Limb amputation may be recommended in domestic cats following a severe injury or disease. The purpose of the study was to report the signalment, the complications, recovery outcome, owner satisfaction and expectations of domestic cats following limb amputation.Medical records of 3 specialty hospitals were reviewed for cats that received a single limb amputation in a 10 year period (2007–2017). These cat owners were contacted, and 59 owners completed surveys, comprising the study population. The most common reasons for limb amputation were neoplasia , traumatic injury , bone or joint infection , and thromboembolism . Thirty-four cats (57.6%) had postoperative complications. Of the fifty-nine surveys, 52.5% reported minor complications and 5.1% reported major complications. There were no differences in postoperative complication rates for thoracic versus pelvic limb amputations. All owners reported either excellent , good (20.3% 12/59), or fair  satisfaction with the procedure. Based on their previous experiences, 84.7% (50/59) of owners would elect limb amputation if medically warranted for another pet. The remaining 15.3% of owners who would not elect limb amputation again had experienced death of their pet with a median survival time of 183 days.Owners reported a positive satisfaction when considering complications, recovery outcome, and expectations. This study can be used by veterinarians to guide cat owners in the decision making process of limb amputation.The online version contains supplementary material available at 10.1186/s12917-022-03246-z. Limb amputation is a common surgical procedure performed in domestic cats and dogs. The most common reasons for performing a limb amputation include surgical removal of a neoplastic lesion, traumatic injury to the limb, congenital limb deformity, peripheral neuropathy, vascular compromise, and infection , 2. WhenThere are several reports that indicate high owner satisfaction in dogs , 4 folloThe previous literature evaluating owner satisfaction after limb amputation is primarily derived from canine studies. The owner’s decision to pursue limb amputation frequently presents an emotional situation . HoweverIt is typically assumed that high owner satisfaction outcomes have also been reported in domestic cats. In the United States, there are 2 limited reports , 7 incluQuadrupedal locomotion has been examined in dogs more than cats. The musculoskeletal systems of quadrupeds are able to modify the gait pattern in response to painful stimuli as well as amputation. A study in clinically healthy cats revealed the percentage weight distribution, peak vertical forces, and vertical impulse were higher at the forelimbs than the hind limbs which is also consistent in healthy dogs . AlthougThe purpose of this study was to report the signalment of domestic cats with limb amputation, the complications, recovery outcome, and owner satisfaction and expectations. We hypothesized most owners would report a positive satisfaction when considering limb amputation complications, recovery outcome, and expectations. We also hypothesized there would be no significant difference in post-operative complications of cats after thoracic limb amputation, compared with pelvic limb amputation according to owner survey.Ninety-eight cats met the inclusion criteria during the given time period that underwent thoracic limb or pelvic limb amputation. The pets that met the inclusion criteria whose owners were unable to complete the survey were not included in the study. Fifty-nine cats were included in the study.p = 0.001). The age distribution for cats that had an amputation due to neoplasia was significantly greater than the age distribution for cats that had an amputation due to infection (p = 0.010) or trauma (p < 0.001). The most common reason for limb amputation or injury/disease type was neoplasia , followed by trauma , infection (3.4% 2/59), and vascular causes  , 23 were spayed females (38.9%), one was an intact male 1.7%), and one was an intact female (1.7%). The median age of the included cats was 9.7 years (range 0.2–18.2 years). The median age for cats that had amputations due to neoplasia was 12.6 years (range 4.0–17.0 years), trauma was 3.5 years, infection was 2.0 years (range 1.0–3.0 years), and thromboembolism was 13.0 years. There was a significant difference noted in age when comparing reasons for limb amputation  or sex (p = 0.811). Median body weight of the cats was 4.62 kg . There was no difference in injury/disease type occurrence when comparing body weight (p = 0.075).There were a variety of cat breeds including 36 (61%) domestic short hair, 10 (16.9%) domestic long hair, 5 (8.5%) Siamese, 2 (3.4%) Maine Coon, 2 (3.4%) Ragdoll, 2 (3.4%) Russian Blue, and 1 (1.7%) Bengal, and 1 (1.7%) domestic medium hair. There was no difference in injury/disease type occurrence by breed (Twenty-six (44.1%) cats underwent thoracic limb amputation. There were 16 (27.1%) cats with right thoracic limb amputations, and 10 (16.9%) cats with left thoracic limb amputations. All thoracic limb amputations were performed by scapulothoracic disarticulation. Eighteen amputations (30.5%) were due to neoplasia, 7 (11.9%) were due to trauma, and 1 (1.7%) was due to thromboembolism. Thirty-three (55.9%) cats underwent pelvic limb amputation. There were 18 (30.5%) cats with right pelvic limb amputations, and 15 (25.4%) cats with left pelvic limb amputations. There were 28 (47.5%) coxofemoral joint disarticulations and 5 (8.5%) mid-femoral amputations. There were 2 (3.4%) right mid-femoral amputations, and 3 (5.1%) left mid-femoral amputations. Fifteen (25.4%) were due to neoplasia, 16 (27.1%) were due to trauma, and 2 (3.4%) were due to infection.p = 0.275).Postoperative complications were reported in 34 (57.6%) cats and were classified as minor in 31 (52.5%) cats and major in 3 (5.1%) cats. Minor complications included mild balance difficulty in 12 (20.3%) cats, mild incisional pain in 14 (23.7%) cats, mild depressed mentation in 4 (6.8%) cats, and a combination of mild incisional pain and mild balance difficulty in one (1.7%) cat. The major complications reported were severe balance difficulty in 2 (3.4%) cats, and a combination of major decrease in appetite and severe balance difficulty in one (1.7%) cat. There were 25 (42.4%) cats with no postoperative complications. All 4 cats that were reported to have depressed mentation underwent thoracic limb amputation. There was no statistical difference between the presence of postoperative complications when comparing thoracic limb amputation to pelvic limb amputations .Owners of 59 of the 98 cats were available for interview 60.2%). The median time of follow-up was 5.2 years (range: 0.4–10.9 years). All owners administered analgesic medication to their cats. The majority of owners reported excellent (59.3%) and good (37.3%) pain management with the analgesic medication , or good (20.3%) overall satisfaction with the procedure. The majority of cat owners reported no change in attitude (81.4%) after the procedure. Approximately half (47.5%) of the owners felt the recovery was better than expected, and less than half (42.4%) of the owners had no change in expectation. When asked if owners would elect to pursue amputation on another pet when medically recommended, the majority of owners (84.7%) would elect the procedure again. The remaining 15.3% of owners, which would not elect limb amputation again, had experienced death of their pet with a median survival time of 183 days. The majority of owners (81.4%) would also recommend the procedure to others, the remainder (18.6%) of owners were unsure. Of the 11 owners that were unsure about recommending the procedure, 9 (15.3%) cats had limb amputation due to a mass, and 4 (6.8%) cats had the limb amputation due to trauma. Seven owners  had cats who received a thoracic limb amputation and four owners  had cats who received a pelvic limb amputation.The 59 cats included in the study had a median survival time of 850 days (range 29 to 3000 days); Twenty-four cats (40.8%) were still alive at the time of follow-up and were censored on that date. Seventeen cats  were euthanized or died due to evidence of metastasis, with survival times ranging from 28 days to 850 days, with a median of 365 days. Six (10.2%) cats were either euthanized or died naturally, within 1 to 8 years, secondary to unknown causes according to the owner or as recorded in the medical records. Additional causes of death were related to renal failure, unrelated neoplasia, resistant urinary tract infection, heart failure, progression of feline immunodeficiency virus disease, adrenal disease, or gastric disease.Based on the results of the present study, cats that underwent limb amputation tolerated the procedure well with only minor complications including mild balance difficulty, mild incisional pain, and mildly depressed mentation. Approximately 1 in 20 cats that underwent limb amputation were reported to have major complications, which were reported as severe balance difficulty, and major decrease in appetite. The results of the owner survey were consistent with previous studies of owner satisfaction following limb amputation in cats in a UK population . PreviouThe prevalence and types of postoperative complications after limb amputation in cats have not been extensively described in the literature. In our study, the most common postoperative complication was mild balance difficulty. Although cat and dog owners have reported concerns related to anticipated problems with mobility and adaptation before limb amputation , postope3 whereas in our study 6.8% of cat owners reported depressed mentation in their pet. Owner observation , is an important resource when assessing and managing pain in the patient [The second most prevalent postoperative complication of limb amputation reported by the owner was mild pain, which has been reported in two studies , 10. In  patient . AlthougLimitations of this current study are primarily related to its retrospective design and the use of questionnaire-based surveys. These limitations included the potential for incomplete medical records and the subjectivity of surveys with having to rely on one’s memory. A prospective and standardized time to follow-up for data collection would yield a reliable degree of satisfaction. These questionnaires introduce owner bias by the level of knowledge, emotional involvement with the cat, and ability to interpret behavioral changes. However, the satisfaction of an owner represents useful information combined with the recommendations of the veterinary surgeon in the ultimate decision to treat the pet.Previously, other postoperative complications identified in dogs have included surgical site infection, seroma, incision dehiscence, and incision revision , 5. AlthAlthough the mode of research conducted was primarily following a hypothesis-generating paradigm, the descriptive statistics have identified areas of additional research including a pet’s mobility and perceived pain. Future studies should be considered to objectively validate these findings. A prospective study including statistically significant case number and objective data, via kinetics and kinematic analyses, would be beneficial in identifying and quantifying orthopedic changes arising from amputation.Results presented by this study suggest that limb amputation in the cat is well tolerated. The majority of owners were satisfied with the outcome post-amputation and they did not regret pursuing the procedure for their cat. However, owners should be educated on the potential for postoperative complications including balance difficulty, pain, and change in mentation, with the majority of these complications being classified as minor.Domestic cats that had undergone a limb amputation at Purdue University Veterinary Teaching Hospital (Indiana), Affiliated Veterinary Specialists (Florida), and Long Island Veterinary Specialists (New York) in a 10 year period were identified. Patient records were retrospectively reviewed and the owners of included patients were asked to complete a questionnaire. All patient records were deidentified.Domestic cats that had a single limb amputation were included in the study. Cats with concurrent orthopedic or neurologic disease affecting one or more of the remaining three limbs, or hemipelvectomy, were excluded from the study to limit variables that may affect owner satisfaction.Data collected included patient signalment, weight, reason for amputation, the limb amputated, type of amputation performed, analgesic medication provided, postoperative complications, and histopathological results of the amputated limb in cats due to neoplasia. The time between amputation and death, when applicable, were recorded.After data collection, owners were contacted by telephone and interviewed using a 13-question survey to determine their satisfaction with the limb amputation procedure . Values of Recovery time to normal quality of life (QOL) was stratified into 5 groups: less than or equal to 1 week , 1 to 2 weeks , 3 to 4 weeks , 5 to 12 weeks , and greater than 12 weeks .Additional file 1. Owner Survey. This document provides the questionnaire that owners completed as part of the study.Additional file 2.


