 0.01% for 10 min. For cucumbers, antioxidants were found to increase with EO at 0.5% for 20 min, whereas hydrosol application resulted in decreased antioxidants. It has been previously shown that EO application in fruits and vegetables can ignite the mechanisms related to plant tissue defense such as the production of antioxidants and the activity of antioxidant enzymes . This cols work) . The antomponent .Lycopene and β-carotene) content observed in the present study might be attributed to the antioxidant activity of EOs (and other plant extracts such as hydrosols), which can ignite the production of antioxidants in fruits as well as prevent the oxidation and loss of components of high nutritional value  [The increase in fruits’ (for both commodities) AA and tomato’s carotenoid (itamins) ,53. Fromitamins) ,55.O. dubium has been shown to present great in vitro antioxidant and antimicrobial activity; however, there is no known information about its in vivo application in fresh produce or its effects [E. coli in cucumber fruit, preserving the fruit’s quality and flavor [Satureja thymbra presented great antibacterial activity against Staphylococcus simulans, Lactobacillus fermentum, Pseudomonas putida, S. enterica and L. monocytogenes [S. thymbra EO are γ-terpinene and carvacrol, which are responsible for the antibacterial activity of this EO, and are also the main compounds of O. dubium. It seems that these compounds might present a synergistic effect in the action of EOs against a plethora of bacterial pathogens and non-pathogens. Moreover, O. dubium EO and hydrosol were found to be more effective against L. monocytogenes (in both fruits) compared to S. enterica. This is due to the different bacterial cell wall structure of Gram-bacteria  which contains a double lipid layer preventing hydrophobic molecules  from entering the cell wall [Clavibacter michiganensis subsp. michiganensis) to be more sensitive than three Gram- bacteria, including Pseudomonas syringae pv. tomato, Xanthomonas axonopodis pv. Vesicatoria and Xanthomonas axonopodis pv. phaseoli, when exposed to O. dubium EO. The fungicidal, insecticidal, antimicrobial and anticarcinogenic properties of O. dubium EO are related to the increased levels of carvacrol content [O. dubium EO was more effective than contact antibacterial activities [The essential oil of  effects . In the d flavor . Oreganod flavor . A previytogenes ,59. The ell wall . Similarell wall  found Gr content . A strontivities .The exploitation of MAPs for obtaining EOs and other plant extracts, and their use during postharvest treatments of fresh produce, should take place in moderation, especially for endemic species, and they should only be used as long as they can be cultivated and present high EO yields and quality. Another thing to consider for the use of essential oils is that they are considered to be a product of high cost; however, using them in the optimum dose (concentration × duration of application) might be cost-effective. Another factor for consideration when using EOs is the possible phytotoxicity when applied to produce and allergy issues during consumption. On the other hand, hydrosols are considered as by-products produced in greater quantities (opposed to EOs), with their biological activity providing the opportunity for further investigation of their uses.O. dubium) EO and hydrosol could be considered as alternative sanitizing agents of tomato and cucumber fruits. The applied EO doses (0.01% for 10 min and 0.1% for 10 min) were able to decrease the population of two main foodborne pathogens (L. monocytogenes and S. enterica—up to a 3.04 log decrease for L. monocytogenes). Similarly, O. dubium hydrosol (0.1% for 20 min and 0.5% for 20 min) resulted in decreased bacterial numbers. The most efficient sanitizing agent among the applied treatments  in the present study was found to be EO application at 0.1% for 10 min (in both fruits). The lower concentrations combined with shorter durations of application  were found to preserve the quality attributes  of tomato and cucumber, increasing the antioxidants and phenolic content of the produce and resulting in products of slightly increased nutritional value. Based on these promising results, further research is needed on O. dubium product  application at different doses and on other fresh produce.To conclude, Cypriot oregano (


In the US, approximately 60% of antimicrobial prescriptions (Rx) are written in the outpatient setting, and roughly 30% of those are unnecessary. The Tennessee Department of Health (TDH) previously described outpatient antimicrobial use in 2016 and 2018. TDH acquired additional data from the IQVIA Longitudinal Prescription and Medical Claims datasets. We sought to link antimicrobial Rx to diagnosis claims from preceding outpatient office visits to measure appropriateness of statewide antimicrobial Rx.IQVIA medical claims data and antimicrobial Rx data for calendar year 2020 were used in this study. A unique patient ID was used to track antimicrobial Rx over time. Prescriptions filled within 7 days after a patient’s medical visit were included. Diagnoses codes from the medical visits were categorized as Tier 1  and Tier 3 . Tier 2 diagnoses were excluded. We compared Tier 1 prescriptions versus Tier 3 Rx volume.We identified 2.3 million Rx linked to a preceding outpatient office visit within 7 days; 70.5% were filled within 3 days of the corresponding office visit, 14.1% within 4–5 days, and 15.4% within 6–7 days. Of all included Rx, 16.4% were prescribed following a pure Tier 1 diagnosis, and 83.6% were prescribed following a pure Tier 3 diagnosis. Diagnoses for respiratory conditions accounted for 38.4% of the pure Tier 3 visits, urinary tract conditions for 17.7%, gastrointestinal conditions for 16.2%, and skin and soft tissue conditions for 15.8%. For the respiratory conditions, viral upper respiratory infection accounted for the highest percent of antimicrobials prescribed (27.1%), followed by asthma/allergy indications (17%), and bronchitis (8.9%).A significant number of antimicrobials prescribed in Tennessee in 2020 were able to be linked to office visit diagnosis codes. Most Rx were prescribed for indications that do not require antimicrobial therapy. Respiratory conditions accounted for the highest percentage of visits resulting in antimicrobial therapy that did not require treatment. Continued educational efforts and provider feedback of these data are planned to combat unnecessary overprescribing in Tennessee.Milner B. Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds.


Psychiatric staff could be exposed to various types of violence that might have potential consequences on their psychological balance.To detect post-traumatic stress disorder (PTSD). To assess the professional quality of life among psychiatric hospital workers.A descriptive cross-sectional study was conducted in the psychiatric department of the Hedi Chaker University Hospital in Sfax. The questionnaire study had three major components: the baseline participant characteristics,the post-traumatic stress disorder Checklist (PCL-5) for which a total symptom severity score cutoff of 38 was recommended as the cutoff for a positive screening test and the Professional Quality of Life Scale (ProQOL).Thirty-one participants completed the questionnaire. The sex-ratio was 0.93. The mean age was 41.5 years. All participants were exposed to physical or verbal assault. Physical aggression was the most traumatic behavior reported by 39.3% of psychiatric professionals. A feeling of insecurity when performing professional tasks was reported by 93.3% of participants. Among participants, 41.9% expressed the desire to change workplace. The mean score on the PCL-5 was 21.6 ± 15.35. Five participants (16.7%) had a PCL-5 score ≥ 38. The Compassion Satisfaction mean score was 37.48 ± 5.64. The burnout mean score was 26.41 ± 7.3 and the mean score at the secondary traumatic stress scale was 27 ±6.7.PTSD could result from stressful events encountered in the course of managing patients in mental health departments. Attention to post-traumatic event interventions may be useful both to reduce the rate of PTSD and to improve the professional quality of life among psychiatric staff.


