Mean PA increase from baseline to the end of the study was equal to 125% (p < 0.001) in normal patients, 200% (p < 0.001) in overweight patients and 100% (p < 0.001) in obese patients. After 70 months of follow-up, the 5-year overall survival (OS) rate was 96%, 96%, and 93%, respectively in normal, obese, and overweight patients. Overweight patients had significantly worse OS than normal ones  whereas no statistically significant differences were seen between obese and normal patients . Conclusions: A lifestyle intervention can lead to clinically meaningful weight loss and increase PA in patients with BC. These results could contribute to improving the OS in obese patients compared to overweight ones.Background obesity and sedentary lifestyle have been shown to negatively affect survival in breast cancer (BC). The purpose of this study was to test the efficacy of a lifestyle intervention on body mass index (BMI) and physical activity (PA) levels among BC survivors in Modena, Italy, in order to show an outcome improvement in obese and overweight patients. Methods: This study is a single-arm experimental design, conducted between November 2009 and May 2016 on 430 women affected by BC. Weight, BMI, and PA were assessed at baseline, at 12 months, and at the end of the study. Survival curves were estimated among normal, overweight, and obese patients. Results: Mean BMI decreased from baseline to the end of the study was equal to 2.9% ( Breast cancer (BC) is the most common cancer in women worldwide. In Italy, between 2008 and 2012, breast cancer reached an age-standardized incidence rate of 126.9 per 100,000 women in northern Italy, 111.2 per 100,000 women in central Italy, and 98.9 per 100,000 women in southern Italy, Sicily, and Sardinia  and fourIt is well known that obesity influences BC risk and affects survival in patients diagnosed with BC. For this reason, in a recent study, we evaluated the relationship between body mass index (BMI) and the risk of breast cancer (BC) as well as the outcome in 14,684 women recruited between ages 55 and 69 who resulted eligible to participate in the mammography screening program (MSP) in the province of Modena, Italy. We reported a significantly higher risk of BC in obese women and we also demonstrated that obese women had more second events and poorer event-free survival compared to non-obese women [Already in 2010, a review of 43 prospective studies evaluating the effect of obesity on BC prognosis had shown a poorer overall and BC-specific survival in obese patients compared to non-obese women . Two furOn the other hand, physical activity (PA) has been associated with improved outcomes in BC survivors in many epidemiological studies ,16,17,18International recommendations for cancer prevention published in 2007 by the World Cancer Research Fund, include eating a healthy diet, being physically active and maintaining a healthy weight . In the Findings from experimental studies involving BC survivors suggest that a behavioral intervention may support clinically meaningful weight loss ,28,29,30However, in our knowledge, no studies have reported the effects of lifestyle interventions on body weight in breast cancer survivors in the Italian population so far.The purpose of this single-arm pilot study was to test the feasibility and efficacy of a lifestyle intervention through diet and PA on body weight in a population of more than 400 patients with BC followed at Modena Cancer Center, Modena, Italy.p = 0.041). On the whole, with regards to the menopausal status, the vast majority of patients were in postmenopausal condition (49.8%); this hormonal status was particularly predominant in obese women (56.9%) and overweight patients (52.1%), whilst 58% of normal weight patients were in premenopausal status (p < 0.001). Luminal cancers were the most frequent tumor subtype, being luminal A equal to 48.7% in the obese group and luminal B equal to 36.4% in the overweight group. Triple negative tumors arose more frequently in the normal weight group of patients (9%) (p = 0.001). A previous BC was particularly evidenced in overweight patients compared to other groups (p < 0.001). Finally, looking at tumor size and grade of invasive BC, obese patients showed the highest percentage of tumor larger than 5 cm (30%) (p = 0.001) and the highest percentage of grade III (60%) (p < 0.001).A total of 430 patients were included in the study. Fifty-seven patients developed a second tumor (34 BCs and 23 other cancers). The time of study enrollment was equal to 78 months. Ninety-two patients left the study before the end (21.2%). On 31st March 2020, excluding seven patients who left the study during the first year, the median follow-up was equal to 70 months (range 12–124). The median follow-up was equal to 64 months in the underweight patients, 71 months in the normal weight group, 71 months in the overweight patients, and 70 months in the obese patients. The median time on treatment in underweight patients was 7 months, in normal weight patients was 84 months, in overweight patients was 64 months and in obese patients was 96 months. The median age at the diagnosis was 53 years (range 30–76 years). We observed that, considering BMI values, 3 (0.7%) patients were underweight at the baseline, 100 (23.3%) had normal weight, 167 (38.8%) were overweight, and 160 (37.2%) were obese. In total, 267 patients (76%) were overweight and obese. At the last follow-up, 127 patients were undergoing hormonal treatment. Baseline characteristics of the study population are reported in p < 0.001, mean difference −3.39, 95%CI = −4.41−2.36).). The differences in weight throughout the study period reflected the BMI changes amongst the four patients’ categories . Overweight women moved from 72.2 kg, at the entry to 67.6 after one year . In parallel, there were also highly significant  changes in total physical activity levels. Normal patients increased their weekly activity by 1 h in the first year, from 1.0 to 2.25 at the end of the study with an increment of 125% , overweight patients increased physical activity moving from 0. to 2.0 h throughout the entire study period (increment of 200%)  finally obese patients moved from 0 h per week to 1.0 throughout the study period (increment of 100%) .In regard to the definitive results of the lifestyle intervention, only patients belonging to the overweight and obese groups derived a benefit. Any change in BMI was registered for underweight or normal-weight patients. As shown in tegories B. ParticIn In the overweight group the benefit of the intervention was more effective at 12 months, and less at the end of follow-up. In the obese group of patients there was a continuous benefit along the follow-up period time.p = 0.097).Breast cancer recurrences including local and distant metastases occurred in 55 patients (12.8%). There were 38 (9.0%) patients who died from BC recurrences (24 patients) or other causes (14 patients). Excluding patients with a follow-up less than 12 months and patients with a second tumor, the 5-year OS was equal to 95%, with 35 deaths, and the 5-year PFS corresponded to 90%, with 55 relapses A,B. In rp = 0.027, HR 3.69, 95%CI = 1.17−13.4)) than overweight patients, but not compared with obese patients ) . In regard to the PFS, no statistically significant differences were seen among normal plus underweight patients versus overweight and obese patients . (p = 0.097).Other causes of death were represented, in three cases by other cancers, in four cases by pneumonia disease whereas in the remaining seven cases the cause of death was unknown. No differences in BC specific survival were seen between overweight and normal patients (data not shown). Since only 3 patients were underweight, they were combined with the normal weight patients; all together were compared to overweight and obese patients, having a statistically significant better OS ) A. By asstively). B. The asp = 0.007; PFS:HR = 3.10, p = 0.002).A multivariate analysis among BMI, stage, and second tumors were performed in order to evidence if some factors were independently related to the overall survival in specific subgroups of patients . Overweip = 0.431).The percentage of second tumor in normal plus underweight, overweight and obese patients was 2%, 5%, and 6% , despite following the Mediterranean diet . TherefoThe relationship between obese patients and AI treatment is well known, but we have clearly shown that obesity is a metabolic condition regardless the hormonal treatment and it is not the consequence of the therapy. In fact, obesity represents the most frequent condition in postmenopausal status, where AI are mostly used. However, as reported by a recent study that investigated the BC prognosis in obese women treated with AI , no worsWe have shown a relationship between obese patients and luminal A subtype tumor, as already seen in another study . The firFurthermore, we documented a statistically significant worse prognosis of overweight patients compared to obese and normal-weight patients. By the univariate analysis, no statistically significant differences were seen among BMI, menopausal status, or tumor phenotypes and survival curves, although a trend toward worse prognosis was revealed in overweight patients. Since the study was concluded after seven years, we can’t derive any conclusion on the better prognosis of obese patients than overweight patients at the end of data collection. However, a longer intervention control and data registration could provide new insight on efficacy of this program. We are conscious that a benefit on other diseases, such as cardiovascular risk factors, or diabetes is probably seen with a BMI decrease in the range of 5–10%, being considered as secondary objective in a large randomized trial for adults with a recent diagnosis of type 2 diabetes , but it The strength of this research derives from the methodology used to provide a real and