Variability in gene expression levels was then estimated for the subset of these genes that was found to be adequately expressed in two relevant resources: the Genotype-Tissue Expression (GTEx) and Eye Genotype Expression (EyeGEx) datasets. We found that genes suspected to be associated with variable penetrance tended to have significantly more variability in gene expression levels in the general population (p = 0.0000015); this finding was consistent across tissue types. The results of this study point to the possible influence of cis and/or trans-acting elements on the expressivity of variants causing Mendelian disorders. They also highlight the potential utility of quantifying gene expression as part of the investigation of families showing evidence of variable penetrance.Inherited eye disorders (IED) are a heterogeneous group of Mendelian conditions that are associated with visual impairment. Although these disorders often exhibit incomplete penetrance and variable expressivity, the scale and mechanisms of these phenomena remain largely unknown. Here, we utilize publicly-available genomic and transcriptomic datasets to gain insights into variable penetrance in IED. Variants in a curated set of 340 IED-implicated genes were extracted from the Human Gene Mutation Database (HGMD) 2019.1 and cross-checked with the Genome Aggregation Database (gnomAD) 2.1 control-only dataset. Genes for which >1 variants were encountered in both HGMD and gnomAD were considered to be associated with variable penetrance ( Incomplete penetrance and variable expressivity (hereafter referred to as variable penetrance) are two closely linked biological phenomena leading to non-linearity between genotype and phenotype. Incomplete penetrance occurs when individuals with a particular disease-predisposing genetic change fail to express the corresponding disease phenotype; variable expressivity occurs when individuals carrying identical genetic changes display significant variability in terms of disease severity and/or onset. These phenomena are widespread in human genetics, even in the context of Mendelian disorders, i.e., conditions that are driven by monoallelic or biallelic variants with strong effects . Importain silico tools) [cis-acting expression regulation in genes that are implicated in retinal disorders exhibiting variable penetrance [cis-acting effects despite the fact that these account only for a fraction of gene expression variability [The mechanisms underlying variable penetrance remain largely unknown . While mo tools) . Anothernetrance . Notablyiability . Here, we integrate publicly available genomic and transcriptomic datasets to study variable penetrance in a well-characterized group of Mendelian conditions: inherited eye disorders (IED). The central hypothesis driving this work is that IED-implicated genes associated with variable phenotypic expression in patients will exhibit variable gene expression in the general population. To test this hypothesis, we: (i) identified a subset of IED-implicated genes that are enriched for variants with possible variable penetrance (IP/VE-associated genes) and (ii) compared gene expression levels between these genes and other IED-implicated genes for which there was no evidence of variable penetrance. IED-implicated genes were obtained through PanelApp, a publicly available knowledgebase that combines expert reviews and manual curation to create diagnostic-grade gene lists . We focun = 8; RP9, TUB, TMEM126A, IDH3B, FOXD3, SSBP1, MIR184, and OVOL2).Disease-associated variants in the above IED-implicated genes were obtained from the Human Gene Mutation Database (HGMD) Professional . The HGMD represents an attempt to collate all published variants that underlie, or are closely associated with, human inherited disease . At presTo limit the potential impact of annotation errors in HGMD, we obtained the Combined Annotation-Dependent Depletion (CADD) PHRED-scaled score (a widely used measure of variant deleteriousness) for each variant and only considered changes with a score >15 as disease-associated. CADD is an integrative annotation tool built from more than 60 genomic features. A PHRED-scaled score ≥10 indicates a raw score in the top 10% of all possible single nucleotide variants, while a score ≥20 indicates a raw score in the top 1% . CADD veInitially, we aimed to identify IED-associated variants that are present in unaffected individuals. To achieve this, we looked for HGMD-listed changes that have a CADD score >15 and are present in the Genome Aggregation Database (gnomAD). GnomAD incorporates exome or genome sequence data from >140,000 humans; these data were obtained primarily from case-control studies of adult-onset common diseases, including cardiovascular disease, type 2 diabetes, and psychiatric disorders . GnomAD Subsequently, we aimed to identify a subset of IED-implicated genes that are possibly associated with incomplete penetrance and/or variable expressivity (IP/VE-associated genes). The following criteria were used to define IP/VE-associated genes: (i) genes classified as green and monoallelic in PanelApp for which at least two HGMD-listed variants (with a CADD score >15) were found to be present in a heterozygous state in at least two individuals from the gnomAD control-only dataset, (ii) genes classified as green and biallelic in PanelApp for which at least two HGMD-listed variants (with a CADD score >15) were found to be present in a homozygous state in at least two individuals from the gnomAD control-only dataset, (iii) genes classified as green and both monoallelic and biallelic in PanelApp for which at least two HGMD-listed variants (with a CADD score >15) were found to be present in a homozygous state  or heterozygous state  in at least two individuals from the gnomAD control-only dataset, and (iv) genes classified as green and X-linked in PanelApp for which at least two HGMD-listed variants (with a CADD score >15) were found to be present in either a hemizygous or homozygous state in at least two individuals from the gnomAD control-only dataset.We used a cut-off of two individuals to account for (i) contamination of the gnomAD control dataset with individuals who have Mendelian disorders, (ii) sequencing errors, and (iii) the presence of a disease-predisposing variant in a gnomAD control individual who is too young to be symptomatic. A flow-chart outlining the classification of genes into IP/VE-associated or “other” is shown in Two gene expression resources were used to determine variability in population mRNA levels for IED-implicated genes: the GTEx  and the et al. and using parameters broadly in keeping with those used by the GTEx consortium [Variability in mRNA levels in the population was assessed for the entire GTEx v8 dataset using a method similar to that developed by Simonovsky nsortium . First, nsortium . Prior tnsortium . A comprnsortium . The locnsortium  and distnsortium ) but morThe same procedure was performed for the single-tissue EyeGEx dataset. Raw estimated gene reads (output from RMEM) were downloaded from the GTEx web server and normalized in the same manner as the GTEx data, as described above. The LCV was calculated for all genes expressed at 7 cpm in at least 80% of retinal samples. This yielded variability estimates for 9,942 genes based on a total of 453 samples. Tables containing the calculated LCV scores for all genes across the GTEx and EyeGEx datasets are provided in p-values were computed conventionally  were linked to more than one disorder ; 46%  were missense and 17%  were nonsense changes. In terms of mode of inheritance (according to PanelApp), 24%  of variants were in genes labeled as monoallelic, 51%  in genes labeled as biallelic, 16%  in genes labeled as both monoallelic and biallelic, and 9%  in genes labeled as X-linked.In total, 1.3%  of these IED-associated variants were present in at least two individuals in the gnomAD control-only cohort in a disease-causing state; 86% (244/285) of those had a CADD score >15  and 76% (i) For genes labeled as monoallelic in PanelApp, 152 HGMD-listed variants with a CADD score >15 were found to be present in a heterozygous state in at least two individuals from the gnomAD control-only dataset.