Background and Objectives: Inflammatory bowel diseases (IBD) are chronic conditions with an unpredictable course and a remitting–relapsing evolution. Fatigue is a frequent complaint in patients with IBD, affecting approximately half of the newly diagnosed patients with IBD. The aim of this study was to analyze fatigue in patients with IBD in remission. Materials and Methods: One hundred nineteen consecutive outpatients diagnosed with IBD for over 3 months that were in corticosteroid-free clinical and biochemical remission at the time of assessment were included in this cross-sectional study. Out of them, 72 (60.5%) were male; the median age was 39 years (IQR 30–47). Seventy-seven patients (64.7%) were diagnosed with Crohn’s disease and forty-two (35.3%) with ulcerative colitis, with a median disease duration of 6 years (IQR 2–10). Fatigue, health-related quality of life (HR-QoL), anxiety and depression were evaluated using the following self-administered questionnaires: FACIT Fatigue, IBDQ 32 and HADS. Results: The mean FACIT-Fatigue score was 41.6 (SD ± 8.62), and 38.7% of patients were revealed as experiencing fatigue when a cut-off value of 40 points was used. The mean IBDQ 32 score was 189.4 (SD ± 24.1). Symptoms of anxiety and depression were detected in 37% and 21% of the patients, respectively. In the multivariate analysis, fatigue was significantly associated with lower HR-QoL , symptoms of anxiety , female sex  and longer disease duration . Conclusions: Fatigue is highly prevalent even in patients with inactive IBD and is correlated with lower HR-QoL and anxiety, as well as with clinical factors such as longer disease duration and female sex. Inflammatory bowel diseases (IBD) with the two subtypes of Crohn’s disease (CD) and ulcerative colitis (UC) represent chronic inflammatory diseases with an unpredictable course, which leads to significant impairment in affected patients’ health-related quality of life (HR-QoL) and high levels of fatigue ,2.Fatigue is defined as ‘a persistent, overwhelming sense of tiredness, weakness or exhaustion resulting in a decreased capacity for physical and/or mental work’ ,4. It isPatients with IBD deal with fatigue more often than healthy controls. Active disease, lower hemoglobin values and altered sleeping patterns are among the predictors of fatigue .The etiology of fatigue is multifactorial: chronic inflammatory state, anemia, micronutrients deficiencies due to malabsorption or accelerated intestinal transit, self-imposed dietary restrictions, adverse effects of medication, psychological disturbances, intestinal dysbiosis or dysregulations of the brain–gut axis may play important roles .The management of fatigue in patients with IBD can be quite challenging because of its complex etiology and the limited knowledge on the pathogenesis of IBD-related fatigue, and requires a multidisciplinary approach. Kreijne et al. proposed a fatigue attention cycle that consists of seven steps: screening, assessment of concurrent symptoms, thorough fatigue evaluation, general anti-fatigue strategies, interventions and re-evaluation . PatientAnxiety and depression are frequently encountered comorbidities in patients with IBD. Up to 35.1% and 21.6% of patients with IBD have symptoms of anxiety and depression, respectively . They plThe majority of studies available in the literature that assess fatigue in patients with IBD are not specially focused on patients in remission. Moreover, studies that are designed for patients in remission assess disease activity only on a clinical basis, without considering biochemical markers of disease activity such as CRP and fecal calprotectin.The aim of this study was to analyze fatigue in patients with IBD in both clinical and biochemical remission and to identify factors associated with it.This was a cross-sectional, observational study.All patients included in this study were at least 18 years old and were in corticosteroid-free clinical and biochemical remission for more than three months. Pregnant females, patients being treated with corticosteroids, patients with ostomy, perianal disease, extraintestinal manifestations or other significant comorbidities or medical conditions that could have influenced their level of fatigue or quality of life were excluded. Patients already diagnosed with anxiety, depression or other psychiatric conditions were also excluded.One hundred and forty-one consecutive outpatients diagnosed with IBD for over 3 months that fulfilled the eligibility criteria at the time of assessment were invited to participate in the study. Out of them, 130 accepted and provided their consent to be included in this study. Eight patients had incomplete data and were excluded from the analysis. Another three patients had proof of endoscopic activity and were not considered eligible. Therefore, 119 patients were effectively enrolled in the study.The patients were treated for IBD at Fundeni Clinical Institute, a tertiary gastroenterology center in Bucharest, Romania. They were invited to participate in this study when they had their routine follow-up visit or treatment administration visit in the outpatient clinic. The enrollment took place between September 2022 and November 2022.The participants answered a series of auto-administered questionnaires evaluating their level of fatigue, their HR-QoL and their experiences of anxiety and depression: FACIT Fatigue, IBDQ 32 and HADS. Validated Romanian versions of these questionnaires were used.The Functional Assessment of Chronic Illness Therapy—Fatigue (FACIT-Fatigue) is a unidimensional scale used to assess fatigue, validated in the general population and a series of chronical conditions, including IBD. The total score ranges from 0 to 52 points, with lower scores representing greater fatigue .The Inflammatory Bowel Disease Questionnaire (IBDQ) is a 32-item questionnaire developed by Guyatt et al. in 1989 used to assess the HR-QoL in patients with IBD. The total score ranges from 0 to 224 points, with higher scores representing better HR-QoL .Hospital Anxiety and Depression Scale (HADS) is a questionnaire used to assess patients for clinically significant anxiety and depression. A total score over 7 points is considered pathological for both anxiety and depression ,20,21,22Fatigue was considered for FACIT-Fatigue score ≤ 40. Symptoms of anxiety and/or depression were considered to be present when patients had a HADS-A score > 7 and/or a HADS-D score > 7, respectively.Results from blood samples collected during the visit at the hospital were used in this study. Male patients that had a hemoglobin level < 13 g/dL and female patients with a hemoglobin level < 12 g/dL were considered to have anemia.Data regarding the patients’ demographics, lifestyle and the characteristics of the disease were collected during a short interview and from the patients’ records.Disease activity was assessed using the Harvey Bradshaw Index (HBI) for CD and Simple Clinical Colitis Activity Index (SCCAI) for UC. Remission was defined for a HBI score ≤ 4 points and SCCAI score ≤ 1 point. In addition, all patients had a CRP level lower than 5 mg/L at inclusion and last fecal calprotectin (within the last 6 months) below 150 ug/g.©2021 The R Foundation for Statistical Computing).Statistical analysis of the data was performed using R version 4.1.2 (1 November 2021)  were male; the median age was 39 years (IQR 30–47). Seventy-seven patients (64.7%) were diagnosed with CD and forty-two (35.3%) with UC, with a median disease duration of 6 years (IQR 2–10). The median duration of remission was 23.5 months (IQR 10–32.5).The characteristics of the study population, such as demographic data, data regarding the treatment and the disease as well as the prevalence of symptoms of anxiety and depression and the assessment of the HR-QoL are depicted in The vast majority of the patients (88.2%) were following a treatment with a biological agent at the time of inclusion, most of them with infliximab (50.5%) and vedolizumab (32.4%); a smaller proportion of patients were treated with adalimumab (12.3%) and ustekinumab (4.8%); and 11.8% of the patients were following a conventional treatment, either with 5-ASA or azathioprine. Regarding the exposure to previous biological agents, 23.5% of the patients had more than one biological treatment (they had at least one switch). Thirty-seven patients (31.1%) had a history of IBD-related surgery . One-third of the patients (34.5%) were active smokers.Regarding the level of education, 6.7% of patients had a low level of education (they completed only the primary cycle of education), 40.3% had a medium level (they completed high-school studies) and 52.9 had a high level of education (they graduated from university or they had a master’s degree or PhD).Anemia was identified in 14.3% of patients, all of them having only a mild form.The mean FACIT-Fatigue score was 41.6 (SD ± 8.62), and 38.7% of patients were revealed as having experienced fatigue when a cut-off value of 40 points was used (they had a FACIT-Fatigue score ≤ 40). The mean IBDQ 32 score was 189.4 (SD ± 24.1). Symptoms of anxiety and depression were detected in 37% and 21% of the patients, respectively.Endoscopic evaluation was not mandatory for inclusion in the study. However, three patients were excluded due to proven endoscopic activity in spite of clinical and biochemical remission. Overall, 40 patients (33.6%) had at least one endoscopic evaluation within the last year. Out of them, 21 had UC and 19 CD. Regarding the patients with UC, 13 underwent rectosigmoidoscopies, and 8 had complete colonoscopies. All patients with CD had ileocolonoscopies. All patients were in endoscopic remission at their last evaluation.Twenty-eight patients with CD (36.4% of CD patients) underwent CT/MRI enterography or bowel ultrasound within the last year. Out of them, two had small bowel strictures, without dilatation of small bowel loops. The strictures were clinically asymptomatic. Both patients had normal ileocolonoscopies.Fatigue as assessed by the FACIT-Fatigue score was evaluated in different categories of patients .p = 0.001). Regarding the disease duration, patients affected by fatigue had a significantly longer disease duration . Patients with a low level of education also seemed to experience fatigue more frequently; however, the number of patients with a low level of education included in this study was low.Female sex was associated with higher levels of fatigue, with 57.4% of female patients experiencing