Gastrointestinal stromal tumor (GIST) is a rare small intestinal tumor. Most patients usually report long-period complaints due to difficult diagnoses. A high grade of suspicion is required for early diagnosis and initiation of the proper management.A retrospective study of all patients with small intestinal GIST who were operated in the period between January 2008 and May 2021 at Mansoura University Gastrointestinal Surgical Center (GIST).Thirty-four patients were included in the study with a mean age of 58.15 years (± 12.65) with a male to female ratio of 1.3:1. The mean duration between onset of symptoms and diagnosis was 4.62 years (± 2.34). Diagnosis of a small intestinal lesion was accomplished through abdominal computed tomography (CT) in 19 patients (55.9%). The mean size of the tumor was 8.76 cm (± 7.76) ranging from 1.5 to 35 cm. The lesion was of ileal origin in 20 cases (58.8%) and jejunal in 14 cases (41.2%). During the scheduled follow-up period, tumor recurrence occurred in one patient (2.9%). No mortality was encountered.Diagnosis of a small bowel GISTs requires a high grade of suspicion. Implementing new diagnostic techniques like angiography, capsule endoscopy, and enteroscopy should be encouraged when suspecting these lesions. Surgical resection is always associated with an excellent postoperative recovery profile and very low recurrence rates. Gastrointestinal stromal tumors (GISTs) are the commonest mesenchymal tumor of the gastrointestinal tract . HoweverKIT receptor tyrosine kinase gene) Reviewer (2) or platelet-derived growth factor receptor alpha (PDGFRA). Conversely, succinate dehydrogenase deficiency Reviewer (2) is less frequent .OthIn the current study, Lesion size had a mean value of 8.76 cm, and it ranged between 1.5 and 35 cm. Baheti et al. reported that the tumors of the included 102 patients with small bowel GISTs had a mean size of 8.5 cm  . AnotherIn the current study, small intestinal resection-anastomosis was performed for all patients. The two cases with surrounding organ infiltration (colon and pancreas) were managed by right hemicolectomy and distal pancreatectomy in the same session. Currently, radical surgical resection is the gold standard option for small bowel GISTs . The adeOur findings showed that CD 117 was positive in the majority of patients (97.1%). It is agreed that CD 117 (KIT) is the most prominent diagnostic marker for GIST, with about 95% of lesions are positive for CD 117 on IHC –40. HoweLikewise, Hirota et al. reported that about 72 – 78% of GIST lesions were positive for CD 34 . We deteOur findings showed that S-100 and SMA showed positivity in 8.8% of patients (three cases for each marker). Other previous studies stated that between 30 to 40% of GIST show positivity for SMA, whereas only 5% show positivity for S-100 protein , 45, 46.When it comes to pathological classification, half of our cases were low grade, while high-grade lesions were detected in 32.4% of patients. The remaining patients (17.6%) had intermediate lesions. Beheshti et al. reported the low-, intermediate- and high- malignant risk small bowel GISTS were detected in 20.59%, 16.67%, and 62.64% of patients, respectively .It is expected to find some differences between various studies regarding the malignant potential of the included tumors due to different tumor criteria, grading methods, or sample size included. The difference in tumour location could be another explanation, as previous authors reported a higher prevalence of high-risk lesions in the ileum compared to the proximal small bowel portions .We did not encounter any cases of mortality in the scheduled follow-up period. Also, recurrence was detected in only one case (2.9%). Zhou and his colleagues reported no recurrence during the planned 30-month follow-up period  .Other authors reported a higher recurrence rate, as 44 out of 85 patients who underwent curative resection developed recurrence. Recurrence occurred within 3.7 – 125.1 months after the operation. Disease-free survival was 85.2%, 53.8%, and 43.7% after 1, 3, and 5 years, respectively .One could see differences in postoperative recurrence rates throughout the literature, and different tumor characteristics could explain this, the operation performed postoperative adjuvant regimen, or follow-up duration.The current study has some limitations. Small sample size, along with its retrospective nature, are the main cons. Hence, an international registry might be useful Reviewer (2), including more cases from different surgical centers, especially with this rare clinical entity.Small bowel GISTs often need a long time to be diagnosed. Implementing new diagnostic techniques like angiography, capsule endoscopy, and enteroscopy should be encouraged when suspecting these lesions. Surgical resection is always associated with an excellent postoperative recovery profile and very low recurrence rates.


Dizziness is a common and challenging symptom, which can be caused by different pathophysiological mechanisms and might affect a large number of population. However, up to now, there have been limited research on the characteristics of dizziness as the chief complaint in hospitalized patients in the Department of Neurology. Thus, the aim of this study was to investigate the hospitalized patients with dizziness as their chief complaint in the Department of Neurology.In this cross‐sectional study, we conducted a retrospective document analysis of hospitalized patients admitted to a tertiary neurological department with the symptom of dizziness during the period of September 2019 to December 2020. We included 211 patients with dizziness as their chief complaint from 1841 patients admitted to this tertiary neurological department during that period.p = .004). More patients presented with vertigo (40.8%) and light‐headedness (39.8%) than disequilibrium (17.1%) and pre‐syncope (2.4%). Nausea (48.3%), vomiting (34.1%), headache (13.3%), walking unsteadily (13.3%), and ear symptoms (12.8%) were the most common concomitant symptoms. Dix‐Hallpike test (24.6%) and Romberg's sign (11.4%) were positive in these dizzy patients. Nystagmus (2.4%), vision changes (1.4%), and hearing disorders (8.5%) were relatively rare symptoms. Common auxiliary examinations were performed, such as magnetic resonance imaging (60.2%), computed tomography (31.8%), carotid duplex ultrasound (30.8%), and echocardiography (28.0%). Benign paroxysmal positional vertigo (24.2%) and stroke/transient ischemic attack (19.0%) were confirmed to be common causes of dizziness. Note that 97.2% of dizzy patients were in improved recovery after treatment.Of all 1841 hospitalized patients, those with dizziness as the chief complaint accounted for 11.5% and most of their past medical history included hypertension, diabetes, cerebrovascular diseases, dyslipidemia, and coronary heart disease. Among these 211 patients, dizziness was more common in women than in men (The diagnosis and management of dizziness remain a challenge for clinicians. Vertigo and light‐headedness were the most common symptoms among different types of dizziness. Benign paroxysmal positional vertigo and stroke/transient ischemic attack were among the leading causes for common dizziness disorders. The prognosis of most dizzy patients was good.  Patients were diagnosed based on the findings of symptoms, past history, auxiliary examination, and clinical examination such as presence or absence of headache, tinnitus, hearing loss, nystagmus characteristics, signs of sympathetic release, focal neurologic findings, and so forth. The diagnosis of dizziness conformed to the latest international diagnostic standards. The final decision on the diagnosis of dizziness was made based on the results of brain imaging or para‐clinical findings and the opinion of an expert neurologist. We declared that the study was approved by our hospital ethics committee. The researchers adhered to the principles of Helsinki Declaration and confidentiality of patient information over the course of the study.2.1t test. Categorical variables were introduced as frequency and percentage; a chi square test or Fisher's exact test was performed to establish differences between groups. Significance level was considered p < .05.Data analyses were performed using Statistical Package for the Social Sciences (SPSS) . Normally distributed continuous variables were reported as mean value ± standard deviation; differences were assessed by a two‐tailed 33.1p = .004), while no significant difference in frequency was observed between male cases and female cases in each age group (p = .549).During the period of this study, 1841 patients were admitted to our department of neurology with the mean age of 65.92 ± 18.612 years (ranging from 7 to 95) and 54.6% male and 45.4% female. Among them, 211 patients reporting dizziness as their chief complaint were included, with the mean age of 58.76 ± 14.817 years (ranging from 17 to 89) and 44.1% male and 55.9% female. Table 3.2p = .001). Nausea (48.3%), vomiting (34.1%), headache (13.3%), walking unsteadily (13.3%), and ear symptoms  (12.8%) were the most common concomitant symptoms in 211 hospitalized patients with dizziness as shown in Table The distribution of different types of dizziness was described with more patients presenting with vertigo (40.8%) and light‐headedness (39.8%) than disequilibrium (17.1%) and pre‐syncope 2.4%). More female patients than male patients presented with vertigo (28.0% vs. 12.8%), whereas the ratio of females to males was roughly the same among those with light‐headedness (21.3% vs. 18.5%) and pre‐syncope (1.4% vs. 0.9%). A significant difference was observed between males and females  is common in department of neurology, and physicians often use HINTS test to make a differential diagnosis of acute vestibular syndrome, especially to differentiate vestibular neuritis (the most common cause of an AVS) from ischemic stroke involving the cerebellum or the brainstem (the second most common cause of an AVS) Kattah, . PatientSimilar to a previous study, benign paroxysmal positional vertigo was also the most common disease among dizzy patients in our study  as soon as possible and help these patients get the right treatment in time.This was a retrospective study based on past medical records, so the findings were fairly objective. However, our study inevitably has some limitations as well. First, our study was conducted among hospitalized patients in a department of neurology, so the results can only reflect the characteristics of hospitalized patients with dizziness in one department, was different from population‐based studies and other studies from otolaryngology department or emergency department. In addition, without a standardized design in advance, these medical records varied considerably in quality. Therefore, we plan to conduct a randomized controlled trial in the near future.5Dizziness was one of most common clinical symptoms. The hospitalized patients with dizziness as the chief complaint accounted for 11.5% of all hospitalized patients in the department of neurology. Dizziness was more common in women than in men. Vertigo and light‐headedness were the most common dizziness types in the department of neurology. Some concomitant symptoms  and past medical history were critical to the diagnosis of dizziness. Usually, some signs can be found in physical examination and auxiliary examination in dizzy patients. Therefore, it was necessary to master some simple bedside physical examinations  to differentiate dizziness diseases. Benign paroxysmal positional vertigo was the most common disease in dizzy patients in our study and stroke/transient ischemic attack was the second most common dizziness disorder. Although the prognosis of most dizzy patients was good, some malignant dizziness diseases also need to be excluded.The authors declare no conflict of interest.https://publons.com/publon/10.1002/brb3.2864.The peer review history for this article is available at