The authors would like to make a correction to their published paper . We repo1. Paragraphs 2 and 3 in Section 2.2 should be corrected as:3, p = 0.0770, see Figure 2A).Classification and regression tree analysis determined 1.57% MIB1 immunopositivity as the optimal cutoff in this cohort. Tumors with a MIB1 expression below 1.57% had a slightly larger preoperative tumor size compared to tumors with a higher MIB1 expression exceeding or equal 1.57%, but statistical significance was missed . In contrast to MIB1, a higher preoperative tumor volume was seen for higher expression scores for all lymphocyte and macrophage markers, regarding the overall score. For the CART-derived cutoffs this was also the case except for CD3 .2. Paragraphs 1 and 2 in Section 2.3 should be corrected as:3 per year, it showed similar significant differences across the inflammatory marker scores as the preoperative tumor volume. Thus, a higher expression score of CD3, CD8, CD68 and CD163 was associated with larger preoperative tumor size and faster volumetric growth in vestibular schwannomas . In contrast, the proliferative activity (MIB1 expression) did not show a significant difference in volumetric tumor growth in cm3 per year . We next calculated the percentual volumetric tumor growth as a more representative marker for growth dynamic independent of the initial preoperative tumor volume. A MIB1 expression exceeding the cutoff at 1.57% had a significantly faster percentual volumetric tumor growth when compared to tumors with lower MIB1 expression  .Volumetric tumor growth was assessed for 189 cases (20.5%). When regarding tumor growth as the difference in volume in cmp = 0.0465). Otherwise, the growth rate showed no difference when evaluating the immunohistochemical markers for lymphocyte (CD3 and CD8) and macrophage infiltration (CD68 and CD163). Results were not significant for the complete score and CART-specified cutoffs for each marker .VS with a CD163 score of 0 showed a significant slower percentual tumor growth compared to tumors reaching a score of 1–4  was generated from available immune cell marker data. An IS of 0 was given to 343 tumors (37.4%), meaning neither the CART-specified cut off for prominent lymphocytic nor macrophage infiltration was reached. A total of 535 cases (58.4%) received a score of 1 and 38 schwannomas (4.1%) reached the maximum score of 2, indicating prominent expression of lymphocyte and macrophage markers. 3, compared to 3.62 cm3 for tumors with a score of 0 . In contrast to this, the percentual volumetric tumor growth was increased with higher inflammatory scores but without statistical significance . The preoperative tumor volume was increased for tumors with a higher IS . When both cohorts with scores 1 and 2 were combined the mean preoperative tumor volume reached 6.22 cm4. Paragraph in Section 2.5 should be corrected as:p = 0.0103). On the contrary, the inflammatory score did not reach statistical significance.To assess the impact of the proliferative marker MIB1 and the inflammatory score, a multivariate linear regression was used, and the previously established CART-specified cut offs were applied (Table 2). A MIB1 expression exceeding 1.57% was revealed as an independent factor for faster tumor growth The new CART-specific cut-off for MIB1, according to the corrected calculated percentual volumetric growth rates, was 1.57% MIB1 immunopositivity. In contrast to the original version of the manuscript, differences in preoperative tumor volume according to MIB1 expression were not statistically significant. Percentual volumetric growth remained statistically significant .The CART-derived cut-offs were recalculated based on the corrected percentual volumetric growth rates. Significant results for differences in preoperative tumor volumes according to CART-specific expression scores remained the same for all markers except for CD3 .p = 0.0465). However, the overall score was without significant differences. All other markers remained without statistical significance . In the original version of the manuscript, a higher inflammatory score was associated with slower tumor growth. Based on the corrected values, there is no statistically significant impact of the inflammatory score on percentual volumetric tumor growth  was recalculated with the corrected values. An expression of MIB1 above the CART-specific cut-off remained an independent factor for faster percentual volumetric tumor growth . A score of 1 for CD3 was observed in 523/919 cases (56.9% instead of 57.6%). A score of 1 was reached for CD163 325/915 cases (35.5%) instead of 235/915 (25.7%).Furthermore, we would like to correct some minor transition mistakes in the first results, as in The authors apologize for any inconvenience caused and state that the scientific conclusions are unaffected. The original article has been updated.


Our objective was to analyze the contribution of acute kidney injury (AKI) to the mortality of isolated TBI patients and its associated risk factors. Observational, prospective and multicenter registry (RETRAUCI) methods were used, from March 2015 to December 2019. Isolated TBI was defined as abbreviated injury scale (AIS) ≥ 3 head with no additional score ≥ 3. A comparison of groups was conducted using the Wilcoxon test, chi-square test or Fisher’s exact test, as appropriate. A multiple logistic regression analysis was conducted to analyze associated risk factors in the development of AKI. For the result, overall, 2964 (30.2%) had AIS head ≥ 3 with no other area with AIS ≥ 3. The mean age was 54.7 (SD 19.5) years, 76% were men, and the ground-level falls was 49.1%. The mean ISS was 18.4 (SD 8). The in-hospital mortality was 22.2%. Up to 310 patients (10.6%) developed AKI, which was associated with increased mortality . Associated risk factors (odds ratio (OR) ) were age (OR 1.02 (1.01–1.02)), hemodynamic instability (OR 2.87 to OR 5.83 (1.79–13.1)), rhabdomyolysis (OR 2.94 (1.69–5.11)), trauma-associated coagulopathy (OR 1.67 (1.05–2.66)) and transfusion of packed red-blood-cell concentrates (OR 1.76 (1.12–2.76)). In conclusion, AKI occurred in 10.6% of isolated TBI patients and was associated with increased mortality. Medical complications are common in traumatic brain injury (TBI) patients and potentially influence outcomes . SpecifiSpecifically, trauma might be associated with intravascular volume depletion, raised intra-abdominal pressure, rhabdomyolysis or sepsis, which are known to be associated with the development of AKI . IatrogeAKI was found to be an early phenomenon that negatively affected mortality and six-month neurological outcomes in TBI patients . HoweverOur objective was to analyze the contribution of acute kidney injury (AKI) to the mortality of isolated TBI patients and its associated risk factors in a large multicenter sample of TBI patients included in the Spanish trauma ICU registry (RETRAUCI).The observational, prospective and multicenter registry included 52 ICUs in Spain. It works in a web-based electronic database (retrauci.org) and is endorsed by the Neurointensive Care and Trauma Working Group of the Spanish Society of Intensive Care Medicine (SEMICYUC). The study was conducted in accordance with the Declaration of Helsinki, and the registry was approved by the Ethics Committee of Hospital Universitario 12 de Octubre, Madrid (12/209). Due to the retrospective analysis of deidentified data, informed consent was not obtained.All patients admitted to the participating ICUs from March 2015 to December 2019 who presented isolated significant TBI, defined as an abbreviated injury scale (AIS) ≥ 3 in the head area, were included. Patients with AIS head < 3 or patients with AIS ≥ 3 in any other anatomical area were not included in this study. Patients were managed according to the advanced trauma life support (ATLS) principles. Data on epidemiology, acute management in the prehospital and in-hospital stages, type and severity of injury, resource utilization, complications and outcomes were recorded. Patients were followed up with until hospital discharge.In this population, we analyzed the impact of AKI at any stage during hospitalization, evaluated with the risk, injury, failure, loss of kidney function and end-stage kidney disease (RIFLE) definition , which eRisk: serum creatinine × 1.5 or GFR decrease by 25%. UO < 0.5 mL/kg/h × 6 h.Injury: serum creatinine × 2 or GFR decrease > 50%. UO < 0.5 mL/kg/h × 12 h.Failure: serum creatinine × 3, or GFR decrease by 75% or serum creatinine ≥ 4 mg/dL with an acute rise > 0.5 mg/dL. UO < 0.3 mL/kg/h × 24 h, or anuria × 12 h.Loss: persistent acute renal failure = complete loss of kidney function > 4 weeks.End-stage kidney disease: end-stage kidney disease > 3 months.2).Where unknown, an estimation of the baseline creatinine values was calculated by using the modification of diet in renal disease (MDRD) formula  as the alteration of two or more organs with a maximum score ≥ 3 . Early M−Rhabdomyolysis: laboratory test determination of creatine kinase > 5000 U/L .