fatigue (p = 0.003). Another factor associated with fatigue was anemia: the majority of patients diagnosed with anemia also experienced fatigue . Anxiety and depression strongly influenced the level of fatigue, with a significantly higher proportion of patients with symptoms of anxiety  or depression  having fatigue.Exposure to a higher number of biological agents was associated with higher levels of fatigue: 64.3% of patients exposed to more than one biological therapy were affected by fatigue (p < 0.001).Health-related QoL, as measured by IBDQ 32 score, was strongly correlated with the level of fatigue, with patients with fatigue having significantly lower scores , symptoms of anxiety , female sex  and with longer disease duration   .Other variables such as depression, disease phenotype, lower level of education, the use of multiple biological therapies and anemia were not significantly associated with fatigue in the multivariate analysis.This is, to our knowledge, the first study designed to evaluate fatigue in patients with IBD in remission in Romania. It identified several factors associated with fatigue in a population of patients that are considered to be optimally treated, without the need of treatment optimization or surgical procedures, and it highlights the fact that even these patients still have to deal with high levels of fatigue. The early detection of fatigue and acting on factors that are associated with it could lead to a significant improvement in patients’ HR-QoL and psychosocial status.As our study shows, fatigue is a common symptom in patients with IBD in remission, identified in up to 38.7% of the patients in our cohort. While other studies report similar results ,28, thisp < 0.001), which was also significant in the multivariate analysis.In our study population, fatigue was significantly associated with lower HR-QoL, which is also confirmed by other studies ,29,30,32p = 0.008).Depression seems to be highly correlated with fatigue, as reported by multiple studies in the literature ,29,30,31Female sex is a well-known factor associated with fatigue ,28,29,33Patients with a longer disease duration may have experienced a more protracted course and may have had multiple relapses or surgical interventions. In our study, this group of patients was affected more frequently by fatigue. Conversely, other studies report lower levels of fatigue in patients with longer disease durations, which could be explained by the adjustment to the chronic disease over time .Fatigue was not associated with previous IBD-related surgeries. Even if there are studies in the literature reporting that IBD-related surgery is associated with fatigue , other sAnemia, even if it was significantly associated with fatigue in the univariate analysis, was not significant in the multivariate analysis. However, data reported in the literature are divergent. While some studies report the lack of association between fatigue and anemia or iron deficiency in patients with inactive disease ,38, otheVitamin and micronutrients deficiencies may play an important role in the etiology of fatigue . AlthougEven though the vitamin D level was not routinely assessed, an important proportion of patients treated in our center use vitamin D supplements. However, the association between fatigue and vitamin D deficiency in patients with IBD is controversial. While some studies found an association between muscle fatigue and lower vitamin D level , others The study analyzed fatigue in patients with IBD in both clinical and biochemical remission, in correlation with anxiety, depression and HR-QoL. It was conducted on a population of patients that were considered to be optimally treated. Several factors associated with fatigue were identified, such as lower HR-QoL, anxiety, female sex and longer disease duration.On the other hand, it has several limitations, such as the inability to establish the causality due to its cross-sectional design; disease remission was evaluated on clinical and biochemical bases, without colonoscopies performed at inclusion. Given the fact that this was a single-center study and the prevalence of IBD in Romania is low , the samIn summary, this study showed that even in patients with inactive IBD there is a high prevalence of fatigue. In addition, it identified factors that are significantly associated with fatigue: lower HR-QoL, anxiety, as well as other clinical factors such as longer disease duration and female sex.Because fatigue is a multifactorial and complex condition, further research with larger groups of patients and multicenter trials should focus on identifying other predictive or etiological factors for fatigue in patients with IBD.


CTLA4, rs3181098 of CD28, rs36084323 and rs10204525 of PDCD1, and rs11889352 and rs4675379 of ICOS were significantly associated with GO based on genotype analysis and/or allele analysis (p < 0.05). After summarizing the GO data and the previously published SLE and RA data, it was found that rs11571315, rs733618, rs4553808, rs16840252, rs11571319, and rs36084323 were shared in these three diseases. Furthermore, the bio-function was confirmed by dual-luciferase reporter assay. It was shown that rs733618 T > C and rs4553808 A > G significantly decreased the transcriptional activity (both p < 0.001). This study is the first to confirm that these three diseases share genetically predisposing factors, and our results support the proposal that rs733618 T > C and rs4553808 A > G have bio-functional effects on the transcriptional activity of the CTLA4 gene.In clinical practice, it is found that autoimmune thyroid disease often additionally occurs with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). In addition, several studies showed that eye-specific autoimmune diseases may have a strong relationship with systemic autoimmune diseases. We focused on Graves’ disease (GD) with ocular conditions, also known as Graves’ ophthalmopathy (GO), trying to find out the potential genetic background related to GO, RA, and SLE. There were 40 GO cases and 40 healthy controls enrolled in this study. The association between single-nucleotide polymorphisms (SNPs) of the co-stimulatory molecule genes and GO was analyzed using a chi-square test. It showed that rs11571315, rs733618, rs4553808, rs11571316, rs16840252, and rs11571319 of  Systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and Graves’ disease (GD) have many common characteristics, including their prevalence in women and the production of autoantibodies due to the over-activation of autoreactive T cells and the over-proliferation of B cells . AdditioIn recent years, more and more studies have shown that SLE is associated with AITD, including GD and Hashimoto’s thyroiditis . In addiIt is clinically shown that about one-third of SLE patients will have ocular complications . Eye symSLE is a systemic autoimmune disease, which is mainly caused by the loss of immune tolerance and immune imbalance led by genetic factors . GD is aThe diagnosis of GO is made when 2 of the following 3 signs of the disease are present: (1) Circulating thyroid antibodies or a dysthyroid state. (2) Typical ocular signs. (3) Fusiform enlargement of extraocular muscles. The inclusion criteria of the healthy control group were those without autoimmune diseases, immune abnormalities, or using immunosuppressive drugs. A total of 100 volunteers were recruited as control cases in the same IRB, and the same number of control cases was taken from those for SNP analysis.CTLA4, CD28, PDCD1, TNFSF4, and ICOS. Previously, only the CTLA4 gene polymorphism and its correlation were analyzed in GO patients  expression vector  with NanoLuc luciferase. Similarly, these vectors were transferred into competent cells and confirmed by direct sequencing. Next, 1 μg of the pNL1.1 NanoLuc expression vector with the wild-type sequence or single SNP variation and 1 μg of the pGL 4.5 firefly expression vector (Promega) were transfected into 400 μL (2.5 × 105) K562 cells together by using Lipofectamine 2000 (Invitrogen) and cultured, with pGL 4.5 used as the internal control to exclude bias in the transfection efficiency.We routinely cultured 1 × 10® Dual-Luciferase® Reporter Assay System, Promega) according to the manufacturer’s protocol. Each promoter–reporter assay was conducted 5–6 times in parallel. The luminescence of NanoLuc luciferase was divided by Firefly luciferase to exclude bias. In addition, the value of the wild type was referenced as 1 to compare the relative light units (RLUs) of each SNP variation.After culturing for 24 h, these cells were detected using a Luciferase Assay System  to confirm that the included control group was representative of the entire population. Then, the allele and genotype contributions were analyzed using the chi-square test or Fisher’s exact test when the expected value of more than 20% of the cells was less than 5, given the odds ratio (OR) with a 95% confidence interval (CI). Among them, the lower-frequency allele was known as the minor allele, which was used to assess the effect of people with a minor allele on disease development. For multiple comparisons, the false discovery rate (FDR) Q-values were calculated to evaluate the expected proportion of type I errors. The haploid blocks were identified by linkage disequilibrium (LD) analysis, which was defined according to the definition proposed previously by Gabriel et al. . We deleThe GO cases (45.5 ± 15.2 years old) comprised 18 males (45%) and 22 females (55%), totaling 40 cases. The control group (37.6 ± 6.8 years old) for GO contained 7 males (18%) and 33 females (72%).CD28 and rs10932035 and rs11571305 of ICOS deviated from the HWE  to eliminate statistical errors. It was found that most SNPs satisfied the HWE; only rs3181096 of  the HWE . TherefoCTLA4 gene, six SNPs had statistical significance: rs11571315, rs733618, rs4553808, rs11571316, rs16840252, and rs11571319. The genotypes of rs11571315 were significantly different between GO cases and healthy controls . Compared to TT, the CT genotype had 0.327 times lower odds  and it had 0.077 times lower the odds of CC genotype exposure . In addition, when people had at least one C-allele (CT + CC), they had lower odds of GO . In allele analysis, the C-allele of rs11571315 had 0.291 times lower odds of GO . In other words, the T-allele in rs11571315 was a risk allele of GO. The genotypes of rs733618 had significant differences between GO cases and controls . Compared to CC, the TT genotype  and genotype