Androgenic‐anabolic steroid (AAS) abuse is a global health concern, studies revealing an increasing trend of abuse and deleterious effects on reproductive health. Unfortunately, there is no consensus about management pathways due to the lack of specific guidelines.A prospective study, multicentre, online survey, composed of 30 questions, was conducted to investigate the current trend of AAS abuse and the management followed by practitioners from different specialities dealing with this condition.A total of 151 respondents were included. The majority were general urologists (68.21%), andrologists (22.51%), and endocrinologists (9.28%). An increasing trend of AAS abuse was noticed by 90.73% of participants mostly in young age populations. Most of AAS abusers were presented with infertility (64.24%) and erectile dysfunction (59.60%), and their investigations showed abnormal semen analysis (77.48%), abnormal hormones  (94.70%), and reduction in testicular size (50.33%). Most of respondents expected: the need of long duration for spontaneous recovery (6–12 months), relapse of AAS abuse in one‐third of patients, less knowledge about the adverse effects (39.74%), and risk of drug dependence (54.30%). Immediate treatment was the most offered plan of management (44.37%) followed by a waiting spontaneous recovery (32.45%), while the remaining would refer the patients to an either endocrinologist or andrologist. The treating physicians did not follow specific guidelines and most of participants (44.44%) reverted to their personal experience in the management.Our study revealed an increasing trend of AAS abuse, deleterious effects of AAS use on reproductive health, and lack of consensuses among the treating physicians regarding the management of related adverse effects. Our study could be considered a call to the scientific bodies to have more studies, establish guidelines for management, and to have better awareness of this serious public health concern. To the best of our knowledge, this is the first survey study ever to explore the current practice of urologists, andrologists, and endocrinologists involving in AAS management and document the prevalence, evaluation methods, and treatment modalities by determining the areas of the agreement and disagreement among the practitioners and to prepare a common guideline or recommendation. This study will be of value to all practitioners in this field and international scientific bodies to address the weak points in the current practice and improve the management pathways.2An online survey was conducted to investigate the current trend of AAS abuse, and the management guidelines followed by practitioners from different specialists dealing with this condition . It was a prospective, cross‐sectional, multicentre, observational survey, composed of 30 questions, which aimed to identify the responders background speciality, country, and practice setting (Q1–3), AAS abuse trend, age of abusers, purpose and advice of intake, the source of AAS pre‐use counselling, duration and frequency of the courses (Q4–9), the most common presentation symptoms, signs and investigations performed (Q10–16), the management guidelines and medications used (Q17–21), AAS users attitude, the current shortcomings in management guidelines, related educational activity and awareness programs (Q22–30).We used the Google survey tool to formalize the survey. A link of the survey was sent to urologists, andrologists, and endocrinologists through LinkedIn, database emails of Arab Society of Urology, and other social media groups of concerned specialities in different countries. Only the fully attempted survey forms were included.All statistical analysis was performed using the software STATA version 15.0. Each characteristic was illustrated appropriately. For continuous variables, data were formulated and presented using means ± SD. For categorical data, the number and percentages were used in the data summaries.The study was approved by the ethical committee of Arab Society of Urology and all surveyors were asked in the first page of the survey to consent for using their data and responses for publication.3The survey link was sent to 370 specialists. A total of 171 responses were received, out of which 20 incomplete survey responses were excluded. Finally, a total of 151 responses were included. Out of 151 physicians, 146 (96.69%) were men and 5 (3.31%) were women. A total of 110 (72.84%) physicians belonged to private and 41 (27.16%) to governmental hospitals or clinics. In the study, 103 (68.21%) practitioners were general urologists, 34 (22.51%) andrologists, and 14 (9.28%) endocrinologists. Among the 19 countries from different continents, the UAE was the highest in representation (29.8%) followed by equal representation from Oman and Kuwait (9.27%), as depicted in Table The majority (90.73%) of the physicians noticed an increasing trend of AAS abuse and estimated the increase to be moderate (56.95%), and less commonly observed as mild (37.09%), and severe (5.96%). The respondents stated the most common age categories of AAS users are 20–30 years (74.83%), 30–40 years (13.25%), above 50 years (8.61%), and 40–50 years (3.31%). The purposes of AAS utilization among users were to enhance their fitness for training (70.2%) and physical appearance (60.26%), while other reasons (10.6%) to improve self‐esteem or body image. The sources of patient counseling before utilization of AAS were the physical trainer (the coach) (70.2%), followed by advice from friends (56.95%), social media (53.64%), and self‐request (38.41%). The duration of AAS abuse among most of them was between 1 and 3 years (47.68%) followed by less than 1 year (39.74%) and 4–6 years (12.58%). The observed duration of each course was 4–8 weeks (50.99%), followed by 1–4 weeks (16.56%), 8–12 weeks (23.18%), and more than 12 weeks (9.27%), while receiving two courses per year by AAS users was the most common form of use (53.64%), followed by one course per year (25.17%), three courses per year (8.61%), and more than three courses per year (12.58%). Most of the AAS abusers (47.02%) mentioned consumption after being proactively asked for it, (41.72%) of them mentioned it at presentation, and the others (10.72%) remained discrete and released information after receiving abnormal laboratory results.Regarding the presenting symptoms, infertility was the most common 64.24%) followed by erectile dysfunction (59.60%) and loss of sexual desire (56.95%). For the evaluation of AAS users, the hormonal profile was the most performed initial investigation (90.07%), followed by semen analysis (72.19%). The results of evaluation revealed low testosterone (69.54%), low luteinizing hormone (LH) (58.28%), low follicle‐stimulating hormone (FSH) (41.06%), and high estradiol levels (23.18%). More than three‐quarters of the participants (77.48%) found abnormal semen parameters of AAS users at presentation, while the remaining (22.52%) claimed it as being normal. On clinical evaluation of the AAS users, testicular size reduction was perceived by half the participants (50.33%), testicular atrophy by 3.97%, and 45.70% noted no change in testicular size, as shown in Table 4% followRegarding the management of AAS‐related adverse effects showed that the immediate treatment was the most offered plan of management (44.37%) followed by a waiting for spontaneous recovery 32.45%) and referring the patient to an endocrinologist 13.91%), or an andrologist (9.27%). Spontaneous recovery of sexual symptoms following the termination of AAS use was mostly believed to take 6–12 months (42.38%), followed by 3–6 months (32.45%), more than a year (17.88%), and 1–3 months (7.29%). Most prescribed medications to treat sexual dysfunction were phosphodiesterase inhibitors (49.69%), followed by human chorionic gonadotropin (hCG) injection (42.38%), combination of these medications (37.75%), clomiphene citrate (CC) (33.11%), aromatase inhibitors (16.56%), testosterone injections (9.90%), and FSH injections (5.96%); for the infertility, hCG was the most used therapy (47.02%), followed by combination of medications (41.72%), CC (41.06%), antioxidants (35.76%), FSH injections (17.88%), aromatase inhibitors (15.23%), and testosterone injections (4.90%) as in Figures 3.91%, or.45% and Gynecomastia was encountered as rare presentation by 51.66% of participants, was commonly observed in 35.10%, very common in 7.95%, and not examined in 5.29% of participants. The offered management was awaiting spontaneous recovery is more commonly practiced (49.10%), followed by using tamoxifen (29.8%), anastrazole (17.22%), and Letrizole (3.88%). A total of two‐third of participants (65.56%) suggested sperms cryopreservation for AAS abusers, especially for those presenting with infertility and the remaining (34.44%) were not suggesting.The assessment of the AAS abusers' knowledge about related adverse effects revealed they were less knowledgeable (39.74%), knowledgeable (31.13%), had misconceptions (23.18%), or were very knowledgeable (5.95%). Most of the respondents (68) expected relapse of AAS use in 60%–90% of patients, followed by (54) in 30%–60% of patients, (20) in 10%–30% of patients, and (9) in less than 10% of their patients.Along the course of management, AAS users were perceived by their care providers as either weakly (41.37%) or strictly (38.05%) compliant to the prescribed treatment, while 10.60% agreed that they were hesitant and 9.98% not convinced to start the medications. The notion of AAS‐related drug dependence was acknowledged by most of the participants (54.30%), while the remaining (45.70%) did not believe so.Regarding the concepts of treatment of AAS‐related adverse effects, most of participants (44.44%) reverted to their personal experience, while 33.77% followed the insights from relevant studies, and 21.79% followed treatment guidelines of other types of hormonal abnormalities (not specific to AAS abuse). In addition, most of the participants (95.60%) denied participation in any related scientific activity while the remaining (4.40%) rarely attended. Almost all the respondents reported the lack of the national awareness program about the AAS abuse in their countries. Finally, an endocrinologist was the most chosen healthcare provider identified by the participants to manage AAS abuse adverse effects (40.93%) followed by an andrologist (31.79%), a general urologist (22.98%), and by a team of different specialities (4.30%).4Many studies concluded the findings of significant increasing trend of AAS abuse in young populations, not only to enhance physical training but also physical appearance. This finding is confirmed in our survey study as most of respondents (90%) stated the increasing trend of AAS abuse among their patients, which is consistent with other studies both in this region as well as globally.AAS abusers' attitudes were explored in our study, including their knowledge about the adverse effects of AAS abuse on sexual and fertility health as most of respondents believed their patients are less knowledgeable or had misconceptions about the AAS adverse effects. This finding also was acknowledged by Ahmed  et al. studyThe negative impact of AAS abuse on HPA and related induced hypogonadism is well‐recognized adverse effects and eventual sexual dysfunction and impairment of fertility. Although the effects are variable according to the type of used preparations, doses, and duration, most of studiesAnother important finding is half of respondents in our study noted AAS use dependence in their patients, which is considered another serious negative impact and community concern and was noticed in other studies like Kanayama G studyRegarding the management of AAS abuse adverse effects, our study revealed no consensus among the practitioners, as 41% offered immediate treatment while 32% preferred waiting for spontaneous recovery. Also, there is no consensus on the type and duration of medications for the treatment of AAS abuse‐related infertility or sexual symptoms. The same findings were elicited in other studiesThe lack of conclusive and well‐performed studies prevents the possibility of giving clear recommendations on how to manage AAS abuse and its consequences especially infertility and sexual dysfunction, this could explain the diversity of practitioner's decisions about the treatment, as most of participants depends on their personal experience and about one‐third of them follow the insights from studies related to this topic. The lack of focus from andrology societies on this subject and their failure to organize related activities, and motivate the practitioners to engage in such events, could explain that three‐fourth of the participants were not attending any related scientific activity or to have national awareness program. All these factors raise the debates about management of the condition and increase its burden on public health.5Our study concluded an increasing trend of AAS abuse in different regions all over the globe, which imposes deleterious effects on sexual and fertility health. Furthermore, there is a lack of consensus regarding the management of related adverse effects and follow‐up plans among the treating physicians and lack of studies and academic activities to address the problem. Therefore, it is important to conduct further studies and generate specific guidelines for the management of this condition.Manaf Al Hashimi: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; supervision; validation; visualization; writing – original draft; writing – review & editing. Yasser Farahat: Resources; validation. Hussein Kandil: Writing – review & editing. Ismail Al Khalidi: Writing – review & editing.The authors declare no conflict of interest.The lead author Manaf Al Hashimi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.