−Trauma-associated coagulopathy: prolongation of the prothrombin and activated partial thromboplastin times over 1.5 times the control values, or fibrinogen < 150 mg/dL or thrombocytopenia  in the first 24 h.p-value < 0.10). We analyzed the contribution of AKI to crude and adjusted mortality by using logistic regression analysis. A p < 0.05 was considered statistically significant. We reported all results as stated in the RECORD statement [Quantitative variables are shown as mean ± standard deviation (SD), median (interquartile range) and qualitative variables as percentage. Groups with quantitative variables were compared using Wilcoxon test and groups with categorical variables using the chi-square test or Fisher’s exact test, as appropriate. The associated risk factors of developing AKI were analyzed by using multiple logistic regression analysis. The variables entered in the model were those associated with AKI in the univariate analysis  had AIS head ≥ 3 with no other area with AIS ≥ 3 and constituted the study cohort. The mean age was 54.7 (SD 19.5) years, 76% were men, and the main mechanism of injury was ground-level falls (49.1%). Only 2.6% of the cases had a penetrating trauma. Overall, 22% were receiving chronic treatment with antiplatelets or anticoagulants. The median Glasgow coma score was 11 (interquartile range 6–14). Up to 26.2% of the patients received prehospital intubation. The mean injury severity score (ISS) was 18.4 (SD 8). The mean new injury severity score (NISS) was 27.04 (SD 13.89). In 28.2% of the cases, an early (<24 h) neurosurgical procedure was necessary. Invasive neuromonitoring was used in 30.65% of the patients. Up to 62.5% received mechanical ventilation during their ICU stay. In this group, mechanical ventilation was used for 8.24 (SD 9.23) days. Tracheostomy was necessary in 14.18% of the whole sample. The length of patients’ ICU stays averaged 9.61 (SD 14.22) days. In-hospital mortality was 22.2%. The main reason for mortality was intracranial hypertension (65.99% of the deceased).Overall, 310 of the 2964 patients (10.6%) developed AKI, distributed by the categories of risk , injury  and failure . Up to 20 additional TBI patients were classified in the loss or end-stage kidney disease categories.p < 0.001), had a higher severity of injury , required more days of mechanical ventilation  and had a longer ICU stay . Prehospital intubation , hemodynamic instability , transfusion of packed red-blood-cell concentrates in the initial 24 h after injury  and transfusion of fresh frozen plasma in the initial 24 h  were more frequent in the AKI group. Once brain-injury-related variables have been factored in, the severity of brain injury for AKI patients had increased, as stated by the higher number of patients with Glasgow coma scale <9, the higher number of patients with pupillary abnormalities, the higher use of invasive intracranial pressure (ICP) neuromonitoring and the higher scores in the AIS head .No differences were found in sex, blood pressure, cardiac rate, shock index or respiratory rate at the initial medical attention. Ethanol poisoning was more frequent in non-AKI patients  because of AKI (0.5% of the whole sample of TBI and 4.8% of those who developed AKI).p < 0.001), even after adjusting for confounding factors such as age and AIS head (OR 2.22 (1.64–2.99). Mortality increased with higher stages of the RIFLE classification, ranging from 17.1% in TBI patients without AKI to 65.8% in the failure category (AKI was associated with increased mortality (39% vs. 17%, category .The risk factors associated with the development of AKI in isolated significant TBI patients are shown in The main findings of our study were that AKI was found in one in 10 patients with isolated significant TBI, similar to what was previously described in smaller samples of TBI patients. AKI was strongly associated with mortality. The logistic regression analysis identified the following clinical factors as being associated with AKI in isolated TBI: age, hemodynamic instability, rhabdomyolysis, trauma-associated coagulopathy and the early need for packed red-blood-cell concentrates.The pathophysiology of AKI in the neurocritically ill patients is complex and multifactorial ,5. The sSome points need to be addressed to put our results into context. First, our incidence was lower in isolated TBI patients than in the whole sample of trauma patients, including those with major extracranial injuries, despite the fact that some associated risk factors were the same . Second,We observed a low incidence of renal replacement in our patients, as found in previous studies ,19. The Strengths of our study include a large sample of TBI patients with a classification of AKI according to the RIFLE criteria. We believe that it delineates the epidemiology of AKI in isolated TBI patients, supporting the usefulness of trauma registries in the management and benchmarking of severe trauma patients . HoweverIn our study, including a large sample of isolated TBI patients admitted to the ICU, AKI was detected in 10.6% and was associated with increased crude and adjusted mortality. Age, hemodynamic instability, rhabdomyolysis, trauma-associated coagulopathy and the early need for the transfusion of red-blood-cell concentrates were associated risk factors of developing AKI.


Since its advent, the pandemic has caused havoc in multiple waves due partly to amplified transmissibility and immune escape to vaccines. Delhi, India also witnessed brutal multiple peaks causing exponential rise in cases. Here we had retrospectively investigated clade variation, emergence of new lineages and varied clinical characteristics during those three peaks in order to understand the trajectory of the ongoing pandemic. In this study, a total of 123,378 samples were collected for a time span of 14 months (1 June 2020 to 3 August 2021) encompassing three different peaks in Delhi. A subset of 747 samples was processed for sequencing. Complete clinical and demographic details of all the enrolled cases were also collected. We detected 26 lineages across three peaks nonuniformly from 612 quality passed samples. The first peak was driven by diverse early variants, while the second one by B.1.36 and B.1.617.2, unlike third peak caused entirely by B.1.617.2. A total of 18,316 mutations with median of 34 were reported. Majority of mutations were present in less than 1% of samples. Differences in clinical characteristics across three peaks was also reported. To be ahead of the frequently changing course of the ongoing pandemic, it is of utmost importance that novel lineages be tracked continuously. Prioritized sequencing of sudden local outburst and community hot spots must be done to swiftly detect a novel mutation/lineage of potential clinical importance.IMPORTANCE Genome surveillance of the Delhi data provides a more detailed picture of diverse circulating lineages. The added value that the current study provides by clinical details of the patients is of importance. We looked at the shifting patterns of lineages, clinical characteristics and mutation types and mutation load during each successive infection surge in Delhi. The importance of widespread genomic surveillance cannot be stressed enough to timely detect new variants so that appropriate policies can be immediately implemented upon to help control the infection spread. The entire idea of genomic surveillance is to arm us with the clues as to how the novel mutations and/or variants can prove to be more transmissible and/or fatal. In India, the densely populated cities have an added concern of the huge burden that even the milder variants of the virus combined with co-morbidity can have on the community/primary health care centers. Followiary 2020 , 5. A suary 2020 . In Indiary 2020 , 8. StudHence, a comparison between three peaks of infection in Delhi capital region is the focus of the present study. Here we have described clade variation, emergence of new lineages and varied clinical characteristics to understand the trajectory of the ongoing pandemic.Among 612 samples, 560 fell into the defined time period of peak definition. A total of 98 (16%) samples were collected during first peak, 83 (13.5%) during second peak and 379 (61.9%) during the third peak . The remWhenever peak-wise comparison was made, these 560 samples only were taken into consideration. For rest of the analyses, total 612 sequences samples were considered.Complete demographic and clinical details along with comparison across different peaks are as follows:(i) Overall clinical and demographic details. Among 612 cases, 60.4% (n = 370) were males and 39.54% (n = 242) were females. The age-wise distribution was as follows: 67 cases (0–10 yr), 210 cases (11–25 yr), 237 cases (26–50 years) and 98 cases (>50 yr). Majority of the enrolled cases  were symptomatic. Among these, severe acute respiratory illness (SARI) was recorded only in 19% (n = 70) and remaining cases presented with influenza-like illness (ILI). Fatal outcome was reported in 7.5% (n = 46) cases.(ii) Peak-wise comparison of clinical and demographic details. Males were more affected than females, but no significant difference was found across peaks. For age group I (0–10 yr), a significant difference was observed between three peaks (P = 0.03). Similarly, more cases belonging to age group II (11–25 years) were reported in third peak compared with first peak (P < 0.001) and second peak (P = 0.001) . Fraction of symptomatic cases gradually rose from 49% in first peak to 65% in third peak with statistically significant difference (P = 0.01). Maximum SARI cases were recorded during the third peak (P = 0.02). No significant difference in proportion of ILI cases was seen across the peaks  nomenclature .(i) Trends of various circulating lineages across peaks. The most frequently detected lineages in our data set were B.1.617.2 including its sub-lineages  and B.1.36 . However, some of the lineages were observed to emerge and wane with each emerging peak.n = 67, 68.40%) followed by B.1.1 . During the second peak, 13 different lineages were identified, among which B.1.36 was the predominant  followed by B.1.617.2 . Four lineages  continued to be detected during this peak also. There is a substantial rise of B.1.617.1 immediately after the end of second peak along with B.1.617.2. However, during the third peak the overall diversity of circulating lineages decreased to only 8. The B.1.617.2 variant overpowered other circulating lineages and became the most predominant lineage , during the third peak , B.1.1.7  and B.1.617.3 . Lineages detected during 1st peak  were not frequent during third peak. B.1.306 and B.1.456 were shared between second and third peak. B.1.216 was detected in all three peaks. However, these three lineages were found in only one samples each, during third peak.During the first peak, a total of 11 different lineages were identified. The most common lineage was B.1.36 , AY.12 , AY.6 . All lineages detected following third peak belonged to either B.1.617.2 or its sub-lineages.Post second peak, three novel sub-lineages of B.1.617.2,  started emerging. During third peak, these sub-lineages accounted for 16% of the total lineages in circulation  Evolutionary relationship among detected lineages. The phylogenetic relationship of all the lineages detected in our data set shows eight major clade members as per Nextstrain clade assignment  in ORF8 gene  of all the detected mutations were nonsynonymous SNPs followed by synonymous SNPs  . Among the 10 most frequent nucleotide mutations, the only genic deletion observed was of 6 bp region  . The mos= 3,415)  and 4D.In terms of mutation load, samples from first peak contained expectedly lesser number of total mutations compared to subsequent peaks. The median number of total mutations during first peak was found to be only 13 which further increased to 20 mutations/sample during second peak and to much higher number of 36 mutations/sample (2.8 times compared to first peak) during third peak .As depicted in Two of the most frequently detected lineages(B.1.36 and B.1.617.2) in the present study were compared in terms of clinical characteristics and associated mutations.