FGFR2. Additionally, FGFs/FGFRs-dependent signaling has been shown to regulate skeletal development and has been linked to a plethora of heritable disorders of the musculoskeletal system. In this study we present the clinical, biochemical and radiological findings, as well as results of molecular genetic testing of a 13-year-old male proband with heritable osteoporosis, arthralgia and multiple fractures and a family history of abnormal bone mineralization and fractures. Whole exome sequencing found a heterozygous previously undescribed variant in the FGFR2 gene (NM_000141.5) . The same variant was found in two affected relatives. These data lead us to believe that the variant in FGFR2 found in our proband and his relatives could be related to their phenotype. Therefore, modern methods of molecular genetic testing can allow us to differentiate between osteogenesis imperfecta and other bone mineralization disorders.Osteoporosis is a systemic, multifactorial disorder of bone mineralization. Many factors contributing to the development of osteoporosis have been identified so far, including gender, age, nutrition, lifestyle, exercise, drug use, as well as a range of comorbidities. In addition to environmental and lifestyle factors, molecular genetic factors account for 50–85% of osteoporosis cases. For example, the vitamin D receptor (VDR), collagen type I (COL1), estrogen receptor (ER), apolypoprotein Е (ApoE), bone morphogenetic protein (BMP), and Low-density lipoprotein receptor-related protein 5 (LRP5) are all involved in the pathogenesis of osteoporosis. Among the candidate genes, the pathogenic variants in which are involved in the pathogenesis of osteoporosis is  Osteoporosis is a complex, multifactorial disorder characterized by progressive loss of bone mass and degeneration of bone microarchitecture, which leads to increased bone fragility and risk of fractures , 2. AccoFGFR2.One of the candidate genes, the pathogenic variants in which are involved in the pathogenesis of osteoporosis is FGFR2 and the quantity and location of the receptor on the cellular membrane greatly affects the molecular effect of FGFs/FGFR2 signaling [FGFR2 is known to regulate the development of osteoblasts. Increased FGFs/FGFRs-dependent signaling can lead to hyperplasia of immature osteoblasts, inhibit their differentiation and trigger apoptosis [FGFR2 also regulates the development of chondrocytes [FGFR2 in the pathogenetic mechanism of osteoporosis needs further research.Fibroblast growth factor receptor 2 (FGFR2) is a type of receptor tyrosine kinase (RTK) that belongs to the immunoglobulin superfamily . It is eignaling , 9. FGFRpoptosis . The imbdrocytes . HoweverFGFR2 gene.In this study we present the clinical, biochemical and radiological findings, as well as results of molecular genetic testing of a 13 year old male proband that presented with multiple fractures, decreased tolerance of physical activity, arthralgia in the legs, spine and joints, severe dental caries, decreased density of dental enamel and frequent headaches. Based on the clinical and laboratory findings, the original diagnosis was osteogenesis imperfecta type I. However, whole exome sequencing found a single previously undescribed variant in the genu valgum, hip dysplasia, combined thoracolumbar scoliosis, connective tissue disorder; IV - female, born in 2005  occurred at the age of 1. At the age of 3, the proband fractured his nasal bones, and then fractured them again at 4 years old. At the age of 7, he fractured the left ulna and radius. At the age of 9 he fractured his fibula. Since the age of 10 – numerous fractures of the phalanges of the feet and hands: at 11 – fracture of the first toe of the right foot, at 12 - fracture of the fith toe of the right foot and the distal phalange of the second finger of the right hand. The last documented fracture  occurred in January 2022. All fractures resulted from low-impact trauma.BMP1, COL1A1, COL1A2, CREB3L1, CRTAP, FKBP10, IFITM5, LEPRE1, PLOD2, PLS3, PPIB, SERPINF1, SERPINH1, SP7, SPARC, TMEM38B, WNT1) showed no pathogenic variants.In 2019, the proband consulted a geneticist at the Research center for medical genetics, who suggested the presumptive diagnosis of osteogenesis imperfecta type I. Molecular genetic testing using the massively parallel signature sequencing method that involved the analysis of the 17 genes currently associated with osteogenesis imperfecta ; bone alkaline phosphatase: 48,91 mcg/l (N 48.06–120.0); 25–25-hydroxyvitamin D: 14,1 ng/ml (N 14.0–60.0); Calcium (ionized) 1.15 mmol/l ; Calcium  2.58 mmol/l ; Phosphorus (inorganic) 1.66 mmol/l ; Ostase 23.86 mcg/l .Instrumental methods of analysis showed results suggestive of a bone mineralization disorder. Bone mineral density measurements performed on GE MS LUNAR Prodigy densitometer with the protocol AP Spine showed a Z-score= -2,3, and with the protocol Total body: Z-score= -1,6. The radiograph of the knee joints in a direct projection , Ph/Crea 2.02 . Rheumatoid factors were normal.Taking into consideration the clinical data and presumptive diagnosis, the decision was made to start the proband on zoledronic acid and recommending whole exome sequencing in order to determine the underlying genetic cause.Whole exome sequencing (WES) was carried out using Illumina SureSelect All Exon V7 with average depth across the target regions of > 10X, and analyzed using an automated algorithm, that allowed quality control of sequencing (FASTQC tool), trimming of adapter sequences from short read data (SEQPURGE tool), mapping low-divergent sequences (BWA MEM tool), marking duplicates and extracting discordant and split reads from sam files (SAMBLASTER tool), increased accuracy of localized assembly and global realignment (ABRA2 tool), haplotype-based variant detector (FREEBAYES tool), and variant effect predictions (ENSEMBL-VEP tool). The algorithm was tested on pre interpreted exome date from “Genome in a bottle”. The sensitivity of the algorithm is 98,6% and the specificity – 99.1%. None of the authors directly participated in WES.The variants were filtered in order not to include those that have a population frequency of > 10%, as well as those that have no impact on the resulting protein structure. Each variant localized in genes that were potentially related to the probands phenotype was viewed in regard to it’s effect on the protein structure and function, as well as evolutionary conservatism of the position within the gene, the clinical features of the disorder associated with the gene, as well as the population frequency of the variant and the inheritance pattern of the related disorder. The variants were classified into 5 categories: , according to ACMG/AMP 2015 guideline.FGFR2, which consists of a single nucleotide insertion and leads to a frameshift and a premature translation termination (NM_000141.5)  , as well as Beare-Stevenson cutis gyrata syndrome (OMIM: 123790), Apert syndrome (OMIM: 101200), Bent bone dysplasia syndrome (OMIM: 614592) and other conditions, all of which significantly differ from the proband’s phenotype. Meanwhile, there is data available that suggests a relationship between pathogenic variants in FGFR2 and a disorder of bone mineralization that leads to fractures of both small and large tubular bones [The variant is not present in the gnomAD population databases and likely leads to loss-of-function. According to OMIM, pathogenic variants in me OMIM: 3790, Apegenu valgum, hip dysplasia, combined thoracolumbar scoliosis, and a connective tissue disorder. She also had severe dental caries and decreased density of dental enamel. Bone mineral density measurements performed on GE MS LUNAR Prodigy densitometer with the protocol AP Spine showed a Z-score = -1,5, and with the protocol Total body - Z-score = -1,4. The radiograph of the sister’s legs in a direct projection .  was found in the proband’s father, who has had 3 fractures in childhood, two of which resulted from low-impact trauma. He, however, has had neither high-impact trauma, nor fractures in adulthood. The same variant was also observed in the proband’s sister, who presented with The variant (NM_000141.5)  has been classified as pathogenic according to the ACMG/AMP 2015 guideline, with consideration of the recommendations for interpretation of the null variant criteria (PVS1) provided by Abou Tayoun AN et al. [Since the variant is located in exon 6 of 18 and leads to premature translation termination, it is highly likely that the polypeptide chain synthesized from the allele containing the variant undergoes nonsense mediated decay. However, the “in vivo” or “in vitro” validation of this hypothesis has not yet been carried out.Some genes may tolerate loss-of-function (LOF) variants because their functional effects are masked by incomplete penetrance , by compAt the moment of publication of this case report, the proband has had four courses of treatment with zoledronic acid. During the period between hospitalizations, the proband took chondroprotectors (Osteogenon), colecalciferol, and maintained a program of physical therapy and exercise. During another hospitalization in the spring of 2022, we observed significant improvement. Bone mineral density measurements performed on GE MS LUNAR Prodigy densitometer with the protocol AP Spine showed a Z-score L1-L4 = -0,2, and with the protocol Total body: Z-score = -0,9, which is 7% lower than the population norm А/G = 0,8. The main biochemical markers of bone metabolism and rheumatoid factors were normal. The proband’s legal guardians gave consent to the aforementioned procedures, including the molecular genetic testing.FGFR2 gene (NM_000141.5)  that likely leads to its loss-of-function. This gene has a major role in bone tissue development. This, combined with the results of the analysis of segregation of the variant in the probands family, that showed the same variant was present in the father and sister both of whom presented bone mineralization disorders , leads us to believe that the variant in FGFR2 found in our proband and his relatives is related to their phenotype. However, the functional analysis of the gene has not been carried out at the time of publication, and the currently available data can only indirectly explain role of a loss-of-function of FGFR2 in FGFs/FGFRs-dependent signaling and how it could result in a bone mineralization disorder with highly variable clinical features among several affected individuals within one family.In this case report we describe a proband with clinical features of osteogenesis imperfecta, which was later disproven by