with at least one T-allele  had lower odds of GO. Moreover, people with TT in rs733618 had lower odds of GO than those with CT and CC . In allele analysis, the T-allele of rs733618 had lower odds of GO . The genotypes of rs4553808 had statistical significance . In this SNP, there were only two genotypes, AA and AG, found in the population included in this study. Compared to AA, people with AG had 0.214 times lower odds . In allele analysis, the G-allele of rs4553808 had lower odds of GO . The genotypes of rs11571316 were near statistical significance . Compared to GG, people with the AG genotype had 0.321 times lower odds of GO  and people with at least one A-allele (AG + AA) had 0.306 times lower odds of GO . In allele analysis, the A-allele of rs11571316 had lower odds of GO . The genotypes of rs16840252 were significantly different between GO cases and controls . In this SNP, there were only two genotypes, CC and CT, found in the population included in this study. Compared to CC, the CT genotype had lower odds of GO . In allele analysis, the T-allele of rs16840252 had lower odds of GO . The genotypes of rs11571319 located in 3′UTR of CTLA4 were significantly different between cases and controls . Compared to GG, people with the AG genotype  or at least one A-allele  had lower odds of GO. In allele analysis, the A-allele of rs11571319 had lower odds of GO .The allele frequencies are shown in CD28 gene, there were two SNPs associated with GO, rs3181097 and rs3181098. The genotypes of rs3181097 were significantly different between cases and controls . Compared to AA, people with the GG genotype  or at least one G-allele  had lower odds of GO. In allele analysis, the G-allele of rs3181097 had lower odds of GO . The genotypes of rs3181098 were close to being statistically significant . Moreover, the genotype frequencies of AG + GG and AA were significantly different between GO cases and controls . Because there were no GO cases with the AA genotype, the odds ratio is not shown.Regarding the PDCD1 gene, two SNPs had statistical significance, rs36084323 and rs10204525. Compared to the TT genotype, people with the CC genotype in rs36084323 had higher odds of GO . Compared to the TT + CT genotype, people with the CC genotype in rs10204525 had higher odds of GO . In allele analysis, the C-allele of rs36084323 and rs10204525 had a higher risk of catching GO .Regarding the p = 0.045, Q = 0.1800). No matter whether comparing to the AA genotype or AG + AA, people with TT had higher odds of GO . In allele analysis, the T-allele of rs11889352 had higher odds of GO . The genotypes of rs4675379 were significantly different between cases and controls . Compared to the GG genotype, people with the CG  or at least one C-allele  had lower odds of GO. However, the allele contributions of rs4675379 were not significantly different between cases and controls (p = 0.178).Regarding the ICOS gene, two SNPs had statistical significance, rs11889352 and rs4675379. The genotypes of rs11889352 were significantly different between cases and controls , CTLA4 (rs62182595/rs16840252/rs5742909), and PDCD1 (rs2227981/rs2227982/rs6705653/rs41386349) each had one haplotype block, and ICOS had two haplotype blocks (rs11889352/rs11883722 and rs10932036/rs4404254/rs10932037/rs10932038). In haplotype analysis  and one ICOS haplotype (Ars11889352Crs11883722) were associated with GO .In analysis , it was CTLA4 and rs36084323 of PDCD1 had a significant statistical association in these three autoimmune diseases , and the G-allele of rs4553808 reduced the transcriptional activity level to 0.245 times that of the A-allele (p < 0.001).The bio-function of the significant SNPs located in the  did not . The C-aCTLA4 was significantly associated with GO and rs16840252 had a strong tendency towards statistical significance based on the data from 22 GO cases and 20 healthy controls [Previously, we found that rs733618 of controls  and the CTLA4 was significantly associated with GO based on data from 22 GO cases and 20 healthy controls, while rs16840252 had a strong tendency towards statistical significance [CTLA4 gene were also associated with GO in addition to rs733618 and rs16840252. Most studies found that rs231775 of CTLA4 was associated with GO [CTLA4 was undoubtedly one of the susceptibility genes for GD or further development into GO; however, its variants associated with GD/GO varied widely across populations. Concerning our research about the correlation between GD and CTLA4 polymorphism, it was found that rs733618 T/C and rs231775 G/A were associated with GD [In 2019, we found that rs733618 of  with GO ; and rs1According to the available information, there was no literature about the association between the SNPs of rs4553808, rs16840252, rs36084323, rs10204525, rs3181098, rs11889352, and rs4675379, and GD/GO. Although there was no literature associated with GO or GD, these SNPs were associated with other autoimmune diseases or cancers. It was found that rs4553808 was significantly correlated with Hashimoto’s thyroiditis disease, which is also a thyroid disease ; rs16840CTLA4 and rs36084323 of PDCD1, which indicated that these three diseases had a partial genetic background. Thus, these SNPs may play an important role both in the pathogenesis of systemic autoimmune diseases (such as SLE and RA) and eye-specific autoimmune diseases (such as GO). Since they share many features, it was not surprising that they shared the same genetic predisposing factors. CTLA4 and PDCD1 are important negative regulators of T-cell activation [CTLA4, leading us to surmise that these two SNPs may have an interaction with the key SNP that causes the disease. They were significant in SNP analysis, but it was not real pathogenic SNPs. This conjecture was verified in our functional analysis. The SNP variation of rs16840252 did not affect the transcriptional activity of the CTLA4 gene. In the functional analysis, it was found that rs733618 T > C and rs4553808 A > G significantly reduced the transcriptional activity. In addition, the transcriptional activity analysis of rs36084323 of PDCD1 was conducted in our previous study [After integrating the data of SLE, RA, and GO, it was found that several SNPs had intersections, including rs11571315, rs733618, rs4553808, rs16840252, and rs11571319 of us study ,35,36. Mus study , and cisus study , therebyus study , which ius study ,40,41,42CTLA4 had no statistical significance in RA but were only associated with RA in the heterozygous genotype [CTLA4 SNPs may be different from that of SLE and GO. Moreover, the human leukocyte antigen (HLA) gene is one of the SNPs that is closely understood in a broad sense. In immune-mediated diseases in particular, there have been reports of SNPs that were associated with autoimmune diseases. It is known that the HLA and its costimulatory system form a necessary part of the immune response. People with certain HLAs are more likely to develop certain autoimmune diseases. For example, the HLA-DR3 allele was a shared SNP for Sjögren syndrome, diabetes mellitus type 1, and SLE [In the future, large-scale and carefully designed research should be carried out, taking into account detailed environmental factors, to confirm this relationship in different populations, so as to further verify these associations, especially for gene–environment and gene–gene interactions, or researchers could select T cells with specific SNPs or haplotypes from patients to culture in vitro to test the CTLA4-mediated immunosuppression. In addition, functional analysis of the promoter SNP could verify that these SNPs affected the transcriptional function of the gene and were associated with the occurrence of the disease. rs733618 and rs4553808 were related and had a biological function in three autoimmune diseases at the same time, indicating that these two SNPs may play an important role in the mechanism of these autoimmune diseases, which could provide a new direction for their treatment. However, the allele frequencies of these common SNPs of genotype , which c and SLE ,44. An aThe present study has some merits. Previously, GO was mostly discussed with RA, and this study is the first research to show that SLE, RA, and GO share a genetic background. In addition, since the genotype frequency distribution of the control group was evaluated via HWE analysis before the genotype and haplotype analysis, this indicates that our findings are less prone to bias. The sample size of GO was a limitation, though FDR was used to correct for multiple testing, which could have solved the problem that the sample size of GO cases was small, which may have given false-negative outcomes. In addition, we also used a dual-luciferase reporter assay to verify the bio-functional effect of common SNPs on transcriptional activity. However, some limitations of the study should be acknowledged. This study only included the Taiwanese population. Thus, based on ethnic differences, the findings may only apply to the Taiwanese population. Additionally, because the materials of the reporter assay used in the promoter–reporter cannot be shared with the 3’UTR-reporter, and the 3’UTR-reporter assay needs to consider the influence of microRNA , only thCTLA4 gene was verified by dual-luciferase reporter assay. This indicated that these SNPs had a functional effect on the pathogenesis of autoimmune disease rather than just an association. Additionally, T-cell activation can be considered as an upstream pathway of adaptive immunity. Therefore, it can be inferred from this result that these SNP mutations involved in the upstream pathway of adaptive immunity may be related to the regulation of immune response, especially since these SNPs were also associated with other immune-related diseases or cancers.We found that there were six SNPs of genes that are involved in regulating T-cell activation that were common in SLE, RA, and GO. Furthermore, the bio-functional effect of the promoter SNPs on the transcriptional activity of the