effective lifestyle intervention in BC patients, able to statistically reduce body weight, particularly in overweight and obese women throughout the study period. A better prognosis in obese than in overweight women was seen, in contrast to the vast majority of studies where obesity represented the worst category of patients in terms of death and recurrence .The limit is represented by the short period of follow-up, knowing that recurrences and death in patients with hormonal positivity tumors arise after the first five years from the diagnosis. This could have reduced the real impact of the lifestyle intervention on obese women, who show a significant yet slight decrease in weight and BMI. Probably an extension of the study would continue to improve health conditions of our patients.Another important limitation is the high drop-out rate from the study, particularly in the first year of intervention; a high rate in drop-out could probably be reduced by more frequent reminders to patients who do not obtain a BMI decrease at the first six month visitThe study was approved by the Ethic Committee of Modena, Italy. It is a single-arm experimental design conducted to test the efficacy of a lifestyle intervention in patients with BC treated at Modena Cancer Center from November 2009 to May 2016. All participants provided written informed consent in accordance with the Declaration of Helsinki.The study population included 430 women. We included patients with a new diagnosis of hormone positive breast cancer, treated by surgery, with or without radiotherapy, hormonal therapy, and/or chemotherapy in adjuvant setting.2). Based on the BMI, women were grouped into the weight categories recommended by the World Health Organization (WHO) [2), normal-weight (BMI = 18.5–24.9 kg/m2), overweight (BMI = 25–29.9 kg/m2) and obese (BMI ≥ 30 kg/m2). Nutritional history and physical activity (hours/week) were inquired. Finally, the dietician provided patients with recommendations for a healthy lifestyle and a survey on their health status.At the first visit, women were weighed and height was measured; arm, waist, and hip circumferences, along with the tricipital, bicipital, subscapular, and suprailiac folds were also measured; BMI, defined as weight in kilograms divided by height in meters squared (kg/mon (WHO) : underweOne month later, following the evaluation of the survey on health status, the dietician provided patients with a personalized program of nutrition education and physical activity. Written resources containing the food pyramid, healthy eating guidelines and tips, basic information on portion size, examples to reduce food intake , and dietary recommendations were delivered to patients. These latter were specifically designed and tailored taking into account nutritional needs, comorbidities, and other information and/or needs communicated during the first meeting and consisted of daily and weekly meal plans and suggestions for meal composition stimulating patients to self-arrange their diet according to the MedDiet. Patients were re-evaluated at 6, 12 months, and at the end of follow-up. During the subsequent meetings, the dietician also evaluated the adherence to the dietary recommendations, made eventual adjustments, assessed anthropometry, and assisted participants in maintaining motivations.Her2/neu testing was carried out at a single pathology laboratory in Modena by immunohistochemistry, and the results were scored as follows: 0, 1 = negative, 2 = indeterminate, and 3 = positive. Patients with HER2 test results reported as “indeterminate” were evaluated by fluorescence in situ hybridization (FISH). ER and PgR testing were conducted with a single report format of “positive” or “negative” test results, as measured by immunohistochemical analysis  and staining by Ventana Benchmark autostainer. ER and PgR receptor status were tested by evaluating the percentage of nuclear immunoreactivity with respect to all the nuclei in the neoplastic cells, independently of the staining intensity. Nuclear staining 10% of either ER or PgR was considered a positive result. Ki-67 labeling index was determined with the MIB1 monoclonal antibody as nuclear immunoreactivity. The cut-off was equal to 14% to subdivide luminal A and luminal B tumor. Luminal A were tumors with ER/PgR/HER2-/Ki67 < 14%, luminal B were tumors with ER/PgR/HER2-/Ki67 ≥ 14%, luminal/HER2 enriched were tumors with ER/PgR/HER2, triple-negative tumors were ER-/PgR-/HER2-, and HER2 were tumors with ER-/PgR-/HER2.The dietary intervention was based on the MedDiet which was first introduced and described by Keys et al. in “The Seven Countries Study”. Consequently, several other studies confirmed the beneficial effects and outcomes of the MedDiet on health mainly reducing mortality, cardiovascular disease risk factors, and cancer .The MedDiet is based on a balanced use of foods rich in fiber, antioxidants, and unsaturated fats, a healthy approach designed to reduce the consumption of animal fats and cholesterol in a diet with an appropriate balance between energy intake and expenditure . TherefoThe MedDiet is typically represented graphically in the shape of a pyramid whose most updated version is described by Bach-Faig et al. . The graAlong with recommendations regarding the proportion and frequency of food consumption, the incorporation of cultural and lifestyle elements is one of the innovations of the latest version of the pyramid. These concepts are represented outside of the pyramid, and at its base the following concepts are represented: moderation, socialization, culinary activities, physical activity, adequate rest, seasonality and tradition, local/homegrown products, eco-friendly and biodiverse products.Eating habits were recorded using a food diary. A food diary dietary assessment approach records consumption of food and beverages as they are consumed throughout the reporting day thus making it more accurate than food frequency questionnaires which depend on retrospective recall. We recommended a period of 7 days for record-keeping in the week leading up to follow up appointment. For checks after 3, 6, and 12 months, food diaries were recorded over a period of 7 days every month. Food diaries allow the patient to record all food intake in the established period, after which the nutrient intake may be calculated and averaged. At the follow-up visits, we were able to address the compliance to the diet by food diary registrationAs far as physical activity is concerned, the counseling approach was mainly used to stimulate patients to increase their physical activity. A motivational method instead of a more common prescriptive method was used to favor a more active lifestyle taking an incremental approach i.e., trying to increase the general level of activity throughout the day and every day up to a sustainable and compatible level with physical conditions and available time. A physical activity diary, containing the type and duration of exercises, was offered in order to register the patient’s perception and comments every time. The aim was to maintain a regular activity over time or to provide an instrument for modifying some exercises in order to become more pleasant. A self-esteem evaluation was also registered and measured to reach a high level.During the meetings, patients and a dietician tried to set achievable goals tailored to the physical conditions of every single patient. People with (very) limited physical activity levels were stimulated to start identifying and ensuring ways to increase their physical activity. For example, obese patients were stimulated to identify daily activities that could increase their physical activity . All patients without any physical constrain were stimulated to identify and take up/maintain regular physical activity. For these latter patients, the final goal was a habitual physical activity workload > 20 METs/h  in a week  which was used in the study of Montesi et al. .At the follow-up visits, patients exhibited the physical activity diary; the daily type and duration of exercises were registered in order to verify the compliance to the personal program.Patients who continued in the established program were satisfied with the results, in terms of behavioral changes. Many of them tried to convince all family members to change their lifestyle, according to the dietary intervention and physical activity program. On the contrary, patients who did not experience a change in weight and their BMI felt inadequate.p-value, not adjusted by multiple comparison. All statistical tests were two-sided. p < 0.05 was considered statistically significant, and the p-value was two-sided for all analyses. Survival curves were estimated using the Kaplan-Meier method including the log-rank test group comparison. Univariate and multivariate analyses of PFS and OS were conducted using a proportional hazards Cox regression model. All analyses were performed using the Stata statistical package (version 10 SE).A database was set up at our institution, which consisted of collecting individual details, weight, height, BMI, physical activity, and follow-up data, using the Excel program by Window version 10. The follow-up was calculated from the date of the BC onset to the endpoint of interest: the date of death or the end of the study period. The ANOVA test was used to determine differences in clinicopathological features between groups. Since the BMI, Kg, and PA were measured at different time points over the same patient, we checked the association of those variables as function of time points by means of ANOVA for repeated measure. We reported a raw A lifestyle intervention can lead to clinically meaningful weight loss and increase PA in patients with BC. Our obese patients showed a better OS than overweight patients. The worst prognosis of overweight/obese patients aged over 55 years is likely related to death from other causes.