(ii) For genes labeled as biallelic in PanelApp, 48 HGMD-listed variants with a CADD score >15 were found to be present in a homozygous state in at least two individuals from the gnomAD control-only dataset.n = 6) or the heterozygous state  in at least two individuals from the gnomAD control-only dataset.(iii) For genes labeled as both monoallelic and biallelic in PanelApp, 29 HGMD-listed variants with a CADD score >15 were found to be present in a homozygous state  For genes labeled as X-linked in PanelApp, 15 HGMD-listed variants with a CADD score >15 were found to be present in either a hemizygous or homozygous state in at least two individuals from the gnomAD control-only dataset.Using the criteria outlined in the Methods section, we identified 56 IP/VE-associated genes . Thirty-one of these were labeled as monoallelic, 11 as biallelic, 11 as both monoallelic and biallelic, and 3 as X-linked in PanelApp. Variability in gene expression at the population level was studied for IED-implicated genes. The GTEx v8 dataset was initially utilized: 75% (259/340) of genes were found to be adequately expressed in enough samples to allow the estimation of gene expression variability (the exact criteria are outlined in the Methods section); 43 of these were IP/VE-associated genes. The mean and median LCV scores were 57.1 and 60.9, respectively.n = 183). Eighty-eight percent (160/183) of genes were found to be adequately expressed in enough samples to allow estimation of gene expression variability; 23 of these were IP/VE-associated genes. The mean and median LCV scores were 62.7 and 71.8, respectively.As retinal tissue is not included in the GTEx v8 dataset, the EyeGEx resource  was usedn = 43) were significantly more variable than other genes (n = 216)  = 0.0000015) when the median LCV of all tissues was used. To test the hypothesis that variability in gene expression is associated with incomplete penetrance, we compared population variability in gene expression between IP/VE-associated genes and other IED-implicated genes (for which we did not find clear evidence of incomplete penetrance). First, all genes were considered and analyzed based on the LCV scores in the entire GTEx dataset. IP/VE-associated genes with available scores (n = 35) were significantly more variable than other IED-implicated genes (n = 184)  = 0.0000053). Similar results were obtained for whole blood  = 0.018); sun-exposed skin  = 0.0000083); non-sun-exposed skin  = 0.000017), and cultured fibroblasts  = 0.00001).The same comparison was performed for clinically relevant and clinically actionable tissues. For example, when the median LCV of brain tissues was taken as the measure of variability, IP/VE-associated genes (n = 23) were significantly more variable than other genes associated with inherited retinal disorders (n = 137)  < 0.0028). In order to assess genes linked to inherited retinal disorders in more detail, we studied gene expression variability for this subset of IED-implicated genes using expression data from retinal tissue (from EyeGEx). IP/VE-associated retinal genes (CYP1B1 (GTEx median LCV = 97.4), MYOC (GTEx median LCV = 98.5), RP1L1 (EyeGEx LCV = 94.4), BEST1 (EyeGEx LCV = 90.4), and PRPF31 (EyeGEx LCV = 72). It is noteworthy that some genes commonly associated with variable penetrance in the literature were more variable than average at the mRNA level. Examples include All statistical comparisons in all the datasets and tissues assessed are shown in We then assessed whether the observed result was linked to differences in gene constraint. First, we looked for correlation between the LCV score and the missense o/e score in both the GTEx  and EyeGEx  datasets; we found no significant correlation . Second,To look for a possible “gradient effect”, we studied the relationship between the LCV score and the number of HGMD-listed variants that are present in the gnomAD control-only dataset for each gene; we found no obvious correlation .Gene ontology enrichment and interaction information for genes in the IP/VE group are provided in Advances in high-throughput sequencing technologies have enabled the creation of comprehensive catalogues of genetic variation ); the key finding was that 19% of genes and 10% of variants were spurious based on a carrier frequency threshold set by the authors [et al. performed a large-scale analysis of UK Biobank genotyping array data to assess the penetrance of ClinVar-reported variants in genes known to cause maturity-onset diabetes of the young (MODY) and severe developmental disorders; this led to a more refined penetrance estimate for some of the studied variants and to the refutation of a few previous disease associations [A number of studies have looked for overlap between databases cataloguing disease-associated variants (such as HGMD or ClinVar) and resources studying genetic variation at the population level (such as gnomAD or the UK Biobank). Although some of these studies evaluated the penetrance of disease-predisposing variants, the primary focus has typically been around questioning the validity of variant-disease assertions ,30,31,32 authors . Additiociations  and (ii)ciations . We chosciations . Notablyciations . Althougciations . Combinicis-acting regulatory elements. However, there are examples of regulatory variants that modulate the penetrance of variants causing IED in trans [trans- and cis-acting elements.Previous studies have used allele-specific expression  to understand how variability in gene expression impacts variant penetrance ,10. Allein trans . We attein trans  and EyeGin trans ). FutureThis study has a number of notable limitations. First, penetrance and expressivity characterize the relationship between a genotype and a phenotype, while gene expression is a characteristic of a gene; its variation therefore acts only as a proxy for variable expressivity in the case of individual variants. Second, we did not consider the probability of a gene being associated with gain-of-function or loss-of-function (or dosage sensitivity) effects; future studies incorporating data on the pathophysiology underlying each molecule are expected to provide further insights. Third, gene expression for each given IED-implicated gene needs to be assessed in the relevant disease target tissue . It is hcis- or trans-acting genetic regulatory modifiers. Further studies utilizing large-scale genomic and transcriptomic datasets are expected to provide important insights into the precise nature of these regulatory modifier mechanisms and to highlight novel, in-human validated treatment targets.In conclusion, we determined a subset of genes implicated in IED that are associated with a degree of variable penetrance. Many genes in this subset have highly variable gene expression at the population level. It can be speculated that this finding reflects the involvement of


