Our findings add to the literature on neonatal SARS-CoV-2 infections.A number of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections have been reported in neonates. Here, we aim to clarify the transmission route, clinical features and outcomes of these infections. We present a meta-analysis of 176 published cases of neonatal SARS-CoV-2 infections that were defined by at least one positive nasopharyngeal swab and/or the presence of specific IgM. We report that 70% and 30% of infections are due to environmental and vertical transmission, respectively. Our analysis shows that 55% of infected neonates developed COVID-19; the most common symptoms were fever (44%), gastrointestinal (36%), respiratory (52%) and neurological manifestations (18%), and lung imaging was abnormal in 64% of cases. A lack of mother–neonate separation from birth is associated with late SARS-CoV-2 infection (OR 4.94 (95% CI: 1.98–13.08),  There are a growing number of reports of neonatal SARS-CoV-2 infections. Here, De Luca and colleagues systematically analyse 176 published cases to better understand the route of transmission, as well as the clinical features and outcomes of neonatal COVID-19. Of these cases ~40–45% is reported to be asymptomatic3, but more than 900,000 infected patients have died (https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200907-weekly-epi-update-4.pdf?sfvrsn=f5f607ee_2).Since December 2019, the infection of a novel beta-coronavirus, the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread worldwide and caused a potentially lethal illness: the coronavirus disease 2019 (COVID-19). The World Health Organization (WHO) on 11 March 20205. The pathophysiology of COVID-19 includes the direct viral cytopathic effect, but also an exaggerated inflammatory response , with hypercoagulable state and tissue damage6. COVID-19 is more frequent and tends to be more severe with increasing age and in patients with certain characteristics, some of which are represented by comorbidities typical of older adults (such as cardiovascular disorders and diabetes)8. These risk factors have a role both in the disease occurrence and in the progression towards greater clinical severity and mortality8. Moreover, children might be less prone to develop the chaotic inflammatory host response that contributes to the clinical picture of COVID-199 and the disease seems to have a milder clinical course in children than in adults10. However, the proportion of asymptomatic infections seems to be lower in children than in adults12.COVID-19 may appear with a panoply of clinical manifestations. It usually starts with influenza-like symptoms, eventually progressing toward pneumonia and acute respiratory distress syndrome (ARDS), but cardiovascular, renal, neurological, dermatological, and gastrointestinal manifestations have also been reported9, and it has been hypothesized that neonatal COVID-19 might occasionally become clinically apparent. SARS-CoV-2 has been isolated in placental tissues14 and, in a few cases, maternal–fetal transmission was suspected15. Nonetheless, guidance criteria for the diagnosis of perinatal and neonatal SARS-CoV-2 infections have been released only recently and the cases published so far were not systematically analyzed according to these criteria16.Despite these findings, the knowledge about pediatric SARS-CoV-2 infection is still based on a paucity of data and the maternal-fetal transmission of SARS-CoV-2 was initially deemed uncertain. However, with the pandemic spreading around the world, some cases of SARS-CoV-2 infection in the first month of life have been reported in the literature or in the mass mediaCompared with adult medicine, neonatology suffers from a clear knowledge gap about the SARS-CoV-2 infection. In fact, the main transmission route is unknown, as neonates can be infected antenatally (through the placenta), during the delivery, or postnatally  and the clinical features of neonatal SARS-CoV-2 infections are unclear. We performed a systematic review and synthesis of published cases of neonatal SARS-CoV-2 infections, having as primary objective to describe the route of transmission and the clinical characteristics of neonatal SARS-CoV-2 infections. Our secondary objective was to clarify the effect of mother-neonate separation and breastfeeding on the incidence of late-onset neonatal infections.90. Only three articles were not peer-reviewed already. The paper characteristics are reported in Table Figure 82: these cases qualified as possible congenital and probable postpartum acquired infections, respectively, according to the classification system16; all the other cases had at least one positive RT-PCR. Nine (5.1%) neonates required delivery room resuscitation87 and 67 (38.3%) needed to be admitted to the NICU88. The median NICU stay was 8  days . Of these neonates, five were extremely preterm , five were preterm , nine were moderately preterm  and eleven were late preterm ; all other NICU-admitted neonates were term infants.These articles described 176 neonates infected by SARS-CoV-2, whose general characteristics are reported in Table 16 as shown in Fig. SARS-CoV-2 infection was classified90 their distribution is shown in Table 88 and raised liver enzymes88, respectively. Inflammatory markers  were increased in 15 (15.5%) out of 97 neonates88. Lung imaging was abnormal in 62 (64%) out of 97 neonates and consisted of an interstitial-alveolar pattern at lung ultrasound or chest X-ray and ground-glass opacities at CT-scan90. One neonate presenting with neurological manifestations also showed bilateral gliosis of the deep white periventricular and subcortical matter, together with signs of cerebral vasculitis, which was not totally remitted at the hospital discharge77. Seven neonates were treated with oral hydroxychloroquine and/or azithromycin, two with intranasal interferon-α1b and one with intravenous remdesivir, oseltamivir and ritonavir/lopinavir, respectively85; all the others received only supportive care. Three out of 176 neonates (1.7%) died for reasons that seem unrelated to SARS-CoV-2 infection.Ninety-seven neonates presented with clinical features related to COVID-19:p = 0.0002; adjusted OR 6.6 (95% CI: 2.6–16), p < 0.0001), while breastfeeding was not (OR 0.35 (95% CI: 0.09–1.18), p = 0.10; adjusted OR 2.2 (95% CI: 0.7–6.5), p = 0.148); models goodness of fit was always satisfactory .Fig. Several cases of neonates infected by SARS-CoV-2 are reported in the literature and here we have systematically analyzed and synthesized them. Our findings confirm that SARS-CoV-2 can infect neonates and that the majority of these infections occur postnatally, although vertical transmission may be possible in ~30% of cases. Neonatal SARS-CoV-2 become clinically evident in half of the patients as they developed features of COVID-19. The clinical appearance of neonatal COVID-19 seems similar to those reported in older patients, both in terms of symptoms and laboratory or imaging abnormalities, and the outcome is generally favorable. Neonates who were not transiently separated from their mothers seem to have a higher incidence of SARS-CoV-2 infections occurring after the first 72 h of life.91, with the expression reaching a peak at the end of gestation92, and SARS-CoV-2 may invade the placenta14 potentially causing miscarriage93. Second, neonatal COVID-19 manifestations seem similar to those observed in adults, while fever seems to be more frequent in COVID-19 than in common neonatal infections94 and no cases of neonatal ARDS95 were evident.These findings are important as they formally describe neonatal SARS-CoV-2 infection and partially fill our aforementioned knowledge gap. There are some interesting points to be highlighted. First, transplacental transmission of SARS-CoV-2 is indeed possible and this is corroborated by a consistent background of laboratory findings, since angiotensin-converting enzyme receptors are expressed in placental tissues96  and these have been recently highlighted97. Thus, we believe that a correct and complete counselling should be given to families in order to allow a well-informed choice. This should factor in the benefits of mother-neonate bonding, the risk of neonatal infection, their usually (but not exclusively) benign outcome and the higher maternal contagiousness during the symptomatic period98. If rooming-in is chosen, appropriate hygiene advice and personal protective equipment should be given, as these may significantly reduce the risk of transmission99. Hygiene measures during mother-neonate contact were described inconsistently and only in a minority of articles75, and, given the differences in guidelines worldwide97, dedicated studies are warranted to understand what would be the ideal equipment and policy to be applied.The choice between rooming-in or mother-infant separation is an important one and the synthesis of available cases shows that the avoidance of separation might be associated with a higher risk of late-onset neonatal SARS-CoV-2 infections. This is potentially important since neonatal SARS-CoV-2 infections are more commonly acquired postnatally, through environmental exposure. There are wide differences in this matter between the clinical guidelines issued by scientific societies and authorities worldwide100, larger studies are needed to clarify this issue15.Breastfeeding does not seem to be associated with SARS-CoV-2 infections and this suggests that viral transmission through the milk, if any, should be rare. These findings seem to support the safety of expressed breast milk even when the mother is symptomatic and during mother-neonate separation. However, since few studies have investigated this matter and have yielded conflicting results10. Conversely, the analyzed neonates had a quite more frequent need for NICU hospitalization compared to neonates of similar gestational age101 and to older children10. However, not all these NICU-admitted babies may have actually needed critical care and this is not possible to be extrapolated with this type of analysis. The NICU-admission may be influenced by many factors such as local setting, logistics, and isolation policy, since the NICU could represent the only area to isolate infected babies and guidelines are extremely dissimilar between different countries and settings97. This should be avoided if NICU care is not actually needed, in order to avoid the shortage of NICU beds during the pandemic102.The results of this synthesis of neonatal SARS-CoV-2 infections are also consistent with a review performed in older children and adolescents from Asia. This review showed that SARS-CoV-2 infection seems mild in pediatric patients while presenting with the same clinical features or laboratory and imaging abnormalities103.Since a significant proportion of infections are asymptomatic, it has so far been hard to ascertain the disease burden on neonates and the possibility of transmission to healthcare providers. We shed some light on this, although our findings may change as soon as the pandemic progresses and new experience is accumulated. Meanwhile, it is suggested that evidence derived from case reports and series is currently the best available and should be used to inform decision making until higher level of evidence is available103. As this is a meta-analysis of mainly case series, the rating of the quality of evidence is 4, according to the Oxford Centre for Evidence-based Medicine classification (https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/). However, the Grading of Recommendations, Assessment, Development, and Evaluation guidelines admit the decision-making process based on low-quality evidence in some particular circumstances104 and the pandemic surely represents an extraordinary situation. The classification system for diagnosing maternal, fetal, and neonatal SARS-CoV-2 infections may be cumbersome, as it requires consideration of clinical data and of the results of several virological tests16: the relatively low number of confirmed infections may be due to the difficulty in obtaining the virological tests in various samples . However, this represents the best way so far to correctly identify these infections for epidemiological and clinical purposes and it should be promoted. Furthermore, the classification may be adjusted, and a case can be re-classified, if its likelihood of infection changes, as more information becomes available. Similarly, the availability of new diagnostic tests may lead to changes in the diagnostic criteria. Only