Background: Considering the anti-inflammatory properties of the Japanese traditional Kampo medicine Boiogito (BO), we aimed to investigate the therapeutic effect of BO to prevent the development of knee osteoarthritis (KOA) in rats with surgically induced KOA. Methods: Destabilization of the medial meniscus (DMM) was performed to induce osteoarthritis in the right knees of 12-week-old Wistar rats under general anesthesia. The rats were orally administered 3% BO in standard powder chow for 4 weeks after surgery . During this period, the rotarod test was performed to monitor locomotive function. After 4 weeks, histological assessment was performed on the right knee. Results: Oral administration of BO improved locomotive function in the rotarod test. Walking time on postoperative days 1, 14, or later was significantly longer in the DMM + BO group than in the DMM group. Histologically, the DMM group showed significant progression of KOA, which, in the DMM + BO group, was strongly suppressed, as assessed by the Osteoarthritis Research Society International score. Conclusions: Our results showed that oral administration of BO had a clinically preventive effect on early stage posttraumatic KOA. The number of osteoarthritis (OA) patients is >300 million worldwide. OA can affect any joint of the body, such as the hip, spine, hand, and especially, the knee . Knee osCurrently, KOA can be treated surgically and non-surgically. In non-surgical treatments, oral or topical administration of non-steroidal anti-inflammatory drugs (NSAIDs) or oral selective cyclooxygenase-2 (COX-2) inhibitors, intra-articular injection of hyaluronic acid, land-based exercise, dietary weight management with physical exercise, and mind–body exercise (such as Tai Chi and Yoga) have been recommended as effective strategies for KOA patients . SurgicaSeveral compelling reports and a review article on pharmaceutical treatment for KOA by using herbs or flavonoids have been published ,13,14. SBoiogito (BO), a traditional Japanese herbal medicine (Kampo) composed of six medicinal plants, may also be a potent medication for preventing osteoarthritis. BO is effective for the symptoms of chronic fatigue or hyperhidrosis, as well as leg edema or painful arthritis, and its use for these indications has been approved by the Japanese Ministry of Health, Labour, and Welfare. Some clinical studies have suggested that BO potentially can alleviate inflammation and hydrarthrosis in KOA ,17. MajiMale Wistar rats at 12 weeks old, average weight 300–350 g, were purchased from Nippon Bio-Supp. Center . All rats were fed standard powdered rodent chow  and water ad libitum before and after the surgical procedure. The animals were housed two to three per cage in an animal room with a controlled environment . The experimental protocols  were appSinomenium stem 5.0 g, Astragalus root 5.0 g, Atractylodes lancea rhizome 3.0 g, Jujube 3.0 g, Glycyrrhiza 1.5 g, and Ginger 1.0 g. These herbs were mixed and extracted with purified water at 95.1 °C for 1 h, and the soluble extract was then separated from the insoluble residue and dried by removing water under reduced pressure. The dry powdered extract of BO was mixed with powdered chow at a concentration of 3% and fed to the BO-treated rats. The rats not treated with BO were fed powdered chow only. The concentration of BO was chosen on the basis of the effective doses recommended by a previous report [The dry powdered extract of BO was supplied by Tsumura & Co.  and contained a dry extract of the mixed drug substances consisting of s report .® , and the subcutaneous layer was sutured with 5-0 Vicryl®.Destabilization of the medial meniscus (DMM) was adopted as a KOA-inducing model . We diviTo assess the validity of the DMM operation, the degree of extrusion of the medial meniscus was evaluated. The animals were intraperitoneally anesthetized with pentobarbital sodium  and intracardially perfused with phosphate-buffered saline at pH 7.4 until all the blood had been removed from the system. After perfusion with 4% paraformaldehyde in 0.1 M phosphate-buffered saline, only the right leg was amputated because the contralateral side of the knee joint may not yet have an osteoarthritic change . Then, tThe rotarod test easily validates the effects of drugs, brain disorders, and disease on rodent motor coordination and fatigue tolerance ,23. The After measuring the ME ratio with a stereomicroscope, decalcified knees were embedded in paraffin, and specimen preparation and tissue staining were performed following the recommendations of the Osteoarthritis Research Society International (OARSI) . All secn = 6; sham, n = 6; DMM, n = 5; DMM + BO, n = 5). Statistical analysis was performed by using one-way analysis of variance and the Tukey–Kramer method in JMP® Pro version 14.0 software . p values < 0.05 were taken as indicating statistically significant differences.Data are represented as the mean ± SD of multiple repeats of the same experiment for the data of ME ratio and rotarod test, and median and interquartile range for the histological analysis . However, the decreases were inhibited in the DMM + BO group, especially significant on day 1 (p < 0.05). In the chronic phase , the latencies were significantly lower in the DMM group than in the control and sham groups (p < 0.01) Those decreases were significantly inhibited in the DMM + BO group . Furthermore, walking time on day 28 in the DMM + BO group had no significant difference than that in the control group.Rotarod performances were assessed prior to and 1, 3, 7, 14, 21, and 28 days after the DMM surgery . In the p < 0.01) but was significantly lower in the DMM + BO group than in the DMM group (p < 0.05)   B. The to < 0.05) C.Although the pathological mechanism of KOA has not been fully elucidated, KOA is a disease involving articular cartilage but also synovium, subchondral bone, and periarticular soft tissue . InflammAstragalus root [Atractylodes lancea rhizome [Glycyrrhiza [Considering the latency to fall off the rotating drum in the rotarod test in this study, administration of BO improved walking ability in the DMM rat model. Although the rotarod test can detect general locomotive function in experimental rodent models , it can lus root , Atracty rhizome , Jujube  rhizome , Glycyrrcyrrhiza , and Gincyrrhiza  have beeMeniscus extrusion is one of the factors for progression for KOA. In humans, medial meniscus posterior root tear reportedly contributes to meniscus extrusion, possibly because of extensive mechanical loading of the articular cartilage and subchondral bone . The DMMThere has been some basic research suggesting that BO could have a therapeutic effect against KOA, especially on joint fluid retention and the inflammatory response in KOA. Fujitsuka et al.  showed tSinomenium stem, a principal crude drug of BO, has been shown to have anti-inflammatory activity [Sinomenium stem improved symptoms and decreased the expressions of pro-inflammatory cytokines, such as IL-1β and TNF-α [Astragalus root also has been shown to have anti-inflammatory activity by decreasing the pro-inflammatory cytokine, TNF-α, although in a rat autoimmune myocarditis model and mouse diabetic model [Sinomenium stem and Astragalus root may provide the characteristic therapeutic effect of BO against early stage KOA. This ideal combination of chemical components in BO can be applied clinically, such as in the perioperative period for meniscal tears and ACL ruptures, to improve excessive joint effusion and prevent the progression of KOA. Further investigation is needed.As mentioned above, BO is composed of six crude drugs and contains various kinds of chemical components, but it is not clear which components contribute to the preventive effect against KOA progression. Previous studies have investigated some potential components for alleviating the development of KOA. activity . In animnd TNF-α . Astragaic model ,41. GiveSeveral limitations of our study need to be considered. First, as mentioned above, we have to elucidate the therapeutic mechanism to prove drug efficacy. We are performing subsequent studies such as immunohistochemical staining and the gene expression of proteins related to cartilage metabolism, including collagen type II and matrix metalloproteinase (MMP)-13. However, the results from this study would be a proposal of a new strategy for posttraumatic KOA. Second, in this study, we estimated the effect for 4 weeks after surgery to assess a preventive effect on the early stage of posttraumatic KOA. However, we need to verify the efficacy longitudinally. When the disease state lasts long, the contralateral side must also be influenced . TherefoIn conclusion, oral administration of BO was found to have some therapeutic effect on preventing clinical osteoarthritic changes in a posttraumatic KOA-inducing rat model. BO potentially could be applied in various clinical situations, such as for perioperative administration to relieve pain, and prevent the future progression of KOA.


On the other side, commercial chitosan, graphene as organic, while silver, hydroxyapatite, and fumed silica nanoparticles were used as inorganic reinforcements. All the nanoparticles were added at 1 wt% with respect to the PCL polymeric matrix in order to compare the different behavior of the woven no-woven nanocomposite electrospun fibers with a fixed amount of both organic and inorganic nanoparticles. From the thermal point of view, no difference was found between the effect of the addition of organic or inorganic nanoparticles, with no significant variation in the Tg (glass transition temperature), Tm (melting temperature), and the degree of crystallinity, leading in all cases to high crystallinity electrospun mats. From the mechanical point of view, the highest values of Young modulus were obtained when graphene, CNC, and silver nanoparticles were added to the PCL electrospun fibers. Moreover, all the nanoparticles used, both organic and inorganic, increased the flexibility of the electrospun mats, increasing their elongation at break.In this work, different nanocomposite electrospun fiber mats were obtained based on poly(e-caprolactone) (PCL) and reinforced with both organic and inorganic nanoparticles. In particular, on one side, cellulose nanocrystals (CNC) were synthesized and functionalized by “ Poly(ε-caprolactone) (PCL) is a biodegradable and biocompatible aliphatic polyester. It offers a unique combination of polyolefin-like mechanical properties and polyester-like hydrolyzability ,2, proviThe electrospinning process is the most suitable technique for drug delivery and tissue engineering applications of PCL-based nanocomposite fibers ,12,13,14grafting) [Furthermore, the development of nanocomposites is one of the most used approaches to improve PCL properties  . Among nrafting) . The “grrafting) .Chitosan is the second organic substance, most abundant in nature, after cellulose. Moreover, it has generated enormous interest due to its various advantages, such as easy availability, positive charge, renewability, biodegradability, biocompatibility, non-toxicity, and antimicrobial activity . AnotherOn the other hand, PCL can