Individuals with advanced colorectal adenomas (ACAs) are at high risk for colorectal cancer (CRC), and it is unclear which chemopreventive agent (CPA) is safe and cost-effective for secondary prevention. We aimed to determine, firstly, the most suitable CPA using network meta-analysis (NMA) and secondly, cost-effectiveness of CPA with or without surveillance colonoscopy (SC).Systematic review and NMA of randomised controlled trials were performed, and the most suitable CPA was chosen based on efficacy and the most favourable risk–benefit profile. The economic benefits of CPA alone, 3 yearly SC alone, and a combination of CPA and SC were determined using the cost-effectiveness analysis (CEA) in the Malaysian health-care perspective. Outcomes were reported as incremental cost-effectiveness ratios (ICERs) in 2018 US Dollars ($) per quality-adjusted life-year (QALY), and life-years (LYs) gained.According to NMA, the risk–benefit profile favours the use of aspirin at very-low-dose  for secondary prevention in individuals with previous ACAs. Celecoxib is the most effective CPA but the cardiovascular adverse events are of concern. According to CEA, the combination strategy (ASAVLD with 3-yearly SC) was cost-saving and dominates its competitors as the best buy option. The probability of being cost-effective for ASAVLD alone, 3-yearly SC alone, and combination strategy were 22%, 26%, and 53%, respectively. Extending the SC interval to five years in combination strategy was more cost-effective when compared to 3-yearly SC alone (ICER of $484/LY gain and $1875/QALY). However, extending to ten years in combination strategy was not cost-effective.ASAVLD combined with 3-yearly SC in individuals with ACAs may be a cost-effective strategy for CRC prevention. An extension of SC intervals to five years can be considered in resource-limited countries.The online version contains supplementary material available at 10.1186/s12876-021-01715-7. Colorectal cancer (CRC) is the third most commonly diagnosed malignant neoplasm and the second leading cause of cancer death worldwide . SimilarIn high-risk individuals, it is attractive to have chemopreventive agents (CPAs) which are effective in protecting them from getting a recurrence of ACAs after initial polypectomy , 5. In aMeanwhile, screening colonoscopy with resection of detectable adenomas followed by interval surveillance colonoscopy (SC) is typically regarded as the ideal preventive approach . UnfortuTherefore, our objectives were first to identify the ‘ideal’ CPA for secondary prevention using NMA techniques, second to investigate the cost-effectiveness of that CPA alone, SC alone or combination strategy for prevention of new CRCs in a high-risk population with a previous history of ACAs, and third to determine if an extension of surveillance intervals to 5-yearly and 10-yearly is feasible in terms of cost-effectiveness. For the last 2 objectives, a health economic model was developed using data from our NMA as well as population and health-care settings of Malaysia, a developing nation with an estimated population of 30 million in the South-east Asia region.First, systematic review with network meta-analysis (NMA) was performed to identify a CPA with the most favourable risk–benefit profiles to be further examined in the proposed cost-effectiveness model. The NMA was registered with PROSPERO CRD42015025849) [025849 1. The priDetails of statistical analysis are provided in Additional file Based on evidence generated from the NMA, a Markov model , with an assumption that the baseline colonoscopy was 100% successful in removing all adenomas after polypectomy. The model simulated a series of sequential transitions of 12 health states based on yearly probabilities i.e. 1) normal colon, 2) low-risk state, 3) high-risk state, 4) to 7) CRC stage I-IV , 8) to 11) CRC stage I-IV , and 12) death  and reported in 2018 US Dollars ($).Cost estimates used within the CEA analysis have been derived from the amended Malaysia medical fee schedule 2013 , the conOne-way sensitivity analyses were performed to study the effects of altering parameters on the CEA findings. The 95% CI ranges were used whenever such data were available; but if absent, the ± 15% range was applied. Results were shown using the tornado diagrams to identify parameters with the most significant impact on the model results. A probabilistic sensitivity analysis (PSA) was also conducted to simultaneously examine the effects of all parameter uncertainties using a Monte Carlo simulation performed using Microsoft Excel 2003   Results A flow diagram depicting the search and selection process is provided in Additional file Based on NMA, celecoxib 800 mg/day  and celecoxib 400 mg/day  were ranked best for preventing recurrence of ACAs compared to placebo, followed by ASAVLD  and ASALD . Based on comparative efficacy, none of these CPAs was superior over the others, except for ASALD , celecoxib 800 mg/day , and calcium  were associated with increased risk of SAEs. In addition, celecoxib (400–800 mg/day) was associated with increased risk of CV events  Table . Among aTornado diagrams illustrating the one-way sensitivity analysis results of the combination strategy compared to no screening are presented in Additional file Effects on ICER from an extension of SC intervals in combination strategy to 5-yearly and 10-yearly are presented in Table Based on systematic review and NMA, we are able to conclude that ASAVLD is probably the safest although not the most effective CPA for prevention of recurrence of ACAs among individuals with a previous history of colorectal adenomas. Celecoxib is the most effective CPA, but the CV adverse events are of great concern. Moreover, the protective effect of celecoxib does not persist after its withdrawal . The risFrom the CEA, combination strategy (ASAVLD with 3-yearly SC) was the more cost-effective and the best-buy option with significant gains in LYs and QALYs. Moreover, a 63% reduction in the occurrence of new CRC cases was observed with the combination strategy compared to 3-yearly SC alone. Furthermore, ASAVLD has a positive impact on the prevention of cardiovascular events, and this is added benefit besides CRC reduction at fewer adverse outcomes. For countries with limited health-care resources including Malaysia, extending surveillance intervals to 5-yearly or 10-yearly may reduce health costs, however, in our scenario analysis, this was the case. For 5-yearly SC, while costlier, it could be the more cost-effective strategy in the Malaysian setting. However, we found 10-yearly SC was not cost-effective. Our findings may be applicable to countries with similar WTP thresholds as Malaysia .Our findings are unique as none of the previous studies specifically evaluated the effectiveness of aspirin at very-low-dose in high-risk individuals with a history of advanced adenomas. Other differences include the following: 1) previous analyses , 56 haveWhen formulating the aspirin chemoprevention policy with SC, it is important to take into account the way in which aspirin chemoprevention may be implemented. Aspirin chemoprevention is more feasible in terms of human resources and budgetary burdens. Weighing the benefits of ASAVLD against the potential harms is of particular relevance in the chemoprevention setting. The use of aspirin needs shared decision making with patients but also comprehensive understanding of patients’ values and preferences. However, there are other factors relevant to the implementation of this strategy, including the budget impact, feasibility, and ethical and social implications that need to be considered for decision making. At present time, our findings are likely more applicable for countries with established colonoscopy screening programs and regular post-polypectomy surveillance. However, individuals from countries without colonoscopy screening programs but have been identified at increased risk due to advanced adenomas during any endoscopic examinations can still apply these findings, although the number of such individuals is expected to be minimal. Over the last ten years, an increase in screening rates in the general population has been observed in Malaysia . This coThere are some limitations. First, CEA did not include the indirect costs of CRCs due to a lack of published data. Second, there is evidence for suboptimal efficacy of screening colonoscopy for proximal CRCs –62, whicIn conclusion, ASAVLD in combination with 3-yearly SC may be considered a cost-effective and safe strategy to prevent CRCs among high-risk individuals with a previous history of ACAs. For individuals already receiving ASAVLD, extension from 3-yearly to 5-yearly SC could be considered in the setting of limited resources.Additional file 1. Supporting information.