molecular genetic testing. Whole exome sequencing showed a variant in the FGFR2, primarily in the III Ig-like domain and the adjacent linker regions (exons IIIa and IIIc), can cause several different types of autosomal dominant craniosynostosis, including Crouzon syndrome, Pfeiffer syndrome, and Apert syndrome [FGFR2 that for perinatal lethal skeletal dysplasia, termed the BBDS-FGFR2 type, characterized by multiple bone deformities, including impaired mineralization of the calvarium, craniosynostosis, and dysmorphic facial features, as well as long bone deformities and osteopenia [It is known that gain of function (GOF) mutations in syndrome . One stuteopenia .FGFR1 and FGFR2 are expressed by mesenchymal cells before the appearance of the morphological signs of mesenchemal condensation [FGFR1 is evenly expressed in the mesenchyme of limb buds, while FGFR2 expression is increased in the area of chondrogenic condensation and is typically the first observable biochemical marker of this process. Both FGFR1 and FGFR2 are expressed at the periphery of the indurations, where the original cells of the perichondrium and periosteum are found. It was also found that FGFR2 is expressed in the resting zone, while FGFR4 is expressed in both the resting and proliferative zones. FGFR3 is more actively expressed in latent chondroprogenitor cells located in Ranvier’s sulcus and LaCroix’s annulus. The patterns of expression of FGFR1, FGFR2 and FGFR3 are relatively well described in literature. In cranial sutures, FGFRs expression in spatially dependent. FGFR2 is predominantly expressed in osteoprogenitor cells, while FGFR1 - in more differentiated osteoblasts. FGFR3 has a lower expression in the periosteum and suture osteogenic fronts at a late stage of suture development. The binging of FGF2 and FGFR1 on the cellular membrane of osteoclasts can activate MAPK signaling pathway, therefore regulating their differentiation and function [The FGF family includes 23 different genes, and the human FGFR consists of FGFR1-5, so the disruption of each of the components can play a major role in the physiological and pathological processes regulated by FGFs/FGFRs-dependent signaling. ensation . FGFR1 ifunction . Additiofunction , and Weifunction . A growiFGFR2 can lead to the development of a bone mineralization disorder, specifically associated with an earlier age of onset.Therefore, having analyzed the case of early-onset osteoporosis with bone fractures, as well as available scientific data, we consider it likely that pathogenic variants in Currently, the role of numerous molecular genetic factors in the pathogenesis of osteoporosis and other bone mineralization disorders requires further research. Deeper understanding of this problem can bring us closer to understanding their underlying mechanism and help differentiate between heritable osteoporosis, osteogenesis imperfecta and other clinically similar conditions. And early diagnosis allows for development of a more effective therapeutic strategy and rehabilitation program for probands with bone mineralization disorders, as well as decrease the risk of complications, such as fractures and arthralgia.FGFR2 gene could be linked to a new phenotype of early onset osteoporosis with bone deformities and fractures.The available clinical and genetic data indicate that pathogenic variants in the


Using two three-dimensional U-Net architectures for myocardium structure extraction and a distance transformation algorithm specifically for the left circumflex artery, we have designed a fully automated algorithm for coronary artery labeling in coronary computed tomography angiography (CCTA) images.In this retrospective analysis, a cohort of 157 patients who had undergone coronary computed tomography angiography (CCTA) was included. An automated coronary artery labeling algorithm was developed using a distance transformation approach to delineate the anatomical segments along the centerlines extracted from the CCTA images. A total of 16 segments were successfully identified and labeled. The algorithm’s outcomes were recorded and reviewed by three experts, and the performance of segment detection and labeling was assessed. Additionally, the level of agreement in manually labeled segments between two experts was quantified.When comparing the labels generated by the experts with those produced by the algorithm, it was necessary to modify or eliminate 117 labels (5.4%) out of 2180 segments assigned by the algorithm. The overall accuracy for label presence was 96.2%, with an average overlap of 94.0% between the expert reference and algorithm-generated labels. Furthermore, the average agreement rate between the two experts stood at 95.0%.Based on the labels of the clinical experts, the proposed deep learning algorithm exhibits high accuracy for automatic labeling. Therefore, our proposed method exhibits promising results for the automatic labeling of the coronary arteries and will alleviate the burden on radiologists in the near future. Coronary computed tomography angiography (CCTA) is a widely employed diagnostic tool for cardiovascular diseases . In clinRecently, several methods for coronary artery labeling have been developed –12. GulsAll investigations into the automated labeling of CCTA images have consistently demonstrated high levels of accuracy, typically ranging from 87 to 100.0%, when it comes to the three principal arteries: the right coronary artery (RCA), left anterior descending artery (LAD), and left main coronary artery (LM). However, studies have noted that accuracy levels for the left circumflex artery (LCx) and its associated side branches tend to be relatively lower , 13, priIn the present study, we have presented an efficient automatic labeling algorithm for coronary anatomy by using a distance transformation algorithm and involving experts to evaluate the automatic identification results, as well as analyzed the consistency in coronary artery labeling among the experts.This study received approval from the Research Ethics Board of our institution, and the institutional review board granted a waiver for informed consent. The study included retrospectively collected CCTA scans from 157 patients acquired between June 20, 2017, and May 12, 2019. Patients who had undergone cardiac procedures such as bypass surgery or percutaneous coronary intervention were excluded. You can find the baseline characteristics of these 157 patients in Table A 64-row detector CT system , 128-row detector CT system , and 256-row detector computed tomography (CT) system  were used for data acquisition. Furthermore, a prospective electrocardiography-triggered CCTA with a 0.625-mm-thick slice. For body weights of < 100 kg, iodinated contrast medium (either iopromide 370 or iohexol 350) was injected at the rate of 5 mL/s; on the other hand, for body weights of ≥ 100 kg, the medium was injected at a 6 mL/s rate. Thereafter, saline chaser bolus (50 mL) was administered.Figure This algorithm depends on the centerline of the coronary arteries , 16, 17.In this study, skeletonization was performed to transform the binary 3D representation of the segmented arteries into a 1-pixel-wide centerline structure that retains the general shape of the arteries; this provided an accurate depiction of their centerlines. We applied spatial structure rules or the minimum 3D distance transformation method to label and segment the centerlines of the left main coronary artery (LM), right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LCx). Subsequently, the outcomes were compiled and visualized for diagnostic purposes , middle (m), and distal (d) sections of the right coronary artery (RCA), left anterior descending artery (LAD), and the proximal, middle, and distal sections of the left circumflex artery (LCx). Additionally, labels were applied to the right posterior descending artery (R-PDA), left main coronary artery (LM), right posterior lateral branch (R-PLB), ramus intermedius (RI), obtuse marginal branches 1 and 2 (OM1 and OM2), and the first and second diagonal branches (D1 and D2). The labeling methodology employed for the identification of RCA, R-PLB, R-PDA, LM, LAD, and their respective side branches followed the procedures outlined by Chenjun et al. . MeanwhiFrom an anatomical standpoint, the left circumflex artery (LCx) courses through the left atrioventricular groove, situated between the left ventricle (LV) and the left atrium (LA). On the other hand, the left anterior descending artery (LAD) is typically situated within the epicardial fat of the anterior interventricular septum. While there are occasional variations in artery anatomy, it is generally observed that the distances from the LA and LV to the LCx are consistently smaller than those to the LAD. Leveraging this anatomical characteristic, a distance transformation method was developed for the identification of the LCx. The labeling process was as follows:The LCx extends positively along the y-axis and negatively along the x-axis. Utilizing this characteristic, we sequentially stored potential LCx candidates in an array termed “LCx_possible_list.“ The initial point of these candidate LCxs coincided with the starting point of the LAD, marking the endpoint of the LM.Employing a modified distance transformation technique, we computed the distances from the centerline points of the potential LCx candidates to both the LA and LV as reference distances. Each point on the LCxs was represented by coordinates , while the coordinate sets for the LA and LV were denoted as A  and B , respectively. Subsequently, distances were calculated using Eqs. , y1, z1,, y2, z2,3)In the context of each potential LCx candidate, we recorded the number of points with reference distances less than 25 mm to the LA and those with reference distances less than 30 mm to the LV as unique attributes.4)The combined total of these two attributes for each centerline indicated the artery’s proximity to both the LA and LV. The candidate LCx with the highest cumulative value was chosen as the preferred option. Lastly, the LCx with the longest centerline length was established as the final selection.Python 2.0 was used to complete the entire automatic labeling algorithm. In each case, based on the centerline, 16 segments were identified. After completing the automatic labeling process, the results were reviewed by experts based on the SCCT label standards and judged for accuracy.The labeling outcomes underwent independent assessment by two experts, each possessing a minimum of 4 years of experience in cardiac CT imaging. Labels were manually corrected in cases of absence or inaccuracy. In the event of disagreements between these two experts, a third expert with over 10 years of experience in cardiac CT imaging was consulted to make the final determination.For each segment, both presence and overlap were subject to evaluation. Additionally, the agreement percentage between the two experts for each section was computed. To assess the performance of the automated labeling algorithm, a confusion matrix was employed. To maintain objectivity, the experts remained unaware of clinical histories and patient identities.Since the automatic labeling algorithm might omit or inaccurately assign labels to certain segments, an assessment was conducted to determine the presence or absence of each of the 16 segments. True positives (TP) were segments labeled by both the algorithm and the experts, while false negatives (FN) were segments labeled by the experts but not by the algorithm. False positives (FP) represented segments labeled by the algorithm but not by the experts, and true negatives (TN) were segments not labeled by both the algorithm and the experts. Precision, sensitivity, accuracy, and F1 scores were computed to assess the segment detection performance for each segment.