be modified with inorganic nanoparticles, as hydroxyapatite, to improve its mechanical and biological properties for tissue engineering purposes. Hydroxyapatite is an inorganic component of bone with bioactivity and biocompatibility and shows good osteoconductivity and bone-bonding ability ,36,37.2, in general, improves the mechanical performance of the corresponding nanocomposite, even at low concentration as a consequence of their small particle size [Finally, fumed silica is an inorganic and amorphous particle widely used at the industrial level mainly because it is a low-cost material obtained as a by-product of silicon . Nanosizcle size ,39. Besicle size ,41.Therefore, in general, woven no-woven electrospun fiber mats can find applications in tissue engineering since they mimic the microarchitecture of the extracellular matrix ,20. Thei2 were used as inorganic nanoparticles. All the nanoparticles were added to the PCL at 1 wt% in order to compare. The morphology, thermal behavior, and mechanical properties of the woven no-woven electrospun nanocomposite fibers were studied and compared with the neat PCL electrospun mat.In this work, the processing conditions to obtain PCL-based electrospun fibers reinforced with organic as well as inorganic nanoparticles were optimized. Firstly, neat PCL and PCL reinforced with 1 wt% of silica nanoparticles were used to optimize the processing parameters. The optimized processing conditions were then used to produce PCL-based electrospun nanocomposite fibers in order to study the effect of the addition of different nanoparticles on their thermal and mechanical responses. In particular, the nanofillers used as reinforcements were CNC, CNC-g-PCL, chitosan, and graphene as organic nanoparticles, while HA, Ag, and SiOIn particular, due to the intrinsic characteristic of both PCL polymer and the different nanoparticles, these electrospun nanocomposite mats could be considered for potential applications in bioactivity, such as antibacterial, biocompatibility, and biodegradability with proper mechanical performance.Poly(ε-caprolactone) (PCL)  was kindly donated by Perstorp .2/g and particle size distribution from 20 to 70 nm [2/g and an average thickness of a bit less than 10 nm. They were used as supplied by the manufacturer without any functionalization process. Fumed silica dioxide nanopowder, SiO2 (primary particle average size: 7–14 nm), was purchased from Interchim Innovations  [Chitosan (degree of deacetylation > 75%) , microcrto 70 nm . Graphento 70 nm . As indi France) . Chlorof−1 NaOH). Finally, the CNC solution was sonicated to get a stable suspension of the nanofillers.Cellulose nanocrystals were obtained by sulfuric acid hydrolysis of 64% (wt/wt) of microcrystalline cellulose (MCC) stirring at 45 °C for 30 min ,31. The ROP) of ε-caprolactone (ε-CL) by using the surface hydroxyl groups of the CNC as initiator, as schematically shown in CNC surface chemical modification was performed by grafting PCL chains onto the CNC surface by ring-opening polymerization (g-PCL was characterized by Fourier-transform infrared (FT–IR) in the attenuated total reflectance (ATR) mode (as well as Raman spectroscopy), and its thermal stability was studied by thermogravimetric analysis (TGA), as indicated in the characterization section.The CNC-g-PCL nanocrystals were observed by field emission scanning electron microscopy, FESEM, (Hitachi S8000). The structure of CNC-Electrospun fibers were prepared by means of a coaxial Electrospinner Yflow 2.2.D-XXX (Nanotechnology Solutions) with a vertical standard configuration equipped with two concentric needles and connected to a high voltage power. The polymer solution flew through the inner needle, and the solvent flew through the outer one.3:DMF (4:1) using a magnetic stirrer for 24 h at room temperature. The same solution was used to obtain PCL-based nanocomposite electrospun fibers by adding 1 wt% with respect to the polymer matrix of organic as well as inorganic nanoparticles, such as CNC, CNC-g-PCL, chitosan, graphene, Ag, HA, SiO2.PCL electrospun fibers, named ePCL, were prepared from polymer solutions of PCL (10 wt%) in a solvent mixture of CHClTo prepare electrospun nanocomposite fibers, nanoparticles were dispersed separately (1 wt%) in the same mix of solvents using a magnetic stirrer for 2 h and ultrasonication for 2 min. Finally, to achieve homogeneous dispersion of the nanoparticles in the dissolved matrix, the polymer solution and nanoparticles’ suspensions were mixed, stirred (2 h), and sonicated (2 min) to form nanocomposite solutions with 1 wt% with respect to the matrix in the final composition.The polymer solutions were flown through the inner needle, and the same mixture of solvent used for polymer solutions was flown through the outer needle. The applied positive and negative voltages were set at 10 and −10 kV, respectively. The polymer flow rate, as well as the solvent flow rate, were fixed at 1.0 mL/h. Electrospun mats were randomly collected in a grounded aluminum foil collector situated perpendicular at 15 cm from the charged spinneret. The obtained electrospun mats were vacuumed for 48 h in a vacuum chamber to eliminate residual solvents before testing.Neat CNC and functionalized CNC were characterized by Raman spectra using a RenishawInVia Reflex Raman system. An optical microscope was coupled to the system. The Raman scattering was excited using a diode laser at a wavelength of 785 nm. The laser beam was focused on the sample with a 100 × 0.85 microscope objective. The laser power at the sample was 350 mW. The exposure was for 10 s, and there were 10 accumulations for the Raman measurements.−1 with 1 cm−1 of resolution and an accumulation of 16 scans.Fourier-transform infrared (FT–IR) spectra were obtained in the attenuated total reflectance (ATR) mode. The measurements were performed using a Spectrum One FTIR spectrometer Perkin Elmer equipped with an internal reflection element of diamond in the range of 650–4000 cmThe morphology of PCL-based electrospun nanocomposite fibers was analyzed by means of scanning electron microscopy (SEM). Thus, electrospun fibers were sputtered with a gold/palladium layer and observed by a PHILIPS XL30 scanning electron microscope (SEM). Fiber diameters were statistically calculated by means of Fib_thick software executable under image analysis platform Fiji based on ImageJ.−1. In this case, the maximum degradation temperature (Tmax) was calculated from the first derivative of the TGA curves.TGA analysis was performed to study the thermal degradation of the electrospun samples. Thermogravimetric analysis (TGA) was performed in a TA-TGA Q500 thermal analyzer. Dynamic TGA experiments were performed under a nitrogen atmosphere (flow rate of 60 mL/min). Samples were heated from room temperature to 700 °C at 10 °C·minc), were studied by differential scanning calorimetry (DSC). DSC experiments were conducted in a Mettler Toledo DSC822 instrument under a nitrogen atmosphere (50 mL/min). Sample weights of about 4 mg were sealed in aluminum pans and heated from −90 to 100 °C at a heating rate of 10 °C min−1. The glass transition temperature (Tg) was taken at the midpoint of heat capacity changes. The melting temperature (Tm) and cold crystallization temperature (Tcc) were obtained from the first heating, and the degree of crystallinity (χc) was calculated through Equation (1):mH is the melting enthalpy, ΔccH is the cold crystallization enthalpy, and −1) [The thermal behavior, as well as the degree of crystallinity  equipped with a 100 N load cell, at a crosshead speed of 10 mm minFirst, the synthesis and the characterization of the different organic and inorganic nanoparticles were performed. In particular, neat cellulose nanocrystals (CNC) were synthesized and functionalized in our lab, while the other nanoparticles used in this work were purchased. In particular, cellulose nanocrystals were synthesized in the laboratory by acid hydrolysis of commercial microcrystalline cellulose. Then, surface modification of the CNC was carried out by a “grafting from” reaction, grafting PCL chains onto the CNC surface by ring-opening polymerization (ROP) of –CL, using the surface hydroxyl groups of the CNC as initiator .g-PCL during the “grafting from” reaction, vibrational spectroscopies studies were conducted, comparing the results obtained from neat PCL and CNC with CNC grafted with PCL , obtaining a value of 317 ± 59 nm for the length and a value of 24.4 ± 10.0 nm for the diameter, respectively, indicating an increase in both length and diameters due to the polymeric chain grafted onto the surface of the cellulose nanocrystals, in accordance with previous works [From the FE-SEM images, the nanometer range size of the different nanoparticles was confirmed. In particular, the average length of CNC was determined by image analysis (ImageJ software), obtaining an average value of 179 ± 20 nm for the length and of 14.1 ± 1.6 nm for the diameter a, in goous works .Regarding the other nanoparticles used in the present work, the average dimension measured was in accordance with the values indicated by the seller, as indicated in 1/2 [1/2 and 24.9 MPa1/2, respectively [Once the nanoparticles were characterized, we proceeded with the optimization of the electrospinning process and the characterization of the woven no-woven reinforced and no-reinforced PCL-based electrospun fiber mats. In particular, for the electrospinning process, PCL should be homogeneously dissolved in a proper solvent, and it is known that an effective solvent should present a similar solubility parameter (δ) to that of the polymer . The sol1/2 . Chlorofectively . Accordi2). Both neat PCL electrospun fibers and PCL-based electrospun nanocomposite fibers were obtained from a PCL solution (10 wt%) and nanoparticle dispersions (1 wt%) in a mixture of solvents (chloroform-DMF 4:1). Firstly, the PCL solution was prepared, and, at the same time, nanofillers were dispersed separately. Then, the polymer solution and nanoparticles’ suspensions were mixed, and then the final stable dispersion of nanoparticles into the PCL solution was obtained after sonication. Thus, the concentration of PCL solutions was set at 10 wt%, and the working distance between the needle and the collector was set at 15 cm [The electrospinning processing conditions used to prepare electrospun fibers were selected, taking into account the optimization carried out for the production of neat PCL electrospun fibers (ePCL), as well as for silica-reinforced PCL electrospun fibers  solution, while higher concentrations produce a detriment of the structural and mechanical performance due to their reduced dispersion [In accordance with the literature, we chose to study 1 wt% of different organic and inorganic nanoparticles, considering that this amount of nanoparticles could be effectively dispersed into the CHClspersion . It was spersion . Low amospersion . At the spersion . Inorganspersion . TherefoTherefore, the electrospinning process was realized for all the systems, and the ePCL, as well as the PCL-based electrospun fiber mats, were obtained using the same processing window optimized