Over 100,000 cases of COVID-19 patients infected with the novel coronavirus SARS-COV-2 have been reported worldwide in approximately 2 months, resulting in over 3000 deaths. Potential therapeutic strategies, including remdesivir, chloroquine phosphate, abidol, lopinavir/ritonavir, plasma, antibody, vaccine and stem cells are discussed in this review. With the number of patients increasing daily, there is an urgent need for effective therapeutic intervention. With the number of patients increasing daily, there is an urgent need for effective therapeutic intervention. In this article, we will discuss several therapeutic strategies against COVID-19 infection.Since the beginning of December 2019, numerous hospitals in Wuhan, China have reported an increasing number of patients with pneumonia due to the infection with an unknown virus. The virus, first named 2019 novel Corona Virus (2019-nCoV), was later changed to Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-COV-2), and the pneumonia was named Corona Virus Disease 2019 (COVID-19). World Health Organization (WHO) declared COVID-19 a Public Health Emergency of International Concern on January 31, and, as of March 2020, the virus has infected >90,000 people, and killed >3,100 worldwide2. Remdesivir  is a nucleotide analog originally developed by Gilead as a drug against Ebola virus. Mechanistically, it inhibits RNA-dependent RNA synthetase (RdRp) with completed Phase I and/or II clinical trials3,4. Therefore, Gilead has been working with China since February 2020 to conduct a phase 3 randomized, double-blinded, placebo-controlled, multicenter trial to determine the safety and efficacy of remdesivir on hospitalized patients with severe COVID-195. The treatment was designed as 200 mg of remdesivir on day 1 followed by 100 mg/day for 9 days. The study is expected to be completed by May 1, 20206. In addition, other antiviral nucleotide analogs such as fapivir and ribavirin are undergoing clinical trials. Fapivir is a drug approved in Japan for flu treatment.The first case of COVID-19 in the United States was confirmed on January 20, 2020, by qPCR assay with samples from the patient’s nasopharyngeal and oropharyngeal swabs. Probes were based on genomic sequence of 2019-nCoV released by scientists from China. After the development of radiographic pneumonia, the patient was treated with remdesivir intravenously and almost all clinical symptoms resolved the following day7. The results from in vitro studies suggest that chloroquine can actively inhibit SARS-COV-24. Both animal experiments and clinical trials are currently in progress. Results from preliminary clinical trials show that chloroquine phosphate has promising effects on patients with COVID-19. Of note, it has been reported that chloroquine may cause adverse reactions such as ocular disorders, immune system disorders, ear and labyrinth disorders, cardiac disorders, etc.8, therefore precautions and further testing are needed for the safe and effective treatment in COVID-19 patients.Chloroquine phosphate is an antimalarial drug. By increasing the pH of the nucleus, it can inhibit both the virus-host cell interaction and the pH-dependent virus replication9. A randomized multi-center controlled clinical trial wtih Abidol in patients with COVID-19 has started in Xiangya Hospital in China, which has been registered in the US clinical trial database10.Abidol is a broad-spectrum antiviral drug. By inhibiting the fusion between the influenza virus and host cells, it can inhibit virus replication. It has been used to prevent/treat both SARS and Middle East Respiratory Syndrome (MERS). According to an online report, Abidol in the concentration range of 10-30μM not only inhibited COVID-19 duplication, it also significantly reduced the pathological effect of the virusin vitro studies showed that lopinavir/ritonavir can inhibit the replication of both MERS and SARS11. However, whether they can inhibit COVID-19 is unknown. Therefore, a clinical trial to use lopinavir/ritonavir for COVID-19 treatment will be launched soon in a hospital in Wuhan, China. In addition, since darunavir  is another protease inhibitor used for HIV treatment, a combination of darunavir and ritonavir could also be a potential treatment of COVID-19, especially since darunavir has been approved in China since 2018 for HIV treatment.Lopinavir/ritonavir is a combination of drugs mainly used for AIDS treatment. Lopinavir inhibits viral protease resulting in immature/non-infectious virus particles; ritonavir inhibits the degradation of lopinavir in the liver and thereby extends lopinavir’s half-life. Results from 12. The donated plasma with high-titer of SARS-COV-2 antibodies was confirmed without pathogens and with virus inactivation12. Of note, 12 to 24 hours post-treatment, the major inflammation symptoms decreased significantly with increased lymphocytes counts and blood oxygen saturation. Improved vital signs were also observed. Currently, although the exact underlying mechanisms are unknown, it is reasonable to speculate that the antibodies may bind the virus and prevent virus-host cell interaction, and therefore prevent infection. In addition, NK cells and other immune cells may also be involved in clearing the virus by antibody-dependent cell-mediated cytotoxicity. However, the potential risks associated with plasma usage, including pathogen transmission and allergic reaction, should be considered, and therefore this strategy may only be applied for a clinical emergency following standardized procedures. On the other hand, specific immunoglobulin could be a better option for treating critically ill patients with SARS-COV-2 infection.The company CNBG claimed on February 13, 2020, that plasma from recovered patients was used to successfully cure 11 critically ill patients with COVID-19Specific neutralizing antibodies against viral surface proteins may bind and prevent the virus from entering the host epithelial cells and subsequently prevent virus amplification. On the other hand, non-neutralizing antibodies may bind the virus and activate the immune cells (mainly macrophages) to engulf and clear the virus. However, excessive activation of these non-specific immune cells may cause the release of a large number of pro-inflammatory factors leading to cytokine storm and sepsis-related death. Therefore, non-neutralizing antibodies play an antiviral role in the early stages but may cause lung damage at later stages. However, it usually takes an extended period of time to generate monoclonal antibodies for a new pathogen that can be used clinically.13. The German company Inflarx has developed a monoclonal antibody against the human C5a molecule. By specifically binding and inhibiting C5a-mediated biological functions, including the release of neutrophil chemotaxis and intra-cellular lysozyme, the antibodies can limit excessive inflammation without inhibiting immune function. Clinical trials on this antibody are now underway in China to potentially reduce both lung damage and death caused by sepsis infection14. Regeneron Pharmaceuticals is using VelociSuite technology with a humanized mouse immune system to rapidly develop innovative antibodies for the treatment of virus sepsis. This strategy has shown positive results in clinical trials using antibodies to treat Ebola15.There are now at least four candidate vaccines against the sepsis that are under development. Clinical trials on the most promising vaccine candidates may start in three to four months. However, it usually takes more than a year for a vaccine to become clinically applicable16.Due to the self-renewal and multi-directional differentiation capability of mesenchymal stem cells, they can be differentiated to produce multifunctional cells. In damaged lung tissues, stem cells may be able to replenish bronchial epithelial and endothelial cells after the clearance of viral infection. They may also stabilize the pulmonary micro blood vessel and alveolar epithelial cell barriers. These effects could enhance the patient's immunity, alleviate pneumonia, and prevent secondary infections. As of February 14, 2020, more than 4 such projects have been approved for the treatment of COVID-19 in China, and another one has applied to the U.S. Food and Drug Administration (FDA) for emergency approval17. Other clinical trials of treatment options are also on the agenda. A search with the word “COVID-19” in the China Clinical Trials Registry (http://www.chictr.org.cn) revealed that 218 clinical trials have been registered on the platform as of March 9. Dozens of clinical trials have also been registered on the international platform of clinical trials . Recently, as a key target for therapeutic intervention, the cryo-EM structure of the CoV spike protein in its trimer form has been elucidated, which may further contribute to therapeutic designs in the near futureCurrently, remdesivir appears to be the most promising drug for the treatment of pneumonia caused by COVID-19 pneumonia. Many other agents or strategies are being tested for the treatment of patients with COVID-19. However, double-blind, randomized controlled trials are required to investigate their safety and efficacy.◊ The recent COVID-19 disease is due to the infection with the new coronavirus, SARS-CoV-2, causing a pandemic and necessitates the development of effective therapeutics.◊ Many clinical trials are initiated worldwide. Potential therapeutics, including nucleotide analogs，chloroquine phosphate, abidol, lopinavir/ritonavir，plasma antibodies，vaccines, stem cells are among the most important strategies to be developed.