(i) Comparison of clinical characteristics. For age group I (0-10 years), significantly more cases (24.4%) were affected by B.1.36 compared to B.1.617.2 (5.5%) (P < 0.05).2 (5.5%) . In cont(ii) Comparison of mutation profile. The number of nonsynonymous amino acid changes were found to be more in B.1.617.2 (63.7% vs 27%). Indel events were majorly present in B.1.617.2 (82.1%) compared to B.1.36 (7.1%) (6 (7.1%) .n = 13) was present exclusively during the first peak when this lineage was a predominant one. Interestingly B.1.36 acquired novel set of mutations (55.6%) exclusive to the second peak. Similarly in B.1.617.2, only 5.4% (n = 4) and 4.1% (n = 3) were exclusively present during second and pre third peak period respectively. During third peak B.1.617.2 acquired 77% (n = 57) novel mutations. Only one novel mutation was acquired following 30 days after third peak had subsided  and IV (≥51 yr) but during third peak more patients belonging to age groups I 0–10 years) and II 11–25 years) were observed. This can be attributed to the fact that vaccination was not recommendatory for these subsets of susceptible population in India at the time when they got infected. This is in concordance with other studies where younger population was more affected during later peaks .n = 49), AY.12 in 6% (n = 26), and AY.6 in 1.4% (n = 6) of samples.In our study, a total of 26 identified lineages dynamically varied over time. This temporal shifting in lineages is well documented across the world , 14. DurBecause of concerns of increased transmissibility and/or mortality, it is imperative to be vigilant about novel mutations and their biological effects , 14, 16.Furthermore, when we looked at the most frequent mutations , which were present in more than 90% of the sequences across all peaks and almost all lineages . These four mutations appear to dominate the mutation repertoire throughout the world and have been increasing gradually since the start of the pandemic . The mutviz. S:D950N in the S2 region may contribute to the regulation of spike protein . It further strengthens our observation that lineages over time are enriching their mutation repertoire. .Interestingly we also observed that on days when overall cases were not on the rise, the mutation load was still increasing with time, which possibly indicates that the lineages in low-level circulation were silently accruing mutations despite lack of high case burden. For example, the daily mutation load/sample in B.1.36 was 13.2 during first peak but increased to 20.2 during second peak. Similarly, in B.1.617.2 the daily mutation load/sample continuously rose from 24.3 during second peak to 35.9 in third peak and to 40.3 after the third peak had subsided. This shows that case burden and time for which the virus remains in circulation plays an important role toward rise of newer mutations .It was also noted that when gene-wise mutation burden was compared between two dominant lineages, a consistent pattern of over-abundance of mutations in the B.1.617.2 was observed. For E gene no mutation was shared between two lineages. All of the 14 mutations present in M gene was present in B.1.617.2 with only one mutation M:I82T  shared with B.1.36 . As mentioned previously this is the worth highlighting again that this shared mutation is present in high frequency in both the lineages. We also noted that a substantial proportion of S gene mutations (94.6%) in B.1.617.2 were acquired after second peak. As far as clinical characteristics are concerned, greater accumulation of mutations in B.1.167.2 compared with B.1.36 could have contributed toward more severe symptoms and increased fatality as seen during third peak in Delhi.Hence, we conclude that molecular epidemiology of SARS-CoV-2 needs to be studied continuously to track change in the amino acids. In addition, effect of such mutations in the disease transmission dynamics and pathophysiology must be promptly assessed. Recent news of emergence of a new variant “B.1.1.529- Omicron” which contains heavily mutated S gene (∼30 mutations) is making waves and has spread to approximately 30 countries around the world and counting including India . The panThis is a single center study and clinical details fetched from the specimen referral form were limited. Hence genomic studies with larger sample size integrating data detailing patient’s clinical course are warranted.To the best of our knowledge, this is the first study in which the data from three consecutive peaks of COVID-19 pandemic in Delhi, has been analyzed. The findings from our study suggest that lineage tracking and emergence of novel mutation is of paramount importance. Thus, it is strongly believed that we need faster sequencing in a greater number of samples in order to be ahead of the curve in the fight with SARS-CoV-2.The Department of Clinical Virology, at the Institute of Liver and Biliary Sciences, New Delhi (ILBS) is an ICMR  designated COVID-19 diagnostic facility and a satellite site for INSACOG (Indian SARS-CoV-2 Genomics Consortium). Respiratory specimens  tested for COVID-19 in the laboratory from 1 June 2020 to 3 August 2021 were included in the present study. Combined nasopharyngeal and oral swabs were collected from suspected cases of SARS-CoV-2 infection in viral transport media tubes (2 mL) and was subjected to COVID-19 RT-PCR assay for diagnosis. For NGS, RNA elutes after extraction from the viral transport media were used. For the purpose of the study, the time period of different peaks in Delhi was defined as follows: first peak: June to July 2020; second peak: November to December 2020; and third peak: April to July 2021.A total of 1,23,378 samples were tested from 1 June 2020 to 3 August 2021 among which 15,652 (12.6%) were found positive for COVID-19. Among these positives, a subset of 747 (4.7%) samples representing all three peaks of infection having a cycle threshold (Ct) of  ≤ 30 on reverse transcriptase real-time PCR (RT-PCR) were randomly selected from our in-house database and subjected to whole-genome sequencing.Complete demographic and clinical details of patients infected with SARS-CoV-2 were recorded from the specimen referral form issued by ICMR. Cases were divided into different age groups: ≤10, 11–25, 26–50, and >50 years.Outcomes of all the enrolled cases were recorded via telephonic interviews. The cases were classified into various groups as per WHO clinical definition .Total viral RNA was extracted using 300 μL of specimen using Chemagic Viral DNA/RNA kit  in a Chemagic 360 instrument  following manufacturer’s instructions. A 10 μL of the extracted viral RNA elute was further subjected to RT-PCR for the detection of SARS-CoV-2 using RealStar SARS-CoV-2 RT-PCR  targeting E gene and S gene. All the positive specimens were grouped into three categories based on Ct values obtained: low (Ct ≤20), medium (Ct 21–25) and high (Ct 26–30).Sequencing of the viral isolates was done by Illumina COVIDSeq protocol on NextSeq 550 platform as per the manufacturer’s instructions. The quality check of the prepared libraries was performed using DNA high sensitivity assay kit on Bioanalyzer 2100 . The concentration of the libraries was assessed on Qubit . For amplification and cDNA conversion steps during library preparation, Veriti 96-Well Thermal Cycler (Applied Biosystems).NC_045512.2). The alignment of unmapped reads to a reference genome and generation of a consensus genome sequence was done within the custom Illumina BaseSpace Sequence Hub. The lineages nomenclature for each sequence was retrieved using Illumina DRAGEN COVID Lineage App (v3.5.3) following the default parameters. The minimum accepted alignment score was set to 12 and results with scores <12 were discarded. The coverage threshold and virus detection threshold were set to 20 and 5 respectively. The variant calling target coverage which specifies the maximum number of reads with a start position overlapping any given position was set at 50.The raw data in the form of binary base call format (.bcl files) was generated from the NextSeq 550 instrument. These raw files were converted, demultiplexed to fastq file using bcl2fastq  and were aligned against the SARS-CoV-2 reference genome  samples with genomic coverage > 80% were finally selected for downstream analysis. The median genomic coverage of quality passed samples was 98.8 while the median sequencing depth was 1805 .NC_045512.2) was used for generating phylogenetic tree . To do this, first multiple sequence alignment was done using MAFFT (MAFFT v7.487) with the default options. After performing the alignment, the FASTA file was further refined to perform biologically relevant trimming. Finally, FastME was used for distance-based inference to create an output tree file which was used for visualization of phylogenetic tree. The annotation of nucleotide sequences was done based on NUCMER (Nucleotide Mummer) alignment tool, version 3.1 (a part of the MUMmer package). The mutations are classified according to frequency, the genomic coordinates affected and their subsequent effect on amino acid sequences (Table S2). The retrieved sequences were deposited in the public repository, GISAID  details of which are provided as supplementary data (Table S3). Refer to the supplementary data for extended methodology.QC-threshold passed FASTA files containing sequences from 612 SARS-CoV-2 samples and a reference genome of SARS-CoV-2 isolate named Wuhan-Hu-1 (NCBI Reference Sequence: The raw sequencing data of all the samples have been submitted to the GISAID database and the submission details are given in the Table S3 in the supplemental material. Moreover, the sequences in the FASTA format are also supplied as Table S1.