Obstetric outcomes were also assessed. Sixteen cases at an average of 27.0 (22.0–31.1) gestational weeks of pregnancy were included. Obesity and hypertension were frequent comorbidities. PP was associated with a >20% increase in PaO2 levels and in PaO2/FiO2 ratios in 50% and 100% of cases, respectively. The PaO2/FiO2 ratio increased 76.7% (20.5–292.4%) at T1 and 76.9% (0–182.7%) at T2. PP produced sustained improvements in mean PaO2/FiO2 ratio (p < 0.001) and PaCO2 level (p = 0.028). There were no cases of emergency delivery or suspected fetal distress in pregnancies ≥25 weeks during the 24 h period following PP. PP is safe and feasible during pregnancy, improving PaO2/FiO2 ratios and helping to delay preterm delivery in severe ARDS.Prone positioning (PP) improves oxygenation and survival in patients with severe acute respiratory distress syndrome (ARDS). Data regarding feasibility and effectiveness of PP in pregnancy are lacking. This subgroup analysis of a cohort study that included mechanically ventilated pregnant women presenting with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced ARDS who underwent PP aims to assess the efficacy and safety of PP. Ventilatory and gasometric parameters were evaluated at baseline (T PP is indicated in those in whom the ratio of the partial pressure of oxygen to the fraction of inspired oxygen (PaO2) > 95% and arterial partial pressure of oxygen (PaO2) > 70 mmHg to ensure adequate fetal oxygenation [Physiological changes make managing ARDS episodes challenging in pregnant women. Oxygen consumption is increased during pregnancy, demanding oxygen saturation  on the pregnant population, confidence and proficiency in offering and managing PP in pregnant women may provide a low-cost, available, safe, and effective intervention to those who are hypoxemic and even under mechanical ventilation. Recently, technical guidelines for PP have been published, focusing on pregnant women ,11. ThisThis is a secondary retrospective analysis of an ongoing Brazilian cohort study titled “Exploratory study on coronavirus disease (COVID-19) in pregnant women”. The present sub-analysis aims to evaluate clinical and obstetric outcomes following PP in pregnant women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced ARDS who were admitted to the ICU of a tertiary teaching hospital . Data of women enrolled in the study between April 2020 and August 2021 were obtained.2/FiO2 ratio < 150 mmHg, need for mechanical ventilation, and minimum PP duration of 12 h.Patients were selected according to the following inclusion criteria: singleton pregnancy, gestational age at PP ≥ 20 weeks, diagnosis of SARS-CoV-2 confirmed via real-time polymerase chain reaction (RT-PCR) from samples obtained from the respiratory tract  after the third day of symptom onset, PaOPatients with severe ARDS who were on mechanical ventilation and received sedation and paralysis were ventilated with a tidal volume of 6 mL/kg of ideal weight as a routine of the ICU, aiming to achieve a driving pressure equal to or lower than 15 mmHg.2 ratio response.The prone position procedure was performed according to a standardized local protocol, and a multidisciplinary team consisting of physicians, nurses, and physical therapists performed the positioning. The orotracheal tube, catheters, and patient’s head were stabilized while switching positions. The bone prominences and nipples were protected, and pads were placed under the chest, pelvis, and knees to avoid compression of the gravid maternal abdomen during PP. The procedure followed a safety checklist. During PP, the head and upper limbs (swimmer’s position) were switched every 2 h to prevent pressure injury. After PP, blood gas analysis was performed to evaluate the initial PaO/FiOFetal surveillance consisted of computerized cardiotocography, fetal biophysical profiling, and umbilical artery Doppler. These parameters were assessed immediately before PP and soon after returning to the supine position in cases with a gestational age ≥25 weeks. Cardiotocography was only performed during PP if a maternal status worsening was expected.2, PaO2/FiO2 ratio, PaCO2, tidal volume, and positive end-expiratory pressure (PEEP). Gas blood analysis was performed within 12 h of prone- and supine-position placement. Clinical and gasometric parameters were considered at the following three time points: T0 , T1 (within the first 12 h after PP), and T2 (within the first 12 h after returning to the supine position) after the first prone position of each subject.Data regarding maternal demographic characteristics and clinical and obstetric outcomes were assessed. Respiratory parameters considered included the following: PaOp-value < 0.05 in ANOVA test to estimate the effect size. Categorical variables were compared using the chi-square test. Kaplan–Meier survival analysis was performed to assess the duration women remained pregnant after placement in the prone position. Statistical significance was set at two-tailed p-value < 0.05. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software .The categorical variables are described as absolute and relative frequencies. The continuous variables are described as mean and standard deviation (SD) or median, with minimum and maximum. The continuous variables were compared using one-way analysis of variance (ANOVA), and pairwise comparisons were performed using Tukey’s post hoc test. Cohen’s f calculation was applied to variables presenting During the study period, 139 pregnant women presenting with SARS-CoV-2-induced ARDS were referred to our ICU. Among them, 18 patients underwent PP. Two subjects did not meet inclusion criteria; therefore, they were excluded from the analysis. One patient was excluded due to a duration of PP < 2 h due to hemodynamic instability, and another was excluded due to presentation with mild ARDS that did not require mechanical ventilation. Thus, 16 pregnant women were included in the study.2. Obesity and systemic hypertension were the most prevalent comorbidities, accounting for 73.3% and 40.0% of cases, respectively. Most women were multiparous (87.5%), and their gestational age at the first PP was 27.0 (22.0–31.1) weeks. Nine patients (56.3%) underwent PP within the first 24 h after referral to our service (Patients were aged 31.5 (22.0–46.0) years and had a body mass index of 36.0 (23.4–47.9) kg/m service .2O, and had a FiO2 value of 1.0 in 56.3% of cases. Patients were administered a sedative–analgesic regimen plus a neuromuscular blocking agent. Furthermore, 50% of patients required norepinephrine. The most frequently used sedatives were midazolam (78.6%) and propofol (64.3%). Further, all patients received fentanyl and cisatracurium. Baseline blood gas parameters at the indication of PP were as follows: PaO2 of 85.1 ± 15.8 mmHg, PaCO2 of 48.3 ±10.4 mmHg, and PaO2/FiO2 ratio of 102.7 ± 26.9 mmHg.At the indication of PP, patients were on mechanical ventilation with tidal volume of 6.1 (±0.8) ml/kg, PEEP of 12.6 (±3.2) cmH2 and PaO2/FiO2 ratio was observed in 56.3% and 81.3% of patients, respectively. The observed increment in the PaO2/FiO2 ratio was 76.7% (20.5–292.4%) in the prone position and 76.9% (0–182.7%) in the supine position (Patients were maintained in the prone position for 20.0 (14.0–24.0) h and the number of PP events was 1.5 (1.0–7.0) per patient. After returning to the supine position, a >20% increase in PaOposition .n = 7), consisting of refractory oligohydramnios (n = 3), non-reassuring fetal rate (n = 2), and a fetal biophysical profile < 6 (n = 2).Regarding obstetric outcomes, 10 patients had an emergency C-section delivery during the ICU stay at 29.8 (27.1–31.7) weeks of gestation and had a birth weight of 1484 (985–2010) g. Deliveries occurred 7 (2–24) d after the first positioning and 5 (2–4) d after the last PP. The main indication for delivery was fetal distress  at the 24th week of gestation.Five patients remained pregnant at hospital discharge and had uneventful deliveries between 37 and 39 weeks of gestation. 2/FiO2 ratio  and PaCO2  and PaCO2 (Cohen’s f = 0.46). Post hoc analyses confirmed that PP was related to an increased PaO2/FiO2 ratio at T1 (p = 0.001) and T2 (p = 0.001), and to a reduced PaCO2 ratio at T2 (p = 0.022), when compared to baseline  or an increase in the prevalence of norepinephrine administration (p = 0.933). There were no cases of ventilation-associated pneumonia or pulmonary thromboembolism over two weeks after PP.There was no difference in PaCOTo date, this is the largest study investigating cases involving PP in pregnant patients with ARDS. We verified that PP is a safe and effective procedure in women on mechanical ventilation due to severe ARDS who were in the second- and third-trimester of pregnancy. Furthermore, we achieved favorable obstetric outcomes in the very critically ill group of patients. Nearly one-third of our patients left the ICU without delivering.2/FiO2 ratio and PCO2 values after PP. These favorable outcomes may have contributed to delayed deliveries in severe ARDS patients undergoing PP.The literature regarding PP during pregnancy is scarce and comprises reports of PP feasibility and successful cases ,12,13,14There are multiple mechanisms by which the prone position contributes to improved oxygenation including increasing the homogeneity of ventilation and perfusion of the entire lung, relieving alveolar compression in the dorsal lung regions, and changing chest compliance, which improves the distribution of gases toward the ventral and para-diaphragmatic lungs. The impact of PP persists after the patient returns to a supine position ,15.2/FiO2 ratio < 150 mmHg is a classical indication for PP. During and after PP, 62.5% and 68.7% of patients presented with PaO2/FiO2 > 150 mmHg, which is a treatment target when managing patients with ARDS. From another point of view, an increase greater than 20% in PaO2/FiO2 ratio indicates a patient is a responder to PP [A PaOer to PP . All pater to PP ,18,19,202 facilitates gas exchange between the mother and fetus and is important for avoiding fetal distress during the treatment of pregnant women with ARDS. Carbon dioxide elimination is an additional benefit of the prone position because recruitment and perfusion of collapsed lung units reduce pulmonary shunting and decrease PaCO2 [2, which is an additional target when managing ARDS during pregnancy.Maintaining low levels of PaCOse PaCO2 . After PIn this study, PP discontinuation was required in one patient due to hemodynamic instability that occurred less than 2 h after PP; therefore, the patient was not included in the analysis. In general, PP did not affect MAP or increase the requirement for vasopressors. Overall, PP was well tolerated and was administered for approximately 20 