one case was diagnosed based on positive IgM and negative RT-PCR29, thus this is not likely to change the global results of our synthesis. We cannot exclude that some of the clinical features presented by the analyzed cases were due to other concomitant disorders, as this level of detail is not attainable with a synthesis of published reports; however, the analyzed data are coherent and consistent with those from older COVID-19 patients. We have almost no information on neonatal COVID-19 therapies, as these will require more experience and it is unclear if the neonatal SARS-CoV-2 infection may have long-term consequences, as no follow-up studies have been performed so far. Finally, we also enrolled manuscripts posted on preprint server while waiting for peer review and final publication. This might introduce a bias as the quality and reliability of these papers can be suboptimal. However, we provided our own peer review applying rigorous criteria and a specific quality evaluation tool to every and each article103 and we actually have only three reports as preprint. Moreover, the role of preprints during pandemics has been widely recognized as they facilitate the spread of vital information and a recent analysis focused on COVID-19 found the quality of preprint similar to that of final publications106.This work has limitations. Although the quality of the reviewed reports is intermediate, we should remember that uncontrolled case descriptions and their synthesis are at the bottom of the evidence pyramidIn conclusion, the synthesis of uncontrolled cases of neonatal SARS-CoV-2 infection shows that infections mainly occur postnatally through environmental exposure, although nearly 30% of infections may be acquired vertically. Approximately half of the infected neonates develop clinically apparent COVID-19, which is often characterized by febrile status, features similar to those of older patients and favorable outcomes. Mother-neonate rooming-in is associated with a higher incidence of SARS-CoV-2 infections occurring after the first 72 h of life.107. The French Ethical Committee for the Research in Obstetrics and Gynecology reviewed the work and confirmed that the institutional review board approval was unnecessary. The case studies were performed in agreement with principles of the Declaration of Helsinki and all analyzed data were anonymous and respecting local and European privacy regulations.Prior to commencing the search, a detailed protocol was agreed to determine the databases to be searched, search modalities, eligibility criteria, and all methodological details. Several virtual meetings between the authors were organized and a dedicated online archive was created to share the data of the reviewed papers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed throughout the whole project108. Moreover, articles had to be published between 1 December 2019 and 30 August 2020. No language restriction was applied: non-English publications were translated personally by the investigators or using the Google translation service. We excluded conference abstracts, any report of neonates exposed to but not infected by SARS-CoV-2 (according to the aforementioned criteria), articles describing only stillbirths or children aged more than 30 days and paper reporting hypotheses or opinions without any clinical data. Duplicate reports and “grey” literature were also excluded.We looked for cohort, cross-sectional and case-control studies, as well as case series or case reports published as articles or letters to the editors describing neonates (i.e.: infants within the first 30 days of life) infected by SARS-CoV-2, as demonstrated by: (1) at least one positive real-time reverse transcription polymerase chain reaction (RT-PCR) on nasopharyngeal swabs, and/or (2) positive serology with detection of specific IgM. These laboratory tests had to be performed according to World Health Organization technical guidance principles or appropriate national guidelineshttp://www.ncbi.nlm.nih.gov/pubmed/), The Cochrane Library (https://www.cochranelibrary.com), Web of Science (https://clarivate.com/webofsciencegroup/solutions/web-of-science/), as well as BioXRiv (https://www.biorxiv.org) and MedXRiv (https://www.medrxiv.org) preprint archives. We used the following keywords or MeSH terms: “Coronavirus”, “COVID-19”, “SARS-CoV-2”, “newborn”, “preterm” and “neonates”. We also hand-searched references cited in the eligible manuscripts or in review articles on the subject and the authors’ personal archives. We used the following Boolean string: (COVID-19 AND neonates) OR (coronavirus AND newborn)) OR (coronavirus AND preterm)) OR (coronavirus AND neonates)) OR (SARS-CoV-2 AND newborn)) OR (SARS-CoV-2 AND preterm)) OR (SARS-CoV-2 AND neonates)) OR (COVID-19 AND preterm)) OR (COVID-19 AND newborn)) AND ((“2019/12/01”[Date - Create]: “2020/08/30”[Date - Create])).We conducted an extensive search of the following databases: PubMed  the full text of each article, excluding those not meeting the eligibility criteria and removing duplicates. The CARE  recommendations, specifically dedicated to case reports and series, were followed during the evaluation process105. If an article was eligible but reported data on neonates mixed with those of older children (beyond the first month of life), neonatal data were directly extracted or the authors were contacted to provide the needed data. Authors were also contacted when more information was needed and at least two emails were sent to the corresponding author, 1 week apart, asking for additional data. If discrepancies or uncertainties persisted, they were resolved by discussion between the two independent researchers and, if no agreement was reached, with a third researcher (DDL). All articles finally deemed eligible were collected using Zotero  and used for the review.Articles were assessed by two independent researchers (RR and AJV), as recommended by the quality standards issued by the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) GroupWe developed a dedicated online data extraction sheet , pilot-tested it on three randomly selected manuscripts, and refined it accordingly. Data from included records were extracted independently by two investigators (RR and AJV) using the data extraction sheet and then cross-verified. If some data were lacking, at least two emails were sent to the corresponding authors one week apart to ask them for the missing data. If discrepancies or uncertainties persisted, they were resolved by discussion between the two independent researchers and, if no agreement was reached, with a third researcher (DDL).16. In detail, cases were divided into: (1) congenital infections, (2) intrapartum acquired infections, or (3) postpartum acquired  infections and into five mutually exclusive categories of the likelihood of infection: (a) confirmed (strong evidence of infection with confirmatory microbiology), (b) probable (strong evidence of infection but confirmatory microbiology lacking), (c) possible (evidence suggestive of infection but incomplete), (d) unlikely (little support for diagnosis but infection cannot be ruled out), and (e) not infected (no evidence of infection)16. Criteria defining the likelihood of infection were published earlier and are available as Supplementary Material16.Data collected included article type and details, number of enrolled patients, and their basic characteristics, as mean gestational age, birth weight, sex, mode of delivery, Apgar score, postnatal age at the diagnosis and comorbidities. We also recorded all clinical signs and symptoms, imaging and laboratory findings, use of antiviral therapies, isolation and feeding policies, need for neonatal intensive care unit (NICU) admission and mortality. According to postnatal age at the diagnosis, the SARS-CoV-2 infection was classified as early- or late-onset , as commonly done for neonatal sepsis. We recorded any RT-PCR result in placental tissue, amniotic fluid, cord or newborn blood, urine, stool, and swabs. We also recorded the presence of SARS-CoV-2-IgM, and classified the cases according to the classification system defining maternal, fetal and neonatal SARS-CoV-2 infections16, and (2) the occurrence of late neonatal infection .We considered outcome data, respectively for our primary and secondary objective: (1) the identified transmission route and all clinical features103. Two investigators (RR and AJV) independently summarized the results of this evaluation by aggregating the eight binary responses into a 0–8 score. Evaluation results were also qualitatively summarized, as recommended by the tool creators103. If discrepancies or uncertainties persisted, they were resolved by discussion between two researchers (RR and AJV) and, if no agreement was reached, with a third researcher (DDL).Since we expected the majority of analyzed articles to be case reports or case series, we decided to evaluate their methodological quality according to four domains . To perform this evaluation, we used the Mayo Evidence-Based Practice Centre tool, which is specifically dedicated to the evaluation of case report/series qualityCumulative estimates of event rates (frequency) were reported as a percentage for the need of neonatal resuscitation or NICU admission, transmission route, isolation and feeding policies, and for each clinical manifestation, imaging and laboratory findings or therapy. Continuous data were described as mean (standard deviation) or median [interquartile range], as appropriate; minimum and maximum values were also reported: this was the case of basic clinical data  and length of NICU stay.p-values < 0.05 were considered statistically significant.The effect of mother-neonate separation and breastfeeding on the incidence of late-onset neonatal infections was studied with two-sided Fisher’s exact test and association between variables was expressed by means of the odds ratio (OR) and 95% confidence interval (CI). Calculations and statistics were performed with Excel 16  and MedCalc 13.3 . 103 see above). Results were expressed as adjusted OR and 95% CI; model goodness-of-fit was evaluated with Hosmer-Lemeshow test.The effect of mother-neonate separation and breastfeeding on the incidence of late-onset neonatal infections was also investigated using multivariate logistic regressions, with enter method, adjusting for the quality of reviewed article (evaluated by the specific toolFurther information on research design is available in the Peer Review FileReporting Summary


Infertility may be associated with severe psychological burden and many couples need mental support. We used dyadic approach to identify couples with disturbed psychological condition and we tested the WHO-5 Well-Being Index (WHO-5-WBI) questionnaire as a possible, rapid screening method. Extensive psychological assessment of infertile couples was carried out with Beck’s Depression Inventory, Spielberger State-Trait Anxiety Inventory, WHO-5-WBI, Symptom Check List-90 Revised Test, Fagerstrom Test for Nicotine Dependence, Alcohol Use Disorders Identification Test. Data of 128 patients (64 couples) were used in the statistical calculations. The Two-Step cluster analysis has revealed 2 groups, which could be separated supremely based on the level of experienced depression, anxiety and according to the general mental health. The WHO-5-WBI questionnaire showed consistent results while classifying couples into groups, which were formed. Our results indicate that infertility affects both spouses almost in the same extent in several psychological aspects. A cluster of couples with increased psychological burden could be clearly separated. The WHO-5-WBI questionnaire was a promising tool to screen reliably spouses based on their psychological state and identify couples that need psychological support during their fertility work-up and treatment. Infertility can be described as an inability to become conceived within one year despite regular sexual intercourse without contraceptive usage . Approximately 186 million people are facing the problem of infertility worldwide and in Hungary 9 percentage of the population are affected . Even thin vitro fertilization (IVF) programs. Therefore, it would be worthwhile to pay particular attention to the assessment of the psychological state of those who are involved in the fertility programs  was a promising tool for assessing psychological parameters of patients in a previous review . We hypoWe managed a cross-sectional research design with a dyadic