“After confirming the presence of labels, the starting and ending points of a labeled segment, determined through the automatic labeling method, underwent initial evaluation by the two experts. Subsequently, they assessed whether the label for the segment was accurate and recorded any necessary corrections.For each label, if both experts concurred with the results produced by the automatic labeling algorithm, the automatically assigned label was considered correct. However, if there was a lack of agreement between the two experts regarding the results, the automatically assigned label was deemed incorrect. In cases where expert 1’s judgment differed from that of expert 2, the final decision was deferred to expert 3. Overlap was quantitatively measured to assess the accuracy of segment labeling, a method also employed in previous studies , 18. Thea numerical value.The performance evaluation outcomes regarding the presence of a segment, which encompassed precision, sensitivity, accuracy, and F1 scores, were reported as numerical values. The level of agreement or disagreement pertaining to the presence of a segment was expressed as a percentage. Additionally, overlap accuracy was provided as Automatic labeling of the coronary tree was executed on a personal computer equipped with a Xeon Silver 2.2 GHz processor and 64 GB RAM. The total number of segments subjected to labeling by both the algorithm and experts was 2148.Table Figure To further analyze misclassified cases, normalized confusion matrices were employed for segments labeled as true positives (TPs) Fig. . NotablyWhen comparing the results between the two experts, we found that the two experts exhibited disagreements in the labeling of 126 (4.7%) segments within the 157 patients. Disagreement percentages for OM1, R-PLB, OM2, D1, D2, and RI labeling were 20.6%, 19.1%, 15.9%, 11.1%, 10.3%, and 9.5%, respectively. Conversely, agreement percentages for pRCA, mRCA, dRCA, R-PDA, LM, pLAD, mLAD, dLAD, pCx, and LCx labeling were 100.0%, 100.0%, 100.0%, 98.1%, 100.0%, 100.0%, 99.4%, 99.4%, 98.1%, and 94.3%, respectively.In this study, we presented an automatic labeling algorithm designed for coronary artery identification using CCTA images. Initially, we introduced the distance transformation algorithm, highlighting its application in the automatic labeling of coronary arteries. Our algorithm efficiently identified coronary tree segments and assigned accurate labels. We conducted extensive evaluations on a dataset consisting of 157 patients, demonstrating outstanding performance. Notably, our algorithm achieved an impressive overall accuracy of 94.0%, with remarkable results, especially for the four primary arteries.Across all patients, labels for proximal segments, including pRCA, pLAD, pCx, and LM, consistently appeared. Agreement rates were higher in these segments compared to middle and distal segments. This observation aligns with the findings of Cao et al., who developed 3D models for both right- and left-dominant coronary circulation . HoweverIn our study, pCx and LCx segments demonstrated higher accuracy  compared to other methods, especially when considering the distance between LCx and the LA and LV , 21. TypComparing our results with other algorithms, Akinyemi et al. utilized a Gaussian classifier based on geometric features of coronary arteries. However, anatomical differences in training datasets could affect label accuracy. In contrast, our method exhibited robustness by utilizing distances to the LA and LV . AdditioIn our study, we utilized the U-Net architecture, as described by Çiçek et al., and specifically trained a model for coronary artery segmentation . The U-NThis study has several limitations. First, we did not label L-PDA and L-PLB due to their limited consideration in right-dominant diagnostic processes. Second, the performance assessment of the automatic centerline extraction method significantly influenced labeling results. In the future, we will focus on improving artery centerline extraction to enhance labeling accuracy and avoid missed or misclassified arteries. Third, the sample size, particularly for a neural network approach, is relatively small. Multicenter studies with larger sample sizes are warranted to further enhance the method. Future studies will include additional CCTA procedures at our hospital and leverage publicly available datasets to broaden our research scope and increase data diversity, enhancing comparability. Fourth, evaluations in this study were conducted at the segment level rather than the patient level, making it challenging to assess patient-level variability. Future evaluations will consider both segment- and patient-level assessments.In summary, the labeling algorithm presented in this research offers the potential for precise and entirely automated coronary artery labeling in CCTA images. Moreover, this algorithm is applicable to both pathological and healthy datasets. The integration of this algorithm into coronary artery labeling processes holds promise for significantly reducing the radiologists’ workload in the foreseeable future.


Vaccinia virus (VACV) is the causative agent of an emerging viral zoonosis called bovine vaccinia (BV). Several studies have documented characteristics of VACV infections in Brazil; however, the manner in which this virus is maintained in wildlife remains unknown. This work investigated the presence of viral DNA and anti-orthopoxvirus (OPXV) antibodies in samples collected from small mammals in a VACV-endemic area in Minas Gerais, Brazil, in the absence of current outbreaks. Samples did not show amplification of OPXV DNA in molecular tests. However, 5/142 serum samples demonstrated the presence of anti-OPXV neutralizing antibodies in serological tests. These data reinforce the involvement of small mammals in the natural cycle of VACV, highlighting the need for further ecological studies to better understand how this virus is maintained in nature and to develop measures to prevent BV outbreaks. Orthopoxvirus (OPXV) genus have been present among humans for thousands of years, including smallpox, caused by variola virus (VARV), which has been responsible for millions of deaths throughout human history [Infectious diseases caused by viruses belonging to the  history . The era history ,2. Follo history ,4,5,6.Vaccinia virus was first described to cause natural infections in Brazil at the end of the 20th century and has since been associated with outbreaks of bovine vaccinia (BV), a disease affecting dairy cattle and milkers. In cattle, this disease is typically characterized by vesiculopustular exanthematic lesions on the udders and teats of milking cows. In humans, the lesions appear mostly on the hands of milkers which can lead to secondary infections, but systemic symptoms such as fever, myalgia, and headache are also common ,8,9. VACApodemus sylvaticus, Microtus agrestis, and Myodes glareolus, are involved in the natural circulation of CPXV [Funisciurus, Cricetomys, and Graphiurus, among others, but more studies are necessary to better describe the circulation of this virus in nature [Small mammals have been implicated as reservoirs for other OPXVs; serological and molecular studies have shown that three rodent species,  of CPXV . Similarn nature ,21,22.Mus musculus during a bovine vaccinia outbreak investigation [Beyond CPXV and MPXV, an extensive range of studies conducted in Brazilian natural and rural areas have detected evidence of VACV infection in several small mammal species (Rodentia and Didelphimorphia) using molecular and serological tests ,17,23,24tigation ,25. Viratigation . These sSerro county  is located in an area of Brazil where VACV is known to be endemic and has recorded several BV outbreaks, with OPXV infections detected in bovines, equids, rodents, marsupials, and humans ,26,27,28The present work aims to detect evidence of the circulation of OPXV in small mammals captured in and around dairy farms producing artisanal cheese in the city of Serro-MG, Brazil. The study included the capture and sampling of wild animals, testing of liver and serum samples through molecular (quantitative polymerase chain reaction amplification—qPCR), and serological  tests, respectively. Through this study, we aim to contribute to the understanding of VACV circulation in wild animals found in and around farms and how the virus is maintained in the environment. In addition, the results from this study may inform VACV prevention and control efforts in dairy farms by identifying animal species potentially involved in the circulation of this virus.A total of three farms were chosen in Serro county . The farDuring animal manipulation, personal protective equipment was used as recommended by the U.S. Centers for Disease Control and Prevention (CDC) . All proDidelphis and pregnant animals were not euthanized and were released at the site of capture following blood and data collection.A veterinarian was responsible for anesthesia administration and euthanasia procedures for all captured animals. Animals were anesthetized with a combination of ketamine (70 mg/kg) and xylazine (10 mg/kg) prior to blood collection and euthanasia. Data were recorded from each animal including taxonomy, standard measurements, sex, and relative age (juvenile vs. adult). Marsupials belonging to the genus Blood samples were centrifuged at 8000 rcf for two minutes to separate the serum from the clot. Gonads, bladder, intestines, stomach, kidneys, spleen, liver, lungs, and heart were collected from each euthanized animal, and urine and feces samples were collected when present. Liver and serum samples were selected for OPXV screening, and if viral amplification was observed, additional sample types would be tested. Each tissue sample was collected in duplicate and stored in two different microtubes: a dry cryogenic microtube and an Eppendorf microtube with 400 μL of RNA Later  solution. Samples in cryogenic microtubes were stored in liquid nitrogen, while the RNA Later samples were stored in −20 °C freezers until being transported to the BSL-2 laboratory in Diamantina city, Minas Gerais, Brazil, where all the samples were stored in a −80 °C freezer until analysis.