Chrysocyon brachyurus) is the largest South American canid. In Brazil, as in other countries, it is considered an endangered species. Habitat loss, landscape changes, hunting, and roadkill are the main threats to this species. In addition, invasive diseases of domestic animals are considered to be an emerging threat to the maned wolf, where parasitic diseases are relevant. Sarcoptic mange is a skin disease caused by the mite Sarcoptes scabiei. This disease is currently almost globally distributed, with a remarkable host diversity. In Brazil, reports of sarcoptic mange in wildlife include several species, both wild and captive. However, the impact of this disease on wildlife is unknown. At the time of writing, there is only one published report of sarcoptic mange in maned wolves. This study sheds light on the occurrence of sarcoptic mange in free-ranging maned wolves in their natural range. A total of 52 cases (suspected and confirmed) of sarcoptic mange were identified through social media review, camera trapping, chemical immobilization and sample collection. These cases were distributed in southeastern Brazil, in the states of São Paulo (n = 34), Minas Gerais (n = 17), and Rio de Janeiro (n = 1), demonstrating a rapid and widespread spread of this disease, although it still only occurs in part of the species’ range. We expect that these results will help to subsidize future actions relevant to the control of this emerging disease.The maned wolf ( Chrysocyon brachyurus) is the largest native South American canid, weighing up to 30 kg and inhabiting the central part of South America, especially the Cerrado, Chaco and Pampa biomes. Its diet consists primarily of the fruits of a typical savanna shrub, the wolf apple (Solanum lycocarpum), and secondarily, of rodents, birds [2, with little overlap with the home ranges of not paired individuals [The maned wolf  . GloballDirofilaria imitis [Toxocara canis [Tricuris vulpis [Direct contact between pets and wildlife is known to promote the bi-directional flow of pathogens . The impa imitis , Toxocarra canis , and Tris vulpis  in wild s vulpis ,22,23,24Sarcoptes scabiei. It is almost globally distributed, and has been described in humans and animals (domestic and wild) [stratum corneum of the skin, then emerge to mate on the surface and lay eggs, which take 3 to 4 days to hatch [stratum corneum and their secretions cause a hypersensitivity reaction in the host, resulting in severe pruritus [Sarcoptic mange is a parasitic disease caused by the mite nd wild) ,26. In Bnd wild) ,28,29,30nd wild) . Howevernd wild) . The entto hatch . The prepruritus . Dependipruritus .Cerdocyon thous) [Lycalopex griseus) [L. sechurae) [Speothos venaticus) [C. brachyurus) in Bolivia [Sarcoptic mange has been described in crab-eating fox (n thous) ,30,36, cgriseus) , sechuraechurae) , bush donaticus) ,40, and  Bolivia  and Braz Bolivia . However Bolivia . Neverthhttps://www.gov.br/icmbio/pt-br/assuntos/biodiversidade/pan/pan-canideos (accessed on 16 of January 2023)). The study area for G1 and G2A included the state of São Paulo, along the border with the state of Minas Gerais, in southeastern Brazil ) and all cases were plotted on a thematic map prepared in the QGIS version 3.20 (Odense) software.This study included confirmed cases  and suspected cases . G1 individuals were captured with box traps or rescued from September 2017 to February 2023. In addition, we included in this group a record traced back to January 2008 . For thn Brazil . For G1,Since there are no pathognomonic lesions of sarcoptic mange, a case was considered confirmed if mites were identified in skin scrapings or biopsies. One case included in this study was previously described by Jorge and Jorge .® (tiletamine hydrochloride 125.0 mg and zolazepam hydrochloride 125.0 mg) was used for chemical containment. The anesthetic was administered intramuscularly, using a hypodermic syringe. Clinical parameters  were monitored throughout the procedure. A general condition assessment was performed after chemical containment, and age was estimated based on the dental arches [The number of box traps used simultaneously in each sampling site varied from 2 to 6 (mean = 4). The box traps were used for physical containment and were distributed over the monitored sampling site at pre-determined locations. A dose of 4 mg/kg of Zoletil 50l arches ,43,44. Wl arches  and ICMBl arches . Animalsl arches . CaptureFor this assessment, we use camera trap surveys (G2A) and social media posts (G2B) containing descriptions or photographs of maned wolves with suggestive mange skin lesions. For G2A, a total of 71 different sites were used for camera trapping during the study, with the number of simultaneous sites varying depending on the season and the duration of each field campaign. A number of 30–35 cameras were left in fixed positions throughout the entire sampling period and 15–20 cameras were repositioned after one year. In the daytime images captured by camera traps, alopecia could be identified from the frames of the recorded videos. For the night images, alopecia was observed as peculiar dark patches on the exposed skin in contrast to the animal’s fur.For G2B, we considered records whose published images contained one or more clinical signs of the disease, such as alopecia, scabbing, desquamation, and skin lesions (due to pruritus) at the elbows, hocks, and/or margin of the pinna. The authors of the social media posts  were contacted and asked if, in addition to the suggestive clinical signs, pruritus was observed, as well as the exact location of the recording.In addition, if identification of the mite in skin scrapings or biopsies from the captured wolves (G1) was not possible, and only the presence of the suggestive lesions was observed, these animals were included in G2A.A total of 52 cases of sarcoptic mange were identified, of which 10 (19.2%) were confirmed (G1) and 42 (80.8%) were suspected , includiOf the confirmed animals (G1), eight (53%) were males and seven (47%) were females. The body condition of 13 (86.7%) animals was within the normal body weight range for the species, including 3 juveniles . In six According to the period in which records were noticed, considering G1 and G2: in 2008, one case; from 2009 to 2014, no record was made; in 2015, one case; in 2016, one case; in 2017, five cases; and in 2018, one case. The records became abundant from 2019 on, with six cases; in 2020, nine cases; in 2021, eight cases; in 2022, sixteen cases; and in 2023, four cases were recorded by March.The trapping effort (G1) was 18,312 traps × hours. A total of 67 captures of 20 individual maned wolves occurred at all 14 monitoring sites. The sampling effort for the camera trap survey (G2A) was 870,168 traps × hours, resulting in 731 images of 43 individual maned wolves (adult and juveniles), at 27 sampling sites (55% of the monitored sampling sites).Microscopically, in three cases, the epidermis showed marked parakeratotic hyperkeratosis, degenerate and non-degenerate neutrophils, and multifocal areas of ulceration associated with numerous intralesional adult mites. Within the dermis, a mild mixed inflammatory infiltrate , congestion of deep dermal vessels, and lymphangiectasia were observed. Morphologically, the mites measure between 200 × 400 μm, have articulated appendages, a chitinous exoskeleton, dorsal spines, striated muscle, intestinal and reproductive structures, and a body cavity .The present study described the occurrence of sarcoptic mange in maned wolves in southeastern Brazil. The methodology was limited by the small number of skin scrapings and biopsies obtained from affected animals, which prevented a comprehensive understanding of the dermatological manifestations and maintenance of the disease in this species. Despite these limitations, it is important to emphasize the commendable sampling effort undertaken in this study, which allowed the collection of valuable data on sarcoptic mange in maned wolves.The increasing number of individuals affected by sarcoptic mange reported in a small portion of the maned wolf’s range in Brazil , suggests that this disease is a new emerging threat to the species, especially in anthropized areas. The first report of sarcoptic mange in a maned wolf in Brazil was recorded in 2008 . In thisObservations in G1 animals revealed areas of alopecia and crusts on the skin as clinical signs. However, skin samples from five animals with clinical signs were negative in the parasitological and histopathological diagnoses, and were included in the G2A group. Although a proper protocol for mite isolation has not been established, it has been suggested that the collection of mites depends on the stage of infestation, as they may be difficult to collect at certain stages, leading to false negative results in the laboratory techniques used ,48. Thus® . Although these animals showed improvement in the clinical signs, the diagnosis of sarcoptic mange could not be confirmed because Bravecto®  does not specifically target Sarcoptes scabiei.Individuals Cbr 5, Cbr 8 and Cbr 9 (which were negative in skin scraping) all had a history of direct (pairs during breeding season or parents with youngsters) and/or indirect contact (high home range overlap) with other wolves positive for sarcoptic mange . This contact was recorded using GPS collar monitoring installed on the animals. Once it was known that the mange transmission occurs either directly, through physical contact, or indirectly, through fomites ,50, clinAnimals included in the G2 group were classified as suspect because the images showed clinical signs suggestive of sarcoptic mange ,35. SignAll cases of sarcoptic mange (G1 or G2) were recorded in areas where the landscape is changing due various human activities, especially agriculture and cattle ranching . In addiSus scrofa), which has been reported to have mange in its natural range [Lepus europaeus), which, although not reported to have mange, has mange in other members of the genus [The possibility of anthropogenic changes influencing the epidemiology of sarcoptic mange is suggested. As with domestic dogs and cattle, there are other species that could be part of the epidemiological cycle of mange. Exotic species may be affected and transmit the parasites. Examples include the wild boar  or wild, whether invasive or native. In particular, educational efforts focused on proper land use and responsible care of the domestic animals are important issues to be developed for the conservation of the maned wolf. Disease surveillance of the Brazilian fauna is gradually being standardized and professionalized. In the case of the native wild canids, these actions are being discussed in the National Action Plan for Wild Canids of the Instituto Chico Mendes de Conservação da Biodiversidade (ICMBio) of the Brazilian Ministry of Environment and Climate Change, and the results will be useful in prioritizing public policies to help reduce the spread of sarcoptic mange in maned wolves.