N-3 polyunsaturated fatty acid supplements improve the symptoms of major depressive disorder (MDD) in randomized-controlled trials and meta-analyses, with the higher efficacy from anti-inflammatory eicosapentaenoic acid (EPA) than brain-dominant docosahexaenoic acid (DHA). To investigate the specific brain mechanisms of the anti-inflammatory anti-depressant nutraceutical compounds, we recruited 24 MDD subjects in this double-blind, head-to-head study with a 12-week EPA or DHA treatment . The depression severity was assessed by Hamilton depression rating scale (HAM-D). Brain responses to emotional stimuli were measured by a 3-Tesla MRI. The correlation between HAM-D scores and brain responses also were tested. Compared to 18 healthy controls, the brain responses of untreated 24 MDD patients mainly revealed hypoactivity in the regions associated with emotion perception and emotion control when processing positive emotion. After treatment, more remitted MDD patients have been observed in the EPA as compared to the DHA groups. In addition, the EPA, but not DHA, treatment revealed increased activity in the regions associated with emotion perception and cognitive control when processing positive emotion. The correlation analysis further revealed negative correlation between HAM-D scores and brain responses in cognitive control regions. The results of this study may imply the compensatory brain responses of cognitive and emotion controls by EPA but not DHA and underpin personalized medicine with anti-inflammatory nutraceuticals toward depression treatments. Depression is an increasing mental health problem around whole world. It has been estimated that 6.7% adults in U.S. had at least one major depressive episode in 2014 . The negOmega-3 polyunsaturated fatty acids (ω-3 or n-3 PUFAs), mainly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are essential nutritional compounds with potential preventive and therapeutic effects against several psychiatric disorders, especially depression ,14,15,16Despite the fact that DHA is the main omega-3 PUFA in the brain, EPA is consistently reported to be the most active component of omega-3 PUFAs’ antidepressant effects ,22,23,24In present study, we investigated the possible central mechanisms of EPA and DHA treatment on MDD patients. More specifically, we explore the possible changes of affective stimuli-evoked brain responses with EPA or DHA intervention in MDD patients. Previous meta-analysis of functional imaging studies reported that the MDD patients revealed abnormal resting-state activities in prefrontal cortex (PFC), temporal cortex, insula, anterior and posterior cingulate cortex, hippocampus, amygdala, and thalamus, whereas the antidepressant treatment may reverse the altered brain activations in these regions . Hence, In 24 MDD patients, 12 patients received EPA treatment and 12 received DHA treatment. There is no significant difference in age, sex, and education years among EPA, DHA, and healthy control groups. There is also no significant difference between EPA and DHA groups in depression episodes and body mass index. For clinical outcomes, no significant interaction effect between groups and times has been found in quantitative HAM-D score. With an overall qualitative remission rate of 62.5% (15 in 24 MDD patients), significantly higher qualitative remission rate has been revealed in EPA group than in DHA group . No seriCompared to the DHA group, significantly increased EPA percentage has been found in the EPA group after treatment. Both EPA and DHA groups revealed significantly increased DHA percentage but decreased arachidonic acid percentage after the treatment. No significant difference has been found for adrenic acid in both groups among different time points .Compared to healthy controls, the untreated MDD patients revealed hypoactivity in the right dorsomedial prefrontal cortex (dmPFC), right caudate nucleus, right lingual gyrus, left premotor cortex, left middle occipital gyrus, and bilateral cerebellum when processing positive emotion . When prAfter 12 weeks of EPA treatment, the MDD patients revealed increased brain responses compared to baseline in the bilateral dorsolateral prefrontal cortex (dlPFC), bilateral vlPFC, bilateral caudate nucleus, left middle occipital gyrus, left precuneus, left supramarginal gyrus, and right lingual gyrus when processing positive emotion . No furtFor DHA treatment, the MDD patients revealed decreased brain responses than baseline in bilateral dlPFC and dmPFC when processing positive emotion after 12 weeks treatment. No increased brain response has been found . When prIn the EPA group, the change in HAM-D scores and the change in brain responses to positive emotion were positively correlated in left anterior insula and right perigenual cingulate cortex, whereas the negative correlation has been found in the right vlPFC and left premotor cortex . For negIn the DHA group, the change in HAM-D scores and the change in brain responses to positive emotion were negatively correlated in the left anterior cingulate cortex, whereas no positive correlation has been found in the brain . For negTo our knowledge, this is the first study to utilize fMRI to investigate the possible central mechanisms of EPA versus DHA treatments in MDD. The main finding is that EPA differentiates DHA treatment by revealing the increased activity in the regions associated with emotion perception and cognitive control when processing the positive emotion. Moreover, the change in HAM-D scores was negatively correlated with the changes in brain response to the positive emotion in the cognitive control regions. In concert with previous studies ,32, the The abnormal brain responses to emotion stimuli may be associated with negative affective bias in MDD patients. It has been suggested that dmPFC may be associated with cognitive self-control and impulse regulation . PreviouDespite the anti-inflammatory effect of EPA ,29,30, tThe lower treatment efficacy of DHA may be associated with no compensatory or resilience response in the brain. After DHA treatment, MDD patients revealed no increased brain response but further decreased brain response in dmPFC and dlPFC when processing positive emotion. Since the dmPFC and dlPFC play an important role in cognitive self-regulation and reappraisal of emotional stimuli ,38, the The supplement form of PUFA may influence brain concentrations on EPA and DHA. A recent animal study suggested that dietary free DHA treatment increased DHA concentrations in blood but not in the brain . AnotherSeveral limitations should be noted in the present study. First, a relatively small sample size would lower the statistical power. For clinical outcome (HAM-D score), 22 subjects per group were needed to meet the statistic criteria with alpha = 0.05 and statistical power = 0.8. Hence, to balance the chance of type I and type II error, we applied a less stringent significant threshold on fMRI results. Second, the items of HAM-D were designed for various clinical symptoms of MDD, including mood, insomnia and somatic symptoms. These symptoms may not fully be associated with the negative affective bias. Moreover, one should keep in mind that significant correlation doesn’t imply the causation. Third, we lacked the data of personal history of MDD patients, such as previous medication, hospitalization or refractory symptoms. Fourth, the fMRI has been used to measure the regional neuroactivity changes. The relationship between biochemical and molecular alterations and neuroactivity has not been investigated. Further biochemical or molecular studies may be needed to probe the possible underlining mechanisms to the compensatory but not resilience brain responses of EPA in MDD patients.In conclusion, our results demonstrated that EPA treatment have more treatment efficacy than DHA treatment in MDD. The hypoactivity in brain regions involved in emotion perception and cognitive control regions may associated with the