Hepatitis B virus (HBV) is generally endemic in resource-limited countries, which are characterized by a deficit of technical facilities that could delay diagnosis and treatment. To facilitate the accessibility to diagnostic and connection to treatment, evaluation, and promotion of alternatives and/or simplified strategies and inexpensive tools such as dried blood specimens need to be investigated and implemented. This study aimed to evaluate dried blood spots (DBS) for the detection and quantification of HBsAg. This study included 100 DBS from subjects tested positive for HBsAg, and 50 DBSs from subjects tested negative for HBsAg by the automate Architect i1000sr . Hepatitis B surface antigen detection was performed with determine HBsAg Alere® tests  and Architect® HBsAg Qualitative II Assays  after 15 and 30 days . For HBsAg-positive subjects, the quantification of HBsAg was performed at day zero (D0) from plasma and at D15 and D30 from the DBSs. At D15, the sensitivity and specificity were 96% and 100% for the Determine® tests and 100% and 100% for the Architect® tests, respectively. At D30, the sensitivity and specificity were 96% and 100% for the Determine® tests and 100% and 100% for the Architect® tests, respectively. For HBsAg quantification, the agreement rates were 96%, 96% and 100% between D0-D15, D0-D30 and D15-D30, respectively. This work showed that DBSs can be very useful for HBsAg detection and quantification and therefore in the management of HBV infection in resource-limited settings. With a total of 257 million hepatitis B virus (HBV) chronic carriers, hepatitis B infection remains a major public health problem, especially in endemic areas . In 2015Automated platforms for diagnosis like Architect Analyzer  are widely used in developed regions and have been validated for both plasma or serum ,11,12. HPatients and samples: this prospective study was performed at the Bacteriology-Virology Laboratory of the University Hospital Center Le Dantec, Dakar, Senegal. Whole blood samples were collected in ethylenediamin tetra-acetic acid (EDTA) tubes from patients after informed consent.Specimen preparation: from each blood sample collected from patient, an aliquot was centrifuged to obtain plasma. Testing for HBsAg was first performed on 125 μl of plasma with the automate Architect HBsAg Qualitative II assay , with a positive result if s/co value (Relative Light Units (RLUs) value of the sample/ RLUs value of the threshold value) is greater than 1. Therefore, a total of 100 positive samples for HBsAg and 50 negative samples were retained to prepare the DBSs. Fifty microliters of venous blood were then deposited on each of 5 circles of Whatman 903™ filter paper . After drying, the DBS samples were stored at room temperature (22-25°C) in the presence of desiccants and humidity indicators until detection and quantification tests that were completed at 15 days (D15) and 30 days (D30).Detection of HBsAg from DBSs: at D15 and D30, 3 spots measuring 6 mm each were cut from each DBS card and then eluted in 600 μL of phosphate buffered saline (PBS) buffer for 2 hours at room temperature. The qualitative detection of HBsAg in the eluates was performed using Architect HBsAg Qualitative II and Determine® HBsAg  kits according to the manufacturer´s instructions.Quantification of HBsAg from plasma and DBS: quantification of HBsAg was performed at D0 from 150 μl of plasma for each of the 100 samples positive for HBsAg and from the DBS samples at D15 and D30. Given the dilution of the blood by the elution of DBS and the hematocrit level, all the quantification values obtained at D15 and D30 were corrected by a conversion factor of 35.58. The cutoff point for the positive quantification of HBsAg was 0.05 IU/ml [05 IU/ml .Statistical analysis: the results obtained for the detection and quantification of HBsAg on plasma and the DBSs (D15 and D30) were entered into Microsoft Excel and analyzed with Epi Info 3.5.1.  with a 95% confidence interval (95% CI). For HBsAg detection, the results from Determine® HBsAg and Architect HBsAg Qualitative II tests on the DBSs (D15 and D30) were compared with those obtained by the Architect HBsAg Qualitative II assays on plasma by calculating the sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV). For HBsAg quantification, the results obtained on the DBSs (D15 and D30) and plasma were converted into logarithmic (log) values and were compared to the values obtained with plasma. The log difference was calculated, and any value greater than 1 log was considered significant. In addition, correlation and concordance were determined by regression line calculation and Bland-Altman plots with MethVal software.Qualitative detection of HBsAg in plasma with the Architect HBsAg Qualitative II test: HBsAg-positive plasma samples (n=100) exhibited optical densities (s/co) ranging from 124.7 to 6626.75 with a median value of 3626.84, and 99% had an Optical Density (OD) > 1000 s/co. All negative plasma samples (n=50) presented a s/co ratio less than 1.Qualitative detection of HBsAg on DBS with the Architect HBsAg Qualitative II test: the eluates of the 150 DBS were all tested at D15 and D30 with the Architect® HBsAg Qualitative II test for HBsAg. A 100% agreement was noted between plasma and DBS at both D15 and D30 , resulting in an overall agreement of 97.3% (of 97.3% . Therefoof 97.3% .Quantification of HBsAg in plasma: the quantification of HBsAg from the 100 positive plasma samples showed concentrations ranging from 3.67 IU/ml (0.56 log IU/ml) to 50,208.61 IU/ml (4.70 log IU/ml), and the median value was 6658.38 IU/ml (3.82 log IU/ml).Quantification of HBsAg on DBS on D15 versus plasma: at D15, the HBsAg concentrations varied between 6.04 IU/ml (0.78 log IU/ml) and 40,675.41 IU/ml (4.60 log IU/ml) with a median value of 2739.30 IU/ml (3.43 log IU/ml). The comparison between plasma and DBS at D15 showed a concordance rate of 96% (n= 96) with a log difference less than 1 (not significant), and only 4% (n=4) presented a log difference ≥1. Moreover, the comparison of the quantification of HBsAg between D0 in plasma and D15 for the DBS showed a good correlation with r=0.82 and a bias (mean of the log differences) of -0.332 (- 0.424 to - 0.230), with 5 samples outside the 95% confidence interval  and 43,093.42 IU/ml (4.63 log IU/ml) with a median value of 1798.03 IU/ml (3.25 log IU/ml). Less than 1 log difference was noted between D0 and D30 for 96% (n=96) of the samples versus 4% with a log difference ≥1. By comparing the quantification of HBsAg in plasma at D0 and at D30 for the DBS, regression analysis showed a good correlation (r=0.83), and the Bland-Altman plot indicated a bias of -0.408 (-0.558 to -0.378), with 5% of the samples falling outside the 95% confidence interval , with 10 samples falling below the lower limit of the 95% confidence interval  after HIV/AIDS infection, malaria, and tuberculosis -19. The This study aimed to evaluate the performance of DBSs with two techniques using plasma as a reference sample. In the qualitative detection of HBsAg, the results indicated a good performance from the Determine® HBsAg and Architect® HBsAg tests with DBSs, with respective sensitivities of 96% and 100% at D15 and 96% and 100% at D30 and an excellent specificity of 100%. Several studies have also evaluated DBSs by immunochromatography . Enzyme-In the quantification of HBsAg from plasma, the results obtained varied between 3.67 and 50208.6 IU/ml (0.56 - 4.70 log IU/ml). In addition, the comparison between the quantification values of HBsAg from plasma and DBSs showed good correlations (r=0.82 and 0.83), with biases of -0.332 and -0.408, respectively, on D0-D15 and D0-D30. A better correlation (r=0.98) with a bias of -0.17 was found in the quantification of HBsAg on the Architect platform from DBSs . This imThis study showed that the diagnosis of hepatitis B from DBS specimens is feasible. Therefore, DBSs could be an alternative tool that could be implemented and reach populations in remote areas where there are difficulties in transporting fresh blood samples to referral centers. Optimization studies should be continued with the goal of validating this tool, which could help systematize HBsAg screening, improve the care and follow-up of patients infected with HBV, and vaccinate patients with a negative HBV serology. Finally, this study underlines the importance of this alternative method, which can lead to recommendations for decision-makers and providers for a reorientation of national strategies in the diagnosis and management of HBV in Senegal and other highly endemic, resource-limited countries and may serve as a key element that contribute to reaching the 2030 goals.Access to hepatitis B diagnosis is a difficulty in remote areas where technical facilities are not available.Feasibility of hepatitis B diagnosis from DBS specimens;Possibility for remote areas having difficulties in transporting fresh blood samples to have DBS as an alternative tool.