However, the presence of atrophy did not correlate with tTGA. Mucosal atrophy was detected in 29 (47.5%) out of 61 patients by CE. With this method, no noticeable dependence on uGIP results (24 GIP− vs. 5 GIP+) was observed. Conclusions: The single uGIP test was positive in 11% of CD cases referring a correct GFD adherence. Furthermore, uGIP results significantly correlated with the duodenal biopsy, formerly considered the gold standard for assessing CD activity. Introduction and aim: Usually, adherence to the gluten-free diet (GFD) in celiac patients is indirectly assessed through serological analysis, questionnaires, or invasive methods such as intestinal biopsy. The detection of gluten immunogenic peptides in urine (urinary gluten immunogenic peptides—uGIP) is a novel technique that directly evaluates the ingestion of gluten. The aim of this study was to evaluate the clinical efficacy of uGIP in the follow-up of celiac disease (CD). Methods: From April 2019 to February 2020, CD patients reporting complete adherence to the GFD were prospectively enrolled but were unaware of the reason for the tests. Urinary GIP, the celiac dietary adherence test (CDAT), symptomatic visual analog scales (VAS), and tissue transglutaminase antibodies (tTGA) titres were evaluated. Duodenal histology and capsule endoscopy (CE) were performed when indicated. Results: A total of 280 patients were enrolled. Thirty-two (11.4%) had a positive uGIP test (uGIP+). uGIP+ patients did not show significant differences in demographic parameters, CDAT, or VAS scores. The tTGA+ titre was not related to the positivity of uGIP (14.4% vs. 10.9% in patients with tTGA+ and tTGA−). Regarding histology, 66.7% of the GIP+ patients had atrophy compared to 32.7% of the GIP patients ( Celiac disease (CD) is a systemic immune-mediated disorder triggered by gluten ingestion in genetically susceptible individuals carrying the HLA-DQ2 and/or DQ8 haplotypes. It is characterized by intestinal  atrophy, specific autoantibodies (anti-tissue transglutaminase immunoglobulin A (tTGA), and anti-endomysial antibodies (EMA)) ,2,3,4.CD is currently one of the most common chronic diseases, affecting 0.5% to 1% of the general population nationwide and worldwide, except for areas with a low frequency of genetic predisposition and low gluten consumption ,7.To date, the only effective therapy for CD is a strict, lifelong GFD and it is generally accepted that strict adherence to a GFD results in serological, histological, and clinical remission. A GFD is also effective on extra-intestinal CD manifestations. These could be short stature in children, infertility, anemia, improvement in body weight, metabolic and nutritional changes such as a significant increase in bone density, and the normalization of vitamin  and mineral levels. Notably, a GFD could prevent CD-associated complications: poor dietary adherence favors the development of other autoimmune diseases, fertility problems, and increased risk of bone fractures. Also, although rare, other life-threatening complications can occur including hyposplenism, refractory coeliac disease, intestinal lymphoma, small bowel adenocarcinoma, and ulcerative jejunoileitis [In many cases, the persistence of symptoms despite a GFD may be attributed to other coexisting causes, such as irritable bowel syndrome, microscopic colitis, intolerance to other food ingredients , or inflammatory bowel disease. Non-responsive CD occurs when patients have persistent symptoms or when mucosal damage is present despite an apparently adequate GFD . The persistence of symptoms or intestinal mucosal damage may also be triggered by continued and involuntary gluten ingestion. The frequent daily gluten exposure makes the GFD very difficult to accomplish. Cross-contamination and the unexpected presence of gluten in processed foods or medications could increase the rate of involuntary gluten ingestion, in addition to the significant number of patients who do not adhere to chronic treatment . Thus, iGluten fragments resistant to gastrointestinal digestion and capable of triggering CD are known as “gluten immunogenic peptides” (GIP) . They caThe aim of the study was to evaluate the role of the determination of uGIP test in a single sample of persistent CD outpatients and its correlation with other CD biomarkers previously used for the follow-up of celiac patients.All CD patients referred to our tertiary referral Centre for Celiac Disease of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Italy from April 2019 to February 2020 were prospectively enrolled in the study. The CD diagnosis was posed according to international guidelines [® test kit , which detects the presence of GIP in urine, consequently to the ingestion of the protein complex in the preceding 12–24 h, depending on the individual and the type of gluten intake [The presence of GIP in patients’ urine was assessed with the GlutenDetectn intake . In the Moreover, we evaluated socio-demographic data , age at enrolment, age at diagnosis), CDAT, patient health status by means of visual analogical scales (VAS), tTGA values, duodenal histology , and video capsule endoscopy (VCE) findings . In the case of VCE, the presence of atrophy and its extent was reported as validated in previous studies ,20,21.Briefly, CDAT is composed of seven questions about diet, each assessed on a 5-point scale. The overall score ranges from 7 to 35. Patients with higher scores denoted poorer adherence to a GFD. Values below 13 indicate good or excellent adherence to a GFD, while values equal to or above 17 indicate lower compliance [VAS evaluated abdominal pain, satisfaction with stool consistency, bloating, postprandial fullness, early satiety, epigastric pain, and overall well-being.All CD patients enrolled in the study underwent the GIP urinary test. They received a sterile urine container at the medical center on follow-up visits and were unaware of the test and the purpose of the urine collection. The urine samples were analyzed in the laboratory on the day of collection; the GlutenDetect kit  was used to test for the presence of uGIP. This methodology recognizes, in addition to the 33-mer peptide, similar peptides that react with the G12 and A1 monoclonal antibody, and it was used following the manufacturer’s instructions. Briefly, the test consists of a lateral flow-based strip, a separate tube containing conditioning solution, a disposable plastic syringe, and a quick guide with instructions for use. A urine sample is collected and transferred to the conditioning solution tube. The tube is tightly closed and gently shaken for 5 to 10 s. The lateral flow cassette is removed from its foil package, and 4 drops of the solution are added to the “S” zone on the cassette by unscrewing the transparent cap on the tube. After incubating for 15 min at room temperature, the cassette can be read [Upper gastrointestinal endoscopies and biopsies were performed with a high-definition gastroscope  and standard bioptic forceps . Four oriented biopsy specimens were taken from the duodenum. Briefly, the samples were oriented on adhesive filter paper, fixed in a 10% formalin buffer, and paraffin-embedded. Sections were cut from each block and hematoxylin/eosin stained. Intraepithelial lymphocytes (IELs) were counted by means of anti-CD3 immunohistochemical staining  ,23.CD patients undergoing upper endoscopy and VCE were selected following the international guidelines ,24,25.t-test for independent variables assuming two different variances; for the qualitative variables, association analyses were performed between the independent variables (positive/negative test) and the dependent variables  and compared using the chi-squared test or Fisher’s exact tests if more than 20% of the cells had a predicted count of less than five. When the chi-squared test was used, the correlation coefficient Phi or Cramer’s V was also evaluated to assess how independent the variables were . The significance level α was set at 0.05. All data were analyzed using percentages, mean, standard deviation (SD), median, and interquartile ranges. The distribution of the data was assessed with the Shapiro–Wilk test. Quantitative variables with a normal distribution  were compared between the two groups using the students’ two-tailed ® version 2019  and the Statistical Package for the Social Sciences (SPSS) version 20.0 .The statistical analysis was performed using Microsoft ExcelThe study was approved by the local Ethics Committee Name (Milano area 2), approval code 19_2019bis.A total of 285 CD patients were enrolled in the study. Among them, 113 (39.6%) performed an upper endoscopy with duodenal biopsies, and 61 (21.4%) underwent VCE with different indications . Among the 285 patients, five did not complete the study and were excluded from the analysis. Therefore, 280 patients, including 232 (82.8%) females and 48 (17.2%) males with a median age of 31.7 ± 16.9, completed the prospective study.p < 0.05) ( < 0.05) .Among the 280 celiac patients enrolled, 69 (24.6%) had a tTGA titre above the threshold of normality. In the group with positive uGIP patients, 10 (31.2% of the 32 uGIP+) were positive for tTGA vs. 22 (68.8% of the uGIP+) negative for tTGA, without a statistically significant difference. Furthermore, the tTGA+ titre was not related to the positivity of uGIP (14.4% vs. 10.9% in patients with tTGA+ and tTGA−). Again, no clinical or demographic differences were found between tTGA-positive and negative patients.p < 0.05, A total of 113 patients underwent upper endoscopy with duodenal biopsies. Among them, 71 (62.8%) patients did not show atrophy , and 5 (7.0%) were uGIP positive. Among the 42 (37.2%) patients with duodenal atrophy , ten (23.1%) presented a positive uGIP test  patients did not present any endoscopic sign of mucosal atrophy, and four (12.5%) were positive for uGIP; 29 (47.5%) VCE showed endoscopic signs of mucosal atrophy and five (17.2%) were positive for the uGIP test without a statistical difference, compared to unremarkable VCE. Among VCE, 18 (29.5%) presented an extension of mucosal atrophy for more than 30% of the recording time, and four (22.2%) had a positive uGIP compared to five (11.6%) in the case of no or proximal small bowel atrophy . Distribution of atrophy at VCE in uGIP+ and uGIP- patients is reported in In Our study revealed that 11% of CD patients attending an Italian tertiary referral center, unaware of the test, had a positive uGIP although they declared complete adherence to the GFD. A positive uGFD did not correlate with symptoms, CDAT, or tTGA values, but more frequently duodenal atrophy was observed in patients with a detectable amount of GIP in urine. Actual guidelines suggest that compliance with the GFD should be strict in most cases and voluntary gluten intake (transgressions) is not allowed. The GFD compliance rate could vary between 25% and 89% depending on the age, sex, time of observation, and the minimal amount of gluten to be assumed as gluten exposure ,27,28. SAll these reasons make GFD monitoring a central issue in the management of CD patients, especially when facing a poor clinical, serological, or histological response to the diet. The individuation of subjects with involuntary ingestion of gluten is important to implement the health status of celiac patients. de facto an unconscious gluten ingestion during the last 24 h before the visit. This finding is not very far from those previously reported by Ruiz-Carnicer et al. [The recent introduction of uGIP makes the direct control of a GFD possible. The uGIP is a simple and reliable point-of-care test that is able to detect the ingestion of gluten during the last 12–24 h. In our group, CD patients were unaware of the test, and 11% showed the presence of GIP in urine demonstrating r et al. , which sr et al. . Celiac r et al. ,36,37. Ar et al. . Our stur et al. . These fr et al. ,39,40. There is much debate about follow-up biopsies because in adults neither symptoms nor serology is a reliable predictor of small bowel damage ,39. At pNotably, about 25% of patients with positive uGIP did not present any positivity of tTGA or signs of histological damage. Although one single uGIP test could be of limited statistical significance in the habit or sensitivity of CD patients, a recent study evaluated the possibility that a certain percentage of patients could tolerate occasional ingestion of gluten . From thDifferent limitations of the study have to be explored; all patients were not equally evaluated, and a single urine sample was taken. As a consequence, gluten intake could be under-evaluated, since multiple samples, covering the weekend as well as weekdays, can increase sensitivity and reduce the loss of positive cases .uGIP may play an important role as a point-of-care test to be undertaken by patients themselves or a physician during monitoring (as in the present study). The test has been demonstrated as a useful tool to evaluate adherence to the GFD and/or accidental gluten contamination.