h.Hemodynamic instability is not an absolute contraindication for PP. In fact, half of the patients included in the present study required vasopressors. In the PROSEVA study, 72% of patients who underwent PP received vasopressors, and the procedure did not induce hemodynamic side effects and improved cardiovascular parameters ,15.2/FiO2 ratio after PP. Thus, this study shows a significant effect of PP on ARDS during pregnancy. The small sample size, observational nature of the study, and lack of a control group prevented us from being able to infer that PP was decisive in the clinical improvement of pregnant subjects. Larger and more specifically designed studies are required for these purposes.This study comprises a very small sample size. However, to the best of our knowledge, this is the largest series of cases to address the effectiveness of PP in improving oxygenation parameters during ARDS in pregnancy. Although our sample size was not large, it was sufficient for revealing clear improvement in POIn the population assessed, there were 10 cases of preterm delivery during the ICU stay, and only 1 of them was due to a worsening maternal status. In a multicenter cohort study that enrolled patients from 12 hospitals in the USA, Pierce-Williams et al. described a subgroup of 20 critically ill pregnant women (19 needed intubation and 4 underwent PP), among which 17 delivered during hospitalization  . One-thiThe main indication for delivery in our study was fetal distress. Remarkably, there were no cases of emergency cesarean section or suspected fetal distress throughout PP or in the first 24 h after returning to the supine position. Deliveries during the ICU stay occurred after 7 (2–24) d of PP and at least 2 d after the patient last underwent PP. Fetal well-being is a frequent concern when treating pregnant women in the ICU; therefore, it might be seen as an impediment to PP. However, our findings highlight the safety of PP in pregnant women, confirming results obtained by Oliveira et al. [Our study population presented substantial prevalence of obesity and systemic hypertension, which are known risk factors for severe forms of SARS-CoV-2 ,23. PrevOur study suggests that PP is a valid tool for managing pregnant women with severe ARDS. PP did not prevent preterm delivery in 62.5% of our population; nonetheless, it was able to delay delivery. Considering the care of pregnant women, delaying preterm delivery even for a few days allows for additional fetal lung maturation and delivery at a greater gestational age, providing a potential neonatal benefit. Moreover, PP improved maternal respiratory and metabolic parameters. As a result, PP allowed patients to undergo surgical procedures in less critical conditions, providing a potential maternal benefit due to surgical risk reduction. Notably, PP was indicated after a median duration of 1 d after mechanical ventilation was initiated, suggesting that ventilation may be considered an early indication for PP. Prior evidence has shown that early initiation of PP improves the post-PP response , which c2/FiO2 ratio and PCO2 level and may help delay preterm deliveries. Additional studies will be needed to better assess middle- and long-term outcomes of PP in pregnancy as well as to establish specific protocols and goals related to the use of PP to treat the pregnant population.Prone positioning may be safely used during pregnancy, even after the uterus is enlarged throughout second and third trimesters. PP seems to be effective in improving the PaO


Low eGFR was not associated with mortality (Hazard ratio (HR) 1.00 (95% CI 0.98–1.02) overall or in sub–group analysis by frailty (HR 0.96 (0.92–1.01)) or by eGFR of ≤30 (HR 1.01 (0.95–1.06). We found no evidence of prognostic value of eGFR in predicting in–hospital mortality in the acutely unwell hospitalised nonagenarians.Globally the population of older adults is the fastest growing age group. Estimated glomerular filtration rate (eGFR) is an estimation of true kidney function with lower eGFR associated with higher mortality. However, few studies explore eGFR’s prognostic value in the nonagenarian. We investigated the association between eGFR on admission and mortality among the nonagenarians hospitalised with acute illness. A retrospective analysis of a prospective cohort study included patients aged ≥ 90 admitted into three acute medical assessment units or acute geriatric wards in England and Scotland between November 2008 and January 2009. Association between eGFR and all-cause mortality was evaluated using the Cox proportional hazard models controlling for potential confounders including frailty. 392 patients with mean (SD) 93.0 ± 2.6 years (68.45% women) were included. The median (IQR) eGFR was 26.61 (18.41–40.41) mL/min/1.73 Prevalence of CKD in older persons is high, exceeding 38% in community dwelling persons aged ≥ 70 [The population of older adults is the fastest growing age group  and is rged ≥ 70 ,5.The measurement of GFR can be directly or indirectly measured with various techniques. Direct measurement is practically very difficult to employ due to the rigid timing and a prolonged testing phase. An indirect method that is employed is the measurement of serum creatinine levels (Scr) however this has reliability issues in older people due to sarcopenia and depleting muscle stores of creatine, thus overall calculated eGFR is favored to determine kidney function.2 showing an increased risk of all-cause mortality in nonagenarians, although the same was not true for the more general older population [Data from the United States Renal Data System in 2015 showed that among the 10.6% prevalence of CKD in individuals aged ≥ 65 years old only 1.8% of these individuals had no concomitant diabetes or cardiovascular disease, demonstrating that reduced eGFR is often associated with comorbidities. These co-morbidities include atherosclerotic cardiovascular disease, heart failure, hypertension, diabetes and cognitive impairment . HoweverIn this study we investigated the association between eGFR and mortality in the acutely unwell hospitalised oldest old patients in the United Kingdom (UK).Patient data were collected from 3 UK sites: Norwich and Norfolk University Hospital (NNUH), Aberdeen Royal Infirmary (ARI) and Woodend Hospital, Aberdeen (WH). The NNUH has a general catchment population of ~750,000 with ARI and WH having a combined catchment population of ~500,000. All patients aged ≥ 90 who were admitted to the acute medical assessment units (NNUH and ARI) or acute geriatric wards (WH) were included within the study. Patients who were admitted under non-medical teams such as surgical and Accident and Emergency were excluded from the study. Those who were admitted to a medical specialty other than geriatric medicine were also excluded. The data were collected prospectively in a 3-month period from November 2008 and all admissions during the study period were followed until hospital discharge, whereby the 1 November 2008 was the first admission date and the 24 December 2009 was the final discharge date.The detailed description of study methods are published elsewhere . In briePrior treatment in the community by a GP was also noted along with details of any previous admissions within 1 month of the recorded hospital admission. No formal ethical approval was required as data were collected for a multicenter audit project and respective NHS Institutional Approvals were obtained.−1.154 × (Age)−0.203 ×  × (1.212 if Black). This equation was chosen because it was found that MDRD was more consistent over a 5-year period [2 (≤30 mL/min/1.732 and >30 mL/min/1.732). This stratum was used in order to attempt to balance the distribution of the groups as there was a very large number of participants in the ≤30 mL/min/1.732 group. Furthermore, the current literature uses the groups <30 mL/min/1.732, 30–44.99 mL/min/1.732, 45–60 mL/min/1.732 and >60 mL/min/1.732 to indicate different renal function categories and thus the groups were in line with previously adopted cut-offs.The Cockcroft-Gault modification of diet in renal disease (MDRD) equation was used to calculate eGFR, eGFR = 175 × (Scr)r period  with theMFI-5 was used as it has an equivalent predictive ability as the well-established MFI-11 [Statistical analysis was performed using SPSS version 27.0 . Means (SD), medians (IQR), hazard ratio (HR) and 95% CI were calculated when relevant. Variables were chosen based on whether they have an effect as markers or direct effect on mortality. Patients that had incomplete, missing, or incorrectly entered data for the specified criteria of MFI-5 or eGFR were excluded.Differences between groups were assessed using one-way ANOVA for parametric continuous variables, Kruskal–Wallis for non-parametric continuous variables and Chi-squared tests for categorical variables.p-value of <0.05 were considered to be statistically significant.Multivariable Cox proportional hazards model were constructed to determine the independent contribution of eGFR (predictor/exposure) to the outcome of in-hospital mortality. The following models were constructed. Model (A) age and sex adjusted; (B) adjusted for age, sex and blood parameters  (C) Age, sex, blood parameters and baseline observations (Systolic blood pressure and pulse) (D) Age, sex, blood parameters, baseline observations and comorbidities (E) Age, sex, blood parameters, baseline observations, comorbidities, and polypharmacy (defined as ≥5 medicines being taken) (F) Age, sex, blood parameters, baseline observations, comorbidities, polypharmacy, and MFI-5. There was further stratification to assess risk of frailty and eGFR for MFI-5 and eGFR strata using all the variables from model F. 2 and 155 (39.54%) had eGFR >30 mL/min/1.732. Most patients were non-frail with MFI-5 ≤ 1 = 292 (74.49%) and MFI-5 ≥ 2 = 100 (25.52%). A total of 63 (16.03%) participants died as in-patients. From this univariate analysis shown in The results of the multivariate Cox proportional hazard modelling are shown in p-value of <0.001 and 0.001, respectively. In model D high sodium , high pulse rate , hypertension  and diabetes  showed significance with HR of 1.08 (95% CI 1.04–1.12), 1.01 (95% CI 1.00–1.03), 0.48 (95% CI 0.30–0.90) and 0.13 (95% CI 0.02-0.98), respectively. In model E significance was seen in high sodium , high pulse , hypertension  and diabetes  with hazard ratios of 1.08 (95% CI 1.04–1.12), 1.01 (95% CI 1.00–1.03), 0.47 (95% CI 0.27–0.88) and 0.12 (95% CI 0.02–0.92).Being frail or having increased levels of sodium, albumin and higher pulse showed an increased risk of mortality. Having hypertension or diabetes decrease the risk of mortality in the non-stratified models. In model B and C high sodium showed significance with a HR of 