To evaluate the efficiency and safety of sentinel lymph node biopsy (SLNB) in patients with breast cancer with complete response to neoadjuvant chemotherapy (NAC).  Ninety-two consecutive (T1-4 and N1-2) patients with breast cancer who had pathologic and/or clinical and radiologic axillary lymph node involvement were included. All patients received NAC. Patients with a clinical and radiologic complete response in the axilla after NAC underwent SLNB. Pathologic complete response (ypCR) was defined as the absence of residual invasive and in situ cancer, and near-complete response (ypNCR) represented in situ and/or ≤ 1 mm residual tumor in the breast and/or presence of malignant cell clusters (≤0.2 mm) and/or micrometastases (≤2.0 mm) in the axillary lymph nodes (ALN) . p=0.063).  The mean age of the 92 patients was 49.6 ± 10.3 years and the mean follow-up was 34.0 ± 17.8 months. With respect to breast tumors, 23 (25.0%) patients had complete and 14 (15.2%) had a near-complete response to NAC. Complete response in ALN was obtained in 39 (42.4%) patients and near-complete in six (6.5%) patients. The overall survival of the 33 patients who achieved ypCR and ypNCR was 100% and the remaining 59 patients with partial or no response to NAC was 83.1% at a mean follow-up of 34 months ( In this study, no event developed in cases with ypCR and ypNCR in the breast and axilla. The persistence of the same results in long-termfollow-ups may enable the use of ypNCR as a positive prognostic marker in addition to ypCR. Neoadjuvant chemotherapy (NAC) was used in the 1970s to convert inoperable tumors into operable tumors and was later expanded to include early-stage breast cancer with an intent to perform breast-conserving surgery (BCS), especially for large tumors . TaxanesIn this study, we aimed to retrospectively evaluate the oncologic safety of SLNB in patients with breast cancer whose axilla was pathologically and/or clinically and radiologically metastatic at the time of diagnosis and who had had a complete response after NAC.Between 2013 and 2020, 92 consecutive (T1-4 and N1-2) patients with breast cancer with radiologically and/or pathologically proven axillary involvement, and those who underwent SLNB, following clinical and radiologic complete response after NAC, were included in the study. Patients with T0, N0, or in-situ tumors, inflammatory type and metastatic breast cancers, and those with no axillary response to NAC were excluded from the study. The patients were evaluated using breast ultrasonography (USG), mammography, and magnetic resonance imaging (MRI), and all of them underwent imaging-guidedtru-cut biopsy of the primary tumor and fine-needle aspiration biopsy (FNAB) and/or tru-cut biopsy of axillary lymph node(s). PET/CT was performed in the majority of patients for the assessment of metastasis. Of the patients who could have BCS, the tumor was marked with a metal clip under USG or mammography guidance.2, cyclophosphamide 600 mg/m2 or EC/T; epirubicin 90 mg/m2, cyclophosphamide 600 mg/m2) followed by either weekly paclitaxel (80 mg/m2) for 12 cycles or thrice-weekly docetaxel (80 mg/m2) for four cycles. In addition, patients with c-erbB2 positive luminal B tumors and c-erbB2-rich tumors received dual therapy with trastuzumab and pertuzumab. All patients were clinically and radiologically evaluated every two cycles of NAC, and unresponsive patients or those with progressive disease were excluded from the study and directed to surgical treatment.In this study, NAC consisted of anthracyclines plus taxanes (AC or EC/T). All patients received an anthracycline-based regimen thrice weekly in the first four cycles . Cavity revision was performed in patients with positive surgical margins. The remaining space after re-excision of the tumor was marked with metal clips for adjuvant radiotherapy planning. Mastectomy was performed in patients with extensive primary tumors and poor response to NAC.The sentinel lymph node is identified with a dual method consisting of radiocolloid and isosulfan blue. Three or more sentinel lymph nodes (SLNs) were removed in each patient. They were immediately examined on FS or seldom left to the evaluation of paraffin blocks. Axillary lymph node dissection was performed in patients whose sentinel lymph nodes could not be identified and in those with positive SLNs.All patients received 50 Gy adjuvant radiotherapy (RT) delivered in 25 fractions to the entire breast in those treated with BCS (BCS 10 Gy Boost 5 fractions) or to the chest wall for mastectomy and axillary (level I-II-III) and supraclavicular lymph node regions. Adjuvant trastuzumab treatment was administered to patients who were c-erbB2 positive for 1 year. Adjuvant hormone therapy was given to patients with hormone receptor-positive disease; tamoxifen was given to premenopausal patients and aromatase inhibitors to postmenopausal patients.  Pathologic complete response (ypCR) was defined as the absence of residual invasive and in situ cancer on hematoxylin and eosin evaluations of the completely resected breast specimen and all sampled regional lymph nodes i+) malignant cell clusters (≤0.2 mm) and/or pN1mi micrometastases  in the axillary lymph nodes  Pathologic near-complete response (ypNCR) represented in situ and/or ≤ 1 mm residual tumor in the breast (ypTis/T1mi) and/or presence of pN0 : residual tumor burden in the breast > 1 mm and/or at least one metastasis in the axilla > 2.0 mm  Unresponsive (ypNR): no response in the breast and axilla or progression of the diseasePathologic response to NAC (yp) was classified as follows:t-test for dependent samples. Statistical significance was set at p < 0.05.Descriptive statistics are presented as frequencies and percentages for categorical data and means and standard deviations to summarize scale-type data. Kaplan–Meier survival analysis was conducted to estimate survival and to compare the differences in survival according to breast and lymph node responses to NAC. The patients' pre- and post-NAC pathologic parameters were compared using McNemar's test for categorical variables and pe- and post-NAC mean ER, PR, Ki67, and p53 values were compared using the The mean age of the 92 patients included in our study was 49.6 ± 10.3 years (minimum 30-maximum 77). At the time of diagnosis, 39.4% of the patients had a family history of breast cancer. Fifty-one (55.5%) patients were premenopausal and 41 (44.5%) were postmenopausal. The mean follow-up period was 34 ± 18 months. Axillary FNAB was not present in 21 patients (22.8%) who were referred from other centers. FNAB results were negative or nondiagnostic in 15 (16.3%) patients in our center. Of these 36 (30.1%) patients whose axillary metastasis could not be proved histopathologically, the diagnosis of axillary involvement was substantially based on physical examination findings and at least one of the accompanying axillary USG, Breast MRI, and PET/CT techniques. In the remaining 56 patients, the FNABs of 47 (51.1%) patients were reported positive, and nine (9.8%) were suspicious for metastasis. All patients received NAC and completed the treatment protocol. Thirty-three patients had c-erbB2 positivity. Of these, 25 received 12 months of adjuvant trastuzumab, and eight had dual therapy (trastuzumab + pertuzumab). Genetic counseling and testing were performed in 16 patients and no mutation was identified.p < 0.001). The numbers of patients with clinically near-complete and complete responses after NAC were 16 (17.4%) and 18 (19.6%), respectively.The clinical stages of the patients before and after NAC are shown in The pre- and post-NAC USG and MRI evaluation of the axilla and pathologic evaluation of the breast tumor are shown in Tables 2BCS was performed in 64 (69.6%) and mastectomy in 28 (30.4%) patients. SLNB was performed on 44 patients (47.8%). Axillary lymph node dissection (ALND) was performed on 36 (39.1%) patients with metastasis in SLNs in FS analysis and 12 (13.1%) patients whose SLN was not detected during surgery. SLNs were evaluated using intraoperative FS in 61 patients. The characteristics, pathology results, and complementary treatments of the patients whose SLNs were evaluated from paraffin blocks are shown in p=0.007), and for axillary lymph nodes they were (62.5% vs. 100%) and (6.3% vs. 0%) (p=0.007).In terms of breast tumors, ypCR was obtained in 23 (25%) patients, ypNCR in 14 (15.2%) patients, and partial response in 52 (56.5%) patients after NAC. The response of axillary lymph nodes to NAC