approach to examine the interdependence of the male and female spouses’ psychological state related to infertility. We used the Hungarian version of psychometrical instruments to measure depression (Beck’s Depression Inventory – BDI), anxiety (Spielberger State-Trait Anxiety Inventory – STAI), well-being (WHO-5 Well-Being Index – WHO-5 WBI), general mental state (Symptom Check List – 90 Revised Test – SCL-90R), nicotine dependence (Fagerstrom Test for Nicotine Dependence – FTND), alcohol dependence (Alcohol Use Disorders Identification Test – AUDIT). Our primary outcome measures were the values of the level of depression, anxiety, general mental-health and well-being index. Accordingly, each case as one couple had two test results on each instrument. We identified the main characteristics of the formed clusters and examined whether the responses to the WHO-5 WBI fit the spouses into the formed groups. In addition, the data of WHO-5 WBI, as an independent variable, were not used in the calculation process of clustering.Infertile couples who attended to infertility examination were enrolled in this study at an Andrology Outpatient Clinic during a time period from August 2017 to April 2019. The study was approved by the Regional Ethical Committee (No.: 196/2017-SZTE). All subjects received a written informed consent in accordance with the Declaration of Helsinki. The main exclusion criteria were the presence of any previous psychiatric disorder and/or any severe case in life story.Nine-item shortened version of Beck Depression Inventory with 21 questions, a four-point (from 0 to 3) Likert scale questionnaire asks for symptoms of depression such as social withdrawal, indecision, sleep disturbance, fatigue, excessive anxiety due to physical symptoms, disability, pessimism, satisfaction and lack of joy and self-blame. The total score is 63 points, normal scores of the test differ from 0 to 9, scores above this range indicate more depressive symptoms . BDI serThe State-Trait Anxiety Inventory being widely used in clinical practice and research. It is a short self-report questionnaire to evaluate the level of anxiety and was designed by Spielberger and colleagues. Form STAI-State and STAI-Trait measure state and trait anxiety with 20-20 items . In HungThe SCL-90R is a multidimensional self-reported questionnaire to assess nine different dimensions: somatization, obsessive–compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychotic symptoms. Each dimension can be interpreted separately. Total scores can range from 0 to 450, higher scores in SCL-90R refer to worse general psychological state . To deteThe World Health Organization-Five Well-Being Index is a short self-reported questionnaire containing five items to evaluate current mental well-being in a time period two weeks prior the completion. The questionnaire is based on the WHO-10 Well-Being Index and was developed by Bech in collaboration with the World Health Organization. The instrument contains five different questions about subjective psychological well-being as daily activity; being vigorous; being cheerful; being calm, relaxed; and general interest in life. Each item is scored from 0 to 3, the maximum possible score is 15 . The aveAUDIT is a 10-item short self-reported questionnaire to examine the frequency of alcohol consumption (three questions), the rate of alcohol dependence (three questions) and the derived problems due to the alcohol consumption as well (four questions). Each question is scored from 0 to 4, the maximum possible score is 40. AUDIT provides a simple method of early detection of hazardous and harmful alcohol use in primary health care. Higher scores (above 8 points) in AUDIT refer to more severe alcohol dependence .The FTND is a six-item short self-reported questionnaire to assess the rate of physical addiction to nicotine. The inventory briefly covers smoking habits, such as using a first cigarette a day, smoking control or smoking during illness. The possible maximum score is 10, from 0 to 2 points there is no sign of nicotine dependence. Higher Fagerstrom scores refer to more intense addiction to nicotine .The data of each couple, both male and female were ordered into the same case. Considering the fact, that the scores of WHO-5-WBI for males and WHO-5-WBI for females are independent variables in the classification process, we examined them first for normality and outliers. We experienced one outlier on the scale of WHO-5-WBI among females. Avoiding the distortion, we excluded this case (couple) from the analysis. Health related additional instruments, Fagerstrom and AUDIT results were analyzed as basic characteristic variables.We found that WHO-5-WBI scores differed from normal distribution for both genders, therefore Logistic Regression was used in the later statistical analysis to evaluate its predictive effectiveness.To determine the interdependence between the male and female partner’s psychological involvement , we separated the couples into two clusters, based on BDI-male, BDI-female, STAI-State-male, STAI-State-female, STAI-Trait-female, SCL-90R-male, SCL-90R-female results. Two-Step cluster analysis was carried out consecutively, because it considered as a robust method against a lack of normal distribution and outliers. We also determined the main characteristics of the formed groups.As previously defined, the reliability of WHO-5-WBI classification was tested with Logistic Regression on the clusters. Reaffirming the diagnostic values of WHO-5-WBI, we performed ROC-analysis and determined the effectiveness of WHO-5-WBI.http://www.spss.com).Data were analyzed using the Statistical Package for Social Sciences .The results of the questionnaires in our study population are shown in Table Two-step Cluster Analysis generated two distinct cluster groups with highly homogenous patterns of health-related psychological characteristics. Of the 64 couples, 53.1 % (n = 34) can be classified as Cluster 1: “Infertile couples with high values on mental health inventories” and 46.9 % (n = 30) as Cluster 2: “Infertile couples with low values on mental health inventories”.p = 0.021). The age and the level of nicotine addiction showed no significant difference between the clusters. The results are summarized in Table Cluster 1 produced higher levels on health-related and psychologically relevant questionnaires, in contrast, the couples in Cluster 2 showed lower results. According to the cluster analysis process, all variables showed a significant difference between the two clusters. In the Cluster 1, for both men and women higher average levels of anxiety were experienced on STAI-Trait . STAI-State also showed elevated scores by each gender in Cluster 1 . BDI results also suggested that members of the Cluster 1 experience inferior conditions compared to the Cluster 2 group . Specifying the mental-health condition in general (measured with SCL-90R), we experienced higher total scores for each gender  in Cluster 1, compared to Cluster 2 . In addition, men in Cluster 1 displayed higher risk for alcohol dependency (AUDIT Cluster 1: t(62) = 49.505, total: 64, ncluster1: 26, ncluster: 38) = 14.59, p < 0.0001), explaining that the model was able to distinguish between infertile couple who were separated into clusters based on their results of BDI, STAI, SCL-90R . Congruent association of predicted probabilities and observed responses was 75.0%, which is further evidence of the effectiveness of the classification. Despite the fact that couples were interpreted as cases (dyads), the values of both women and men, had a reliable diagnostic model for the couple’s mental state.Logistic regression analysis was performed to assess the predictive efficiency of WHO-5-WBI on the likelihood that the infertile couples would be classified into the Cluster 1 or Cluster 2. Regarding to this, we used the cluster membership as the dependent variable in the logistic regression. The model representing predictors was statistically significant . The ROC analysis suggests that WHO-5-WBI as a diagnostic test has separative ability to discriminate between cluster memberships.For further confirmation, and showing the tradeoff between sensitivity and specificity, a Receiver Operating Characteristic curve was calculated. The appropriate ROC curve was drawn in Figure   were used in our study. A model free clustering approach was used, and the interdependence of spouses was analyzed regarding the infertility related psychological burden. The results revealed that infertile couples could be separated based on the scores of SCL-90R, STAI-State – Trait and the BDI, we were able to identify two, significantly different clusters, one (Cluster 1) with relatively high and other (Cluster 2) group with relatively low scores. Cluster 1 could be typified as one in which spouses experienced more expressed infertility related psychological symptoms, in contrast, couples in Cluster 2 presented lower level of anxiety and depression. Male and female psychological conditions were similar within the clusters, supporting the interdependence between the spouses. Furthermore, a trend was observed that women experienced higher levels of perceived stress and depression in general, compared to men in both clusters. Our results are in line with the literature, Kim and colleagues investigated how infertility related stress and depression affects the quality of life among spouses: they found that females showed higher depression scores compared to their male partner. On the other hand, they investigated that the level of depression and anxiety level of females affected directly the level of depression and anxiety level of male spouses, even though this interference was not reciprocal . Similarl status . Our datOur results may promote significant changes in the psychological care of infertile patients. During the course of the fertility treatment, couples identified with increased anxiety or depression need mental support. Clustering patients can make the utilization of healthcare services more effective, since in our study population only 53.1% of the couples needed special support from experts, the remaining 46.9% of patients were in good mental condition. Based on the results, it is advisable to handle spouses as a unit during the psychological counseling rather than using individual approaches. However, such a complex testing used in our study is time consuming, may present inconvenience for the patients and the medical staff, and special knowledge is required for the interpretation. The access to professionally competent and adequately resourced staff is often limited during the assisted reproductive courses, a quick, accurate screening method for couples with inferior psychological state would be useful. For this purpose, we applied the WHO-5-WBI to our study population, whether this short, simple test is appropriate for distinguishing between the clusters, which were based on multiple instruments . It might be used as a first line screening by general practitioners or IVF nurses, and couples with low scores can be referred to professionals for further psychological care. In a recent review, Topp and colleagues pointed out that the WHO-5-WBI is a promising tool for assessing psychological parameters of patients, including depression and anxiety . The maiWe observed a relatively high incidence of severe alcohol consumption  and only a low number of strongly nicotine-dependent patients . In Hungary, 7–11% of men between 18–64 years of age are reported as seriously alcohol-dependent, and only about 1% of women . It has Undoubtedly, our study has some limitations. The ratio of infertile couples that attend at infertility specialist in developed countries is around 45–56% , therefoAs we know, this is the first study, which was able to classify couples into two significantly different clusters regarding the infertility-related psychological burden. The mental conditions of the spouses were interdependent and similar; they were assigned into the same cluster allowing us to handle them as a dyad. However, scores from BDI, STAI, and SCL-90R questionnaires characterized mostly the mental health of the couples, as a screening method, the short WHO-5-WBI test also was able to identify couples with significant psychological burden. These patients need professional mental support during the infertility treatment, and we believe, based on our results, that WHO-5-WBI is a convenient tool for health care providers and the patients to identify the couples at need.