pathophysiology of MDD. The compensatory brain responses in cognitive reappraisal of emotion and cognitive control regions may underpin the treatment efficacy of EPA. Further large-scale studies may be needed to verify the central mechanisms of different PUFA treatments and to investigate the underlying biochemical and molecular mechanisms of anti-inflammatory nutraceuticals that associated with personalized medicine toward depression treatments.www.sop.org.tw/dow_a.htm).All MDD subjects were recruited from the outpatient clinics of psychiatric department at the China Medical University Hospital, Taichung, Taiwan. The inclusion criteria were as follows: (i) meeting the diagnostic criteria for major depressive disorder in the 4th edition of diagnostic and statistical manual of mental disorders (DSM-IV); (ii) an age of 18 to 65 years old; (iii) a pre-study rating score on the 21-item Hamilton Rating Scale for Depression (HAM-D)  of 18 orhttps://clinicaltrials.gov/ct2/show/NCT03871088).The research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. The Institutional Review Board of China Medical University Hospital approved the study. All eligible subjects were received a full explanation of the study and signed written informed consent. The study was registered at Clinicaltrial.gov  was conducted at baseline (weeks 0) and after treatment (week 12), respectively.Among these MDD subjects, 1 subject from the EPA group and 2 subjects from DHA group were discontinued to attend the study. Therefore, 24 MDD subjects who completed this 12-week trial were included in the analysis. In order to reveal the possible altered brain responses to affective stimuli in MDD patients, 18 age-matched controls from eligible volunteers were enrolled after exclusion of any psychiatric disorders as determined by the Taiwanese version of MINI . SociodeAll MDD subjects took 5 identical capsules per day for 12 weeks. The experimental capsules were weighted 1000 mg and deodorized with orange flavour. Each capsule solely contained concentrated EPA (700 mg) or DHA (350 mg) as the main component, with tertiary-butyl hydroquinone (0.2 mg) and tocopherols (2 mg) as antioxidants. The sources of EPA and DHA were from anchovy fish body oil  and algal vegetable , respectively.The measurement of blood PUFA level were conducted on coded blood samples by the staff who were blinded to information about the subjects. The blood samples were prepared within 24 h to separate erythrocyte for analysis of variant fatty acids by gas chromatography of methyl esters . The detailed step-by-step procedures have been published elsewhere . Fatty aThe judgment of concomitant medications for anxiety and insomnia or discontinuation from this trial for re-allocation to antidepressant drugs was based on physicians’ clinical judgment. The 21-item HAM-D was used to assess the depressive symptoms as clinical outcomes before (week 0), during , and after treatment session (week 12). The remission of clinical symptoms was considered if the HAM-D score was less than 7.https://csea.phhp.ufl.edu/index.html). To maximize the effect of emotional stimuli, pictures of positive emotion with high arousal level, negative emotion with high arousal level, and neutral emotion were used. Equal numbers of positive, negative, and neutral pictures were presented to each subject within 4 fMRI sessions. In each session, pictures of different emotional conditions were presented in 3 blocks with a counterbalanced order across subjects. Each block presented one emotional condition  and interleaved with a 24-s fix-cross block as baseline control . Prior to the first block of emotional stimulation in each fMRI session, 10 s blank scans were conducted to stabilized the signal. High-resolution, 3-dimensions T1-weighted anatomical images were also acquired with spoiled gradient echo sequence . All scans were acquired within a dim-light shielding room. Before scanning, subjects were instructed to stay relaxed but not to move the head, and to fixate their attention on the stimulation presented in the refractory mirror.Images were acquired with an 8-channel head coil in a 3.0 Tesla GE MRI scanner . The fMRI sessions were continuously scanned with ascending interleaved echo-planar imaging sequence for whole brain scanning .Before the data preprocessing, the blank scans were discarded from each fMRI session. The remaining fMRI images were then preprocessed by statistical parametric mapping 12 . Within each session, the serial fMRI images were firstly corrected for different slice acquisition times and then realigned to correct the head motions occurring alone the session. Subjects who had more than 3 mm translation or 3° of angular rotation were excluded from further analysis. The T1-weighted anatomical image was then coregistrated to the mean image which was generated from the previous realignment step. After the coregistration step, the anatomical image was normalized to the default template of tissue probability map in SPM 12. The normalization parameters were then applied to all fMRI images within the session to normalize them into Montreal Neurological Institute (MNI) reference space and resampled with the voxel size 2 × 2 × 2 mmp < 0.05.The statistical analysis for demographic data, clinical outcome, and blood PUFA levels were conducted using SPSS 21 . To test the possible difference among EPA, DHA, and healthy control groups, one-way analysis of variance (ANOVA) and Chi-square were conducted on continuous data and categorical data, respectively. The mixed-model two-way ANOVA and Chi-square were conducted to test the possible difference between groups (EPA and DHA) and times (week 0 and 12) on continuous data and categorical data, respectively. The significance was considered if For fMRI data, the conventional 2-level  analysis has been conducted using generalized linear model in SPM 12. At the first level, individual brain responses for each emotion condition were modelled through the stimulation paradigm which convoluted with a canonical hemodynamic response function. A high-pass filter of 1/128 Hz and an AR (1) model were used to remove the low frequency drafts and correct for temporal auto correlations. Scans from all 8 sessions (4 from the baseline scans and 4 from the after-treatment scans) were included in the model. Six head motion parameters obtained from the realignment step were further used as covariates in the model. The maps of estimated beta value for each emotion condition were calculated and then the following relevant maps of beta contrasts were computed for second level analysis. The positive and negative emotion stimulations were contrasted against the neutral stimulations to reveal the associated brain regions for positive and negative emotion processing, respectively. The maps of positive and negative emotion processing between different time point (before and after treatment) were also computed to reveal the possible changes of brain responses for each emotion condition, respectively.p < 0.005 at voxel-level with the cluster size > 50, corresponding to the uncorrected cluster-level p < 0.34) was applied in the present study to balance the chance of Type I and Type II error as suggested by a previous study [In second level analysis, several pre-planned tests have been conducted to probe the possible difference between groups and times. For disease-related abnormality, 2-sample t-tests were conducted between all untreated MDD patients  and healthy subjects on positive and negative emotion conditions, respectively. For treatment-related effect, 1-sample t-tests were conducted on positive and negative emotion conditions between different time points of EPA or DHA treatment, respectively. The correlation analysis was also conducted between the change of clinical symptoms severity (HAM-D scores) and the change of brain responses to positive and negative emotion, respectively. Considering that the fMRI study often have low statistical power , a less us study .