before. Thus, the electrospun fibers based on PCL and reinforced with the organic, such as CNC and CNC-g-PCL, chitosan and graphene, as well as the other inorganic nanoparticles, such as silver and hydroxyapatite, were obtained. SEM images for all the PCL-based electrospun fiber mats are reported in g), the melting temperature (Tm), and the degree of crystallinity (Xc) calculated from the DSC analysis and the maximum degradation temperature from TGA analysis are reported.Thermal and mechanical characterization was also carried out. In particular, the main result of the thermal characterization is reported in g and Tm of the PCL-based electrospun fibers, as well as in their degree of crystallinity, were emerged from their comparison , which showed a higher average fiber diameter and the higher elongation at break. Considering the inorganic nanofillers, it was observed that SiO2 nanoparticles were able to produce the highest increment on the elongation at break among inorganic PCL-based electrospun fibers. However, it was quite difficult to differentiate the mechanical response of the PCL-based electrospun nanocomposite fibers regarding the effects of organic and inorganic nanofillers as a clear trend was not found.It is expected that the elastic modulus and the tensile strength of the electrospun PCL-based fibers increase as the fiber diameter decreases . NeverthIt is well known that the different morphologies of the nanoparticles  can strongly affect the mechanical response as well as the degree of crystallinity of the electrospun fibers . Howevergrafting from” reaction, using their superficial OH– group to graft PCL chains. All the nanoparticles were added at 1 wt% with respect to the polymeric matrix, in order to be compared to each other. No difference was found between the effect of the addition of organic or inorganic nanoparticles on the thermal properties, considering that no significant variation in the Tg, Tm, and degree of crystallinity was obtained, leading to a high crystallinity electrospun mats with a degree of crystallinity of the electrospun PCL matrix of about 50%. However, all the nanoparticles increased the maximum degradation temperature of the respective nanocomposite electrospun fibers, indicating a good interaction between nanoparticles and the polymeric matrix. From the mechanical point of view, the highest values of Young modulus were obtained when graphene, CNC, and silver nanoparticles were added to the ePCL. On the other hand, all the nanoparticles used, both organic and inorganic types, increased the flexibility of the electrospun mats, increasing the elongation at break.Woven no-woven electrospun fibers based on PCL and reinforced with both organic and inorganic nanoparticles were obtained. As organic nanoparticles, we used cellulose nanocrystals, chitosan, and graphene, while, as inorganic nanoparticles, we used silver, hydroxyapatite, and fumed silica nanoparticles. In particular, cellulose nanocrystals (CNCs) were synthesized and functionalized by “


Roe deer are among the most frequent wild animals admitted to rescue centers in Italy. Reasons for admission include trauma, predation, starvation, and imprinting, with the final aim of hospitalization being full recovery and release into the wild for all cases. An accurate triage procedure is vital for predicting the outcome, to avoid unnecessary time spent in captivity, and an excessive allocation of time and resources on animals with a minimal chance of recovery. Since lactacidosis is often associated with death in hospitalized animals, and has been associated with poor prognosis in humans and domestic animals, we proposed an evaluation of blood L-lactate using a rapid whole blood test in order to predict the outcome of hospitalized roe deer. A cut-off of 10.2 mmol/L was identified as the best, in order distinguish animals with minimal chance of surviving and release. For these animals, humane euthanasia should be considered as an option. Capreolus capreolus) are among the most frequent patients of rescue centers in Italy. Three outcomes are possible: natural death, euthanasia, or treatment and release. The aim of the present study is to propose blood L-lactate concentration as a possible prognostic biomarker that may assist veterinarians in the decision-making process. Sixty-three roe deer, admitted to one rescue center in the period between July 2018 and July 2019, were sampled and divided into 4 groups according to their outcome: (1) spontaneous death (17 cases), (2) humanely euthanized (13 cases), (3) fully recovered and released (13 cases), and (4) euthanized being unsuitable for release (20 cases). In addition, blood samples from 14 hunted roe deer were analyzed as controls. Whole blood lactate concentrations were measured with a point of care lactate meter. Differences among groups were close to statistical significance (p = 0.51). A cut-off value of 10.2 mmol/L was identified: all the animals with higher values died or were humanely euthanized. The results suggest that roe deer with lactatemia higher than 10.2 mmol/L at admission, have a reduced prognosis for survival during the rehabilitation period, regardless of the reason for hospitalization and the injuries reported. Therefore, humane euthanasia should be considered for these animals. Roe deer ( Capreolus capreolus) is an artiodactyl mammal belonging to the Odocoileinae subfamily—the only Euro-Asian member—and is the smallest European cervid. Roe deer are widely distributed in Europe, with the exception of northern Scandinavia and some of the islands, notably Iceland, Ireland, and the Mediterranean Sea islands. In Italy, an estimated population of more than 426,000 roe deer has been reported [The roe deer . According to the guidelines of the authors’ institution, formal approval from the Ethical Committee was not required .The individuals included in the study are divided into classes depending on sex and age, which were determined based on morphological aspects. As far as age is concerned, three different classes can be identified: fawns, yearlings, and adults. Yearlings can be recognized by their light build and slender body. Young males have antlers which may have up to two tines, whereas females have a slender profile, as their abdomen is not relaxed by gestation. A more precise evaluation of age was obtained following a dental examination to determine the state of eruption and wearing down of the teeth.All admitted roe deer were divided into 4 groups according to their final outcome: (Group 1) spontaneous death during the recovery period, (Group 2) euthanized for welfare reasons , (Group 3) fully recovered and released roe deer, and (Group 4) animals euthanized for other reasons . In addition, as a control (Group 5), blood samples from 14 hunted roe deer, from the same area, were taken from the cardiac cavity immediately after shooting death.In general, a manual restraint during the recovery period  was preferred to sedation, as chemical restraint would invalidate appropriate triage of polytraumatized animals. In the rare cases when sedation was performed, two different protocols were used: dexmedetomidine  + ketamine  + methadone , if the roe deer require surgery, or dexmedetomidine (10 µg/kg) + ketamine (2 mg/kg) + butorphanol , if only chemical restraints, diagnostic procedures and minor surgery were required. All samples were taken from the cephalic vein within 2 h of arrival to the Center, put into EDTA coated tubes, and L-lactate concentrations were evaluated within 10 min from sampling by means of a portable point of care lactate meter . The instrument measures the concentration of L-lactate in whole blood using a reactive strip via a bench top clinical chemistry analyzer system, which has been validated in cattle as reliable and linear up to 16.6 mmol/L . This meDescriptive statistics were calculated. Data from hunted deer were used to calculate reference ranges according to the official guidelines . The DixA Shapiro–Wilk test was performed to assess normal distribution of data among outcome groups. A Kruskal–Wallis test was performed to assess possible differences in L-lactate concentration among outcome groups. Contingency tables were prepared, and the Pearson’s chi-squared test was performed to assess possible differences in sex, age, and cause of admission among outcome groups.ROC curves were drawn, and coordinates were used to determine the cutoff value of L-lactate concentration, having 100% specificity and the highest sensitivity in the identification of animals with a negative outcome. These criteria were applied to select the cutoff value, since we aimed to identify animals with a negative outcome and avoid false positive results.At first, survivors and animals who encountered spontaneous death were included in the ROC curve analysis. Thereafter, humanely euthanized animals (group 2) were also included and grouped together with those who died spontaneously.p ≤ 0.05 for all analyses. All statistical analyses were performed by means of a dedicated software (SPSS 20.0 for Windows). Significance was set at p > 0.05 for all analyses).A total of 77 blood samples with L-lactate concentrations were available and divided into five different groups: (1) spontaneous death (17 cases), (2) humanely euthanized (13 cases), (3) fully recovered and released (13 cases), (4) euthanized for other reasons (20 cases), and (5) control animals (14 cases). A total of 30 females and 47 males, of which 38 adults, 16 subadults (10–23 months old) and 23 fawns (less than 10 months old), were tested. Among hospitalized roe deer, the prevalent causes of admission were trauma (45 cases), followed by predation (9 cases), imprinted animals (1 case) and other causes (8 cases). The four groups were homogeneous as for gender, age, and cause of admission (p = 0.051).Results of blood lactate concentrations in different groups of roe deer are reported in The reference range obtained after exclusion of outliers in our control group was 2.7–5.7 mmol/L.Based on ROC curve coordinates, an L-lactate cutoff of 10.2 mmol/L was selected as the best to classify survivors and animals having encountered spontaneous death, with a 100% specificity and 47.1% sensitivity in detecting animals with a negative outcome.When animals euthanized for welfare reasons (Group 2) were included in the analysis, an L-lactate cutoff of 10.0 mmol/L was selected as the best one, with a 100% specificity and a 46.7% sensitivity in detecting animals with a negative outcome. The aforementioned cutoff of 10.2 had a 100% specificity and a 43.3% sensitivity.Blood L-lactate derives from anaerobic glycolysis and in physiologic conditions, a production of 0.8 mmol/h/kg has been demonstrated, in humans, to contribute to obtain a normal plasma concentration of less than 1 mmol/L ,9. A redIn wild cervids, plasma L-lactate has been evaluated as part of a laboratory panel to check the effects of capture using different methods ,15, in dIn the present study, the analysis of samples from 14 hunted roe deer (control Group 5) provided some reference to compare the concentration of plasma L-lactate from recovered animals. All roes in the study derived