Results: 47% of the patients were older than 65 years; 63% needed home oxygen therapy and/or presented with more than one comorbidity. At home, the mean time to dyspnea and tachypnea resolutions ranged from 21 to 24 days. The mean oxygen-weaning duration was 13.3 ± 10.4 days, and the mean SpO2 was 95.7 ± 1.6%. The nurses and/or doctors managed 1238 alerts. Two re-hospitalizations were required, related to transient chest pain or pulmonary embolism, but no death occurred. Patient satisfaction was good, and 743 potential days of hospitalization were saved for other patients. Conclusion: The remote monitoring of vital parameters and symptoms is safe, allowing for early hospital discharge in patients hospitalized for COVID-19, whether or not home oxygen therapy was required. Oxygen tapering outside the hospital allowed for a greater reduction in hospital stay. Randomized controlled trials are necessary to confirm this beneficial effect.Aim: Since beds are unavailable, we prospectively investigated whether early hospital discharge will be safe and useful in patients hospitalized for COVID-19, regardless of their need for home oxygen therapy. Population and Methods: Extending the initial inclusion criteria, 62 patients were included and 51 benefited from home telemonitoring, mainly assessing clinical parameters  and peripheral saturation (SpO The COVID-19 pandemic affected many patients worldwide, leading to millions of deaths and even more patients suffering greatly from long-COVID or post-COVID conditions. Globally, at the beginning of May 2023, there were 765,222,932 confirmed cases of COVID-19, including 6,921,614 deaths, reported to the WHO . Kaplan–Meier estimators were used to evaluate time to resolution of dyspnea and tachypnea. Categorical data were compared with the chi®  solution. Eleven patients discontinued treatment, mainly due to refusal to continue upon arriving home, or because caregivers were not sufficiently available. Among these 51 patients, 32 (63%) were still receiving nasal oxygen at hospital discharge  and 51 were home telemonitored after hospital discharge with My Prediischarge .2, ranging from 16.9 to 41.7. Fourteen (27.5%) patients were obese with a BMI > 30 kg/m2. The mean age of the patients was 65 years, and 2 (4%), 25 (49%) and 24 (47%) of them were below 45, between 45 and 65 and older than 65 years old, respectively. There were slightly more men than women (55% versus 45%), and mean BMI was 28.6 kg/mThe main risk factors and co-morbidities were hypertension (55%), diabetes mellitus (29%), and obesity (27%). Ninety-eight percent of the patients presented with comorbidities, and 63% of them presented with more than one minor comorbidity . CharlsoIn our cohort, two patients (4%) were re-admitted to the hospital on day 15 after discharge. One, related to chest pain occurrence, resumed spontaneously, and no cause was found. This patient was discharged from hospital on the same day as readmission. The second patient presented with a pulmonary embolism detected by the platform during home telemonitoring and was re-hospitalized with a favorable clinical evolution. No other significant deleterious situations occurred and no death occurred within 30 days of hospital discharge.As presented in The platform raised a total of 1238 alerts, including 722 (58%) red and 505 (41%) orange alerts. No at-home life-threatening emergencies occurred.The longest symptoms were dyspnea and tachypnea. The mean time to dyspnea resolution was 21 ± 1 days and 24 ± 1 days in the entire population and in the patients discharged with oxygen, respectively A. The meThe data concerning oxygen therapy are presented in 2 during home telemonitoring was 95.7 ± 1.6%.Mean oxygen output at hospital discharge and during home telemonitoring was below 2 L/min. Mean SpOFor all patients weaned from oxygen at home, mean and median oxygen weaning durations were 13.3 ± 10.4 days and 9.5 (1–41) respectively. The cumulative total of days required for oxygen weaning (duration +1 day) was 430 days.Thirty-six patients filled out the questionnaire and their assessment of the device’s simplicity to use, their feeling of safety and their satisfaction with the care coordination team was 3.7, 3.6, and 3.8/5. The mean duration of telemonitoring was 9.2 ± 3.5 and 17.8 ± 13.7 in patients without and with home oxygen therapy, respectively. This corresponds to 743 hospital days being saved due to telemonitoring; with most of these (568 days) being related to patients needing oxygen therapy.The main results of this prospective study demonstrate the safety of an early return home of patients hospitalized for COVID-19. Although patients older than 65 years, those presenting with comorbidities, and/or those requiring oxygen therapy were included, no deaths and only two readmissions occurred within the 30 days following hospital discharge. Further, 743 potential days of hospitalization were saved for other patients, with the majority being related to the early return home of patients still under oxygen. At the time of the study, doubts were raised concerning the feasibility of an early return home in patients hospitalized for COVID-19. Fears of aggravation were particularly strong when oxygen therapy was mandatory. Accordingly, although the need for beds was high in view of the exploding pandemic, restrictive inclusion criteria were proposed to select patients for whom early hospital discharge might be proposed. The aim was to limit the risk of re-admission to hospital, potentially due to an emergency. Thus, initially, the inclusion criteria set by the high health authority (HAS) were quite strict, and a single major criterion or more than one minor criteria excluded patients from this early return home protocol. These HAS recommendations define good practices, whose purpose is to guide healthcare professionals in designing and implementing the most appropriate preventive, diagnostic or therapeutic care strategies on the basis of proven medical knowledge at the date of their publication . AccordiAlthough comorbidities likely aggravate COVID-19 patiens’ prognosis , in viewHome localization and the need for a rigorous follow-up for patients at home may also reduce the feasibility of such a protocol. Indeed, not all patients live near a hospital or emergency structure, and these patients could benefit from the daily attentions of a relative or available caregivers.Nevertheless, despite these potential limitations, previous studies reported that an early return home could be proposed for patients suffering from severe forms of COVID-19. Indeed, an overflow of critical care hospitalization capacity occurred in many countries . RetrospIn March 2020 in Wisconsin, Annis et al. reported, in 2255 patients, the quick implementation of a remote patient-monitoring program as an effective approach for managing COVID-19 symptoms at home . In FranIn the early stages of COVID-19, the safety of this measure has been questioned in view of the gravity of the COVID-19 disease and patients’ potential aggravation, particularly when oxygen therapy is needed. In our study, importantly, safety was good in patients, regardless of the requirement for oxygen therapy. Thus, the only two re-admissions at hospital were not directly due to virus-related aggravations. Rather, telemonitoring likely allowed for an earlier diagnosis of pulmonary embolism, detected by the platform during home telemonitoring. Our data are in line with previous studies supporting the safety of an early return home in patients suffering from COVID-19 ,14,15,16Of particular interest, the need for oxygen therapy, and the increasing length of hospitalization until oxygen weaning, suggests that patients are more vulnerable. However, our results are in line with Covidom in the subgroup of patients requiring nasal oxygen therapy  and withThus, early returns home in patients hospitalized for COVID-19, whether or not oxygen is required, appears to be quite safe.Besides allowing for more personalized care to be delivered to patients, early returns home aimed to avoid hospital overflow, and thus to allow for other patients, whether or not they were suffering from COVID-19, to be hospitalized as needed. Indeed, numerous patients may not have always benefited from an adapted and timely therapy because of the unavailability of the hospital structure during the COVID-19 pandemic. This pitfall will probably also apply in future pandemics, whatever their origin.Importantly, in our study we observed 17.8 days and 568 days, respectively, of median duration and cumulative days of home telemonitoring in our oxygen sub-group. This is similar to van Herwerden MC’s data, showing a potential reduction in hospitalization of 616 days . SimilarA usefulness assessment including questionnaires on patient’s satisfaction and assessments of mental stress and anxiety as an outcome measure would have been interesting. Indeed, patients might experience higher anxiety when managing significant equipment at home without the presence of a doctor, compared to being in the hospital with readily available healthcare professionals. Although not mental stress and anxiety were not specifically investigated, we observed a fair level of satisfaction in our patients. Indeed, a majority found the device simple to use and the organization to be efficient, and accordingly felt safe with at-home monitoring. Our results are consistent with previous data showing high satisfaction levels in telemonitored COVID-19 patients . COVID-19 patients’ duration of hospitalization was not compared to that of a control group without telemonitoring. A case-control design with a comparison group matching the characteristics of patients still admitted in the hospital would have strengthened the study. While patients on oxygen might fare better at home compared to those discharged without oxygen, this cannot be guaranteed by our design, supporting the need for complementary studies.Nevertheless, when the length of stay in our hospital of 1756 patients discharged without telemonitoring during the same period was noted, we inferred an important reduction in days spent in a hospital bed (49 days). With the current decline in the number of hospital healthcare professionals, this study shows that this home telemonitoring system is suitable and applicable in the event of hospital tensions linked to strong epidemic periods, such as seasonal flu, which would necessitate increased hospitalization facilities for patients requiring oxygen therapy. A prospective study including a dedicated nurse coordination unit receiving alerts directly from the homecare remote monitoring system, who could contact patients and their healthcare professionals in return, could further improve the efficiency and safety of homecare. This future study would also allow for a comprehensive implementation analysis, including interviews with doctors, teleproviders, and caregivers, in order to improve the design of this useful help in patient care.This prospective study demonstrates that the remote monitoring of vital parameters and symptoms allows for early hospital discharge in patients hospitalized for COVID-19, whether or not home oxygen therapy is required. Extending these criteria to include patients presenting with more than one comorbidity did not reduce safety.Interestingly, patients requiring home oxygen therapy likely benefitted more from TELECOVID-RAD, since it allowed for oxygen tapering to occur outside the hospital, and thus a greater reduction in hospital stay compared to patients who did not require oxygen therapy.Nevertheless, even if our data support the idea that home monitoring reduces the hospital stay of patients with COVID-19, randomized controlled trials are necessary to confirm these beneficial effect  and demo