® Applied Biosystems software version 2.3. The C11R and A56R assays used SYBR® Green I Master Mix with these cycling conditions: denaturation at 95 °C/20 min, 40 cycles of 95 °C/3 s and 60 °C/20 s, and a melting curve using 95 °C/3 s and 60 °C/20 s, followed by an increase in temperature of 4 °C until reaching 95 °C/15 s. The E9L gene assay used TaqMan® Master Mix with cycling conditions of 50 °C/2 min and 95 °C/10 s, followed by 40 cycles of 95 °C/15 s and 60 °C/1 min.DNA was extracted using the PureLink Genomic DNA Mini Kit  following the manufacturer instructions, and the samples were not homogenized or processed prior to extraction. Serum diluted to 1:10 was used for real-time PCR without DNA extraction, as previously described . Serum aIn order to detect and quantify anti-OPXV neutralizing antibodies, all serum samples were analyzed by PRNT as previously described  and inclAt the end of the four expeditions, a total of 210 small mammals were captured, with a capture success of 1.39%. Of these, 143 (68.10%) belonged to 7 species of the order Didelphimorphia, and 67 (31.90%) belonged to 15 species of the order Rodentia . Liver wTrinomys cf setosus, Nectomys squamipes, and Oligoryzomys sp.) and from two animals of one marsupial species (Marmosops incanus)  showed the presence of anti-OPXV neutralizing antibodies in the PRNTs. All positive animals were captured during dry seasons but from three different field expeditions. Neutralizing antibodies were detected in samples from three rodent species (incanus) . At leasincanus) .Zoonotic diseases have major impacts on public health and small mammals have been directly related to their maintenance in nature and in transmission to people . RodentsThe diversity of animals sampled in this study from the different sampling sessions is in line with the documented diversity of Cerrado and Atlantic Forest in Brazil ,45,46. DLiver samples spiked with VACV-WR as positive DNA extraction controls showed no inhibition for extraction or PCR. In addition, β-actin gene and positive control amplification in all PCR tests indicated the assays were performed as expected. In the present study, it was not possible to detect viral DNA in the tested samples. However, anti-OPXV neutralizing antibodies were detected in a small percentage of serum samples from rodents and marsupials collected from different habitats, different farms, and different months of the year. The negative results both in PCR tests and in PRNT assays suggest that most animals sampled had no exposure to VACV. In order to explain these results, it is important to consider the absence of VACV outbreaks in Serro in recent years, as this might be one of the causes of the low seroprevalence in the small mammals sampled in this study. Additionally, the difficulty of sampling an animal with an active infection likely impacted the lack of molecular detection. When a VACV infection occurs in small mammals, similar to what is usually observed in humans, it is unlikely that the animal stays persistently infected for a long period of time ,26,27. ATrinomys cf setosus and Nectomys squamipes have been previously reported from Serro county, while Oligoryzomys sp. have been associated with VACV in other locations in Brazil [Marmosops incanus samples. Interestingly, this animal is a semi-arboreal marsupial with low locomotory behavior and is commonly found in forest areas [The small number of PRNT-positive animals shows the presence of anti-OPXV neutralizing antibodies at low levels in the mammal community. The anti-OPXV neutralizing antibodies were detected in samples collected in the three different habitat types, suggesting the circulation of VACV in each of these areas. Previous studies have shown hypothetical routes of VACV circulation among small mammals found among farms, disturbed areas near farms, and forest areas ,24. The n Brazil ,25. To ost areas . The serPrevious studies have suggested an epidemiological chain between wildlife and domestic animals, with small mammals playing a pivotal role in this cycle ,23,25. H


Our study aims to determine whether the NLR can be reliably used as a tool to predict disease course in patients diagnosed with primary non-muscle invasive bladder tumors (NMIBC).a retrospective study between 2009 to 2014 was conducted on 300 patients newly diagnosed with NMIBC at our institution. The cut-off value of NLR was set at 2.5. Survival curves were compared using the log-rank test. The association between recurrence, progression, and NLR was assessed univariate, and the prognostic significance of high NLR was assessed using multivariate analysis.one hundred and seventy-five patients had an NLR <2.5 and 125 patients had an NLR ≥ 2.5. The survival rate with recurrence at 5 years was higher in the group with an NLR >2.5 , similarly, the survival rate with progression at 5 years was higher in the group with an NLR > 2.5 . The failure rate of immunotherapy using BCG was higher when the NLR was over 2.5. In a multivariate analysis, the factors associated with recurrence were NLR>2.5 , pathologic stage pT1 , high-grade , concomitant CIS lesions , presence of lymphovascular emboli , and BCG immunotherapy failure . With regard to progression, in a multivariate study, the significant factors were NLR>2.5, BCG immunotherapy failure , and the presence of lymphovascular emboli .preoperative NLR value could predict recurrence, progression, and failure of BCG immunotherapy in NMIBC patients. Transur genders ,4.The dilemma in treating NMIBC is to preserve the bladder and its function while acknowledging the risk of recurrence (78% of cases) and progression to muscle-invasive disease (45% of cases) ,7. TheseNumerous biomarkers of inflammation have been studied to predict the evolution and progression of the neoplastic disease, such as the neutrophil-lymphocyte ratio (NLR). In patients with solid tumors, a high ratio is strongly correlated with locally advanced disease and both a lower relative survival rate and disease-specific survival rate . In regaStudy design and setting: this is a retrospective cross-sectional study including 300 patients who underwent transurethral bladder resection (TURBT) at Ibn Sina University Hospital, Rabat, Morocco over a period of 5 years, from January 2009 to December 2014, and was diagnosed histopathologically with a primary NMIBC. Additionally, all patients diagnosed with intermediate or high-risk NMIBC followed by intravesical BCG protocol consisting of induction treatment (6 weekly instillations) followed by monthly maintenance treatment for one year or three years. Depending on the high risk, postoperative follow-up consisted of cystoscopy and imaging of the upper urinary tract performed every 3 months the first 2 years, every 6 months 2 to 5 years after surgery, and annually thereafter.Participants: all patients with a newly diagnosed NMIBC (Ta-1 stage) that meet the inclusion criteria and follow-up until December 2019 were enrolled.Exclusion criteria: patients with a history of anemia, hematological malignancies, HIV seropositive or documented auto-immune disease, patients diagnosed either with an intermediate risk NMIBC and received Doxorubicin, patients with only carcinoma in situ (CIS) lesions at the anatomopathological study of the TURBT specimen, patients with follow-up were short <6 months after initial resection, and incomplete pathological information were excluded.Data collection: clinicopathologic variables included age, gender, smoking history (categorized as former and current smokers compared with nonsmokers), and preoperative neutrophil/lymphocyte ratio from a complete blood count, were collected. The operative report registry was consulted to obtain data concerning the characteristics of the tumors such as the macroscopic aspect, tumors´ size (above or below 3cm), and number and location of the tumor(s). Tumors were graded according to the 1973 WHO grading system, staged according to the 2002 American Joint Committee on Cancer TNM staging system, and the presence of CIS lesions or vascular emboli [r emboli .Risk-adapted management: all the patients underwent a TURBT. A re-resection (second look) was done when indicated two to six weeks after the first resection. European Association of Urology (EAU) and French Association of Urology (AFU) risk stratification was used to determine if the patients would benefit from control cystoscopy only or would receive intravesical instillation of BCG  [ months) . The ris months) . Patient months) . Similar months) .Study endpoints: our endpoints were recurrence, progression, and failure of BCG therapy.Definitions: Bacillus Calmette-Guérin (BCG) failure was defined according to AFU recommendations by any early high-grade recurrence (<12 months from TURBT), late recurrence , or progression to an invasive tumor. However, early or late low-grade recurrence was not considered BCG failure [ failure ,5. A dis failure .Statistical analysis: the qualitative variables were expressed in number and percentage, and the quantitative variables were expressed in mean and standard deviation and/or median and interquartile range. The cut-off value of the NLR used in this study was 2.5 (≥2.5v s <2.5), as mentioned in most previous reports in the literature [terature . ClinicaEthical approval: our study obtained the favorable opinion of the Ethics Committee for Biomedical Research of the Faculty of Medicine and Pharmacy; the University of Rabat under the reference CERB 24-22 dated 03/22/2022. All patients provided informed written informed consent with guarantees of confidentiality.General characteristics of the study population: of the 300 patients who were included in our study, 81.3% were males (n=244) and 18.7% were females (n=56). The mean age of patients was 58.95±9.87 years. The NLR was <2.5 in 58% of the patients (n=175) and ≥2.5 in 42% of the patients (n=125). The median NLR value was 2.20 . 