was ypCR in 39 (42.4%) patients, ypNCR in six (6.5%) patients, and ypPR in 30 (32.6%) patients. In patients receiving trastuzumab or dual therapy, ypCR and ypNCR rates of breast tumor were (50% vs. 50%) and (12.5% vs. 37.5%)  patients died. There was no mortality among the 37 patients who demonstrated ypCR and ypNCR in breast tumors after NAC. Survival at 74 months was 82.7% in patients with ypPR and at 33 months 66.7% in patients with ypNR . Also, eIn this study, 92 consecutive female patients with clinical stage cT1-4 and N1-2 breast cancer underwent NAC to achieve clinical downstaging and subsequently perform as much BCS and SLNB as possible. Slightly different from the literature, we created a separate patient group under the name of near-complete response (ypNCR) to NAC based on the histopathologic evidence and very positive course in their clinical follow-ups. In our patients, there was 93.5% cT1-2 tumor and 6.5% cT3-4b tumor before NAC. As expected, following NAC, 23.9% of patients had cT0, 72.8% had cT1-2, and only one patient had a cT3 tumor. In the examination performed with imaging methods, a clinical complete response was obtained in the breast tumors of 19.6% of the patients (18/92) after NAC. These results were accompanied by a clinical complete response in the axillary lymph nodes of 98% of patients after NAC. With the assurance of these results, BCS was performed on 69.6% (64/92) and SLNB was performed on 57.6% (53/92) of the patients.p=0.3). Concerning breast tumors, 23 patients (25%) had a histopathologic complete response (ypCR) and 14 patients (15.2%) had a near-complete response (ypNCR) after surgery. In terms of axillary lymph nodes, there was ypCR in 39 (42.4%) patients, ypNCR in 6 (6.5%) patients, partial response in 30 (32.6%) patients, and no response in 17 (18.5%) patients. The estimated OS after NAC and surgery was 100% in patients with ypCR and ypNCR in breast tumors and 92.3% and 100%, respectively, in patients with ypCR and ypNCR in axillary lymph nodes.FNAB was performed on the axillary lymph nodes of 56 patients before NAC. Forty-seven of them (51.1%) had a definitive histopathologic diagnosis of metastases and nine patients (9.8%) had suspected metastases. Assuming that all of these 56 patients would otherwise undergo ALND, the administration of NAC reduced this number from 56 to 48 (p=0.3). More importantly, the rate of BCS has increased significantly with the preoperative application of this combination  [Preliminary randomized studies investigating the efficacy of NAC containing doxorubicin and cyclophosphamide (AC) in patients with operable breast cancer achieved nearly the same 5-yeardisease-free and OS rates compared with the placebo group , 8. In rp=0.55). For the cN0/ypN0 group and the cN1-2/ypN0 group, the 5-year axillary recurrence rate was 1.0% and 0% (p=0.44), respectively. This result accentuated the insignificance of clinical nodal status in patients who achieved ypN0 disease after SLNB [There are many studies in the literature showing the oncologic safety of SLNB alone after NAC in patients with breast cancer with clinical N1-N2 disease. For example, Wong et al. reported 11.3% recurrence among 211 women who underwent SLNB alone during a median follow-up of 36 months. The 5-year local recurrence rate was 5.7% for patients with cN0 disease and 4.1% for patients with the cN1-2 disease .During a mean follow-up period of 34 ∓ 18 months, 10 of 92 (10.9%) patients deceased. There was no death among patients with ypCR and ypACR in breast tumors after NAC. However, the survival rates of patients who did not respond to NAC or had a partial response were 66.7% and 82.7%, respectively, and were statistically significantly lower than those with ypCR and ypACR (Pathologic complete response (pCR) is the cornerstone for treatment success after NAC because NAC offers advantages such as higher BCS rates, and identifying subsets of patients with high pCR rates will allow surgeons to perform less invasive surgery. On the other hand, in the analysis of seven randomized studies, the hazard ratio for DFS was found as 0.446 in patients who developed pCR after NAC, and this ratio was observed as 0.523 in patients with in situ residues in breast tumors . AlthougIn this study, no event developed in cases with complete and almost complete histopathologic responses in breast tumors and axillary lymph nodes. The persistence of the same results in long-term follow-ups may enable the use of near-complete response as a positive prognostic marker in addition to complete response.


Soft tissue sarcomas are a highly heterogenous group of tumors with limited systemic therapy options. Eribulin, a synthetic analogue of halichondrin B, is a potent mitotic inhibitor. A phase 3 trial of previously treated advanced Liposarcoma and Leiomyosarcoma demonstrated superiority of eribulin to dacarbazine. Eribulin appears to be particularly effective for liposarcomas. It has also been shown to be a safe and effective treatment alternative to doxorubicin in patients where doxorubicin is contraindicated. From retrospective studies, eribulin has demonstrated efficacy in patients with angiosarcoma, pleomorphic sarcomas, synovial sarcomas, rhabdomyosarcomas, angiosarcomas, and myxofibrosarcomas. Future areas of development include liposomal eribulin, which may provide increased efficacy and lower toxicity, and delineation of biomarkers of response and resistance, allowing better selection of patients for treatment. STS make up approximately 80% of all sarcomas. There are over 100 different subtypes . LiposarDoxorubicin, with or without ifosfamide, is the first line treatment in the majority of patients with advanced STS. There are limited second line treatments and the choice depends on STS subtype and patient performance status. Second line treatments include pazopanib, trabectedin, eribulin, and gemcitabine, with or without docetaxel or dacarbazine. Pazopanib, a tyrosine kinase inhibitor of angiogenic growth receptors, has shown superiority to placebo in a randomized placebo-controlled phase 3 trial in STS . TrabectEribulin is an inhibitor of microtubule polymerisation and is a synthetic analogue of the naturally occurring anticancer agent halichondrin B found in marine sponges . As wellIn this review, we summarize preclinical and clinical data showing efficacy of eribulin in STS. We compare the efficacy across different STS subtypes. We also review potential predictive biomarkers of eribulin response as well as possible combination regimes and other future perspectives.There are several mechanisms of action of eribulin and these are detailed in Although the predominant mechanism of action of eribulin in STS and breast cancer is likely similar, there is evidence that eribulin induces distinct differentiation patterns depending on the cell of origin. In breast cancer cells, eribulin reverses the epithelial to mesenchymal transition . EpithelEribulin has also been shown to have effects on cell motility. In one study LPS cells were treated with Eribulin and compared with untreated cells. Eribulin was found to stop migratory activity in the treated cells and it was shown that Rho proteins, which are believed to be instrumental in cell migratory activity, was downregulated .in vitro activity of eribulin has been shown against a wide range of STS, including fibrosarcoma, LMS, LPS and synovial sarcoma by induction of G2–M cell-cycle arrest and apoptosis  being progression free at 12 weeks. This was followed by 12 (31.6%) in the LMS group, 4 (21.1%) in the synovial sarcoma group and 5 (19.2%) in “other” sarcomas. The five patients in the other histological subtypes were two fibroblastic sarcomas, two epithelioid sarcomas and one solitary fibrous tumor. The most common grade 3–4 adverse events (AEs) included neutropenia (52%), leukopenia (35%), anemia (7%), fatigue (7%) and raised alanine aminotransferase (5%).Another phase 2 study, by Kawai et al., included 51 Japanese patients with STS who had received one or more prior chemotherapies for advanced disease. In that study, 16 patients had LPS, 19 had LMS and the remaining 16 consisted of synovial sarcoma, undifferentiated pleomorphic sarcoma, rhabdomyosarcoma, endometrial sarcoma, fibrosarcoma, solitary fibrous tumor, alveolar soft part sarcoma and malignant peripheral nerve sheath sarcoma. The LPS group had a median PFS of 6.8 months (95% CI 5.1–8.4) and the LMS group 2.9 months (95% CI 1.3–8.2). In the “other” sarcoma group, median PFS was 4.1 months (95% CI 2.6–5.6). The most common grade 3–4 AEs were neutropenia (86%), leukopenia (38%) and lymphopenia (33%) .2 on days 1 and 8) or dacarbazine  in a 21-day cycle. The primary endpoint was median OS. Secondary endpoints were PFS, PFS at 12 weeks, and safety and tolerability as assessed with CTCAE v4.02. 