1.07 (95% CI 1.04–1.11) and 1.07 (95% CI 1.03–1.10) and a eGFR was not associated with mortality in nonogenerians regardless of frialty status.p-value 0.009) with a HR of 0.33 (95% CI 0.15–0.76) and pulse  with a HR of 1.01 (95% CI 1.00–1.03).However, in the non-frail nonogenerains  with a HR of 0.04 (95% CI < 0.01–0.80).In the frail nonogenerians , high pulse , hypertension , diabetes , and high MFI-5  with HR of 1.06 (95% CI 1.02–1.10), 1.01 (95% CI 1.00–1.03),0.36 (95% CI 0.19–0.69), 0.02 (95% CI 0.01–0.62), 2.61 (95% CI 1.27–5.36), respectively  was found for individuals with an eGFR of ˂30 mL/min/1.732. This is diametrically opposed to the results found where no affiliation was discovered even when stratified for frailty . In the aforementioned study the BIS1 equation was used which estimates lower GFR values compared to MDRD [2 (n = 62). When adjusted for gender and eGFR at age 88 a HR of 1.77 (0.52–6.10) for overall mortality and 4.00 (1.04–15.43) for CV mortality was found. This indicates increased risk of mortality with decreased eGFR but, similarly to previously mentioned studies the number of covariates adjusted for were small and there are large confidence intervals. There is further evidence however to suggest acute kidney injury and increased creatine levels are good prognostic indicators of long-term mortality in the patients with ST elevated myocardial infarction with cardiogenic shock [This study’s results are contrary to the findings of Montesanto and colleagues  on 505 c to MDRD  and is nic shock ,14. DemoAnother potentially important explanation is that the patients in our study presented with acute illness. Their acute pathology may be extra-renal in nature making eGFR non-discriminatory in this circumstance, so some deaths may have occurred in people with serious pathology but no renal problems. Furthermore, eGFR was calculated from initial blood tests thus patients with easily reversable renal pathologies may have been included in the statistical analysis affecting the strength of association with all-cause mortality.p-value < 0.05). However, a small sample size was used potentially exaggerating the association although there are other studies including Madsen et al. 2015 [Hypernatremia however showed consistent association with all-cause mortality seen in  with a Hal. 2015  that demSurprisingly increased levels of albumin showed an increase in mortality however this may have been as a consequence of dehydration worsening their CKD rather than a direct action of albumin on mortality. It may also have been a chance finding.This study found no clinical relevance or evidence to propose eGFR as a prognostic indicator in those aged 90 years or over seen in . FrailtySodium levels have evidenced association with all-cause mortality with this study finding no different. We further showed those with hypernatremia had a significant increased risk of mortality seen in . Sodium Race was not recorded so adjustment for it was not possible during the calculation of eGFR thus potentially leading to under reported or over reported eGFR. However, the population aged 90 and over in Aberdeen and Norwich is overwhelmingly white Caucasians. There are some limitations related to the MDRD equation and thus the insignificant results found maybe as a consequence of this rather than non-association. Estimated GFR is less accurate in patients with AKI presenting a higher likelihood of survival. The MDRD equation was derived and validated in a cohort with few nonagenarians thus this potentially effects the accuracy within this population. The MDRD equation, similarly to all creatine-based equations, suffers from physiological variances in creatine including the reduction in older frail patients and conditions associated with reduced secretion. Furthermore, the equation was developed in a population with CKD and thus underestimation has also been highlighted as a limitation. This is not exclusive to MDRD as all the most common equations have quite significant limitations and therefore presents a wider problem requiring a need for more accurate and validated equations or biomarkers specifically designed for nonagenarians ,16,17,182 during the patients stay. This combined with our studies results warrant further investigation around the significance in change of eGFR.This study shows the need for further research in this area. The recording of race is required in future studies as it modifies eGFR calculations, substantially effecting estimation. Moreover, a larger and prospective cohort study of patients ≥ 90 would be required to increase power and allow for specific study design and data collection whilst focusing on nonagenarians. Usage of all common equations combined with inulin clearance, would allow for validation of equations comparative to the gold standard. Furthermore, inulin clearance would validate GFRs association with all-cause mortality and thus clarify if eGFR is a clinically appropriate method for prediction. Ensuring repeated eGFR calculation over time, similarly to that of plasma clearance, would prevent the inclusion of easily reversable renal pathology allowing for the preventing of potential skewing. Analysis of results using trends would be important combined with Cox regression analysis to give a broader understanding of the relationship between eGFR and all-cause mortality. Additionally, the recording of relevant alternative end points including change in functional state and facility placement would be required to gain a more complete understanding of the role of CKD in age. Moreover, change in eGFR rather than low eGFR may cause the increase in risk of all-cause mortality. This was shown by Vart et al. 2019 [In conclusion we have shown that eGFR was not associated with increased mortality in acutely admitted nonagenarians and therefore may not be a good prognostic indicator limiting its clinical relevance for prediction of mortality. This is contrary to the existing literature on older people in other settings where eGFR was shown to be a good prognostic indicator. Hypernatremia and change in eGFR show potential as better prognostic indicators however further elucidation on the clinical application within this population is required. There are still significant limitations around all existing eGFR equations for this population that must be addressed in future research to fully evaluate the clinical relevance of GFR. Whilst eGFR must be considered when understanding overall health and diagnosis upon admission, it may not be the most useful tool upon admission to predict underlying chances of mortality or general trajectory for nonagenarians.


Although gaming addiction has received a great deal of attention from researchers, few studies have evaluated its effect on health related quality of life in adultsTo study the relationship between gaming addiction and perceived health statusWe conducted a cross-sectional, descriptive and analytical study.Data were collected using a self-administered questionnaire on social networks targeting adults between 18 and 40 years. We used the gaming addiction scale (GAS) in its validated Arabic short version. we also used the 36-Item Short Form Health Survey questionnaire (SF-36) in its validated Arabic versionOne hundred and nine participants were included. The mean age was 29.6 ±10.3. Males accounted for 60.6% of the study population. A history of anxiety or depression was found in 4.6 % of participants and 3.6% had an organic affection .The mean GAS score was 13.11± 6.08. According to this scale, 25.7% were addicted gamers. We found a significant difference between the group of participants considered addicts and those who were not in the following items: vitality (p=0.002), mental health (p=0.004) and role limitation due to emotional health (p=0.05). We found a correlation between the GAS score and role limitation due to physical problems ( p= 0.41), role limitations due to emotional problems (p=0.004 ), vitality( p=0.005) and mental health ( p= 0.001).Our data showed significantly lower health related quality of life related to higher exposure to games especially in the psychological health.In future researches, the effect of gaming addiction on other domains of quality of life can be investigatedNo significant relationships.


The purpose of this study was to compare short and mid-term outcomes in esophageal squamous cell carcinoma (ESCC) patients undergoing open or minimally invasive McKeown esophagectomy (MIE) after neoadjuvant PD-1 inhibitor plus chemotherapy.Patients with locally advanced ESCC underwent open or minimally invasive McKeown esophagectomy after neoadjuvant PD-1 inhibitor plus chemotherapy were retrospectively included from June 2019 to June 2021. The baseline characteristics, pathological data, short-and mid-term outcomes were collected and compared based on the surgical approach.vs. 277.9 ± 30.2 min, P = 0.009). The total number of resected lymph nodes was not significantly different, but more left recurrent laryngeal lymph nodes were harvested from the Open group . The median follow-up time was 1.42 years  from the first day of treatment. Three patients (8.6%) died during follow-up, one in the open surgery group and two in the MIE group. There were six (17.1%) patients developed recurrence, three in each group. The 2-year cumulative survival rates were 92.3 ± 7.4% and 89.5 ± 7.1% for the open and MIE groups, respectively. Overall survival was not different between the two surgical approaches.A total of 35 patients were included in the study. An open procedure was performed for 13 patients (37.1%), and 22 (62.9%) patients underwent MIE after neoadjuvant therapy. Compared with open group, MIE group had shorter operative times (350.8± 117.8 MIE might be safe and feasible for patients with locally advanced ESCC undergoing neoadjuvant PD-1 inhibitor plus chemotherapy. More thIn recent years, the inhibition of programmed death receptor 1 (PD-1) and its ligand combined with chemotherapy have demonstrated great promising benefits for patients with advanced ESCC . CamreliThis retrospective study aimed to compare short- and mid-term clinical outcomes between MIE and traditional open surgery for locally advanced ESCC patients who received neoadjuvant PD-1 inhibitor plus chemotherapy.2Ethical statement: This retrospective study was approved by the Institutional Review Board of The First Affiliated Hospital of Zhejiang University School of Medicine . Written patients informed consent was waived by the Institutional Review Board.A retrospective data analysis was undertaken on all patients with locally advanced ESCC who received neoadjuvant PD-1 inhibitors plus chemotherapy followed by open or minimally invasive McKeown esophagectomy at the First Affiliated Hospital