The link between psoriasis and obstructive sleep apnea (OSA) has not been confirmed. We aimed to investigate the relationship between psoriasis and OSA. We conducted a systematic review and meta-analysis of case-control, cross-sectional, and cohort studies on the association between psoriasis and OSA. We searched MEDLINE and Embase for relevant studies on May 11, 2019. The Newcastle-Ottawa Scale was used to evaluate the risk of bias of included studies. We performed random-effects model meta-analysis to calculate pooled odds ratio (ORs) with 95% confidence intervals (CIs) for case-control and cross-sectional studies as well as pooled incidence rate ratio (IRR) with 95% CIs for cohort studies in association between psoriasis and OSA. A total of 4 case-control or cross-sectional studies and 3 cohort studies with a total of 5,840,495 subjects were included. We identified a significantly increased odds for OSA in psoriasis patients , and significantly increased risk for psoriasis in OSA patients . In conclusion, our study identified a bidirectional association between psoriasis and OSA. Sleep quality should be inquired in patients with psoriasis. Respirologist consultation or polysomnography may be indicated for those presenting with night snoring, recurrent awaking, and excessive daytime sleepiness. The prevalence was estimated 0.5–11.4% in adults2. Psoriasis is considered as a multisystemic disease involving proinflammatory cytokines such as tumor necrosis factor (TNF), interleukin (IL)-1, and IL-174. Various comorbidities have been linked to psoriasis including cardiovascular disease, metabolic syndrome, chronic kidney disease, uveitis, thyroid diseases, vitiligo, and inflammatory bowel disease11.Psoriasis is a chronic inflammatory skin disease with characteristic feature of sharply circumscribed erythematous plaques with silvery scales on the trunk and limbs13. OSA is characterized with night snoring, recurrent awaking, and excessive daytime sleepiness14. The gold standard test for diagnosing OSA is polysomnography15. The prevalence of OSA ranges from 3 to 17%12. Risk factors of OSA include obesity, aging, male gender, anatomical predisposition, and alcohol consumption13. OSA induces systemic inflammatory and increases the risk of hypertension, stroke, cardiovascular disease, and metabolic disorder, in particular of diabetes mellitus type 2 and metabolic syndrome regardless of the obesity17.Obstructive sleep apnea (OSA), also called obstructive sleep apnea-hypopnea syndrome, is a chronic disorder of intermittent upper airway collapse during sleep resulting in recurrent hypoxia19. The association between psoriasis and OSA has been examined in many studies but the results were limited and inconsistent27. The objective of this study was to assess the evidence regarding the bidirectional association between psoriasis and OSA.Psoriasis and OSA share a common pathogenesis of inflammatory and immune imbalance28. We have registered the study protocol with PROSPERO .We conducted a systematic review and meta-analysis of observational studies  on the association between psoriasis and OSA. The reporting of this study followed the Meta-analysis of Observational studies in Epidemiology (MOOSE) guidelinesWe searched the MEDLINE and Embase for relevant studies from inception to May 11, 2019. The search terms included psoriasis and sleep apnea and their synonyms. The search strategy is shown in the Supplement. No geographic or language limitations were imposed.The criteria for studies to be included were as follows: (1) observational studies investigating the association between psoriasis and OSA, including case-control, cross-sectional, and cohort studies; (2) research on human subjects; (3) the case group consisted of patients with psoriasis and the control group consisted of people without psoriasis in studies that examined the odds or risk of OSA in psoriasis patients; the study group was composed of patients with OSA and the control group was composed of people without OSA in studies that evaluated the odds or risk of psoriasis in OSA patients. We screened titles and abstracts for the initial study selection and obtained the full text of potentially eligible studies to confirm if they met our inclusion criteria. Two authors (T.G. and Y.F.) independently selected studies and disagreement was resolved by consulting the other author (C.C.).We extracted the following data from the included studies: first author, year of publication, country of study, number and gender of study subjects, definition of the case group, definition of outcome, and risk estimates including hazard ratio (HR), incidence rate ratio (IRR), and odds ratio (OR) with 95% confidence interval (CI) on the association between psoriasis and OSA.29. For case-control and cross-sectional studies, we examined the following eight domains: adequacy of case definition, representativeness of cases, selection of controls, definitions of controls, comparability of cases and controls, ascertainment of exposure, same method of ascertainment for cases and controls, and non-response rate. For cohort studies, we evaluated the following eight domains: representativeness of exposed cohort, selection of non-exposed cohort, ascertainment of exposure, absence of outcome of interest at start of study, comparability of cohorts, assessment of outcome, follow-up duration, and adequacy of follow up of cohorts.The risk of bias of included studies was assessed by using the Newcastle-Ottawa Scale30. The statistical heterogeneity was assessed by the I2 statistic across the included studies. An I2 of >50% represents substantial heterogeneity31. We chose random-effects model for meta-analyses because clinical heterogeneity was anticipated. Therefore the DerSimonian and Laird method that takes between-study variability into account was used to obtain the pooled OR and IRR estimates32. Also, we conducted a sensitivity analysis after excluding studies that were rated with a high risk of bias.The Review Manage version 5.3  was used for conducting all analyses. We calculated the OR with 95% CI in included case-control and cross-sectional studies and IRR in included cohort studies. If OR was not reported in an included study, we calculated the crude OR based on published data for example the number of events in the case and control groups. The most fully adjusted OR, HR, or IRR were adopted if reported. We performed meta-analyses to evaluate the bidirectional association between psoriasis and OSA. For included case-control and cross-sectional studies, we calculated pooled OR to examine the association between the two diseases. For cohort studies, we treated HR as IRR and calculated the pooled IRRThe PRISMA flow chart of study selection is shown in Fig. 33. Two studies were rated with an unclear risk of bias in the ‘representativeness of cases’ and ‘selection of controls’ domains because patients were selected from hospital not community35. We rated two studies as unclear risk of bias in the ‘comparability of cases and controls’ domain because only age and gender, but not body mass index, were controlled35. Moreover, three studies were rated as unclear risk in the ‘ascertainment of exposure’ domain because only medical records or ICD codes were employed34. In three included cohort studies, we rated the Cohen 2015 study at high risk of bias in the ‘representativeness of exposed cohort’ domain . One included cohort study illustrated a consistently increased risk for OSA in patients with mild psoriasis , severe psoriasis , and psoriatic arthritis 25.One cohort study27 and one case-control study34 found a consistent increase in psoriasis among patients with OSA. The meta-analysis of three included cohort studies with 5,544,674 study subjects showed a significant association of OSA with psoriasis . The Cohen 2015 study was rated with a high risk of bias in the representativeness of the exposed cohort because all the study subjects were nurses23. However, the association of OSA with psoriasis remained positive after excluding the Cohen 2015 study . One case-control study showed a significantly increased odds for psoriasis in relation to OSA 34.Conversely, three cohort studies35 and a 13-fold increased odds for prevalent psoriasis in relation to OSA34. Similarly, the evidence from an included cohort study demonstrated consistently increased risk for incident OSA among patients with mild and severe psoriasis as well as psoriatic arthritis25. Conversely, OSA patients were 2.52-fold more likely to develop incident psoriasis when compared with non-OSA controls27. Our meta-analysis possesses high generalizability because of including studies from various ethnicities for example the United States, France, Denmark, Greece, Israel, and Taiwan.To the best of our knowledge, the present study is the first meta-analysis investigating the bidirectional association between psoriasis and OSA. The evidence from included case-control and cross-sectional studies found a 2.6-fold greater odds for prevalent OSA in relation to psoriasis36. Patients with psoriasis have been found to have increased body mass index (BMI) than healthy controls37. Besides, OSA was related to obesity and thus weight loss is the recommended fist-line therapy39. Obesity may promote upper airway inflammation, reduce muscle contractibility, and induce airway collapse during sleep40. BMI has been correlated with psoriasis severity37 and OSA26. Among most of included studies in our meta-analysis34, the confounding from obesity has been considered and BMI was adjusted in the statistical analysis. The bidirectional association between psoriasis and OSA remained significant after adjustment for obesity or BMI. Only one included case-control study of Tsai 2011 did not contain any information about BMI or body weight33. Another included cross-sectional study of Sacmaci 2019 did not perform adjustment for obesity, but there was no significant difference in BMI between psoriasis patients and non-psoriasis controls 35. Therefore, confounding by obesity could not fully explain the association between psoriasis and OSA.Obesity is a trigger for inflammation and has been linked to chronic inflammatory diseases19. OSA is considered a systemic inflammatory disorder. High levels of systemic inflammatory molecules are part of mechanism leading to OSA42. The activities of IL-17, TNF, IL-6, IL-7 and C-reactive protein are significantly increased in patients with OSA compare to obese patients45. These pro-inflammatory cytokines decreased after continuous positive airway pressure (CPAP) treatment44. Studies have shown that the circadian rhythm of TNF release was significantly disturbed in patients with OSA47. The inflammatory process may predispose them to the development of psoriasis27. Elevated circulating levels of IL-17, TNF, IL-6, and IL-22 were also associated with psoriasis48. One previous study