130 (43%) patients received BCG immunotherapy, and 48 of them (16%) presented with BCG failure later on, of the 48 patients who failed BCG treatment, 30 received induction and maintenance therapy, while 18 received only induction therapy and presented early recurrence before starting maintenance treatment. One hundred and fifty-eight patients (55.6%) presented a recurrence of their disease at a median time of 26 months (IQR: 6-37), and 44 (15%) had progression of their disease at a median time of 16 months (IQR: 9-40), and 31 patients underwent a cystoprostatectomy with a median follow-up in this group of 105 months. Survival analyses: the survival rate with recurrence at 5 years was higher in the group with an NLR ≥2.5, and the mean survival time without recurrence was 35 months in the group with an NLR <2.5 compared to 18 months in the group with an NLR≥2.5 and was statistically significant  ( months) . Similar months) .In our study, the NLR influenced the response to BCG immunotherapy. Of the 130 patients who received intravesical instillations of BCG, 48 of them (16%) were resistant to it. In the group with an NLR <2.5, the mean survival time without BCG failure was 38 months, compared to 29 months in the group with an NLR ≥2.5 and was statistically significant  . The meaEuropean Organisation for Research and Treatment of Cancer risk stratification: the risk stratification allowed us to identify an association between an NLR ≥2.5 and a high or very high risk of recurrence or progression of the disease. Among the patients (n=44) whose tumors´ risk stratification was very high, 96% (n=42) of them had an NLR ≥2.5. On the other hand, in the patients whose tumors risk stratification was low, 94% (n=51) had an NLR <2.5  and multivariate analysis . In univariate analysis, predictive factors for disease recurrence were pathologic stage pT1 , high-grade tumors , multiple lesions , tumor size >3cm , concomitant CIS lesions , presence of lymphovascular emboli , and BCG immunotherapy failure . In multivariate analysis, by adjusting the significant factors in univariate analysis , all the factors aforementioned were found to be predictive of disease recurrence except a tumor size >3cm (p=0.37) and multiple lesions (p=0.07) ((p=0.07) .Factors associated with tumor progression: a high NLR above 2.5 was also found to be predictive of tumoral progression in univariate  and multivariate analysis . In univariate analysis, we also identified as predictive factors for disease progression: size >3cm , BCG immunotherapy failure , lymphovascular emboli  and concomitant CIS lesions . By adjusting the most significant factors in multivariate analysis, failure of BCG immunotherapy  and lymphovascular emboli  were identified as significant factors  and (27 vs. 36 months). Similarly, an NLR >2.5 was statistically significantly associated with recurrence and progression in univariate and multivariate analysis. A high NLR is associated with a tumor at a high or very high risk of recurrence and progression according to the EORTC risk calculator. In addition, a high NLR was predictive of resistance to intravesical immunotherapy by BCG. Patients with high NLR have had BCG failures precociously. As it concerns the cut-off of NLR, recent studies recommended an NLR cut-off value of 3. But the method for selecting the NLR cut-off value remained unclear . Currentl. study .Regarding literature data, a metanalysis of 2298 NMIBC patients mentioned that a high preoperative NLR was associated with lower survival rates without recurrence in four of the studies , and in two of them with lower survival rates without progression even in patients who received intravesical immunotherapy . This meta-analysis pointed out that NLR was associated with an increased risk of disease recurrence and progression in patients who underwent TURBT for NMIBC. Furthermore, NLR was an independent predictor of disease recurrence and progression in NMIBC treated with BCG patients. NLR could be used to improve clinical decision-making regarding treatment and follow-up scheduling . Anotheret al. the NLR was evaluated as a prognostic biomarker for follow-up of NMIBC, revealing a statistically significant association between an NLR ≥3 and the recurrence of the NMIBC but not for progression [et al. reported in their 166 patients cohort study a statistically significant correlation between the recurrence of NMIBC pT1 and an NLR ≥ 2.43. Multivariate logistic regression analysis identified high NLR, multifocality of the lesions, and tobacco use as significant independent factors of recurrence. However, no statistically significant correlation between high NLR and progression was described [et al. demonstrated the existence of a link between immunotherapy response in NMIBC and systemic inflammatory biomarkers, including NLR. Authors evaluated retrospectively in a cohort of 1117 patients, the high recurrence and progression risk of NMIBC in patients with an elevated NLR. The association was confirmed in a subgroup of 300 patients who benefited from BCG intravesical instillations. They recommend adjoining the NLR to other prognostic markers [In a prospective cohort study of 178 patients led by Favilla gression . Ozyalva markers . Our reset al. meta-analysis corroborated the results of four studies that all linked an elevated NLR to an inferior response to BCG immunotherapy [As for the impact of the NLR on the response to BCG immunotherapy, the Vartolomei otherapy . A retrootherapy . CompareIn addition to the statistically significant association between an elevated NLR and high to high-risk tumors, our study demonstrated a statistically significant correlation between an NLR ≥ 2.5 with unfavorable prognostic factors such as CIS and lymphovascular emboli. Our results are in agreement with those already published in the literature thus supporting the prognostic value of a high neutrophil/lymphocyte ratio in the prediction of recurrence, progression, and failure of BCG immunotherapy in NMIBC ,10,17,18Cells involved in inflammation in particular, neutrophils and lymphocytes play a central role in the process of carcinogenesis and tumor development via a very complex interaction . As in oLimitations: the retrospective nature constitutes the main limitation of our study. The small number of samples, non-randomized, and single referral institutions also represent limitations. Further prospective, well-controlled clinical studies of diverse patients in multiple institutions are required to validate the role of NLR as a prognostic marker, which may improve current risk stratification tools and treatment outcomes in this group of patients.Our study demonstrated that an elevated NLR is a predictive factor of the recurrence and progression of NMIBC. Furthermore, the NLR could identify patients who didn’t respond to BCG immunotherapy. All this makes an NLR a valuable biomarker that is simple to obtain, reproducible, and cost-effective. Still, our results need to be confirmed by larger multicentric prospective studies.th most frequent cancer diagnosed in men and the 11th in both genders;Bladder cancer is the 7Despite the different therapies available, recurrence and progression rates are still high reaching respectively 70% and 30%;The impact of biological markers of inflammation, in particular the NLR, is still poorly understood.Our cohort study demonstrated that an elevated NLR is a predictive factor of the recurrence and progression of NMIBC;The NLR could identify patients who didn't respond to BCG immunotherapy.


Introduction Overactive bladder (OAB) is a medical state that presents as the urgency of urine and increased frequency of micturition and is diagnosed on the basis of the presence of these symptoms in the absence of other explainable diagnoses. The management of this condition includes conservative management, medical management/pharmacotherapy, and surgical management. The overactive bladder has been treated with smooth muscle relaxants, but there are conflicting results. Hence, this study aimed to assess the result of the two smooth muscle relaxants, mirabegron and solifenacin, and their combination to manage an overactive bladder.Methodology A clinical trial was conducted at Swaroop Rani Nehru Hospital, Motilal Nehru Medical College, Prayagraj, India, over the period from November 2019 to December 2020. Ninety patients with OAB were divided into three groups: G1, G2, and G3. These groups were administered solifenacin, mirabegron, and a combination of mirabegron and solifenacin (S+M), respectively. Follow-ups were conducted at 2, 4, 12, and 18 weeks for evaluation. Data were entered into IBM SPSS Statistics for Windows, Version 23 . Appropriate statistical tests, including the chi-square and ANOVA, were employed in this study.Observation The combination of mirabegron and solifenacin was significantly more effective in terms of response compared to solifenacin alone. There was no significant difference between solifenacin versus mirabegron, or between mirabegron (M) and the combination of mirabegron (M) and solifenacin (S). Side effects were more severe in patients taking high doses of solifenacin.Conclusion The S + M combination has higher efficacy than solifenacin and mirabegron when given alone. Overactive bladder (OAB) is a medical state that presents as urgency of urine and increased micturition frequency which may be associated with urge incontinence and nocturia. However, there must be an absence of local pathologies or metabolic factors that might produce these symptoms. The causative factors include uroepithelial factors, neurogenic factors damaging inhibitory pathways, myogenic factors, and miscellaneous factors such as infections like recurrent urinary tract infection (UTI), cystitis, chronic prostatitis, etc., as well as metabolic syndrome and bladder outlet obstruction resulting from prostate cancer, benign prostatic hyperplasia, bladder cancer, urethral stricture, and bladder calculi .Risk factors include advanced age, post-menopausal women, pelvic organ prolapse, incontinence surgery, neurological diseases, depression, hypertension, recurrent UTI, prostatitis, irritable bowel syndrome, sleep apnea, diet factors like caffeine, artificial sweeteners, carbonated drinks, spicy food, etc., smoking and alcohol intake, and both excessive and inadequate fluid intake .It is diagnosed based on the presence or absence of symptoms of the lower urinary tract (LUTS) in the absence of other explainable