of Zhejiang University School of Medicine between June 2019 to June 2021. There was no commercial support for the study. The study was designed and written by the authors, who ensured the accuracy and completeness of the reported data and compliance with the study protocol. All tumors met the following criteria: (1) histologically confirmed ESCC; (2) potentially resectable and locally advanced ESCC, defined as cT1N1-3M0 or cT2-4aN0-3M0 ; (3) lo2.12) on day 1 and (2) carboplatin  or cisplatin (60 mg/m2) on day 2 during each 21-day cycle. After two cycles of neoadjuvant treatment, contrast-enhanced thoracoabdominal computed tomography was performed to assess the treatment response according to the Response Evaluation Criteria in Solid Tumors, version 1.1. A multidisciplinary discussion determined whether to continue with neoadjuvant therapy or perform surgery.Patients received at least two cycles of neoadjuvant treatment before surgery. The detailed treatment regimen was as follows: (1) an intravenous PD-1 inhibitor (200 mg of camrelizumab) and nanoparticle albumin-bound paclitaxel  , 12. PatAll patients were recommended to reexamination regularly after being discharge from the hospital. Patients were followed up every 3 months during the first year after surgery and every 6 months in subsequent years. Overall survival (OS) was defined as the time from the date of first neoadjuvant treatment to death by any cause. Disease-free survival (DFS) was defined as the time from the date of first neoadjuvant treatment to recurrence. The primary endpoints were safety and feasibility, and the secondary endpoints included overall survival and disease-free survival.2.4The categorical variables were presented as frequencies and percentages. Continuous variables were expressed with a mean ± standard deviation when the normality was verified by Shapiron-Wilk test (P > 0.1), otherwise median and range. Spearman’s correlation was used to assess associations. Comparisons between the subgroups were performed using chi-square tests or Fisher’s exact test. The median follow-up time was calculated by using the Kaplan–Meier method. The Kaplan–Meier method was used to calculate DFS and OS. The reported P values are bilateral, and the significance level was set at 0.05 for all analyses unless otherwise indicated.33.1Between June 2019 to June 2021, a total of 35 patients with locally advanced ESCC were included in this study. All the patients underwent neoadjuvant camrelizumab plus chemotherapy followed by McKeown esophagectomy, and patients were grouped by the surgical procedure. The cohort was primarily male  with a median age of 65 years  patients received two cycles of the neoadjuvant treatment, and the rest of eight patients received three cycles. Cisplatin was used in 28 patients (80.0%). Treatment-related AEs were manageable and summarized in Based on radiological evaluation after neoadjuvant therapy, all 35 patients showed a reduction in tumor size. Two (5.7%) patients achieved a radiological CR, 26 (74.3%) patients achieved a radiological PR, and 7 (20.0%) patients had varying degrees of reduction, but did not meet the PR criteria. None of the patients showed disease progression during neoadjuvant therapy. Accordingly, the clinical overall objective response rate (ORR) and disease control rate (DCR) was 80.0% and 100%, respectively.Postoperative pathologic analysis showed that 4 (11.4%) patients achieved PCR and six (17.1%) patients achieved MPR. In addition, 28 (80.0%)patients obtained preoperative clinical downstaging, and 22 (62.9%) achieved postoperative pathological downstaging. Thirteen of 32 (40.6%) patients with node positivity before neoadjuvant therapy achieved nodal clearance. Postoperative pathological analysis showed that 14 patients (40.0%) were stage IA to IIB, and 21 patients (60.0%) were stage IIIA to IVA. No difference was found between the two surgical approaches about Pathological stage after neoadjuvant treatment, which was showed in the 3.3vs. 277.9 ± 30.2min, P = 0.009). The total number of resected lymph nodes was not significantly different between the two groups, but more left recurrent laryngeal lymph nodes were harvested from the open surgery group than the MIE group .All patients underwent scheduled Mckeown esophagectomy, R0 resection was achieved in all patients. No treatment-related surgical delays were recorded, and the mean interval from the end of neoadjuvant therapy to surgery was 32.4 ± 3.9 days (Range: 23–40). Thirteen (37.1%) patients underwent open surgery, while 22 (62.9%) patients underwent MIE. No patient converted to open surgery. Compared with patients who underwent open surgery, patients who underwent MIE had a shorter operative time . The length of postoperative hospital stay was not significantly different between the two groups, but the open surgery group had more patients with postoperative hospital stays of more than 2 weeks .The postoperative complications are summarized in 3.4The median follow-up time was 1.42 years  from the first day of neoadjuvant treatment. Three patients (8.6%) died during follow-up, one in the open surgery group and two in the MIE group. One patient with cT2N0M0 stage disease in the open surgery group died suddenly 6 months after surgery. In the MIE group, patient one with cT4aN3M0 stage who achieved an MPR after two cycles, died for drug-induced liver injury 10 months after surgery. Another patient with cT3N1M0 stage died for deep venous thrombosis 2 months after surgery. There were six (17.1%) patients developed recurrence during follow-up, three in the open surgery group and three in the MIE group. Four patients developed local recurrence in the regional lymph nodes. Two patients developed the distant metastasis, one with supraclavicular lymph nodes metastasis in the open group, the other with pulmonary metastasis and mediastinal lymph node metastasis in the MIE group. There was no significant difference between the two groups about the recurrence site. The mean DFS time was 1.46 ± 0.49 years, with a 2-year DFS rate of 81.8%. Meanwhile, the mean OS time was 1.45 ± 0.49 years, with a 2-year OS rate of 90.7%. The 2-year cumulative survival rates were 92.3 ± 7.4% and 89.5 ± 7.1% for the open surgery and MIE groups, respectively Figure 14To the best of our knowledge, this is the first study to compare the outcomes of the open surgery and MIE approaches in ESCC patients after neoadjuvant immunochemotherapy. The results of this study showed that (1) after neoadjuvant therapy of camrelizumab plus chemotherapy, the clinical ORR and DCR were 80.0% and 100%, respectively; (2) after surgery, the PCR and R0 resection rates were 11.4% and 100%, respectively; (3) the 2-year cumulative survival rates were 92.3 ± 7.4% and 89.5 ± 7.1% for the open and MIE groups, respectively. Accordingly, MIE might be safe and feasible for ESCC patients who received neoadjuvant camrelizumab plus chemotherapy.ESCC remains a challenging malignancy with a poor prognosis and limited therapeutic options. Although improvements in surgical techniques and neoadjuvant therapy strategies for locally advanced ESCC have been achieved, the survival rates for ESCC patients after multimodal therapy remain unsatisfactory. Although neoadjuvant chemoradiotherapy can further increase the R0 resection rate, it is associated with more postoperative complications and higher postoperative mortality. Developing novel efficacious therapeutic strategies is urgently needed to improve prognosis. Immunotherapy has recently been highlighted for the treatment of solid tumors. Several trials are currently underway to assess neoadjuvant anti-PD-1/PDL1 therapy combined with chemotherapy for locally advanced ESCC , 14. HerAlthough neoadjuvant chemotherapy contributes to tumor downstaging to allow a more radical surgical resection, it may result in tissue edema and adhesion, which makes tumor dissection more difficult and increases the likelihood of bleeding and injury to adjacent organs. Technical challenges and perioperative issues are concerns for patients after neoadjuvant immunotherapy with chemotherapy. Open esophagectomy appeared to have advantages in dealing with tissue adhesion and bleeding under direct vision. With the development of endoscopic techniques, MIE is gaining popularity for the treatment of ESCC, as it is less invasive and has lower complication rates , 19. PreIn this study, patients with locally advanced ESCC receiving neoadjuvant camrelizumab plus chemotherapy reached a clinical ORR of 80.0% and a DCR of 100%. This therapeutic strategy conferred a PCR and MPR in 28.6% of resected tumors. The PCR rates with the doublet chemotherapy drugs were approximately 2.5–33% in previous studies . Shen etThe neoadjuvant therapy in this study did not delay surgery, and the R0 resection rate reached 100%, while in previous studies, the reported R0 resection rates with neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy were 60% and 98.4%, respectively , 24. We Lymph node metastasis is closely associated with poor prognosis in ESCC. Therefore, the dissection of lymph nodes was very important in the esophagectomy, especially along with the recurrent laryngeal nerve nodes. The average number of resected lymph nodes (29.6) was significantly higher than the numbers reported in the CROSS (15.0) and NEOCRTEC5010 (20.0) studies , which wThis study has several inherent limitations. First, it was limited by its retrospective design which may cause biases. Patients were not randomly assigned to open esophagectomy or MIE group but were treated based on surgeon’s inclination. Second, the number of included patients was small. Third, the follow-up time was short. Long-term follow-up is necessary to assess the effect of neoadjuvant camrelizumab plus chemotherapy on disease-free and overall survival.In conclusion, MIE might be safe and feasible for patients with locally advanced ESCC who undergoing neoadjuvant camrelizumab plus chemotherapy in this small, retrospective study. The optimal treatment regimen and long-term results are important issues that need further investigation.The original contributions presented in the study are included in the article/This retrospective study was approved by the Institutional Review Board of The First Affiliated Hospital of Zhejiang University School of Medicine . The ethics committee waived the requirement of written informed consent for participation.All authors made substantial contributions to the conception of the study. QC, SM and PY conceptualized the study, revised the manuscript and supervised the study. QC and ZW collected the data, drafted the manuscript and made the figures RA, JC and PY revised the manuscript. All authors contributed to the article and approved the submitted version.