from the same area of study and were killed by selector hunters with a single shot when they were calm and minimally alert; blood samples were immediately taken via intracardiac puncture after being shot and were rapidly transported to the center for analysis. For these reasons, we consider this group as an adequate control for defining plasma L-lactate concentration in free ranging roe deer in the study area. However, the authors acknowledge that these control animals’ elevated L-lactate levels were likely associated with acute death, and that these values do not represent those of normal, healthy roe deer. In addition, cardiac blood could have a lower L-lactate concentration in comparison with venous peripheral blood, especially if oxygenated. In comparison, the reference range obtained in our control group was 2.7–5.7 mmol/L, lower than previously reported for 22 trapped roe deer (5.1–18.9 mmol/L) . This suIf we considered hospitalized roe deer, in which the modality of rescue, immobilization and handling are consistent, we found that the overall ranges of plasma L-lactate concentration are similar to those reported in previous studies for trapped animals ,19, furtThe cutoff value of 10.2 mmol/L was chosen as a negative prognostic indicator, representing deer that are most likely destined to spontaneous death or require humane euthanasia. We selected a cutoff value with 100% specificity, where few, if any, animals with L-lactate above this level would survive, to avoid under-treatment or euthanasia of animals with a possible chance of surviving. This high cutoff value is responsible for the low sensitivity found. The limited sensitivity allowed us to identify less than half of the deer with a poor prognosis, but we cannot state that the low L-lactate concentrations are necessarily associated with a good outcome. This choice was made since, from a clinical point of view, we preferred to avoid any under-treatment (or euthanasia) in roe deer with a chance of survival. We are aware that this value may induce an overestimation of the chances of survival for some animals, but we consider it an acceptable risk from an ethical perspective. If we also apply this cut-off value to Group 4  we found that 5 cases out of 20 (25%) showed L-lactate concentrations higher than the value of 10.2 mmol/L, thus supporting euthanasia in these animals. The median concentration of L-lactate found in non-surviving deer compares well  with those found at admission in one study of horses with colonic volvulus (non-survivor: 9.1 mmol/L) . HoweverThe present study has some limitations. First, the limited number of cases did not allow us to stratify cases according to age and cause of admission. Second, plasma L-lactate concentration was evaluated at arrival at the rescue center, even though the time from being found to arrival at the center was variable according to different aspects, which may have biased our results. However, blood withdrawal was not always possible at the time of animal discovery or injury,  and therefore, we chose to use the time of first admission to the center to best standardize and compare results. Third, few of the roe deer were sedated to allow for easier transportation and to decrease stress. However, this procedure was not standardized, since it depended upon the clinical condition, type of problem, and the presence of a veterinarian, and it was not possible to revisit which cases received sedation. Premedication with acepromazine has been reported to possibly decrease capture stress and myopathy, and reduce L-lactate concentration, thus increasing survival . HoweverIn addition, in the present work we also added a control group from hunted roe deer who were shot dead as a comparison. The authors are aware that this group is probably not ideal for the creation of a reference interval, since it is biased by many different conditions and also influenced by different methods of blood withdrawal . However, obtaining a reference interval in healthy wild animals is often challenging, since many blood analyte concentrations are strongly influenced by capture stress, and the use of a control group kept in captivity is probably not adequate as a comparison. Despite these limitations, the authors speculate that results from hunted deer may be useful for comparison since they were lower than the trapped roe deer reference value. Lastly, our work only included L-lactate values at admission and did not evaluate serial L-lactate in these animals, which has been reported to be more valuable than a single admission value when determining a prognosis ,23.Future studies should assess possible fluctuations of L-lactate concentrations over the time between admission and release and their possible prognostic role. In addition, it would be interesting to validate the same test and define accurate cutoff values for other types of samples, such as capillary blood taken from an ear-edge prick, which is minimally invasive and does not require a veterinary professional. Considering the limited volume of blood required for the test (50 μL), such a small amount of blood could be sufficient for such testing.The data obtained in the present research support the use of plasma lactate concentration at admission to predict outcome of recovered roe deer, independently from the cause of recovery. Plasma lactate may be easily evaluated using a point of care portable analyzer in a very rapid, cheap, and feasible way. The results obtained may be interpreted by veterinary professionals in conjunction with other clinical information to predict prognosis, thus avoiding directing excessive efforts and resources on untreatable animals, and reducing over- and mis-treatments. Furthermore, our results will help guide euthanasia as a humane solution for wild animals facing little chance of release back into the wild.


The LUME-Lung 1 study has brought consistent evidence of the effective use of nintedanib in lung adenocarcinoma as a second line of treatment; however, differences among ethnicities have been found in some studies.This was a retrospective review among 21 medical centers of 150 patients with a confirmed diagnosis of lung adenocarcinoma, included in a compassionate use program of nintedanib from March 2014 to September 2015. The current study aimed to analyze the effectiveness of nintedanib in combination with docetaxel in the Mexican population, using progression-free survival rate and the best objective response to treatment by RECIST 1.1 as a surrogate of effectiveness. In addition, we examined the toxicity profile of our study population as a secondary end point.After exclusion criteria, only 99 patients met the criteria for enrollment in the current study. From the total study population, 53 patients (53.5%) were male and 46 (46.5%) were female, with an average age of 60 years and stage IV as the most prevalent clinical stage at the beginning of the compassionate use program. A total of 48 patients (48.5%) had partial response; 26 (26.3%), stable disease; 4 (4%), complete response; and 16 (16.2%), progression; and 5 (5%) were nonevaluable. We found a median progression-free survival of 5 months . The most common grade 3 or 4 adverse reactions were fatigue (14%) and diarrhea (13%).Nintedanib, as part of a chemotherapy regimen, is an effective option with an acceptable toxicity profile for advanced lung adenocarcinoma after first-line treatment progression. The toxicity profile associated with the use of docetaxel with nintedanib was acceptable, with diarrhea and fatigue being the most common grade 3 or 4 adverse reactions.RelevanceNintedanib, when used as part of a chemotherapy regimen, can be an adequate alternative for the treatment of advanced lung adenocarcinoma and for those who have faced disease progression after receiving other antiangiogenic agents as first-line therapy.16 Because of its triple angiokinase inhibitor activity, nintedanib competitively binds ATP-binding sites within the PDGF receptor family, the FGF receptor family, and the VEGF receptor family, thus halting their signaling pathways and limiting angiogenic progression on multiple fronts.18 Recent publications have presented evidence of the strong antiangiogenic capacity of nintedanib with downstream effects on multiple cell types including endothelial cells, smooth cells, pericytes, and fibroblasts.20 In addition, because of its pharmacokinetic properties, nintedanib has minimal drug interactions, which permits its combination with other chemotherapy agents, improving its efficacy.22 Nintedanib has shown a good tolerability profile with grade ≥ 3 adverse events, related mainly to increases in transaminases and asthenia.23 However, phase I nintedanib trials have reported differences between Japanese and European patients, with greater liver-limiting toxicity at a lower dose in the Japanese population,26 resulting in a need for a more precise security profile among different ethnicities.Nintedanib is a tyrosine kinase inhibitor with the ability to target 3 major angiogenesis pathways, and it is now considered a promising agent for multiple antiangiogenic antineoplastic therapies, including NSCLC adenocarcinoma.5 In addition, in the LUME-Lung 1, the median progression-free survival (PFS) of 3.4 months in the nintedanib plus docetaxel group was significantly prolonged compared with the PFS of 2.7 months in the docetaxel plus placebo group. The study also showed a good safety profile, with a similar frequency of adverse events to the prior treatments.27In a phase III, multinational, randomized, placebo-controlled clinical trial (LUME-Lung 1), nintedanib showed positive and additive results in combination with docetaxel, an antimitotic chemotherapeutic agent, in the treatment of patients with advanced lung adenocarcinoma, but no reported benefit was shown in patients with squamous histology.28 Recently, the NIS VARGADO study, which is currently ongoing, investigated the efficacy and tolerability of nintedanib plus docetaxel as second-line treatment in patients with advanced NSCLC after first-line chemotherapy and/or immunotherapy; the study showed that 58.3% of patients developed a partial response, a disease control rate of 83.3% with a median PFS of 5.5 months.29After the previous study, the LUME-Lung 2 clinical trial was performed, which compared nintedanib plus pemetrexed versus pemetrexed and placebo in patients with advanced NSCLC after the failure of first-line chemotherapy. Results from this study showed a better PFS in the nintedanib with pemetrexed arm, but because the study was stopped prematurely, no data on overall survival (OS) were recorded.30 Regarding both OS and PFS analysis, there was a statistically significant advantage of nintedanib plus docetaxel over monotherapy with docetaxel, erlotinib, and gefitinib.30 Comparison between nintedanib plus docetaxel and the newer treatment option, ramucirumab plus docetaxel, presented a similar relative efficacy, shown by no difference in either OS or PFS.30, Interestingly, when the combination of nintedanib plus docetaxel was compared with nivolumab as monotherapy, programmed death-ligand 1 (PD-L1) expression levels showed