diagnoses. Management of OAB can be conservative , medical/pharmacological , or surgical . When all management fails, the following alternatives are used: Suprapubic or urethral catheters, urethral closure and diversions, appliances, etc. [The use of smooth muscle relaxants for treating overactive bladders has been introduced recently, but the results are conflicting . Hence, A randomized clinical trial was done in Swaroop Rani Nehru Hospital of Motilal Nehru Medical College, Prayagraj, India, from November 2019 to December 2020 among 90 patients of OAB.Inclusion criteriaAll newly diagnosed patients of any age, complaining of increased urination frequency, urinary urgency, urinary incontinence, and nocturia were included in the study.Exclusion criteriaPatients who did not give consent, those with the presence of any pathology , patients in which drugs could not be given , and patients who had a history of any operation of the urinary bladder, urethra, or endoscopic intervention were excluded from the study.Sampling procedureThe institute's Ethics Committee clearance was obtained before the initiation of the study . All new patients were consecutively randomized and divided into three groups: G1, G2, and G3. Ninety patients were evaluated for the entire study period, that is, 30 patients in each group. The groups were allotted the drug as follows: (1) G1-Solifenacin (S) ; (2) G2-Mirabegron (M) ; and (3) G3-Combination of S+M (S-5mg +M-25mg)/(S-5mg+M-50mg).The patients were examined and evaluated. A semi-structured questionnaire was employed for data collection from patients. Follow-ups were carried out at 2, 4, 12, and 18 weeks, with no patients lost to follow-up. At every follow-up, the following points were evaluated: micturition frequency per 24 hours, urgency episodes per 24 hours, incontinence episodes per 24 hours, urge incontinence episodes per 24 hours, and nocturia episodes per 24 hours.The data were entered into IBM SPSS Statistics for Windows, Version 23 . Appropriate statistical tests including chi-square, ANOVA, and repeated measures ANOVA were utilized in this study. In this study, a comparison of improvement and side effects was measured in terms of Good, Bad, or No response.Good ResponseThis was assigned to patients if there was a decrease in the number of nocturia episodes, decreased urinary frequency, fewer episodes of urinary incontinence, improvements in lifestyle, and a decrease in urge incontinence.Bad ResponsePatients were assigned this if there was no decrease or an increase in nocturia episodes, no decrease or an increase in urinary frequency, no decrease or an increase in incontinence episodes, no improvement in lifestyle, and no decrease or an increase in urge incontinence.No ResponseAfter prolonged treatment, patients were assigned to this group if their response was between Good and Bad, or if they showed no response or improved symptoms.In this study of 90 patients presenting with symptoms of overactive bladder, the efficacy of solifenacin, mirabegron, and their combination was compared over a one-year period from December 2019 to November 2020. Patients were allocated to groups 1 through 3, and treatments were administered using solifenacin, mirabegron, and a combination of the two, respectively.The study showed a male preponderance and the mean age of the participants was approximately 60 years across all three groups. Among all the groups, the highest mean baseline score for micturition episodes per 24 hours and mean urge incontinence score were observed in group 3, with scores of 7.067±0.868 and 1.467±0.630, respectively. The highest mean baseline score for urgency episodes per 24 hours and mean incontinence score were noted in group 2, with scores of 1.566±0.820 and 1.630±0.850, respectively  and mirabegron (M) is notably more effective than using either of these medications on their own. The combination of S+M led to a mean reduction of 4 episodes of micturition per 24 hours. This compares favorably to a reduction of 3.47 episodes for the Solifenacin group and 3.67 episodes in the Mirabegron group. Similarly, mean urgency episodes decreased by 1.33 per 24 hours when treated with the S+M combination.Moreover, the combination of solifenacin and mirabegron appears equivalent to mirabegron alone and superior to solifenacin in decreasing the number of incontinence episodes per 24 hours. Specifically, the S+M combination led to a mean decrease of 1.34 incontinence episodes per 24 hours, compared to 1.2 for the solifenacin group and 1.4 for the mirabegron group.In terms of nocturia episodes per 24 hours, the S+M combination was superior to either of the individual drugs, reducing episodes by 2.267 per 24 hours. This was better than the 1.977 episodes reduced in the Solifenacin group and 2.17 episodes in the Mirabegron group (Table The majority of the study participants in the S+M group (86.66%) showed good results with the drug, compared with those in the mirabegron (76.66%) and solifenacin 63.33%) groups (Table .33% grouThe table shows that the combination of mirabegrone + solifenacin was significantly superior in terms of response than solifenacin. There was no significant difference between solifenacin vs mirabegron and mirabegron (M) vs mirabegron (M)+solifenacin(S) Table .Analysis of the side effects data for the three drugs reveals that the most commonly reported adverse events were anticholinergic in nature. These adverse events ranged from mild to moderate symptoms, and no patients discontinued the medication due to side effects. However, it is worth noting that side effects were more severe in patients who were taking higher doses of solifenacin Table .Overactive bladder is a prevalent issue in elderly patients, and antimuscarinics are currently the most commonly prescribed medications for treatment. Mirabegron, a newly FDA-approved drug, offers an additional option for treating overactive bladder. However, solifenacin and other antimuscarinics remain widely used and are the mainstay of treatment. In this comparative study, we evaluated the clinical efficacy of flexible dosing of solifenacin (5mg and 10mg), mirabegron (25mg and 50mg), and their combination (solifenacin 5mg + mirabegron 25mg/50mg). The study involved 90 patients, and there were no losses to follow-up.Demographic characteristics of the study participantsThe study showed a male preponderance, and the mean age of the participants across all three groups was approximately 60 years. These characteristics are comparable to those found in a study by Tang et al., which also compared solifenacin and a combination of solifenacin and mirabegron. In that study, the mean patient age was 45 years, and there were no discernible differences between the two groups in terms of age and gender [Efficacy of the drugIn this study, almost all episodes of incontinence were episodes of urge incontinence. This study demonstrated a statistically significant reduction in all symptoms of overactive bladder syndrome across all three groups. Changes were measured by a decrease in pad use and the wetting of clothes, as well as in episodes of nocturia. These changes were observed after a duration of 18 weeks. A combination of mirabegron and solifenacin was found to have superior efficacy and response in reducing the symptoms of overactive bladder compared to either solifenacin or mirabegron alone.Our study corroborated the findings of previous studies conducted on the same subject. For example, Sacco et al. reported that the incidence and severity of treatment outcomes were similar to those observed with antimuscarinics . Maman eAdverse events associated with the drugsIn the present study, the analysis of side effects for three drugs shows that the most commonly reported side effects were anticholinergic side effects. The adverse effects were mainly mild to moderate and none of the patients discontinued the drug because of side effects. However, side effects were more severe in patients taking high doses of solifenacin.Sacco et al. reported that serious adverse events were comparable to antimuscarinics, but with a significantly lower incidence of dry mouth as compared with antimuscarinics . AccordiIf patients felt their treatment was ineffective after four weeks of active treatment, our study's design permitted them to request an increase in drug dose, and then patients were re-evaluated after the duration of 18 weeks. After a dose increase, a small number of individuals on solifenacin reported experiencing antimuscarinic adverse effects such as dry mouth, diarrhea, and impaired vision. However, the symptoms and complaints are less or absent with mirabegrone and its combination. Taken together, these results imply that patients may be less tolerant of lack of efficacy than of antimuscarinic side effects. Despite rising side effects, in fact, about half of the patients wanted a dose increase. All of these factors are crucial because an effective treatment should strike the ideal balance between the greatest possible improvement in clinical symptoms and accepted tolerability, leading to a discernible and valuable increase in quality of life.The main limitation of this study was the short (18 weeks) duration of treatment. The study needs a larger group and long-term follow-up to study the side effects and neoplastic potential of mirabegron, and also for a significant increase in blood pressure and cardiovascular symptoms. In our trial, mirabegron was used to treat OAB and showed higher efficacy and tolerability with fewer side effects. Mirabegron provides a new class of medication for OAB with proven efficacy and good tolerability.The combination therapy exhibits greater efficacy than either solifenacin or mirabegron when administered individually. Mirabegron demonstrates superior efficacy to solifenacin in reducing episodes of micturition and urge incontinence per 24 hours. Both the combination therapy and mirabegron are nearly equally effective but surpass solifenacin in reducing episodes of urgency and incontinence per 24 hours. In terms of reducing nocturia episodes per 24 hours, solifenacin and mirabegron are equally effective; however, the combination therapy proves to be superior. The most frequently reported side effects across all three groups are anticholinergic in nature, yet these side effects occur significantly less often in groups treated with Mirabegron and the combination therapy. Therefore, for the treatment of overactive bladder, the combination therapy can be recommended as the first-line medication due to its enhanced control and rapid response over symptoms of OAB.