found that treatment with etanercept significantly improved symptoms of OSA in moderate to severe psoriasis49. The increase of IL-17 is related to atherosclerotic vascular disease, which is a risk factor for OSA50. Moreover, psoriasis causes pruritus and may lead to sleep disturbance, which contributes to systemic inflammation and consequently induces OSA53.The bidirectional association between psoriasis and OSA suggest the shared common systemic inflammatory pathogenic pathways55. Some scholars assumed that psoriasis-related itching and pain could disrupt sleep and thus increase autonomic activation, which possibly induces OSA54. On the other hand, Gabryelska et al. proposed low grade inflammation in OSA patients with elevated levels of IL-1 and TNF could stimulate hypothalamus and increase hypothalamic-pituitary-adrenal activity with resultant surging of autonomic activity56. The inflammation and autonomic activation involved in OSA may be a risk factor for psoriasis55.Autonomic activation is considered an important factor between OSA and psoriasis57. HIF-1α, a transcriptional regulator of cell oxygen metabolism, is a specific marker for diagnosing OSA58. The levels of HIF-1α correlate with the severity of OSA and can be effectively reduced by CPAP treatment57. Besides, vascular risk response to hypoxia was detected in OSA patients. A significant upregulation of NF-κB, HIF-1α, endothelial nitric oxide synthase, vascular cell adhesion molecule 1, and vascular endothelial growth factor (VEGF) were expressed in the skin biopsy specimens of OSA patients59. Increased circulation of VEGF promotes angiogenesis which is also an important process in initiating psoriasis60. VEGF is a marker of tissue response to hypoxia and activated by HIF-1α59. There is evidence indicating activation of excess HIF-1α and VEGF in psoriatic skin when compare to normal skin62. In addition, HIF-1α is involved in T-cell regulation and survival which are crucial in psoriasis formation62. The effects of hypoxia with elevated levels of HIF-1α and VEGF may explain the association between OSA and psoriasis.Intermittent hypoxia during sleep in OSA patients induces oxidative stress. Some markers including nuclear factor-κB (NF-κB) and hypoxia-inducible factor-1α (HIF-1α) could detect the oxygen stress and activate the inflammatory pathway33 and misclassification bias might have been present. Second, high statistical heterogeneity was detected as to the association of psoriasis with OSA (I2 = 89%; see Fig. There are a few limitations of the present study. First, OSA was identified by the use of ICD codes in four included studiesIn conclusion, the evidence to date supports a bidirectional association between psoriasis and OSA. All patients with psoriasis should be informed about the risk of OSA, and vice versa. OSA is a comorbidity of psoriasis that should not be ignored, and sleep quality should be inquired in patients with psoriasis. Respirologist consultation or polysomnography may be indicated for those presenting with night snoring, daytime sleepiness, and insomnia.Supplementary Table S1.


In recent years there has been a trend towards an increase in the proportion of non-small cell lung cancer patients diagnosed with localized stage instead of advanced. However, 5-year survival rates continue to be low, even among patients diagnosed at early stages. In recent years major advances have been made in the treatment of advanced NSCLC, in large part due to the irruption of immunotherapy. PD-1 axis blocking-based immunotherapy is already a well-established standard of care treatment for patients with advances NSCLC, in frontline setting and in pretreated patients. Our greatest challenge now is to move the benefit of immunotherapy to patients with early-stage NSCLC so as to increase 5-year survival rate. The aim of this manuscript is to make a comprehensive review of available evidence, make a critical review of the results of published and ongoing studies, and analyze the role of biomarkers, main areas of controversy and future challenges.Despite numerous advances in targeted therapy and immunotherapy in the last decade, lung cancer continues to present the highest mortality rate of all cancers. Targeted therapy based on specific genomic alterations, together with PD-1 and CTLA-4 axis blocking-based immunotherapy, have significantly improved survival in advanced non-small cell lung cancer (NSCLC) and both therapies are now well-established in this clinical setting. However, it is time for immunotherapy to be applied in patients with early-stage disease, which would be an important qualitative leap in the treatment of lung cancer patients with curative intent. Preliminary data from a multitude of studies are highly promising, but therapeutic decision-making should be guided by an understanding of the molecular features of the tumour and host. In the present review, we discuss the most recently published studies and ongoing clinical trials, controversies, future challenges and the role of biomarkers in the selection of best therapeutic options. Lung cancer is the most common type of cancer worldwide, with 2.1 million new cases annually, and also the leading cause of cancer-related mortality (1.8 million deaths in 2018) . Major advances have been made in the treatment of NSCLC in recent years, leading to a significant improvement in survival outcomes . Most ofAdvanced NSCLC refers to those patients with metastatic NSCLC and treatment objectives focus on prolonging survival and improving quality of life of these patients. On the other hand, early-stage NSCLC comprises those tumours between stages I and III of the TNM classification system developed by the American Joint Committee on Cancer (AJCC) and treatment aim is curative. We need to add surgery and/or radiotherapy to achieve this goal so far in early-NCSLC.At present, immunotherapy is approved only for the treatment of advanced NSCLC, with the notable exception of consolidation durvalumab, which has been approved to treat unresectable locally-advanced NSCLC after radical chemoradiation (CRT). In advanced setting, immune checkpoint inhibitors (ICI) based immunotherapy has demonstrated overall survival (OS) improvement both in palliative first line and second line setting. In unresectable stage III NSCLC, consolidation durvalumab improved disease-free survival (DFS) and OS after radical CRT.Antitumour effect of ICI-based immunotherapy is based on enhancing the ability of the host’s immune system to recognize tumour cells as strange to trigger an antitumour immune response that ends up eliminating the tumour cells. The presence of tumour cells with neoantigens different from the normal origin cells are present from the beginning of tumour growth, both in early and advanced stages, so there is biological rational for immunotherapy to be also effective in early stages.Numerous studies are already underway to assess the role of these treatments in early-stage NSCLC, with early results supporting this therapeutic approach in these patients, which is particularly relevant given that early treatment could have the greatest impact in terms of reducing mortality rates . PresentIn every step of the tumorigenesis process, tumours must overcome the body’s antitumour effector immune response. To avoid the effects of the immune system, tumours deploy a multitude of immune escape mechanisms. Recent clinical evidence shows the relevance of one of these mechanisms present in multiple cancer types, including NSCLC: the PD-1/PD-L1 pathway. Inflammatory cytokines such as interferon-gamma induce PD-L1 expression, both in tumour cells and in myeloid-derived cells infiltrating the tumour microenvironment. Interaction between PD-L1 and PD-1, expressed on activated T lymphocytes, limits the proliferation, activation, and effector mechanisms of tumour-specific T lymphocytes. The remarkable clinical efficacy of mAbs targeting PD-1 or PD-L1 has led to the approval of these agents as monotherapy or combination therapy in different stages of NSCLC. However, primary and secondary resistance is frequent, thus limiting the long-term clinical benefit of these treatment modalities . HoweverConventional cancer therapies can complement anti-PD-1/PD-L1 mAbs, thus providing early control of disease progression. However, in addition to early clinical control, surgery, chemotherapy, and radiotherapy also enhance the priming phase of the immune response, and can, therefore, synergize with anti-PD-1 mAbs.Regarding surgery, preclinical research has demonstrated the superiority of neoadjuvant immunotherapy over adjuvant immunotherapy. Neoadjuvant immunotherapy is characterized by an increase in tumour-specific CD8+cells, suggesting a role in T cell priming or in T cell migration into the tumour, although further research is needed to decipher immune mechanisms implicated. Many more preclinical studies have evaluated the potential of chemotherapy and radiotherapy combined with immunostimulatory monoclonal antibodies. Several chemotherapy and radiotherapy regimens induce immunogenic cell death, characterized by tumour-associated antigen release in the context of danger signals that promote the activation of the cross-presenting dendritic cells, characterized by the expression of the Batf3 transcription factor. In addition, elimination of immunosuppressive immune populations, such as T regulatory cells and myeloid-derived suppressor cells, has also been frequently reported for a variety of chemotherapy and radiotherapy regimens. In the case of radiotherapy (RT), a robust abscopal effect has been observed in preclinical models using ablative hypofractionated radiation dose schedules, such as 8 Gy × 3 fractions. These RT regimens allow cytoplasmic DNA accumulation and subsequent activation of the cGAS-STING (stimulator of interferon genes) pathway, leading to high type I interferon production. In contrast, a single dose of 20 Gy induced the expression of the exonuclease Trex, which prevents the accumulation of cytoplasmic DNA and induction of immune response priming .p = 0.0043).Surgery is the main treatment option in patients with resectable localized NSCLC, with 5-year OS rates ranging from 36%  to 92% (stage IA1) . NumerouSurvival rates in patients surgically-treated for NSCLC remain poor, underscoring the need for novel therapeutic strategies. Multiple clinical trials are currently underway in early-stage NSCLC to assess the role of ICIs in both adjuvant and neoadjuvant settings. Initially, several vaccines were evaluated, with one study demonstrating that immunotherapy against the tumor-specific MAGE-A3 antigen in melanoma showed anti-tumour activity . Based oNeoadjuvant and adjuvant therapy have a comparable impact on OS outcomes , althougImmunotherapy administered in combination with neoadjuvant therapy could potentially induce an antitumour immune response that persists