The coronavirus disease pandemic was declared in March 2020, as the southern hemisphere’s winter approached. Australia expected co-circulation of severe acute respiratory syndrome coronavirus 2, influenza and other seasonal respiratory viruses. However, influenza notifications were 7,029 (March–September) compared with an average 149,832 for the same period in 2015–2109, despite substantial testing. Restrictions on movement within and into Australia may have temporarily eliminated influenza. Other respiratory pathogens also showed remarkably changed activity in 2020. The World Health Organization (WHO) declared a coronavirus disease (COVID-19) pandemic on 11 March 2020, as southern hemisphere countries prepared for their usual winter respiratory pathogen epidemics. The announcement prompted concern that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza and other respiratory viruses might co-circulate, straining and possibly overwhelming healthcare systems. In Australia, these fears were not realised and—in contrast to expectations—influenza activity was at an all-time low during the southern hemisphere’s 2020 winter. Here, we describe the decreased activity of influenza and other respiratory pathogens in Australia and the measures that have likely contributed to their decline.Key government measures to restrict movement and mixing are displayed in Influenza is notifiable in Australia and notifications averaged around 2,000 cases per week from January to March 2020, with a precipitous drop between mid-March (week 11) and mid-April (week 14), when travel and work restrictions were introduced . ConcurrIn Australia, influenza-like illness (ILI) surveillance in primary care is conducted year-round to capture seasonal and inter-seasonal influenza patterns, as well as activity in the tropical northern region and infections in individuals following international travel . ILI surNational sentinel hospitalisation data  reflectConsistency in primary care, hospitalisation and mortality data all suggest that these declines cannot be entirely attributed to changes in healthcare-seeking behaviour.Real-time RT-PCR testing capacity in Australia considerably expanded in 2020 with the introduction of, and substantial demand for, SARS-CoV-2 testing. Initially, COVID-19 disrupted testing for non–SARS-CoV-2 respiratory viruses at some laboratories. However, even after public and private laboratories increased testing capacity for other respiratory viruses (by up to a three-fold increase in some jurisdictions (data not shown)), influenza virus detections remained exceedingly low . Data frTo enable total case finding for COVID-19, the threshold for respiratory virus testing has declined, with the broadening of case definitions and indications for testing, irrespective of the presence of symptoms. These minimal criteria may explain the very high percentage of detections positive for rhinovirus infection in NSW and WA since around week 22 . It is pThe very low numbers of influenza virus detections since April raises the possibility that some of the notified infections may be false positive. Among 10 influenza viruses  received in August and September at the WHO Collaborating Centre for Reference and Research on Influenza in Melbourne, none could be confirmed as influenza by real-time RT-PCR or culture. Given that the surveillance data suggested a prevalence < 0.05% [Australia’s annual influenza vaccination campaign commenced in April 2020. Vaccination, funded under the National Immunisation Program, was provided free of charge to many high-risk individuals ,12 and aWe have previously shown that influenza epidemics in major Australian cities are highly synchronous, with frequent co-circulation of viruses from genetic subgroups in cities up to 3,000 km apart, suggesting significant mixing of the national population . The cloLike Australian jurisdictions, European countries frequently observe coinciding influenza seasons  that areThe COVID-19 pandemic and related mitigation strategies have exerted a strong impact on the circulation of influenza, RSV and other respiratory viruses. Globally, influenza viruses are in a severe bottleneck, complicating influenza vaccine decision-making for the upcoming seasons. Recent circulation of influenza A(H3N2) viruses in Cambodia and Bangladesh from July to September highlights the potential for the re-introduction of annual epidemics once global travel resumes. Recent increases in RSV activity in NSW and South Africa  suggest


Peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of rare and aggressive non-Hodgkin’s lymphomas. Clinical staging, prognostic scoring, and initial treatment strategies have historically been based on paradigms developed in B-cell lymphomas. Despite primary treatment protocols that are typically anthracycline-based and frequently involve consolidative autologous stem cell transplantation in first remission, many patients develop disease progression. There remains a high unmet medical need for improved treatment strategies in the relapsed or refractory setting. Salvage chemotherapy and stem cell transplantation in those who are suitable has traditionally been the accepted approach, but this remains a minority of the total patient population. As increasing knowledge is gleaned regarding the biological heterogeneity within the various PTCL subtypes, newer targeted agents have been developed, studied, and approved in this small, heterogeneous population of relapsed or refractory disease. Given its success and tolerability in this pretreated population, brentuximab vedotin, an anti-CD30 antibody drug conjugate, was brought earlier in the disease course and is a model for advances in the targeted treatment of PTCL. As others undergo further development in the relapsed setting and successes are brought earlier in the disease course, the outcome for PTCL patients is likely to improve. However, innovative clinical trial designs are crucial for the assessment of targeted agents in this highly heterogeneous population. This review explores the current treatment environment for patients with relapsed and refractory PTCL, including newer strategies such as targeted agents and immunotherapy. T-cell lymphomas are a heterogenous group of uncommon non-Hodgkin’s lymphomas (NHLs) which account for approximately 10–15% of all NHLs. The prevalence varies geographically, with the highest incidence in Asia, particularly of natural killer (NK)/T-cell lymphoma and adult T-cell leukemia lymphoma (ATLL) due to variations in exposure and susceptibility to HTLV-1 and EBV. Subtypes which arose from mature T-cells were classified as peripheral T-cell lymphomas (PTCLs) and could be subdivided into clinically indolent or aggressive lymphomas. Historically, these variations in clinical behavior rather than a pathologic basis determined the therapeutic approach. Treatment protocols were chosen to treat aggressive PTCLs owing to their success in treating aggressive B-cell lymphomas; however, outcomes were not as successful. It is amongst the aggressive group of PTCLs that the most recent WHO classification has incorporated significant advances in the knowledge of the biological heterogeneity of PTCLs to better classify and describe new entities which may help to explain the clinical heterogeneity of these aggressive lymphomas. The relapsed and refractory (RR) setting remains an important population with aggressive disease in which to explore novel targeted approaches prior to moving them into the frontline setting and addressing an unmet need in NHL treatment.2.Established upfront therapies in the treatment of aggressive PTCL include anthracycline-based chemotherapies, such as CHOP  and stem cell transplantation (SCT), with this approach adapted mostly from success in treating aggressive B-cell NHLs. The International T-cell Lymphoma Project examined a cohort of 1,314 cases of PTCL and NKTCL and while cases of ALK-positive anaplastic large cell lymphoma (ALCL) had a 70% 5-year overall survival (OS), the remaining subtypes had worse outcomes, with 5-year OS for PTCL-NOS, angioimmunoblastic T-cell lymphoma (AITL), and all NKTCLs of 32% and a more dismal 14% for ATLL. Outcomes for ALK-negative ALCL patients were intermediate, with a 5-year OS of 49%. Thus, outcomes remain poor in the majority of subtypes and RR disease is a frequent problem for patients with PTCL4. Targeted agents have already been approved for use in PTCL, with brentuximab vedotin now established as a clear standard in the primary treatment of CD30-positive PTCL based on the randomized ECHELON-2 clinical trial5. With the majority of patients in this study with systemic ALCL, it remains unclear whether brentuximab vedotin has the same effect in AITL and PTCL-NOS. A small post-hoc analysis of non-ALK-positive ALCL patients in this study favored consolidative SCT in first remission; however, sample sizes were quite small6. Careful consideration must be taken during further trial designs to identify which patient or disease subgroups are most likely to benefit from brentuximab or from other targeted agents, a challenge in this rare group of diseases.Both autologous SCT (ASCT) and allogeneic SCT  have been offered to patients in both the primary and the RR setting, with ASCT being offered as consolidation in many patients undergoing frontline treatment. SCT has been established as standard of care in PTCL frequently in the absence of randomized evidence, which is challenging to achieve in rare diseases. Enteropathy associated T-cell lymphoma (EATL) is a rare subtype with dismal outcomes. A retrospective series and a small phase II study in which patients with EATL were treated with an intensive chemotherapy regimen followed by ASCT suggested improved outcomes with this approach9. Data from the BC Cancer Agency reported the outcome of 153 patients with a median OS and