Sexualized drug use (SDU) to enhance and extend sexual relations may involve risks of substances abuse  and higher exposure to HIV and other sexually transmitted infections. There are inconsistencies in the methodology and findings of previous research on SDU in Latin America (LA), and more studies are required. The purpose of this research was to characterize SDU in gay men and other men who have sex with men from 18 LA countries, and describe the aspects by comparing people who practice and do not practice SDU, at the general and country levels.Cross-sectional study based on the data collected by LAMIS-2018. Dependent variable was SDU (last 12 months), and the independent variables were: drug use , sociodemographic, socioepidemiological, and psychosocial aspects. A descriptive analysis was carried out, comparing those who practiced and did not practice SDU.LAMIS-2018 included 64,655 participants, averaging 30 years of age. 13.6% declared having practiced SDU (6.6% with multiple partners). In the last sexual encounter the most commonly used drugs were cannabis (9.3%), poppers (6%), and Viagra (5.4%), and in the last encounter with multiple partners, poppers (19.7%), cannabis (17%), and Viagra (13.2%). HIV diagnosis was reported by 27% of people practicing SDU, vs. 14.3% in the other group. Severe anxiety-depression symptoms were more common among people practicing SDU (9.2% vs. 7%), as were the episodes of homophobic intimidation (52.6% vs. 48.2%), insults (34.4% vs. 28.6%), and aggression (4.1% vs. 3.0%).SDU was reported by a high percentage of people, with a predominance of the use of drugs related to sexual practice, and others for recreational use. Aspects described as the higher proportion of self-reported HIV diagnosis and severe symptoms of anxiety-depression among those who practiced SDU, show that is necessary to implement preventive strategies to reduce the harmful impacts that can sometimes result from this practice, including harm reduction policies, promote access to mental health services and support in situations of homophobia and stigma. Drug use is a multidimensional phenomenon that covers a wide spectrum of scenarios, ranging from recreational use of psychoactive substances (PS) to their abuse . Drug coGay men and other men who have sex with men (MSM) constitute a key population in efforts against HIV, where the transmission of the virus is favored by aspects of sexual health, individual behaviors such as alcohol and drug consumption and phenomena such as discrimination and criminalization . ChemsexDetermining the prevalence of this phenomenon in LA is a complex task, owing to the lack of information and the methodological differences among studies that hinder the comparison of their results. In a study conducted in Colombia on 766 people (78% men and 21% women), among whom 80% people were homo/bisexual, 54% participants reported engaging in “chemsex” for more than a year; poppers, MDMA, cocaine, and ketamine were the most commonly used substances . In BrazThis research used the term “sexualized drug use” as it allows a broader exploration of the phenomenon, regardless of the type of drugs consumed. From the perspective of the social determinants of health , multiplThe purpose of this research was to characterize SDU in gay men and other MSM from 18 LA countries, and describe the sociodemographic, socioepidemiological and psychosocial aspects by comparing people who practice and do not practice SDU, at the general and country levels. Consequently, this research hopes to contribute to public health providing detailed information on an emerging phenomenon whose characteristics and impact on the population are still unknown, constituting a possible input for future health policies in the region.This was a cross-sectional study based on the data collected by the Latin America Men who have Sex with Men Internet Survey (LAMIS) 2018 , the firThe included population comprised gay men and other MSM who were 18 or older and resided in one of the 18 participating countries.The online questionnaire used for the study was adapted from the EMIS-2017 . The quePromotion and recruitment of participants was carried out from January 24 to May 13, 2018, using mobile dating applications for men, web pages, social networks, clinics, NGOs, organizations and leisure places commonly visited by the study population. For online promotion, different images and banners (dynamic and static) were created in the three study languages using a common base graphic that was modified according to the language and colors used in each participating country. In addition, offline promotion was carried out using printed materials (posters and cards) that were displayed in the gay leisure venues , depending on the country. People reached by recruitment strategies gained access to a link that directed them to the survey web page. The first page contained the informed consent providing study information, including a brief summary of the study purpose and its relevance, institutions involved, inclusion and exclusion criteria, benefits and potential harms, estimated time to complete the survey, and data management. Before moving on to the survey questions, all participants must have stated that they understood the nature and purpose of the study and that they consented to take part in it. After consent, the only compulsory questions were the first ones about age, sexual identity, sex assigned at birth and country of residence, to verify inclusion and exclusion criteria.SDU practice was defined based on the question “When was the last time you used drugs to make your sexual relations more intense or last longer?,” with eight options as answers: last 24 hours, last 7 days, last 4 weeks, last 6 months, last 12 months, last 5 years, more than 5 years ago, and never. For the analysis, all categories were merged to obtain a qualitative/dichotomous variable, where 0 indicated “Never or more than 12 months ago” and 1 indicated “In the last 12 months”.Drugs use in any context : alcohol consumption (last 12 months), alcohol abuse , drugs Drugs use in the sexual context: SDU with multiple partners at the same time (last 12 months), place where the SDU with multiple partners occurred, and drug use during the last sexual encounter .Sociodemographic aspects: age, migratory status, highest educational qualification, occupation, and self-perception of economic income.Socioepidemiological aspects: stable partner, casual partners (last 12 months), number of casual sexual partners (last 12 months), number of casual sexual encounters without using a condom (last 12 months), satisfaction with sexual life, payments received  in exchange for sex with men (last 12 months), self-reported HIV diagnosis, use of pre-exposure prophylaxis (PrEP) (sometime in life), and positive diagnosis for hepatitis C, syphilis, gonorrhea, chlamydia, and anal or genital warts (condyloma), sometime in life.Psychosocial aspects: anxiety-depression symptoms  were determined. The categorical, continuous, and discrete variables were compared using Chi-square, Student’s T, and Mann–Whitney U tests, respectively. Outcomes were recorded in tables for all samples and participating countries, distributing in columns the respective values for those who practiced SDU in the last 12 months, those who did not practice SDU in the las 12 months and, the p-value obtained from the comparison between both groups.The LAMIS-2018 study obtained the ethical approvals for its execution at the regional level by the committees of the Universidad Peruana Cayetano Heredia (612-19-17), Escuela de Salud Pública Salvador Allende, School of Medicine, Universidad de Chile (009–2017), Santa Casa de Misericórdia de São, Brazil , Comité Nacional de Ética en Salud, Guatemala  (39–2017), and the Faculty of Psychology and Neuroscience of the University of Maastricht, Netherlands (186-01-12-2017).LAMIS-2018 included 64,655 participants, wherein most participants were from Brazil , Mexico , Colombia , Argentina , and Chile . The estimated recruitment rate revealed that there were 3.3 participants for every 10,000 men included in the study and were aged between 15 and 65 years .The prevalence of alcohol consumption in the last 12 months overall was 90.1% , 13.6% declared having practiced SDU in the last 12 months Tables . The praRegarding drug use during the last casual sexual encounter with a partner or while being part of a threesome that involved a stable partner Tables  and 4, tThe results of the descriptive analysis of the independent variables are presented below, based on the statistically significant differences observed between the study groups.Overall, the group of people who practiced SDU and other participants comprised mainly young men with a mean age of 30 years SD = 9.5), and a median age of 28 years (IQR = 12) . This trend was observed in most countries . This situation was also observed in Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru, Suriname, and Mexico; the greatest difference between the groups was observed in Mexico (31% vs. 13.1%). The prevalence of diagnosis of other STIs was reported by a higher proportion by people who practiced SDU than the other respondents, including hepatitis C (1.7% vs. 0.8%), chlamydia (7.6% vs. 3.8%), gonorrhea (21.7% vs. 11.7%), syphilis (27.1% vs. 14.5%), and condyloma (25% vs. 15.4%). At the country level, high prevalence rates were observed in people who practiced SDU in Brazil, Colombia, and Mexico, and the highest prevalence rates for syphilis and chlamydia were seen in Brazil (36.5%) and Paraguay (32.8%), respectively. The use of PrEP (sometime in life) was reported by a higher proportion of people who practiced SDU than the other respondents overall (3.3% vs. 1.3%) and in most countries.Severe anxiety-depression symptoms were more common among people practicing SDU, overall (9.2% vs. 7%) and in almost 50% participating countries Tables –16. GreaThe LAMIS-2018 was the first survey to describe the SDU phenomenon in a large population of gay men and other MSM from LA countries, addressing multiple aspects of the psycho-socio-sexual health in 18 countries of the region. Literature has revealed that gay men may be more prone to excessive alcohol consumption and drug use than the general male population , in partThe prevalence of SDU (last 12 months) in this study was relatively similar to that reported in the EMIS-2017 conducted in the European region (13.6% vs. 10.4%)  and non-users (1.3%). This observation is in contrast with the phenomenon observed in other regions such as the UK, wherein usage rates exceed 20% , and FraPeople who practiced SDU reported high levels of satisfaction with their sexual life, which is consistent with the increased sexual enjoyment and less anxiety reported by people who use drugs in the sexual context . On the LAMIS-2018 was conducted using an online questionnaire, implying that the participants had a certain level of knowledge and access to mobile or desktop devices and the Internet. However, it was not a major obstacle among the population of gay men and other MSM . BesidesSDU practice was reported by a high percentage of the people surveyed in LAMIS-2018, wherein a predominance of drugs related to sexual practices  and other related to recreational use like cannabis was observed. This SDU phenomenon is consistent with the availability of substances and the typical consumption profile in the LA context, and needs to be made visible as a public health problem in the region. The aspects described in this study, such as the higher proportion of self-reported HIV diagnosis and severe symptoms of anxiety-depression among those who practiced SDU, show that in order to reduce the harmful impacts that can sometimes result from the use of drugs in the sexual context, the implementation of combined preventive strategies adapted to each country is essential. This strategies must have the active participation of the most exposed communities, through community outreach programs and peer education, using technology to improve the reach of preventive efforts in the target population. Facilitating access to PrEP through dispensing from community organizations is key. Finally, given the multidimensional nature of the phenomenon, it is necessary to develop health policies that address drug use from a harm reduction perspective and promote access to mental health services and support in situations of homophobia and stigma, from a transdisciplinary, inclusive perspective and with an approach based on human rights.