beyond surgery, thus preventing recurrent disease. Indeed, various studies have demonstrated the feasibility and safety of ICI as a neoadjuvant therapy in NSCLC .In the trial carried out by Forde et al. NCT02259621) [9621 [25]2 + carboplatin AUC 6 IV every 3 weeks) plus nivolumab (360 mg IV), 3 cycles, followed by surgery and one year of adjuvant nivolumab (240 mg IV every 2 weeks for 4 months and 480 mg IV every 4 weeks for 8 months) in 46 patients with resectable stage IIIA (N2 or T4) NSCLC [2 on days 1, 8, and 15) and atezolizumab 1200 mg IV every 3 weeks for 4 cycles. The primary endpoint was MPR. Thirty patients were included and 17 (57%) achieved a MPR [Studies demonstrating that chemoimmunotherapy is superior to CT alone in patients with metastatic NSCLC have prompted interest in evaluating the role of chemoimmunotherapy as neoadjuvant therapy in early-stage NSCLC followed by surgery. The NADIM study NCT03081689) is an open-label, phase 2, single-arm clinical trial to evaluate the safety and efficacy of neoadjuvant CT (paclitaxel 200 mg/m4) NSCLC . The pri81689 is ed a MPR . The mosStereotactic body radiation therapy (SBRT) has become the standard treatment for inoperable early-stage NSCLC (ES-NSCLC) . SBRT isVarious trials have reported excellent results with SBRT in ES-NSCLC. The phase 2 RTOG 0236 trial in patients with inoperable ES-NSCLC yielded an impressive 5-year local tumour control rate of 93% ,40, withMost patients with ES-NSCLC who are candidates for SBRT (but not surgery) cannot safely receive CT. Moreover, the combination of adjuvant CT plus SBRT has not shown positive results in frail patients with ES-NSCLC who have multiple underlying pathologies . The comDespite the proven clinical benefit of SBRT plus immunotherapy in metastatic disease, there is still no demonstrated benefit for this combined treatment in ES-NSCLC, although several phase 1/2 clinical trials are currently investigating this approach. NRG Oncology is carrying out an interesting phase 3 trial of durvalumab vs. adjuvant placebo after SBRT in patients with unresected ES-NSCLC (PACIFIC-4) .One-third of NSCLC patients have stage III disease at diagnosis. In these patients, the standard of care (SoC) is concurrent platinum-based chemotherapy and radiation . Unfortup < 0.0001) [p < 0.001) [RT may increase the production and presentation of tumour antigens, which may enhance the antitumour immune responses elicited by ICIs . Preclin 0.0001)  and OS ( 0.0001) ,65. Durv< 0.001)  and decr< 0.001) . Safety < 0.001) ,66. More< 0.001) . Althoug< 0.001) , careful< 0.001) .Enrolment in the PACIFIC trial was not restricted to any specific PD-L1 expression threshold level, and PD-L1 status was not mandatory for inclusion. A prespecified exploratory analysis assessed the benefit of durvalumab according to PD-L1 expression ≥ 25% (by SP263 IHC assay). Of the 63% of patients assessable for PD-L1 expression, 35% and 67% had PD-L1 ≥ 25% or PD-L1 ≥ 1%, respectively. In patients with PD-L1 ≥ 25%, durvalumab improved PFS  and OS , whereas in those with PD-L1 < 25%, it improved PFS  but not OS  . The EurThe combination of pembrolizumab and CRT was evaluated in the phase 2 LUN 14-179  and KEYNThe optimal duration of neoadjuvant or adjuvant treatment with ICIs is unknown. At present, treatment duration is based on data from clinical trials that have evaluated neoadjuvant and adjuvant therapy in NSCLC. Treatment duration is an important consideration due to its potential impact on patient quality of life and with respect to the cost. Currently, there is no evidence of any correlation between longer treatment duration and increased survival in advanced NSCLC ,79,80,81In terms of neoadjuvant therapy, the trials that have evaluated platinum-based induction CT combined with third-generation CT agents have generally administered three cycles of neoadjuvant CT, with one study using four cycles . For thiNo evidence is available about the optimal timing of surgery after neoadjuvant treatment. The interval between the first neoadjuvant dose and surgery has varied in the different clinical trials. Thus, surgery was performed two weeks after the second cycle in the first trial of nivolumab, 3–4 weeks after the 21st day of the third cycle in the NADIM trial, and on day 29 after the 2nd cycle of pembrolizumab in the NEONUM trial. However, experimental analyses suggest that the efficacy of neoadjuvant immunotherapy in terms of survival may be dependent on an optimal duration between the first dose and resection . The onlOne difficulty that surgeons may face in patients who receive neoadjuvant ICI therapy prior to surgery is the response to immunotherapy, such as the contradictory response between the primary tumour and the hilar and mediastinal lymph nodes , in which an initial “tumour flare”, caused by immune cell infiltration, is observed. In these cases, it can be difficult to distinguish between pseudo-progression and real tumour progression. If this response is not interpreted correctly, surgery might be erroneously ruled out , a phenoMost trials to date have focused on the complete resection rate, even though they agree that surgical morbidity and mortality do not differ from series without neoadjuvant therapies . It is wBiomarker studies in early-stage tumours are approximately similar to those in advanced tumours. In advances setting most developed biomarkers are PD-L1 expression and TMB, and are the only ones that we use in daily clinical practice, but there are several biomarkers that have been or that are being studied. Neoadjuvant trials are an ideal setting for exploring predictive biomarkers and same markers as in advanced disease are being explored in resectable NSCLC, that include four major categories: tumour cell-associated biomarkers as PD-L1 expression and TMB, tumor microenvironment-related biomarkers, liquid biopsy-related biomarkers and host-related markers. We need to take into account that biomarkers in early-stage NSCLC have only been explored preliminarly and that we cannot confirm their value so far and even compare to their role in advanced disease. PD-L1 expression and TMB have not shown a consistent association with response to neoadjuvant immunotherapy. In the study by Forde and colleagues , tumoursBoth the NEOSTAR and LCMC3 trials found that immunotherapy showed activity (measured by MPR) against early-stage NSCLC. PD-L1 was positively correlated with MPR in NEOSTAR, but neither PD-L1 nor TMB correlated with MPR in LCMC3 ,31. RadiT-cell expansion and ctDNA are emerging biomarkers that may prove useful in the future. In the CheckMate 159 trial, T-cell receptor (TCR) repertoire was significantly expanded in patients who achieved MPR and ctDNA clearance prior to surgery was detected in all patients who achieved a reduction ≥ 30% . FurtherIn early stage, non-operable NSCLC without nodal involvement, SBRT is the RT modality of choice. However, although SBRT achieves a local control rate of approximately 90%, lymph node and distant relapse rates range from 25% to 35% ,40. For Although the tumour microenvironment is strongly immunosuppressive, administration of SBRT can alter this microenvironment, making it proinflammatory. Several studies have demonstrated that the antitumour effects of radiotherapy are at least partially based on activation of immunity , which pAt present, there are numerous unknowns, including the optimal dose and fractionation schedule required to achieve the immunogenic effect, the optimal manner of combining RT and immunotherapy, and how to best measure response. Golden et al. showed that immunogenic cell death depends on the dose per fraction ,105. PreThe duration of the immune response could also depend on the dose per fraction. At doses of 10 Gy, markers of immune activation are evident at 72 h, while PD-L1 expression is reduced 6 days after administration of SBRT . HettichUntil now, only curative-intent surgery had a role in NSCLC. However, paradigms of extended and unresectable disease have changed with the introduction of targeted therapies and immunotherapy in lung cancer . The wayAlthough the PACIFIC trial was not designed to evaluate durvalumab based on archival tumour PD-L1 expression, the results of exploratory analyses support a treatment benefit for durvalumab versus placebo irrespective of archival pre-specified tumour PD-L1 expression status. In that trial, the only patients who did not benefit in terms of OS from durvalumab were those with PD-L1 expression levels < 1%. However, this finding was based on an unplanned post hoc analysis with a PD-L1 cut-off level that differed from the original (25% vs. 1%) . In the Moding and colleagues conducted a retrospective study to determine whether ctDNA, determine through a personalized profiling by deep sequencing (CAPP-Seq), could help to identify patients with NSCLC who might benefit from consolidation therapy with ICI after chemoradiation and also be used to monitor treatment response . Those aImmunotherapy and targeted therapy have revolutionized the treatment landscape in advanced NSCLC. For this reason, the role of these therapies in localised disease is current being studied, with promising results to date. However, in these early stages, administration of immunotherapy is more complex as their purpose is different, we look for the cure of the patient, so objectives are different. In this regard, surrogate markers of OS are needed to obtain more conclusive results earlier in the treatment process. In addition, we need to find the best way to combine it with radical RT and surgery, which is not an easy task, in part because there are still many unresolved questions in this area. In the adjuvant studies that are currently underway, the most common primary endpoint is DFS, rather than OS. Importantly, we lack predictive biomarkers and the optimal duration of adjuvant treatment remains unclear. We are currently awaiting the results of several trials evaluating the role of PD-1 axis blocking-based immunotherapy as an adjuvant therapy, although vaccine-based strategy failed to demonstrate survival benefit. In the neoadjuvant setting with immunotherapy, the combination of CT and immunotherapy appears to be more promising than immunotherapy alone, significantly increasing pCR rates. The studies conducted to date leave numerous unresolved questions, including the lack of predictive biomarkers and that we still do not know how to optimally assess radiological response or the optimal duration. However, we fully expect that ongoing trials will demonstrate a benefit for immunotherapy in early-stage disease as well. In short, it seems clear that immunotherapy (at least in patients without driver mutations) will inevitably form part of the treatment arsenal for early NSCLC in the near future based on the promising results of the studies published thus far and on the numerous trials currently in progress.