an important impact on patient outcomes. In those with low PD-L1 expression levels, there was no difference in OS between nivolumab and nintedanib plus docetaxel. In addition, in this same group, PFS favored those treated with nintedanib plus docetaxel. However, when PD-L1 expression levels were higher, nivolumab offered a greater advantage in OS.30 These findings suggest that the large proportion of patients with low PD-L1 expression levels could potentially receive a greater benefit when treated with nintedanib plus docetaxel.30 As of today, precise cutoff levels for PD-L1 in different subsets of patients remain to be determined for making appropriate treatment decisions in the future.31A network meta-analysis published in 2017 analyzed data across multiple randomized controlled trials and evaluated the relative efficacy of nintedanib plus docetaxel compared with other second-line agents in patients with adenocarcinoma histology NSCLC.The current study aimed to analyze the effectiveness of nintedanib in combination with docetaxel in the Mexican population, using PFS rate and the best objective response to treatment as a surrogate of effectiveness. In addition, we examined the toxicity profile of our study population as a secondary end point.This was a descriptive, observational, retrospective, multicenter study of patients with nintedanib compassionate program in combination with docetaxel. The study design was approved by Instituto Nacional de Enfermedades Respiratorias’ Institutional Ethics Board following the Declaration of Helsinki, Fortaleza Brazil 2013. The study population met the following criteria: patients older than 18 years of age with a confirmed histopathologic diagnosis of lung adenocarcinoma, relapse, or failure of 1 first-line prior chemotherapy, Eastern Cooperative Oncology Group (ECOG) 0-1 at the beginning of the second-line treatment, locally advanced and/or metastatic clinical stage at the beginning of the second-line treatment, and acceptance to participate in the nintedanib compassionate use program by informed consent between March 2014 and September 2015. Excluded were those with more than 1 prior chemotherapy regimen, a previous non–platinum-based chemotherapy regimen, active CNS metastases, therapeutic anticoagulation (with the exception of low-dose heparin) or antiplatelet therapy, a history of major thrombotic or clinically relevant major bleeding, and any contraindications for docetaxel therapy, and those without a complete medical record or lost to follow-up.33 PFS, and response as per Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST 1.1)34 using computed tomography scan. SPSS software version 24.0  was used for analysis. The variables were expressed as median values, together with total values and percentages. PFS was graphed using a Kaplan-Meier plot. The criterion for statistical significance was P < .05. All financially related issues from the study were absorbed by the investigation group.The following clinical and pathologic variables were reviewed: sex, age, smoking status, ECOG, TNM initial clinical stage, mutational status, first-line treatment, response to treatment, adverse effects associated with the use of nintedanib ,A total of 150 patients with a confirmed diagnosis of lung adenocarcinoma included in the compassionate program of nintedanib from March 2014 to September 2015 in 21 medical centers in Mexico were identified. After exclusion criteria, only 99 patients met the criteria for enrollment in the current study . From thAfter evaluating response to nintedanib therapy by RECIST 1.1, we found 48 patients (48.5%) with partial response, 26 (26.3%) with stable disease, 4 (4%) with complete response, 16 (16.2%) with progression, and 5 (5%) who were nonevaluable . The med5 reported a total of 58 rapid progressors and 34 patients who progressed beyond 9 months after first-line treatment. The median PFS shown in P = .058). After bivariate analysis between those with rapidly progressive disease and those without, no statistical difference was found in the comparison of median duration of treatment with nintedanib (P = .835), the best response to nintedanib (P = .100), or disease control rate .Exploratory analysis of patients with rapidly progressive disease (defined as a progression within 9 months after first-line treatment)29 The average age was 60 years , and stage IV was the most prevalent clinical stage at the beginning of the compassionate program. The current study allowed the inclusion of patients who had received antiangiogenic agents, other than nintedanib, as part of their first-line treatments, of whom only 7% had received bevacizumab as a first-line agent and 38% had received maintenance therapy. This proves relevant because both strategies increased both the PFS and the OS of patients. Greater response rates than those obtained in LUME-Lung 1 were obtained in this study,5 which could be explained by the high prevalence of patients without previous exposure to antiangiogenic drugs.35 Nonetheless, the retrospective nature of this study and the heterogeneous evaluation of each researcher is an important variable to consider. The PFS in the current study was similar to values reported in previous studies,29 giving greater validity to nintedanib as an effective second-line treatment option in a real-life setting.The general characteristics of the population are consistent with previous reports described in the literature.5 this study did not find any statistical difference between this group and the group without rapidly progressive disease. This is relevant because immunotherapy as a second-line treatment has shown an attenuated efficacy in patients with a negative PD-L1, in those with rapidly progressive disease, in women, and in nonsmokers.36Although traditionally, patients with a better PFS and OS after docetaxel with nintedanib were those with rapidly progressive disease,25The toxicity profile of this study reported less adverse events and an adequate tolerance to treatment. Diarrhea, neutropenia, and febrile neutropenia were seen less frequently than reported in the literature, which is probably because of the retrospective nature of the study. In this study, oncologists were constantly aware of reported toxicity profiles, which may have helped them prevent and treat these scenarios more efficiently.The LUME-Lung 1 trial demonstrated a benefit not only in PFS, but also in OS in patients treated with docetaxel plus nintedanib when compared with nintedanib alone as second-line treatment in advanced lung adenocarcinoma, with a disease progression of less than 9 months. Because of the retrospective nature of our study, limitations in collecting OS rates were found.Finally, it is important to consider that second-line treatment of wild-type lung adenocarcinoma has changed dramatically since the approval of immunotherapies  such as nivolumab, pembrolizumab, and atezolizumab, increasing OS when compared with docetaxel alone. However, these studies do not include the use of second-line–approved antiangiogenic agents such as nintedanib or ramucirumab in combination with docetaxel, and although immunotherapies have shown benefit to those with some degree of expression of PD-L1, the same benefit is not so clear for those with a PD-L1–negative tumor; therefore, additional investigation is required.The previous results were extracted from Mexican patients included in the compassionate use program with nintedanib in a real-life setting. In Mexico, access to oncologic treatment has multiple limitations including economic, sociodemographic, and health system access issues, hindering access to novel treatments. The advantages of participating in a compassionate program are invaluable, not only because patients can receive novel treatments, but also because it increases oncologist expertise in the management of agent toxicity, which generates new information for the management of populations with similar ethnic profiles and provides greater insight for future research.Nintedanib, as part of a chemotherapy regimen, is an effective option for advanced lung adenocarcinoma after first-line treatment progression; however, additional investigation making direct comparisons with immunotherapy should be performed, taking into account a wider oncologic profile, such as the expression of PD-L1.


Pulmonary infection is the most common complication to develop after intracerebral hemorrhage (ICH). Antibiotics have certain limitations when used to treat pulmonary infection, while Tanreqing injection (TRQI) is extensively used to treat pulmonary infection as an adjuvant to antibiotics. The aim of this meta-analysis was to investigate the clinical efficacy of TRQI for the treatment of lung infection secondary to ICH.Randomized controlled trials (RCTs) assessing the combination of TRQI and antibiotics compared to antibiotics alone for pulmonary infection after ICH were comprehensively searched for in 7 electronic databases from their establishment to August 2020. Two independent researchers conducted the literature retrieval, screening, and data extraction. The assessment tool of Cochrane risk of bias and Review Manager 5.3 software were applied to assess the methodological quality and analyze the data, respectively.Seventeen RCTs involving 1122 patients with pulmonary infection after ICH were included. Compared to antibiotics alone, the combination treatment enhanced the clinical effective rate, shortened the hospital stay, reduced the white blood cell, procalcitonin, and C-reactive protein levels, ameliorated the times to the resolution of fever, cough, and lung rales, and increased the oxygenation index. The evidence indicated that TRQI combined with antibiotics caused no adverse reactions.Our study showed that the combination of TRQI and antibiotics was effective for treating pulmonary infection after ICH. However, high-quality multicenter RCTs are needed to further verify the clinical efficacy of TRQI due to the publication bias and the low methodological quality of the included RCTs. The mortality rate within 1 month of ICH is as high as 46.5%. Most surviving ICH patients have significantly limited function regarding daily activities, with only 12% to 39% regaining functional independence. In addition to the brain tissue damage caused by primary and secondary injuries, severe complications can also lead to poor function; the most common and most serious complication is lung infection.Intracerebral hemorrhage (ICH) refers to primary nontraumatic cerebral parenchymal hemorrhage, also known as spontaneous cerebral hemorrhage. ICH is a common subtype of stroke, accounting for 10% to 20% of all strokes, and it is characterized by high disability and mortality rates. age, disturbances of consciousness, swallowing dysfunction, bed rest, vomiting, history of smoking, cardiac insufficiency, underlying lung diseases, and diabetes,–9 The other type of factor relates to the use of preventive measures after hospital admittance, including nasal feeding therapy, ventilator therapy, and drug therapy.