351 patients of the 452 randomized patients were anthracycline pre-treated (77.7%). The LMS group made up 297 (67%) patients and 131 (45%) were of uterine origin.To further assess the efficacy of eribulin in STS, a phase 3 randomized open label trial was undertaken . PatientThe primary endpoint of median OS was met. The median OS was 13.5 months (95% CI 10.9–15.6) in the eribulin arm compared to 11.5 months (95% CI 9.6–13.0) in the dacarbazine arm, with a HR of 0.77 (95% CI 0.62–0.95). There was no statistically significant difference in median PFS, with 2.6 months (95% CI 1.9–2.8) PFS in both arms (95% CI 1.8–2.7). Likewise, the proportion of patients who had not progressed at 12 weeks was also similar, with 76 patients  having not progressed after 12 weeks in the eribulin arm versus 64 patients  in the dacarbazine group. Furthermore, the response rates were low, with a non-significant difference (ORR 3.9 vs. 4.9%).Treatment related AEs were common, with 224 (99%) and 218 (97%) patients experiencing AEs in the eribulin and dacarbazine arms respectively. Grade 3 AEs were higher in the eribulin  versus the dacarbazine arm . There was study drug withdrawal in 17 (8%) patients in the eribulin arm versus 11 (5%) in the dacarbazine arm, and dose reduction in 58 (26%) patients in the eribulin arm versus 32 (14%) in the dacarbazine arm.As a highly heterogenous group of tumors, it is unsurprising that a variety of responses would be seen in different subtypes of STS. In the preplanned OS subgroup analysis, performed in the previously described phase 3 randomized trial, LPS patients benefited from eribulin  compared to LMS patients . Although the small numbers involved in different LPS subtypes make it difficult to make any firm conclusions on the relative responsiveness of different LPS subtypes, the benefit from eribulin was observed across all LPS subtypes. The analysis showed more robust benefit for pleomorphic LPS, with a median OS of 22.2 months in the eribulin arm versus 6.7 months in the dacarbazine arm (HR 0.18 95% CI 0.04–0.85). The dedifferentiated subtypes had an extended median OS in the eribulin arm of 18.0 versus 9.6 months (HR 0.43 95% CI 0.23–0.79) in the dacarbazine arm. The myxoid subtype showed a more modest 13.5 months OS in the eribulin arm, versus 8.1 months in the dacarbazine arm (HR 0.79 95% CI 0.42–1.49) .Furthermore, performance status (PS) is important when selecting patients most likely to benefit from eribulin. Patients with a PS of 0 showed greater benefit when given eribulin compared to dacarbazine, with an OS of 19.9 vs. 13.1 months . However, in patients with a PS of 1–2 there was no statistically significant difference in OS between the eribulin group (9.2 months) and the dacarbazine group at .p = 0.036; HR 0.51 (95% CI 0.26–0.93)] but no impact on OS was seen. ATRX mutations were shown to have a negative impact on both PFS and OS . Grade 3 and 4 non-hematological toxicities were also associated with low skeletal muscle gauge (p = 0.04) as well as low serum albumin level (p = 0.02)  .Angiosarcomas are a highly aggressive tumor of endothelial tissue. They represent 1–2% of all sarcomas. They can develop throughout the body but about 60% are cutaneous . AnthracIn a single-arm prospective observational study of 25 patients who had previous treatment with a taxane, eribulin was given for cutaneous angiosarcoma . The ageThere are many other subtypes of STS that have limited treatment options. Small numbers of non LPS and LMS STS subtypes were included in phase 1 and 2 studies. These data are summarized in, Median age in the study was 62 (range 17–87) years and 84% (214 out of 256) had an ECOG performance status of 0 or 1. Median time from diagnosis to initiation of eribulin was 2.5 years (range 0.2–29.2). Target lesions were most commonly retroperitoneal or intraperitoneal (40.4%). The most common number of prior chemotherapy regimens was one (31.8%) followed by two (29.0%). Only 7.1% received eribulin first line. The most common prior chemotherapeutic regimen was doxorubicin monotherapy (36.9%), followed by pazopanib (32.2%), gemcitabine and docetaxel (26.7%) and doxorubicin and ifosfamide (22.7%). A total of 174 grade 3 or 4 SAEs were seen. The most AE was neutropenia, which was seen in 52.5%. Fifty-five patients (21.6%) underwent dose reduction.A partial response was seen in 17 patients. Excluding LPS and LMS, 10 out of 143 had partial responses. This was seen in 2 out of 19 undifferentiated pleomorphic sarcomas, 3 out of 15 synovial sarcomas and 2 out of 12 rhabdomyosarcomas. A partial response was also seen in one patient, each in the angiosarcomas , myxofibrosarcoma  and undifferentiated round cell sarcoma .Another retrospective Japanese study of 82 STS patients treated with eribulin included 45 patients that had neither LPS nor LMS STS. Overall, 72% had received prior anthracycline based chemotherapy and 75% had a PS of 0 or 1. The 45 patients that had neither LPS nor LMS STS consisted of 13 undifferentiated pleomorphic sarcomas, six synovial sarcomas, five malignant peripheral nerve sheath tumors and 21 unspecified subtypes. A partial response was seen in one myxofibrosarcoma. Stable disease for at least 6 months was seen in one undifferentiated pleomorphic sarcoma, one synovial sarcoma and one sclerosing epithelioid fibrosarcoma . EribuliLiposomal preparations of several chemotherapeutic agents have been developed and have the advantage of improved targeting of tumor sites and decreased toxicity. This has been shown to produce improved efficacy in several cases . A liposPatient selection is key in determining response to eribulin in STS and identification of biomarker signatures is key . In one p < 0.05) have been identified by using archival tumor tissue from patients treated in the non-randomized phase 2 trial of eribulin. However, this hypothesis should be validated by prospective trials   receiving eribulin had a better disease-free survival than those with lower levels of TILs . The epi= 0.024) . A recen= 0.024) . This su= 0.024) . Recentl= 0.024) . FurtherEribulin in combination with other anticancer therapies may produce synergistic anticancer activity. Cyclin dependent kinase (CDK) 4/6 inhibitors restrict phosphorylation of the retinoblastoma protein stopping cells from exiting G1 and proceeding through the cell cycle. They have found widespread use in advanced hormone receptor positive breast cancer. A phase 2 trial of palbociclib in well differentiated or dedifferentiated LPS showed a favorable PFS of 17.9 weeks . A combiRetroperitoneal sarcomas (RPS) make up about 16% of all sarcomas . Local rIt is still unclear why eribulin is more effective at extending OS than PFS. To date, this was replicated with similar results in the EMBRACE trial, a phase 3 study of eribulin in advanced breast cancer . One posEribulin is licensed by the FDA for the treatment of unresectable and metastatic liposarcoma for patients who have received prior chemotherapy with an anthracycline. It is also useful off-label as a first line treatment, particularly in patients at risk of doxorubicin toxicity. Responses have also been demonstrated in LMS, however it failed to show superiority to dacarbazine in a phase 3 trial so any use in LMS would be off-label. Responses have also been demonstrated in angiosarcomas, undifferentiated pleomorphic sarcomas, synovial sarcomas and rhabdomyosarcomas. Low numbers of patients in these cohorts make comparisons with other chemotherapeutic regimes difficult.In the future, biomarkers such as P-glycoprotein and miRNAs may improve patient selection. The development of a liposomal formulation of eribulin may allow for higher doses to reach tumor cells while reducing the side effect profile. Clinical trials for this in breast cancer are ongoing. Eribulin may have synergistic effects when combined with other therapies such as CDK 4/6 inhibitors, AKT inhibitors and immunotherapies. There may be a role for eribulin as a neoadjuvant treatment for RPS and a clinical trial is ongoing. It is uncertain why eribulin extends OS but not PFS. However, the most likely explanation is that eribulin sensitizes tumor cells to later lines of chemotherapy.