Cancer patients represent a vulnerable cohort during the Sars-CoV-2 pandemic. Oncological societies have generated a plethora of recommendations, but precise instructions about routine oncological procedures remain scarce. Here, we report on local COVID-19 protection measures established in an interdisciplinary approach at a tertiary care center during the first wave of the pandemia in Germany. Following these measures, no additional morbidity or mortality during oncological procedures was observed, and no nosocomial infections were registered. However, Validation of our measures is outstanding and regional SARS-CoV-2 prevalence was low. However, specific oncological measures might be important to ensure optimal oncological results, especially for advanced cancer stages during this and future pandemia. In the future, communication about these measures might be crucial to a cancer patient´s assigned network to reduce the danger of excess mortality within the second wave of the COVID-19 pandemic.The online version contains supplementary material available at 10.1007/s10585-021-10083-1. SARS-CoV-2 spread from Wuhan all over the world, ultimately causing a global pandemia affecting several aspects of medicine, as well as oncology. Patients and physicians have had to face several new challenges . AlthougPreliminary data suggest that infection rates with SARS-CoV-2 are comparable between cancer and non-cancer patients –8. At prOncologic practitioners are challenged to manage under- and over-treatment in the everyday world, and even more so within a pandemic Further on, cancer patients are at particular risk of excess mortality, as well as increased SARS-CoV2-related mortality . SeveralIn general, procedural questions arise at several oncological decision steps, requiring interdisciplinary exchange Fig. . In addiBeyond SARS-CoV-2 evaluation, once the decision is made in favor of anti-cancer therapy, the question of treatment urgency needs to be addressed. Apart from objective remission pressure, there are little data on the benefit of immediate versus delayed treatment initiation, in particular in the metastatic setting. Therefore, depending on local infection rates, availability of resources and an individual patient´s risk for a severe course of a potential SARS-CoV-2 infection must be weighed against the benefits of immediate treatment initiation. Drug holidays or watchful waiting might be considered as alternatives to active treatment, especially in the advanced disease cases, during a high SARS-CoV-2 prevalence, and in high risk patients Fig.  23]. At. At23]. SARS-CoV-2 represents a new relevant differential diagnosis for infectious complications during therapy. The management of febrile neutropenia according to the S3 guideline and the local Sars-CoV-2 standard appears appropriate . A shift in chemotherapy e.g. to four weeks and continuation of systemic therapy after recovery of lymphopenia or granulopenia seem justifiable . In principle, an earlier preventive use of hematolymphopoietic growth factors is another possibly useful supportive measure, considering potential bottlenecks in blood supply . In the Radiotherapy usually consists of a longer serial therapy period without interruption . This type of therapy needs to remain feasible during a pandemic, in particular in the curative setting, or once tumor burden qualifies a patient for radiotherapy. Nevertheless, depending on the risk posed by the pandemic situation, the need for therapy must be checked critically in an interdisciplinary manner. Also dosing has to be critically evaluated. In order to keep the total treatment time as short as possible, hypofractionated radiation could be used preferentially during a pandemic, in accordance with the current recommendations and level of evidence  .Although considerations were made mainly for the advanced or metastatic setting, application to the limited diesease setting is also feasible, as illustrated in Supplemental Figs. S3 and S4.In summary, the Sars-CoV-2 pandemia poses a major challenge to interdisciplinary oncology and a strong interdisciplinary discussion – always essential in oncology—is necessary for now and in the near future to ensure a more individualized approach to treatment decisions. Due to our experience, oncology in its best form according to interdisciplinary consensus is essential more than ever. due to our experience. The procedural considerations presented here, resulting from an ongoing interdisciplinary structured discussion, enabled our center to continue oncological therapies in the CCC-N without relevant additional Sars-CoV-2-related morbidity or mortality. No nosocomial infections were so far observed. Doubtless, this has to be critically reflected by the fact that local SARS-CoV-2 infections rates were low during the first wave of the pandemic and resource bottlenecks did not define our daily work. However, our measures have not yet been stress tested.Under or over-treatment, as well as increased excess mortality, must also be avoided in future pandemic phases. The cumulative oncological network knowledge and data expertise, both in the context of interdisciplinary tumor conferences and in national network structures such as CCCs and NCTs, appear to be required and useful to optimally adjust and communicate the individual therapy algorithm during the pandemic. This is essential for the foreseeable future. Ultimately, the current SARS-CoV-2 pandemc is an opportunity to generate evidence to better define needs of oncological patients for future pandemia, which hopefully won’t appear to soon.Supplementary file1 (JPG 575 KB)Supplementary file2 (JPG 590 KB)Supplementary file3 (JPG 286 KB)Below is the link to the electronic supplementary material.


Tuberculosis (TB) is a significant public health problem that causes substantial morbidity and mortality. Current first-line anti-TB chemotherapy, although very effective, has limitations including long-treatment duration with a possibility of non-adherence, drug interactions, and toxicities. Dose escalation of rifampicin, an important drug within the regimen, has been proposed as a potential route to higher treatment efficacy with shorter duration and some studies have suggested that dose escalation is safe; however, these have almost entirely been conducted among human immunodeficiency (HIV)-negative TB patients. TB-HIV co-infected patients on antiretroviral therapy (ART) are at increased risk of drug-drug interactions and drug-related toxicities. This study aims to determine the safety of higher doses of rifampicin and its effect on the pharmacokinetics of efavirenz (EFV) and dolutegravir (DTG) in TB-HIV co-infected patients.This study is a randomized, open-label, phase IIb clinical trial among TB-HIV infected adult outpatients attending an HIV clinic in Kampala, Uganda. Patients newly diagnosed with TB will be randomized to either standard-dose or high-dose rifampicin (35 mg/kg) alongside standard TB treatment. ART-naïve patients will be randomly assigned to first-line ART regimens (DTG or EFV). Those who are already on ART (DTG or EFV) at enrollment will be continued on the same ART regimen but with dose adjustment of DTG to twice daily dosing. Participants will be followed every 2 weeks with assessment for toxicities at each visit and measurement of drug concentrations at week 6. At the end of intensive-phase therapy (8 weeks), all participants will be initiated on continuation-phase treatment using standard-dose rifampicin and isoniazid.This study should avail us with evidence about the effect of higher doses of rifampicin on the pharmacokinetics of EFV and DTG among TB-HIV co-infected patients. The trial should also help us to understand safety concerns of high-dose rifampicin among this vulnerable cohort.ClinicalTrials.gov, ID: NCT03982277. Registered retrospectively on 11 June 2019. Tuberculosis (TB) is a significant public health burden that causes substantial morbidity and mortality. Globally, approximately 10 million people developed TB in 2017, 9% of whom were people living with human immunodeficiency (HIV) (72% of these residing in Africa). Eighty-seven percent of all the world’s TB cases were accounted for by the 30 high-burden TB countries [Rifampicin is a key component of current first-line TB treatment. It contributes to rapid bactericidal activity during the first few days of TB treatment, and it has a sterilizing effect that lasts throughout the treatment course . Even wiRifampicin induces a plethora of metabolic processes through the pregnane-x receptor , includiRifampicin induces CYP2B6 (responsible for efavirenz (EFV) metabolism) and UGT1A1, and CYP3A4 (responsible for dolutegravir (DTG) metabolism). Although earlier studies demonstrated that the standard-dose rifampicin does not significantly decrease EFV concentrations, , anRifampicin-dose escalation may help to improve TB treatment outcomes. However, there is almost no information on the enzyme-induction effect of high-dose rifampicin on EFV and DTG and a paucity of data on the safety of higher rifampicin doses in HIV-infected patients on ART. If higher doses of rifampicin are to be considered for routine TB treatment in African countries, such data will be critical for the high number of HIV co-infected persons. The aim of this study is to determine the effect of higher-dose rifampicin on the pharmacokinetics (PK) of EFV and DTG in TB-HIV co-infected patients, and to establish whether higher-dose rifampicin is safe for HIV-infected patients with TB.This study is being conducted at the integrated TB-HIV Outpatient Clinic of the Infectious Diseases Institute Makerere University College of Health Sciences in Kampala, Uganda, which is an urban outpatient HIV clinic that provides care to 200 patients infected with TB annually.This is a randomized, open-label, phase IIb clinical trial of HIV-infected patients newly diagnosed with TB.(1) adults of age ≥ 18 years, (2) confirmed HIV-1 infection, (3) already started on EFV- or DTG-based ART or planned to start on ART , and (4) diagnosed with TB and due to initiate rifampicin-containing therapy.Patients are enrolled if they fulfill the following inclusion criteria: Mycobacterium tuberculosis/rifampicin (MTB/RIF), (2) pregnant women, (3) women of reproductive age on DTG who decline the use of effective contraception methods , (4) decompensated liver disease and/or aminotransferases > 5 x upper limit of normal (ULN), and (5) glomerular filtration rate (GFR) < 50 ml/min.Patients will be excluded if they meet any one of the following criteria: (1) have rifampicin-resistant TB identified by baseline Xpert To determine the effect of a high dose of rifampicin  on the PK of first-line antiretroviral drugs (EFV and DTG) in TB-HIV co-infected patients on TB treatment2.To investigate the safety/tolerability of higher doses of rifampicin in TB-HIV co-infected patients on TB treatment and first-line antiretroviral drugs (EFV and DTG)3.To determine if TB-HIV co-infected patients on higher doses of rifampicin are more likely to have negative sputum cultures by the end of the intensive phase of TB treatment than patients on standard-dose rifampicin4.To explore the relationships between exposure to rifampicin, EFV, and DTG and the tolerability and efficacy of these drugs (PK-pharmacodynamic (PD) analysis)Patients on a high dose of rifampicin will have a minimal decrease in exposure to EFV and DTG compared to those on standard-dose rifampicinA higher proportion of patients on first-line ART and high-dose rifampicin will experience hepatotoxicity compared to those on standard-dose rifampicin, but this increase will be modest, and hepatotoxicity