The longitudinal monitoring of patient circulating tumor DNA (ctDNA) provides a powerful method for tracking the progression, remission, and recurrence of several types of cancer. Often, clinical and research approaches involve the manual review of individual liquid biopsy reports after sampling and genomic testing. Here, we describe a process developed to integrate techniques utilized in data science within a cancer research framework. Using data collection, an analysis that classifies genetic cancer mutations as pathogenic, and a patient matching methodology that identifies the same donor within all liquid biopsy reports, the manual work for research personnel is drastically reduced. Automated dashboards provide longitudinal views of patient data for research studies to investigate tumor progression and treatment efficacy via the identification of ctDNA variant allele frequencies over time. A major goal of precision medicine in cancer is to provide effective and specific therapies for patients by incorporating more biomarker-directed therapies . To faciCompared to traditional biopsies, liquid biopsies are more convenient, easily obtainable, and present minimal procedure risks to patients. ctDNA, as a part of circulating cell-free DNA (ccfDNA) in peripheral blood, contains gene mutations found in primary tumors, and the serial sampling of ctDNA can have diagnostic value and predict the response to treatment and the clinical outcome. Earlier studies have shown the potential power of this approach to monitor tumor burden in cancer patients ,4. So faPharmacological studies focus on drug testing to estimate efficacy, while genomic analyses focus on the identification of pathogenic mutations in the patient . The ideHere, we describe an automated way of identifying pathogenic mutations from liquid biopsy reports and grouping them at a patient level. The method uses no patient identifiable markers and is essentially anonymous. We discuss the underlying theory of this process using the techniques in data science and provide a way to replicate it in any organizational setup. The focus of this paper is to provide a replicable, automated methodology to organize ctDNA information sourced from liquid biopsy and identify the patients to perform longitudinal analyses. Extraction was performed on 655 human plasma samples. Informed consent was obtained from all subjects involved in the study, which was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of Sutter Health (protocol code 2015.059-1 approved on 3 October 2022). Blood samples were collected in tubes (PAXGene blood tubes) with preservatives to increase shelf life and ccfDNA  was isolated using the QIAamp Circulating Nucleic Acid kit , and quantified using PicoGreen . We selected the 56G Oncology Panel V2 from Swift Biosciences , which contained 56 gene targets: ABL1, AKT1, ALK, APC, ATM, BRAF, CDH1, CDKN2A, CSF1R, CTNNB1, DDR2, DNMT3A, EGFR, ERBB2, ERBB4, EZH2, FBXW7, FGFR1, FGFR2, FGFR3, FLT3, FOXL2, GNA11, GNAQ, GNAS, HNF1A, HRAS, IDH1, IDH2, JAK2, JAK3, KDR, KIT, KRAS, MAP2K1, MET, MLH1, MPL, MSH6, NOTCH1, NPM1, NRAS, PDGFRA, PIK3CA, PTEN, PTPN11, RB1, RET, SMAD4, SMARCB1, SMO, SRC, STK11, TP53, TSC1, and VHL. MiSeq 2 × 151 base paired-end sequencing was performed to detect single-nucleotide variant (SNV) and insertion/deletion (indel) at 1% allelic frequency or higher in target regions with sufficient read coverage (at least 100×).ccfDNA data obtained using the 56G Oncology Panel V2 was analyzed using Genialis Expressions . In brief, quality trimmed (Trimmomatic v.0.36) sequencing data was aligned to the human genome (GRCh37 assembly) using BWA MEM (v. 0.7.17-r1188). The aligned data were further processed by trimming primer sequences  and using GATK (v.3.6) tools  to prepare the analysis-ready BAM file. SNP/INDELs were named using LoFreq (v.2.1.3.1) and annotated using snpEff (v.4.3k).Reference data were obtained from the COSMIC  database that consolidates data from peer-reviewed publications and other genomic data screening sources in order to provide a comprehensive overview of cancerous genetic mutations . This daInput Genialis files (or similar sequencing results with comparable structure) were uploaded into an internal database via Python script (an open-source object-oriented computer programming language). This programming code serves multiple functions beyond database creation and data load. Built-in functionality includes a check for whether the sample is already included in the database in order to prevent redundancy in data collection. The program identifies the level of pathogenicity, based on the gene and amino acid mutations within the sample and identical combinations in the COSMIC database, before consolidating data from both sources into a database for further analysis.Liquid biopsy reports collected from the patients are anonymous. A major part of the genomic analyses involves tracking of pathogenic mutations that are detected from the bloodstream. With anonymity, there is a need to identify liquid biopsy reports that belong to the same patient. This could be accomplished by leveraging the fact that the fragments of ccfDNA detected from the bloodstream are unique to each human. We, therefore, attempted to quantify the similarity of liquid biopsy reports to identify if they would belong to the same patient. We leveraged the cosine similarity method from vector algebra . The matIn order to increase the range of similarity scores, we added another layer before the similarity score calculation. We used k-means clustering method to separate the samples set into two groups to ease the computation process by reducing the number of samples that are compared to one another. This clustering method ensures that no two samples falling into the two different groups are similar to each other, but that each remains comparable to the ones within the group. Similarity scores were computed within each group, and any sample that had not seen a match based on the score was extracted from both groups. They were shuffled to increase the probability of obtaining the right match while reducing computation time overall.https://github.com/azurey0/cpmc-prac (accessed on 1 April 2023).After the pathogenic matching and the patient similarity analysis were conducted, the final data were uploaded via the Python script into a database for integration with Tableau, a visualization platform . This taThe project’s initial objective was to improve research efficiency by automating the classification of pathogenic gene mutations presented in the liquid biopsy reports. As our understanding of the data structure improved, we uncovered a second objective: to expand the research by identifying the liquid biopsy samples that belonged to the same patient without the need for specific patient information. Lastly, we combined the gene classification with the patient matching to show how the pathogenic genes evolved in the same patient. To deliver the results, we used Tableau , in whicFirst, gene and mutation data points were mapped from Genialis standard forms  to the nDuring loading, the Python program presented in the Materials and Methods section identified the Amino Acid Change column . Scores over 0.98 belonged to the same patient in 100% of the cases based on external validation. Due to the presence of noise and inaccuracy in the sequencing of ctDNAs from the blood, some reports that belonged to the same patient could have scores less than 0.98. We have identified a score range, between 0.95 and 0.98, which contained reports that had the potential to belong to the same patient, i.e., a range that could have a potential match but not with 100% accuracy. An example of a result set is shown in Final results from the pathogenic matching and the patient similarity analysis were uploaded via the same Python script into an output database as structured in ctDNA analysis in peripheral blood is a liquid biopsy that contains representative tumor information, which includes information concerning gene mutations found in primary tumors . These sThe longitudinal visualization of the pathogenic gene mutations can improve patient monitoring . With a The methodology presented here would help any team in a research context to build a data platform to automatically map identified mutations with their pathogenicity score and link reports to the same patient based on their genetic identity, i.e., their germline mutations, polymorphisms, and synonymous mutations originating from normal tissues. With improved technology, it might be possible to detect fragments of RNAs and/or proteins in the blood that might serve as a hint to signal disease or disorder in certain parts of the human body. Blood can serve as an important medium of inspection due to the presence of cell components circulating throughout the body . The pot