The real-world clinical and economic burden of graft-versus-host disease (GVHD) following allogeneic hematopoietic stem cell transplantation has not been comprehensively studied in France. Clinical outcomes, healthcare resource utilization and costs associated with acute GVHD (aGVHD), chronic GVHD (cGVHD), acute plus chronic GVHD (a+cGVHD) versus no GVHD were compared using French administrative claims data. After propensity score matching, 1934, 408, and 1268 matched pairs were retained for the aGVHD, cGVHD, and a+cGVHD cohorts, respectively. Compared with patients with no GVHD, odds of developing severe infection were greater in patients with aGVHD . Compared with patients with no GVHD, mortality rates were higher in patients with aGVHD (rate ratio (RR): 1.6 ) and with a+cGVHD  but similar in patients with cGVHD . Mean overnight hospital admission rates per patient-year were significantly higher in patients with aGVHD and a+cGVHD compared with no GVHD. Total direct costs  were 1.2, 1.5, and 1.9 times higher for patients with aGVHD, cGVHD, and a+cGVHD, respectively, versus patients with no GVHD. These results highlight the significant unmet need for effective treatments of patients who experience GVHD. Hematopoietic stem cell transplantation (HSCT) is an effective and, in some cases, the only treatment option for many patients with hematological malignancies . AdvanceGVHD is traditionally categorized as either acute (aGVHD), usually presenting within 100 days of transplantation, or chronic (cGVHD), which more frequently occurs 100 days after transplantation . Both aGAn unmet need exists for effective therapies to prevent and treat GVHD following allo-HSCT . TreatmeThis study was a retrospective, nationwide cohort study using administrative claims obtained from the French national health data system, Système National des Données de Santé (SNDS). The SNDS contains health records of an estimated 65 million insured individuals. The French national health system offers universal coverage, so this is a representative sample of the whole population. SNDS data are linked via unique identifiers to primary care, hospital, pharmacy, and death registration databases, allowing for the linkage of patient treatment history, treatment patterns, and hospitalization based on International Classification of Diseases, 10th revision (ICD-10) codes.The study period ran from January 1, 2011 through December 31, 2019. The index date was defined as the date of the first allo-HSCT procedure between January 1, 2012 and December 31, 2018. The baseline period was defined as the 12 months prior to the index date . The follow-up period was a minimum of 12 months after the index date, until the last available information, death, or the end of the study , whichever came first.This study was conducted in accordance with legal and regulatory requirements, as well as with scientific purpose, value, and rigor. The study followed generally accepted research practices described in the Guidelines for Good Pharmacoepidemiology Practices issued by the International Society for Pharmacoepidemiology, Good Epidemiological Practice guidelines issued by the International Epidemiological Association, Good Practices for Outcomes Research issued by the International Society for Pharmacoeconomics and Outcomes Research, International Ethical Guidelines for Epidemiological Research issued by the Council for International Organizations of Medical Sciences, and the European Medicines Agency, as well as the European Network of Centres for Pharmacoepidemiology, and Pharmacovigilance Guide on Methodological Standards in Pharmacoepidemiology. The final protocol was reviewed and approved by a scientific committee and the national data protection agency. All patient data were pseudonymized, which according to applicable legal requirements renders the data exempt from privacy laws; therefore, obtaining informed consent from patients was not required.Patients (aged 18 years and above at the index date) who underwent allo-HSCT for any hematological malignancy between January 1, 2012 and December 31, 2018 were eligible for the study. Patients were excluded if they had an allo-HSCT prior to the start of the study or multiple allo-HSCT procedures during the study period. All patients were required to have at least 12 months of baseline data prior to the allo-HSCT and 12 months of possible follow-up data (unless they died). Eligible patients were identified in the database using the common classification of medical procedure codes or, where applicable, diagnosis-related group or ICD-10 codes.Using ICD-10 codes, patients were divided into 1 of 4 categories by GVHD type: aGVHD, cGVHD, a+cGVHD, or no GVHD , median, minimum and maximum, and lower and upper quartiles . Frequencies and percentages were reported for categorical variables. The chi-square test was used for categorical variables.The crude mortality rate was calculated as a ratio of the number of deaths during the follow-up period divided by the total person-years in the given cohort. The crude rates of HCRU and of severe infections were calculated as the total number of events divided by the person-years. A mean value was then estimated for each cohort.No imputed data were used for missing values for outcomes assessments. Statistical analyses were conducted using SAS (version 9.4 TS1M4). Percentages were based on available observations , and outliers were included in ranges and percentiles. The rate ratios (RRs) were calculated using the OpenEpi statistical tool .For the comparative analysis, separate 1:1 propensity score matching was used to balance covariates between the aGVHD, cGVHD, and a+cGVHD groups versus the no GVHD group. The propensity score, defined as the probability of a patient to develop GVHD conditional on observed baseline covariates, was estimated using a logistic regression model. The baseline covariates explored were hematological condition for the allo-HSCT, age, gender, comorbidities, and preparative regimens. The final model was chosen based on the Akaike information criterion  and the sample size retained for each comparison. The final covariates were selected based on clinical relevance and/or statistical significance.p values were estimated.All binary outcomes were described using frequencies. The excess number of infections , the excess number of deaths, and the excess number of HCRUs were assessed using conditional logistic regression stratified by the paired identifier. Odds ratios (ORs) with the associated 95% confidence intervals (CIs) and two-sided The effect of GVHD on each time-to-event outcome of interest (time to first severe infection and time to death) was summarized using Kaplan–Meier (KM) methodology on the matched population. The assumption of proportional hazards was evaluated by visually inspecting the KM plot and confirmed by testing the significance of interactions between treatment and the log of time. Hazard ratios (HRs) were used to assess excess time to death , and excess time to severe infections.p values.Actual costs reimbursed were considered (without inflation to a standard cost year). Cost data were not normally distributed. The effect of GVHD on costs was investigated in the propensity score-matched populations using the generalized linear models with gamma distribution and log-link function. Excess cost was assessed using mean differences and cost ratios, together with the associated 95% CIs and A total of 10,579 patients were identified in the SNDS database as recipients of allo-HSCT during the study period. After applying inclusion and exclusion criteria, 6385 patients were included in the study population Fig. .Fig. 1StPatients with GVHD had lower rates of relapse than those with no GVHD. Overall, 16.3% of the total study population (1043 patients) had a relapse . Among all patients who had a relapse, the median time to relapse was 1.2 (range 0.1–56.5) months.The final covariates selected to pair for propensity score matching for all groups were age at allo-HSCT, gender, year of allo-HSCT, and preparative regimen (use of clofarabine). Additional covariates for each GVHD type included related donor, other preparative regimen (use of carmustine), and the presence of diabetes for aGVHD and a+cGVHD; lymphoid leukemia, acute myeloblastic leukemia, and total body irradiation for aGVHD; congestive heart failure and connective tissue disorder for cGVHD; and cerebrovascular disease and any tumor  for a+cGVHD.After propensity score matching, 1934 matched pairs were retained for the aGVHD cohort; 408 matched pairs were retained for the cGVHD cohort and 1268 matched pairs were retained for the a+cGVHD cohort (Table p < 0.001), and 30.6% (592 patients) had four or more severe infections, compared with 18.5% (357 patients) in the no GVHD cohort . Although a numerically greater proportion of patients with cGVHD than no GVHD developed severe infection , the difference was not statistically significant . Significantly more patients with cGVHD had four or more infections compared with no GVHD . Significantly more patients with a+cGVHD had severe infection compared with no GVHD , and significantly more patients with a+cGVHD had four or more infections compared with no GVHD . The most common infections were bacterial, recorded in >70% of all patients; and viral infections recorded in 47.4%, 44.9%, 59.1%, and 27.5–31.9% of patients with aGVHD, cGVHD, a+cGVHD, and no GVHD, respectively. The most frequent viral infection was CMV, reported in 28.6%, 23.5%, 36% of patients with aGVHD, cGVHD, a+cGVHD respectively versus 12.5%–13.7% of patients with no GVHD .Patients with aGVHD and a+cGVHD had an increased rate of hospitalization for severe infection, with an RR of 1.3  and 1.1 , respectively, versus no GVHD. The rate of hospitalization for severe infection was similar for patients with cGVHD compared with no GVHD , and 10.1 (SD 0.1) months for a+cGVHD compared with 16.4 (SD 0.8) months for no GVHD . The mean time to first infection was not statistically different for patients with cGVHD compared with no GVHD . KM curves in Fig. The mean time to first infection for patients with aGVHD was 10.0 (SD 0.5) months, compared with 15.6 (SD 0.7) months for patients with no GVHD  versus patients with no GVHD; the mortality rate was slightly higher, although not statistically significant, for the a+cGVHD versus no GVHD groups  and similar between patients with cGVHD and patients with no GVHD . KM curves in Fig. Patients with aGVHD had an increased mortality rate . Mean overnight hospitalizations per patient-year were similar for patients with cGVHD compared with no GVHD   for patients with aGVHD, cGVHD, and a+cGVHD, respectively, compared with no GVHD. Total indirect costs (including sick leave and transportation) were similar for patients with aGVHD versus patients with no GVHD, 1.3 times higher for patients with cGVHD (p = 0.017), and 1.3 times higher for patients with a+cGVHD than those with no GVHD (p < 0.001)  were 1.2, 1.5, and 1.9 times higher . These costs were primarily driven by subsequent hospitalizations and drug costs. Patients with aGVHD had a significantly higher number of documented hospitalizations for severe infection as well as a higher rate of mortality than patients with no GVHD. These results are aligned with other studies conducted in Europe [Patients with GVHD had a longer mean initial length of hospital of stay and a significantly higher number of subsequent hospital stays, including intensive care unit (ICU) visits during these subsequent hospitalizations, compared with patients with no GVHD. During the follow-up period, total direct costs were 1.2, 1.5, and 1.9 times higher for patients with aGVHD, cGVHD, and a+cGVHD, respectively, than for those with no GVHD  was associated with significant clinical and economic burden, including higher rates of infection and mortality as well as increased hospitalizations and direct costs, compared with no GVHD. The results of this study highlight the significant unmet need for effective prophylaxis and treatment options for GVHD, which could reduce or prevent the clinical burden borne by patients experiencing GVHD of all types , the increased cost of allo-HSCT procedure due to aGVHD, and the potential development of cGVHD, itself leading to further increase in HCRU and costs. Recent advances in allo-HSCT technology, especially in the area of GVHD prevention and treatment, could add to the drug cost; however, it should also reduce the risk of complications and hence the overall clinical and economic burden.Supplementary Table 1Supplementary Table 2Supplementary Table 3