events will be mostly low-gradeA higher proportion of patients on high-dose rifampicin will have negative cultures at week 8 compared to those on standard-dose rifampicinAntiretroviral response will be similar among patients who use standard- or high-dose rifampicin as part of their TB treatmentTB is diagnosed using chest x-ray, sputum florescent microscopy or Xpert MTB/RIF, and a clinical history that includes any one of the following symptoms: cough, fever, weight loss, and drenching night sweats. Patients with confirmed TB , or TB adenitis confirmed by Ziehl-Neelsen (ZN) staining or histopathology) are included in the study.Participants are randomized to either standard-dose (10 mg/kg) or high-dose (35 mg/kg) rifampicin. All other anti-TB drugs ) are given at their standard dose for weight bands using Fixed Dose Combination (FDC) tablets supplied by the National TB Control Program. The patients on high-dose rifampicin have their additional doses supplemented by rifampicin capsules.ART-naïve patients are randomly assigned to first-line ART regimens (DTG 50 mg twice daily or EFV 600 mg once daily) which is initiated 2 weeks into TB treatment. Those who are already on ART at enrollment continue the same ART regimen; however, participants on DTG are switched to twice-daily DTG while they are on rifampicin. EFV/DTG is given in combination with tenofovir, zidovudine, or abacavir plus either lamivudine or emtricitabine. Most patients are given tenofovir/lamivudine as backbone therapy because it is the preferred first-line backbone therapy nationally and they are only offered zidovudine or abacavir if there are contraindications to tenofovir. Viral-load measurements are performed at baseline (for patients on ART at baseline) and at the week-24 visit (6 months after initiation of ART).Participants are followed up every 2 weeks for study procedures including assessment for toxicities , and at 1, 2, 4, and 8 h following observed intake of the anti-TB drugs. Mid-dose EFV concentrations are measured at 0 h.The blood samples are immediately placed in a dark cooler and transported to the laboratory within 30 min of collection, after which samples are centrifuged, aliquoted, batched, and frozen at − 80 °C until quantification of drug concentrations is done. Quantification of the drug concentrations  will be performed using pre-established, validated, high-performance liquid chromatography (HPLC) assays.Sputum samples are collected from patients with pulmonary TB for culture on liquid medium (Mycobacteria Growth Indicator Tube (MGIT) and solid medium (BACTEC) at baseline and 8 weeks of anti-TB treatment. Additional samples will be collected for storage every 2 weeks during the first 2 months of TB treatment, for storage for future cultures using mycobacterial-load assay.Participants are assessed for adverse events on every study visit using direct questioning, physical examination, and laboratory parameters; alanine transferase (ALT) and bilirubin (2 weekly) and creatinine (4 weekly). The severity of liver toxicity is graded according to the National Institutes of Health DAIDS . Study mAnti-TB medication, under the standard of care, will be reintroduced at their standard doses when ALT is within the normal range. All serious adverse events are followed up until resolution even after participants are withdrawn from study.There is no anticipated harm and compensation for trial participation.Additional blood samples will be stored at baseline, weeks 2, 4, 6, and 8 for validation of new biomarkers used for early detection of drug-induced liver injury.We applied a sample size calculation using coefficient of variation and percentage change in geometric mean of EFV mid-dose concentrations. This study is powered on the primary endpoint of mid-dose EFV concentrations. We varied the difference in the concentrations among the different dose arms (high-dose arm vs. standard-dose arm) between 5 and 30%, which is close to the bioequivalence accepted by the Food and Drug Authority. With a power of 80%, a difference in mid-dose EFV concentrations of 30% and assuming loss to follow-up of 25%, we would need a sample size of 120 participants (30 patients in each group). Patients are actively referred from city council hospitals in order to achieve our sample size within the target recruitment period of 1 year.Patient retention: the study team is responsible for tracking participants using phone calls, and where possible, home visits, to ensure retention rate. Locator information is collected and updated at each visit where necessary. Outcome data will be collected from patients who deviate or discontinue assigned treatment on their clinic visits or through phone interviews.T test on logarithmically transformed PK measurements or a Wilcoxon rank sum test on untransformed data.We will compare the EFV mid-dose concentrations and the trough concentrations of DTG in patients on 35 mg/kg and 10 mg/kg doses using an independent samples In addition, we will apply a population PK-modeling approach for PK data. We will develop population models to describe the PK parameters of rifampicin, EFV, and DTG and the between-subject and between-occasion variability in these parameters. The models will be based on previously developed PK models that will be adapted by fitting them to the data collected in the study.We will compare the proportions of patients who develop liver toxicity and the severity/grade of liver toxicity among patients on the different doses of rifampicin using the chi-squared test. We will determine the association between each rifampicin dose and hepatotoxicity using Cox regression.We will estimate the proportion of patients who remain culture-positive after 8 weeks of anti-TB treatment in each treatment arm and compare them using the chi square test. Using non-linear mixed effects modeling, we will develop PK-PD models to determine the relationship between PK exposure and PD response including virological suppression, toxicities, and bacteriological response.Analysis of primary endpoint will be performed per protocol whereas intention-to-treat analysis will be performed as sensitivity analysis. Missing data on drug concentration will be imputed using multiple imputation when performing sensitivity analysis.During the study, periodic monitoring is conducted to ensure that the protocol and International Conference on Harmonization-Good Clinical Practice (ICH-GCP) principles are being followed. Additionally, the study site may be subject to review by the Institutional Review Board and the regulatory authorities.De-linked clinical and demographic data is collected on Case Report Forms (CRF) and kept in a locked cabinet with access granted only to authorized study staff. Data from the CRFs is stored via Datafax, which reads the data using intelligent character recognition and enters the data into a secure server at the Infectious Diseases Institute. Data will be securely stored for a minimum of 20 years according to the local National Drug Authority regulations for clinical trials.The independent Data Safety and Monitoring Board (DSMB) will make recommendations concerning the study to the Trial Steering Committee. The DSMB is chaired by Dr. Catriona Waitt a clinical pharmacologist from the University of Liverpool and based at the Infectious Diseases Institute, Kampala, with experience in dose-finding PK studies, Dr. Agnes Kiragga, a senior statistician at the Infectious Diseases Institute with experience in HIV clinical trials and cohort studies, Dr. Marta Boffito, the clinical research lead at St Stephen’s AIDS Trust in the U.K, who has extensive expertise in complex pharmacological issues, and Dr. Eric Decloedt, a registrar in clinical pharmacology and a senior lecturer and researcher at Stellenbosch University in South Africa. The DSMB is independent from the sponsor and has no competing interests. The first interim analysis will be conducted when 10% of the participants complete the study medication. Trial monitoring is conducted independent of the investigators by internal monitors at the Infectious Diseases Institute. The Trial Steering Committee is composed of Dr. Stella Zawedde (chair), a representative from the National Tuberculosis and Leprosy Program in Uganda, Dr. Pauline Byakika-Kibwika and Associate Professor David Meya, both infectious disease specialists at the Department of Internal Medicine of Makerere University, Dr. Susan Adakun, head of the Mulago National Referral Hospital Tuberculosis Unit, and Elizabeth Tindyebwa, a lay representative from the Friends’ Council (patient group at IDI). Regular discussions are held over email or conference calls when required but at least once a year. The Trial Management Group meets weekly and is responsible for the day-to-day study activities. It is composed of the Dr. Christine Sekaggya , Dr. Derek Sloan, and Dr. Mohammed Lamorde (co-investigators), Dr. Ruth Nabisere , Dr. Brian Otalo (study physician), Florence Aber, Juliet Nampala (study nurses), Joseph Musaazi (statistician), and Hamza Mayanja (pharmacist and person responsible for randomization).All precautions are being made to ensure the safety of patient data and identifying information. All patients provide written informed consent for participation in the study and the storage of biological samples including blood, urine, and sputum for ancillary studies, a process conducted by the study nurse and study coordinator.JC2218), the National Drug Authority, and the Uganda National Council for Science and Technology.Ethical approval for this study was sought from the Joint Clinical Research Council . It should provide crucial evidence about the PK and the safety of co-administration of EFV and DTG with 35 mg/kg of rifampicin in a TB-HIV co-infected population. We are including a population of patients with severe immunosuppression that will be representative of the high proportion of TB patients, who are also co-infected with HIV.This study should be able to demonstrate whether higher doses of rifampicin can be safely used in HIV-positive patients on ART, and whether this has an impact of their treatment outcomes with faster mycobacterial-load clearance.With the stored samples from this population, we will conduct a pharmacogenomic analysis to understand the role of genetic polymorphisms in the PK of the investigated drugs and evaluate new molecular assays that can be used for early detection of hepatotoxicity.There is need for more vigilant safety monitoring coupled with a very strong Data and Safety Monitoring Board due to the anticipated toxicities and drug-drug interactions that we might experience in the trialSecondly, there is no blinding in this clinical trial, hence it is hard to completely rule out the effect of bias in interpreting possible toxicities that are not backed by objective laboratory parametersCurrently, because of the test-and-treat recommendation, some patients are already on ART and, therefore, randomization to ART for some patients is not possibleHowever, the investigators also acknowledge some of the anticipated challenges and/or limitations of this study which include:Despite these, we believe that this study will demonstrate that early phase trials can be successfully conducted in resource-constrained settings where the highest burden of the dual epidemic lies.The study, with protocol version 3, 17 December 2018, began enrollment on 30 April 2019 and had recruited 37 participants by 18 October 2019. The expected end of enrollment is 30 December 2020.Additional file 1. Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Checklist: recommended items to address in a clinical trial protocol and related documents.