EGFR, KRAS, NRAS, BRAF, PIK3CA, ERBB2, MET, KIT, PDGFRA, ALK, ROS1, RET, NTRK1, NTRK2 and NTRK3 genes which serve as biomarkers for guiding treatment decisions in NSCLC patients.This is a pilot proof-of-concept study to evaluate the utility of a custom 15-gene circulating tumor DNA (ctDNA) panel as a potential companion molecular next-generation sequencing (NGS) assay for identifying somatic single nucleotide variants and indels in non-small-cell lung cancer (NSCLC) patients. The custom panel covers the hotspot mutations in EGFR mutations. The bioinformatics analysis was performed using the proprietary Archer Analysis Software.The custom 15-gene ctDNA NGS panel was designed using ArcherDX Assay Designer. A total of 20 ng or 50 ng input ctDNA was used to construct the libraries. The analytical performance was evaluated using reference standards at different allellic frequencies . The clinical performance was evaluated using plasma samples collected from 10 treatment naïve advanced stage III or IV NSCLC patients who were tested for tissue EGFR mutation were 83.3% and 100% respectively. In addition, the NGS panel also detected other mutations of uncertain significance in 6 out of 10 patients.For the analytical validation, we achieved 100% sensitivity and specificity for the detection of known mutations in the reference standards. The limit of detection was 1% allelic frequency. Clinical validation showed that the clinical sensitivity and specificity of the assay for detecting EGFR mutation. Further studies incorporating the validation of other candidate gene mutations are warranted.This preliminary analysis showed that the custom 15-gene ctDNA NGS panel demonstrated good analytical and clinical performances for the  Non-small cell lung cancer (NSCLC) represents the most common type of lung cancer which accounts for approximately 11% of all cancer types in Malaysia . While PEGFR mutations; combination of dabrafenib and trametinib for BRAF mutations; crizotinib, alectinib and lorlatinib for ALK/ROS gene fusions; larotrectinib for NTRK gene fusions; and Enhertu for ERBB2 mutations. To truly enable precision oncology, National Comprehensive Cancer Network (NCCN) and US FDA have recommended biomarker testing for genetic alterations in at least seven cancer genes  for guiding treatment decisions in NSCLC  were recruited into this study. All the blood samples were taken within 1-month from the date of tissue biopsy. A total of 20 ml peripheral blood samples was taken from eligible patients before the initiation of first line treatment. The blood samples were collected into Cell-Free DNA CT™ tube  and processed within 4 hours post-collection. The plasma fraction was separated from the blood cells by two consecutive rounds of centrifugation for 10 min at room temperature, at 1600 g and at 16,000 g, respectively. The plasma fraction (~ 4 ml) was used to isolate ctDNA using the Maxwell RSC LV cfDNA extraction kit . The ctDNA was eluted with ultra-pure nucleic acid free water , and stored at -80°C. The purity of ctDNA was determined using Nanodrop , whereas the concentration and integrity of ctDNA were determined using Quant-iT dsDNA HS Kit  and DNA 1K Hi Sens LabChip  respectively. Samples which passed quality assessment were subjected to targeted NGS assay.In this pilot study, a total of 10 patients in Sunway Medical Centre with newly diagnosed stage III or IV NSCLC and tested for tissue 2 clusters passing filter as per manufacturer’s instructions. Following this, the mutations were identified using Archer Analysis software (version 6.2).The regions of interest were amplified from 20 ng or 50 ng input ctDNA and the barcode/adaptor was added to each library using Archer MBC Adapters. The libraries were constructed using Archer custom 15-gene lung cancer panel kit according to the manufacturer’s instructions. The concentration of the constructed libraries was assessed using Kapa Library Quantification Kits  prior to sequencing. For each sequencing run, a range of 12 pM to 16.5 pM libraries were pooled and sequenced on Illumina Miseq using Miseq Reagent Kit V3 (600-cycle). The sequencing run were optimized to achieve the optimum target specification of 1200–1400 k/mmEGFR , KRAS (p.G12D), NRAS  and PIK3CA (p.E545K). In addition, Seraseq ctDNA Mutation Mix v2  was used as reference material for detecting BRAF (p.V600E), EGFR , ERBB2 (p.A775_G776insYVMA), KIT (p.D816V), KRAS (p.G12D), NRAS (p.Q61R), PDGFRA , PIK3CA , and RET (p.M918T). The analytical performance of the assay was determined by comparing the NGS results with known mutations of the reference standards.In order to evaluate the analytical performance of the 15-gene lung cancer panel, a set of 4 multiplex I ctDNA reference standards at different allellic frequencies  from Horizon Discovery were used for detecting variants in the genes. The covered gene variants were EGFR mutations, only treatment naïve advanced stage III or IV NSCLC patients who were tested for tissue EGFR mutations  and had ctDNA samples collected within 1-month interval from tissue biopsy were subjected to targeted NGS assay. The performance of the NGS assay in detecting EGFR mutations was determined by using tissue EGFR result as reference .In order to evaluate the clinical performance of the 15-gene lung cancer panel for detecting The bioinformatics analysis was performed by using the proprietary Archer Analysis Software Version 6.2 . The fastq data were uploaded to the cloud and analyzed according to the following settings: alternate observations (AO) ≥ 5, unique alternate observations (UAO) ≥ 3, gnomAD allele frequency ≤ 0.05, variants that have a consequence, variants with an AF outlier p-value ≤ 0.01, and mutant allelic frequency ≥ 0.0055. The variants were confirmed manually with the Integrative Genomics Viewer .EGFR mutation. The tissue EGFR mutations were confirmed via single-gene test [Cobas® EGFR Mutation Test v2 or Therascreen EGFR RGQ]. To evaluate the performance of the custom 15-gene ctDNA NGS panel for detecting plasma EGFR mutation in clinical setting, peripheral blood samples were collected from these 10 patients prior to the administration of tyrosine kinase inhibitor , or other therapies . The demographic and clinicopathological characteristics of these patients are summarized in This pilot study has prospectively enrolled a total of 10 patients who were newly diagnosed with advanced stage III or IV lung cancers, and had tested for tissue 2 clusters passing filter. However, our results showed that increasing library loading concentration from 12 pM to 16.5 pM improved the cluster densities and data output. The clusters passing filter of the four sequencing runs were 711 ± 14 k/mm2 (12 pM), 880 ± 20 k/mm2 (13 pM), 907 ± 45 k/mm2 (15 pM), and 1001 ± 23 k/mm2 (16.5 pM). It is noteworthy that data quality met the expected threshold value in which >90% of bases had Phred quality scores above 30.A total of 4 sequencing runs were conducted to evaluate the performance of the custom 15-gene ctDNA panel for detecting the clinically relevant somatic mutations in liquid biopsies. Our results  demonstrThe reference materials and clinical samples were pooled together in each run to maximize the cost-effectiveness of the testing. A total of 8 samples was sequenced in the first 2 runs, whereas 5 samples were sequenced in the third and fourth run to optimize the assay performance. As shown in ®ctDNA Mutation Mix v2 [allelic frequency: 1% (n = 1)]. In the first run, a total of 12 pM pooled libraries was sequenced, and yielded a total of 16,872,852 reads passing filter. The 15-gene ctDNA assay detected all the known 8 variants in 5% and 1% Horizon ctDNA, but no variants in 0.1% Horizon ctDNA. All the known variants were not detected in the duplicates of Horizon parental reference standard, giving rise to 100% specificity of these regions. The assay only detected 10 out of 14 known variants in Seraseq®ctDNA Mutation Mix v2. The four missing variants were EGFR (p.T790M), EGFR (p.L858R), KIT (p.D816V), and PIK3CA (p.Glu545Lys). In the second run, the same set of reference standards were analyzed by increasing the loading concentration to 13 pM, and the run yielded a total of 20,317,542 reads passing filter. Increasing the loading concentration significantly improved the sequencing output. Similar to the performance of first run, the 15-gene ctDNA panel detected all the known 8 variants in 5% and 1% Horizon ctDNA, but failed to detect the presence of variants with 0.1% allelic frequencies. The known variants were absent in the Horizon parental duplicates. The assay detected all the 14 known variants with 1% allelic frequencies in Seraseq®ctDNA Mutation Mix v2 when sequenced to ~1.7 million mapped reads.The analytical performance of the assay was assessed in 4 independent experiments, and the results are summarized in Figs The input of Horizon 0.1% ctDNA was increased to 50 ng in the third and fourth runs to optimize the detection limit of the assay. In parallel, 20 ng Horizon 0.1% was used in the third run for comparison purposes. The third run was loaded with 15 pM pooled libraries and yielded 21,028,976 reads passing filter. The fourth run was loaded with 16.5 pM and yielded 23,341,198 reads passing filter. Notably, approximately 1.5 million to 2.4 million mapped reads were generated from 20ng of 0.1% Horizon ctDNA, whereas approximately 3.8 million to 4.6 million mapped reads were generated from 50 ng of 0.1% Horizon ctDNA. Our results suggested that the increase of input and throughput of 0.1% Horizon ctDNA did not improve the detection limit of the assay whereby all the known variants in 0.1% Horizon ctDNA were not detected.BRAF p.Val600Glu, ~20% in EGFR p.Gly719Ser, ~25% in NTRK1 p.Leu585CysfsTer73, and ~23% in PIK3CA p.His1047Arg. In addition, the combined analysis of these 4 independent runs revealed that this panel may not be suitable for reporting the following variants which are randomly detected in the samples, including KRAS , NRAS (p.Ser65Asn), PDGFRA (p.Leu723TyrfsTer12), and ROS1 .Our analysis consistently detected four variants in the Horizon Multiplex I cfDNA Reference Standards which were of parental cell line origin. The allelic frequencies were ~30% in Overall, our analysis demonstrated that the detection limit of the custom 15-gene ctDNA assay was at 1% allelic frequency. The assay achieved 100% analytical sensitivity and 100% specificity when 20 ng ctDNA was sequenced to at least ~1.7 million mapped reads.EGFR variants, the peripheral blood samples were taken within 1-month interval from the date of the tissue biopsies. A total of 10 patients with newly diagnosed advanced stage III or IV lung cancer were recruited into this study. These clinical samples were sequenced concurrently with analytical reference standards in 4 independent runs. A total of 4 clinical samples was tested by using 20 ng input, whereas 7 samples were tested by using 50 ng input ctDNA. As shown in To determine the concordance between plasma and tissue EGFR, the 15-gene ctDNA assay detected 5 out of 6 known positive variants, and 4 out of 4 known negative variants, giving rise to 83.3% clinical sensitivity and 100% clinical specificity. The discordant result was observed in Lung 04 which harbored EGFR p.L858R mutation. The circulating EGFR variant remains undetectable even though the experiment on Lung 04 was repeated by increasing the ctDNA input from 20 ng which yielded 1,778,994 mapped reads to 50 ng which yielded 3,053,604 mapped reads. We postulated that the discordance could be attributed to the low abundance of circulating EGFR mutation during sampling time, and was below the detection limit of the assay.The clinical performance of the assay was assessed in 4 independent experiments, and the results are summarized in EGFR variants, the assay also detected additional variants in these 10 clinical samples. BRAF p.Val600Glu was found in Lung 01 and Lung 02, while KRAS p.Gly12Cys was found in Lung 09. EGFR p.Lys754Gln and ERBB2 p.Ser310Phe were found in Lung 06. KRAS p.Ser65Asn was detected in Lung 01, duplicates of Lung 04 and Lung 05. Also, KRAS p.Glu76Gly and NRAS p.Ser65Asn were detected in Lung 04.Other than known tissue EGFR variants. The usefulness of the panel in detecting other variants remains unknown and confirmation via orthogonal method is required for low confidence variants which were randomly detected in the tested samples.Overall, our analysis demonstrated that the custom 15-gene ctDNA panel achieved 83.3% clinical sensitivity and 100% specificity for detecting ™ demonstrated analytical sensitivity down to 0.1% mutant allele fraction, and clinical sensitivity and specificity of 85%, and 99.6% respectively as compared to tissue-based NGS , and their therapeutic impacts remain to be investigated. Multigene testing is advantageous in providing a more comprehensive genetic information for guiding treatment decision. BRAF, ERBB2 and RET have molecular targeted drugs available for use as therapy. Therefore in 30% of patients, liquid biopsy identified additional therapies that would not have been detected on standard molecular testing. Within this context, Lung 06 may be more amenable to afatinib, evidenced by the success of afatinib in treating metastatic lung adenocarcinoma harboring EGFR (p.L858R) and ERBB2 (p.S310F) co-mutations [In addition to survival –52. Thesutations . Lung 02® EGFR Mutation Test v2 and Therascreen EGFR plasma RGQ. The assay achieved 100% analytical sensitivity and specificity when sequenced to at least ~1.7 million mapped reads. The clinical sensitivity and specificity of the assay for detecting EGFR mutations were 83.3% and 100% respectively. Our preliminary analysis suggests that the custom NGS assay is of good performance. Extension studies are warranted in order to optimize the assay and to include validation of other candidate gene mutations.Overall, our analysis demonstrated that the limit of detection for the 15-gene ctDNA NGS panel for EGFR variants was at 1%, and is comparable to other PCR based methods, including CobasS1 Table(XLSX)Click here for additional data file.S2 TableThe analysis was performed by Archer Analysis software.(XLSX)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.