–12 Once a patient with ICH develops pulmonary infection, the treatment duration and the hospital stay may be prolonged, the cost may increase, and the patient's life may even be endangered. Therefore, early diagnosis and timely treatment of lung infection after ICH significantly improves the prognosis of patients. However, the extensive use of antibiotics to prevent and treat pulmonary infection can very easily lead to drug resistance, and the treatment effects will decline.,15Many factors influence pulmonary infection after ICH. One type of factor is the patient's general condition and related factors, including the patient's gender,,17 are widely used. Many studies have shown that combining Chinese medicine preparations and western medicines can produce synergistic effects.–20 Tanreqing injection (TRQI) is a famous and effective Chinese medicine preparation. It is composed of Scutellaria baicalensis, cornu saigae tataricae, fel ursi pulvis, flos lonicerae, and fructus forsythia. It has antiviral, antibacterial, and anti-inflammatory effects, and can effectively treat pneumonia, upper respiratory tract infection, and chronic obstructive pulmonary disease.–24 Experimental research has shown that TRQI not only has an antibacterial effect but it also synergistically increases the antibacterial activity of antibiotics when used in combination. Studies have shown that TRQI can effectively treat pulmonary infection that is complicated by other diseases.,27 Although many clinical studies have shown that TRQI can be used to treat pulmonary infection secondary to ICH, its efficacy has not been systematically reviewed in a meta-analysis. Hence, we conducted a meta-analysis to assess the clinical curative effect of TRQI in patients with pulmonary infection secondary to ICH.Traditional Chinese medicine preparations, with clear curative effects and high bioavailability,2 checklist.This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)2.1Since this study is a meta-analysis with no patient recruitment and personal information collection, the approval of the ethics committee is not required.2.2Randomized controlled trials (RCTs) that met the following conditions were included:1.Patients were diagnosed with pulmonary infection after ICH (with clear diagnostic criteria).2.All patients received conventional antibiotics, such as ceftriaxone sodium, cefuroxime sodium, levofloxacin lactate, cefoperazone sodium, or sulbactam sodium. The control group was given antibiotics only, while the experimental group was given TRQI combined with antibiotics.3.Outcomes included at least one of the following: the clinical effective rate (the primary outcome), length of hospital stay, procalcitonin (PCT), C-reactive protein (CRP), and white blood cell (WBC) levels, times to the resolution of fever, cough, and lung rales, oxygenation index (OI), and adverse reactions (ADRs). The clinical effective rate was calculated using the following formula: (number of cured patients + number of patients with notable improvement + number of patients with improvement) / total number of patients × 100%.4.The study was an RCT.2.3The exclusion criteria included:1.Non-RCTs.2.The patients had other cerebrovascular diseases complicated with pulmonary infection.3.Incomplete or incorrect data.4.The outcome data could not be analyzed.2.4Two independent researchers conducted literature searches using the China Science and Technology Journal Database (VIP), Chinese Biomedical Literature Database (CBM), Wanfang Database, China National Knowledge Infrastructure (CNKI), Cochrane Library, PubMed, and Embase from database establishment to August 2020, with no language restrictions. The search terms were as follows: (#1) cerebral hemorrhage OR hematencephalon OR encephalorrhagia OR intracerebral hemorrhage OR brain hemorrhage OR ICH; (#2) pulmonary infection OR pneumonia OR lung infection; (#3) Tanreqing OR Tanreqing injection OR TRQI; (#4) #1 AND #2 AND #3. The references of the included articles were also searched to avoid missing any relevant RCTs.2.5The retrieved articles were screened for potential inclusion by 2 independent researchers (XWS and SW), and if any disagreements were encountered, a third researcher (LDX) resolved them. Regarding the included RCTs, the extracted data were as follows:1.first author and year of publication;2.sample size, gender distribution, and mean age;3.types, dosages, and duration of treatments;4.outcomes and ADRs.2.6 The tool includes 7 items:The Cochrane risk of bias tool was used to assess the methodological quality of the included RCTs.1.generation of random sequence;2.concealment of the allocation plan;3.blinding of subjects and researchers;4.blinding of outcome evaluators;5.completeness of the outcome data;6.selective reporting of the results;7.other sources of bias.Each item is evaluated as unclear, high risk, or low risk. If any disagreements were encountered, a third researcher (LDX) resolved them.2.7I2 statistics were used to evaluate the heterogeneity among the RCTs. If the heterogeneity across studies was low (P ≥ .1 and I2 < 50%), a fixed-effect model was applied for data analysis. If the heterogeneity across studies was high (P < .1 and I2 > 50%), a random-effects model was applied to analyze the data. The sources of heterogeneity were confirmed using subgroup analysis. Publication bias was planned to be assessed using a funnel plot if there were >10 studies.Review Manager 5.3 software was used to analyze the data. Dichotomous variables are presented as odds ratios (ORs) and continuous variables as mean differences (MDs). Additionally, 95% confidence intervals (CIs) were calculated for these statistics. Qualitative and 33.1Based on the search strategy, we retrieved a total of 200 articles after searching 7 databases, comprising 119 from Wangfang, 37 from CBM, 25 from CNKI, and 19 from VIP . After eliminating duplicates and screening the titles and abstracts, 27 documents were obtained for further screening. There were 10 documents that did not meet the inclusion criteria; the details are as follows: not RCTs (1), the patients had other cerebrovascular diseases complicated with pulmonary infection (4), the intervention did not meet the inclusion criteria (3), incomplete or incorrect data (1), and the outcome data could not be analyzed (1). Finally, 17 RCTs were enrolled in the meta-analysis. Figure 3.2A total of 17 RCTs involving 1122 patients were included, all of whom were from mainland China, comprising 565 in the experimental groups and 557 in the control groups. The maximum and minimum sample sizes were 100 and 30, respectively. The dosage of TRQI was 20 ml once per day (10 RCTs) or 30 ml once per day (7 RCTs). The treatment duration ranged from 7 to 16 days. TRQI was administered by intravenous drip in all cases. Table 3.3Two studies (which were considered low risk) clearly illustrated the method of random sequence generation; the remaining 15 studies (which were considered of unclear risk) described the method used to generate random sequences as “random” but did not describe the specific randomization method. All of the studies (which were considered of unclear risk) failed to mention allocation concealment. One study (which was considered low risk) blinded the subjects and researchers; the remaining studies (which were considered of unclear risk) did not mention blinding of the subjects and researchers. All of the studies (which were considered of unclear risk) failed to clarify whether there were other biases. Figures 3.43.4.1–45 involving 1062 patients reported the clinical effective rate of pulmonary infection secondary to ICH. The results of the meta-analysis showed that the clinical effective rate of TRQI combined with antibiotics was superior to that of antibiotics alone  , a random-effects model was applied for analysis. The results displayed that TRQI adjuvant treatment effectively reduced the length of hospital stay  , 10 days , and 14 days . Thus, the results indicate that the heterogeneity may be related to the varying treatment durations    Fig. A.3.4.6,40,42,46 involving 410 patients reported the time to the resolution of cough. Due to the obvious heterogeneity , a random-effects model was used for data analysis. TRQI combined with antibiotics relieved cough more rapidly than antibiotics alone   Fig. B.3.4.7,46 involving 160 patients reported the time to the resolution of lung rales. TRQI combined with antibiotics had obvious an advantage regarding shortening the time to the resolution of lung rales compared to antibiotics alone    RCTs reported on ADRs , so definitive conclusions cannot be drawn. The ADRs listed in the TRQI instructions mainly include dizziness, nausea, vomiting, allergic reactions, and itching or rash, which are mainly related to the age and physique of the patients, solvent used, medications that TRQI is combined with, and intravenous drip speed.The overall methodological quality of the RCTs enrolled in this study was not high. All of the studies were randomized, but no specific randomization method was described for 15 of them. None of the RCTs mentioned allocation concealment and none clarified whether there were other biases. Only 1 RCT reported double-blinding (of subjects and researchers). These issues may weaken the reliability of the evidence in our study.Based on clinical efficacy, we created a funnel plot to assess publication bias and found that it was asymmetric, indicating a small degree of publication bias. Although we conducted a comprehensive literature search, this study lacks the support of other languages, unpublished studies and grey articles, which may lead to selection bias.This meta-analysis objectively assessed the clinical efficacy of TRQI in combination with antibiotics, and it provides medical evidence for the therapeutic use of TRQI for pulmonary infection secondary to ICH. However, there were several limitations. Since TRQI is exclusively used in China, therefore, the recruited patients in the RCTs were all from China, with a lack of patients from other countries. Some of the RCTs had small sample sizes, so it is uncertain whether they had any influence on the assessment of the clinical efficacy of the combined treatment of TRQI and antibiotics. Hence, high-quality multicenter RCTs are needed to provide more solid evidence for the use of TRQI.5This meta-analysis showed that the combination of TRQI and antibiotics may improve clinical efficacy, shorten the hospital stay, reduce inflammation levels, and ameliorate other clinical symptoms and signs, and the evidence indicated that the combination treatment is safe. However, due to the small sample sizes, low methodological quality, and potential publication bias related to the included RCTs in this study, large high-quality multicenter RCTs are needed to further verify the efficacy of TRQI for treating lung infections after ICH.Conceptualization: Dongrui Zhou, Lingqun Zhu.Data curation: Ruijia Liu.Formal analysis: Fengzhi Liu, Shuangshuang Zhang.Funding acquisition: Jingling Chang.Methodology: Xiaowei Shi, Fengzhi Liu, Shuang Wu.Software: Dongrui Zhou.Supervision: Liandi Xie, Lingqun Zhu.Visualization: Liandi Xie.Writing – original draft: Dongrui Zhou.Writing – review & editing: Liandi Xie, Xiaowei Shi, Jingling Chang.