The purpose of this study is to evaluate the effects of chemotherapy and radiotherapy on the prognosis of unresectable HCC patients with portal and/or hepatic vein invasion.A retrospective analysis of unresectable HCC patients with portal and/or hepatic vein invasion registered in the Surveillance, Epidemiology, End Results (SEER) database was performed. The propensity score-matching (PSM) method was used to balance differences between groups. Overall survival (OS) and cancer-specific survival (CSS) were the interesting endpoints. OS was calculated from the date of diagnosis to the date of death caused by any cause or the last follow-up. CSS was defined as the interval between the date of diagnosis and date of death due only to HCC or last follow-up. OS and CSS were analyzed by using Kaplan-Meier analysis, Cox proportional hazards model, and Fine-Gray competing-risk model.A total of 2,614 patients were included. 50.2% patients received chemotherapy or radiotherapy and 7.5% patients received both chemotherapy and radiotherapy. Compared to the untreated group, chemotherapy or radiotherapy (COR)  and chemotherapy and radiotherapy (CAR)  showed better OS. In the COR group, Cox analysis results showed AFP, tumor size, N stage and M stage were independent risk factor of OS. Competing-risk analysis results showed AFP, tumor size and M stage were independent risk factor of CSS. In the CAR group, AFP and M stage were independent risk factors of OS. Competing-risk analysis results showed M stage were independent risk factor of CSS. Kaplan Meier analysis showed chemotherapy combined with radiotherapy significantly improves OS  and CSS  than monotherapy.AFP positive and distant metastasis are the main risk factors affecting OS and CSS of unresectable HCC patients with portal and/or hepatic vein invasion. Chemotherapy combined with radiotherapy significantly improves OS and CSS of unresectable HCC patients with portal and/or hepatic vein invasion. Approximately 10% to 40% of HCC patients show macrovascular invasion at the time of initial diagnosis . It has In recent years, hepatectomy, local interventional therapy, radiotherapy, molecular targeted therapy and immunotherapy have been widely used, which is of great significance for the quality of life and prolonging survival time of some patients. Currently, Sorafenib or Lenvatinib are recommended as first-line TKI treatment for HCC combined with PVTT . SeveralTransarterial chemoembolization (TACE) and hepatic artery infusion chemotherapy (HAIC) have become the most commonly used palliative treatments for patients with unresectable HCC and are no longer considered an absolute contraindication for patients with PVTT/HVTT- HCC . Moreove22.1The SEER registry is a multicentric database for cancer research. This database contains data from 17 areas of the United States, representing roughly 28% of the total U.S. population. Patient demographics, initial cancer location, illness grade/stage, surgery, radiotherapy, chemotherapy, and survival status can all be obtained from the SEER database.2.2We use the PICO principle to filter data, P (Patient): We selected patients diagnosed with HCC from 2004 to 2015 in the SEER database according to the International Classification of Diseases for Oncology. The inclusion criteria were as follows (1): a clear histopathological diagnosis of HCC (2); the primary site of the tumor is located in the liver with only one primary tumor (3); tumor invades the portal or hepatic veins and has not been treated surgically (4); follow-up for more than one month (5); age over 18 years old (6); complete survival data. The screening process is shown in 2.3Demographic variables include age, sex, race, marital status, AFP, tumor size, SEER stage (SEER-specific), N and M stage, TNM, radiotherapy, chemotherapy, SEER classification of causes of death, months of survival, and final status. Since SEER stage, M stage and TNM results are the same, we only show the results of M stage.2.4Age and tumor size were categorically divided based on the optimal cut-off value generated by X-tile software version 3.6.1  Figure 233.1A total of 2,614 patients with HCC were extracted from the SEER database. 1105 were not treated with chemotherapy and/or radiotherapy and 1509 were treated with chemotherapy and/or radiotherapy, of which 1313 patients received chemotherapy or radiation therapy and 196 patients received both chemotherapy and radiotherapy. About 45.0% patients are > 62 years old and predominantly male. Among our subjects, the white population had a significantly higher incidence of HCC than other races. Interestingly, the majority of the unmarried are more inclined to do no treatment at all, while the married opted for chemotherapy or radiotherapy. Most patients were AFP positive and without lymph node and distant metastases. Of the patients under treatment, nearly 90% received chemotherapy or radiotherapy, and very few received both chemotherapy and radiotherapy. More details are shown in After grouping according to whether or not to receive treatment, using PSM for age, sex, race, marital status, AFP, tumor size, N stage, and M stage for 1:1 proximity matching, all variables in the two matched groups were not significantly different after PSM. The Kaplan-Meier analysis showed OS (p < 0.001) and CSS (p < 0.001) of the matched pre- and post-treatment groups were superior to the untreated group Figure 33.2Univariate and multivariate Cox analysis results of all patients before PSM showed AFP, tumor size, N stage, M stage, and treatment were considered as independent predictors of OS. Especially in terms of treatment modality, patients who received COR  and CAR  showed better OS compared to receive no treatment Table 2.3.3We further explored the impact of different treatment strategies (COR and CAR) on patient survival. There were no significant differences between the COR and CAR groups, so PSM matching was not needed Table 3.Univariate and multivariate Cox analysis results showed AFP , N stage  M stage  were independent risk factors for OS. Compared with tumor size < 6.2 cm, 6.2-9.3 cm  and > 9.3 cm  had worse OS. Patients who received CAR had better OS than COR.  Table 4.3.4To identify the effect of various factors on different treatment groups, univariate and multivariate analyses of OS and CSS were performed in each group. In the COR group, univariate and multivariate Cox analysis results showed AFP , tumor size , N stage , M stage  were independent risk factor of OS. Univariate and multivariate competing-risk analysis results showed AFP , tumor size > 9.3 cm , M stage  were independent risk factor of CSS Table S1When the two groups of patients were stratified by different variables, Kaplan-Meier analysis showed age > 62 , male , the white , other race , married , AFP positive , tumor size > 9.3 cm ), N1 , N1 ,M0 , and M1  had better OS in the CAR group, while no significant differences were seen within the other groups . Traditional systemic chemotherapy is limited in clinical application due to severe systemic adverse reactions, while HAIC is widely used because it can carry anti-cancer drugs directly to the tumor site and reduce systemic adverse reactions. HAIC was first proposed by Japanese researchers and recommended by Japanese guidelines as the standard treatment for PVTT-HCC. Most of these HAIC-based studies focused on patients with PVTT-HCC, and 5-fluorouracil and systemic interferon or cisplatin were reported to be the most effective combination chemotherapy for PVTT-HCC with a median survival time of approximately 7 months , 14. TheConventional radiotherapy is not suitable for HCC because the liver is a radiation-sensitive viscus and the lack of precise irradiation of the target area usually involves the surrounding normal liver tissue, leading to an increased incidence of radiation liver disease. However, with the advent of new radiation technologies such as 3-Dimensional Conformal Radiation Therapy(3D-CRT), Stereotactic Body Radiation Therapy (SBRT), and proton beam therapy (PBT), the clinical application of external radiotherapy for liver cancer is becoming more widespread. Previous studies reported that the OS of patients with PVTT/HVTT-HCC could be appropriately prolonged from 6 to 18 months regardless of radiotherapy modality . A retroFor the treatment strategy of chemotherapy combined with radiotherapy, previous single-center, small sample size studies have found that HAIC combined with radiotherapy was effective in extending the OS of patients with PVTT from 7.5 months to 12 months –26. In aNext, we explored the prognostic factors affecting patients with concomitant PVTT/HVTT. In the survival analysis of all patients, we found that AFP, tumor size, N and M stage, and therapy strategy were independently associated with patient OS. To further explore the impact of different treatment strategies (COR and CAR) on patient survival. We used Cox proportional hazards model and competing-risk model to analyze OS and CSS in the whole treatment group and in each group, and found that AFP and distant metastasis were always the main independent factors affecting OS and CSS regardless of therapy strategy, which is consistent with previous findings , 29, 30.In 2017, based on the CheckMate 040 study, the FDA approved the PD-1 inhibitor (Nivolumab) for advanced HCC patients who did not respond to sorafenib therapy, marking the arrival of the era of HCC immunotherapy . SubsequThe latest results of KEYNOTE-524, a phase I single-arm trial, showed that the mOS, mPFS and ORR of Lenvatinib combined with Pembrolizumab for advanced HCC were 22 months, 8.6 months and 36.0%, this combination regimen has been granted by the US FDA as a breakthrough therapy for the first-line treatment of unresectable HCC . In receObviously, our study also has several limitations. First of all, this study is a retrospective study, and selection bias caused by incomplete data is inevitable. Although we adopted PSM to avoid selection bias, potential confounding factors cannot be ruled out. Second, because the SEER database only records yes or no for chemotherapy and radiotherapy, the lack of detailed information on chemotherapy and radiotherapy makes it difficult to conduct further studies, which also bodes well for more precise studies of the impact of each treatment on patient benefit. Undeniably, with the development of targeted and immunotherapy in recent years, the treatment of HCC has undergone earth-changing changes, greatly improving the survival of patients with advanced HCC. Unfortunately, the SEER database did not record information of targeted or immunotherapy for patients from 2004 to 2015. So we put it up in limitation; Finally, portal vein tumor thrombus and hepatic vein tumor thrombus were uniformly recorded in the SEER database as macrovascular invasion, which could not be studied separately. Even so, we demonstrated the benefit of radiotherapy combined with chemotherapy for long-term survival in PVTT/HVTT-HCC patients using a country-scale database.5It is recommended that surgically unresectable advanced PVTT/HVTT-HCC be treated with radiotherapy combined with chemotherapy. Positive AFP and distant metastasis are risk factors affecting patients’ long-term survival, and it is suggestive to actively treat these patients to prolong the survival of patients.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. Written informed consent was not obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.XQ, JC, and HC contributed to the conception and design of the study. JY, CX, RL, JX, JZha, XS, and TL collected the details of the patients and extracted and analyzed the data. XQ, JC, and HC drafted the manuscript. JZhe, YZ, and YY contributed with a critical revision of the manuscript. All authors contributed to the article and approved the submitted version.