progression-free survival (PFS) after relapse or progression of 5.5 and 3.1 months, respectively. Patients with good performance status appeared to have more favorable outcomes with standard chemotherapy8. A smaller series from Modena, Italy, of 53 patients reported similarly poor outcomes with a median survival after relapse of 2.5 months7. The International T-cell Project reported the results of 436 (47%) patients who were refractory and 197 patients (21%) who had relapsed out of 937 patients who had received first-line treatment10. The median OS was 5.8 months, with univariable analysis showing that refractory disease (hazard ratio [HR] 1.43) and salvage therapy with SCT (HR 0.36) were associated with better survival. The only histologic subtype with a more favorable outcome was ALK-positive ALCL, which had an approximately 50% OS. All three series highlight the minority of patients undergoing SCT approaches, with only 99 patients (16%) in the population able to undergo SCT.There are few series that report the outcomes of RR-PTCL at a population levelThese three series highlight the challenges in assessing the literature in this setting. Retrospective series often require 10 to 20 years to accumulate a reasonable number of patients to report and are forced to group multiple histologies and eras into a single report. The prospective T-cell Project has the advantage of multiple centers accruing data prospectively and thus has the strength of reasonable patient numbers, even within rare subtypes of PTCL. Histology was reviewed by an expert hematopathology panel in 70% of these patients, although imaging and response assessment were performed locally with no central review, limiting some interpretation of the data.While PTCL histology does not appear to be a major driver in outcome post failure of primary treatment (with the exception of the more favorable prognosis of ALK-positive ALCL), poor performance status and the presence of refractory disease appear to be recurrent independent predictors of inferior survival. The definition of refractory disease often varies between studies; the T-cell Project defined this as no response or progression to treatment within 1 month from the end of initial therapy or unsatisfactory partial remission (PR) according to physician judgement that would immediately require second-line treatment. There are some similarities present in the use of staging and prognostic scoring tools in PTCL, as they have largely been adapted from systems developed for use in B-cell NHLs; however, there are no uniformly accepted approaches.12. However, the data driving the significance of PET/CT remain restricted to smaller series. A few small retrospective studies have explored the prognostic use of interim PET/CT and end of treatment PET/CT with conflicting results16; therefore, interim PET/CT are not routinely done. Series incorporating PET/CT as part of response assessment in RR-PTCL remain limited. Shea and colleagues reported a cohort that did not associate a negative FDG-PET scan with favorable outcomes in patients undergoing ASCT or allo-SCT17. The BC Cancer Agency and International T-cell Project series do not allow interpretation of functional imaging and relationship to outcome10. Interestingly the IPI and the Prognostic Index for PTCL-U (PIT) do not appear to influence outcome in RR-PTCL beyond the importance of performance status. The PIT uses the clinical characteristics of age, performance status, LDH level, and bone marrow involvement to classify patients into four prognostic risk groups18; only ECOG PS appears to broadly predict outcome in RR-PTCL.The Ann Arbor staging system is commonly used despite T-cell lymphomas frequently presenting with extranodal sites of disease. PET/CT is now recommended as part of the pre-treatment staging evaluation for newly diagnosed PTCLs19. A prospective analysis from the CISL group in Korea using GDP reported a favorable ORR of 62%. Numerically, this result looks superior to the CCTG trial, but disease and patient heterogeneity along with sample size likely contribute to some potential differences in outcome20. Other regimens such as ESHAP  or ICE  have been evaluated with similar results22. As such, there is no gold standard salvage therapy regimen employed for RR-PTCL.In general, there are two approaches in the setting of primary treatment failure; the first emphasizes a goal of curative therapy with a plan to proceed to SCT, while the second is typically palliative in nature and often driven by patient age, comorbidity, and/or performance status. There are no randomized trials that have specifically evaluated chemotherapy in RR-PTCL, but the CCTG LY.12 trial included PTCL in a population of patients planned for ASCT. Skamene and colleagues reported a subset analysis of the study in 59 patients with PTCL who were randomly assigned to DHAP  or GDP  and demonstrated similar overall response rates (ORRs)  with 1-year event-free survival (EFS) of 16% and 1-year OS of 28%. In patients going on to receive ASCT, the 2-year EFS and OS were 21% and 42%, respectively23. The ORR ranged from 22–86%, incorporating a variety of targeted approaches along with single and multi-agent chemotherapies. Similarly, ORRs varied between disease subtypes from 14–72% for PTCL-NOS, 8–54% for AITL, and 24–86% for ALCL. PFS and OS ranged from approximately 2 to 15 months. This study appears to be the only systematic review in the field highlighting the lack of data guiding clinical decision-making when choosing specific treatment approaches.A systematic review published in 2015 identified 14 studies using 12 different salvage approaches and included 618 RR-PTCL patients24. A total of 70% of patients were treated with “curative intent”, and these patients were more likely to receive combination therapy versus single-agent therapy (85% versus 58%). Combination regimens were typically traditional chemotherapy based , while single agents were more typically newer or targeted agents . A higher proportion of patients in the single-agent group achieved complete remission (CR) (41% versus 19%) and subsequently underwent SCT (26% versus 8%), resulting in improved PFS (11 versus 7 months) and OS (39 versus 17 months).Typically, conventional chemotherapy has been given prior to SCT, as “chemosensitivity” remains a core concept to demonstrate, particularly in the ASCT setting. If disease is not responding to salvage chemotherapy, then there is doubt that SCT may be beneficial. However, given the favorable single-agent activity of targeted agents in RR-PTCL and the underwhelming results of conventional therapies, targeted therapies have been used without chemotherapy, with sensitivity to the agent prior to SCT remaining an important goal. There are few datasets that have analyzed patients receiving a variety of therapies in a SCT-eligible population. A retrospective analysis from the COMPLETE dataset in RR-PTCL showed that 46% of patients received combination therapy while 54% of patients received monotherapy as a salvage approach25. The Parma study established the role of ASCT in the treatment of relapsed NHLs, and multiple subsequent series have been published reporting the outcomes of SCT for PTCL from institutional and registry series33. A systematic review published in 2016 highlights ASCT outcomes in the RR setting with a PFS of 36%, OS of 47%, relapse/progression of 51%, and non-relapse mortality (NRM) of 10%34. Favorable outcomes were seen in patients with ALCL. The largest series included 241 patients with ALCL, PTCL-NOS, and AITL who underwent ASCT or allo-SCT reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). ASCT patients beyond CR1 had a 3-year PFS of 42% and OS of 53%. Among allo-SCT patients who received transplant beyond CR1, 31% remained progression-free at 3 years31. Rodriguez and colleagues used the GELTAMO database and identified 123 patients with relapsed or primary refractory PTCL. With a median follow-up of 61 months, the 5-year OS was 45% and PFS was 34%29. A small retrospective series that included 32 patients auto-transplanted in second complete or partial response found a 5-year PFS of only 12% and OS of 40%32. While difficult to undertake in a rare and heterogeneous disease, prospective studies are certainly needed in order to clarify the role of transplant in relapsed PTCL.Prospective randomized trials for SCT in the relapsed setting are also lacking; however, expert consensus strongly recommends ASCT for relapsed chemosensitive disease (in most subtypes) when it wasn’t performed frontline and consideration of allo-SCT in some cases35. In general, the results of these largely national or registry studies report similar results, with 50% of patients experiencing long-term survival with a PFS of approximately 40%. The series all have heterogeneity in patient population, donors , intensity of preparative regimens (myeloablative or reduced intensity conditioning [RIC]), and PTCL subtypes as well as the use ofin vivo T-cell depletion with agents such as antithymocyte globulin. RIC allograft recipients appear to have less NRM but higher rates of relapse, as has been seen in other types of lymphoma.Schmitz recently reviewed the results of allo-SCT in RR-PTCLSCT approaches have been utilized in RR-PTCL as a standard treatment modality for many years. The safety and feasibility of these approaches have improved because of better supportive care and the adoption of RIC strategies and the use of T-cell depletion (depending on donor type). Given the preference to consider consolidation of primary treatment response with ASCT in PTCL, patients may typically flow towards allograft strategies in the relapse setting. Unfortunately, prospective comparative research has not been performed in the RR setting, though attempts have been made to perform prospective comparative trials in the consolidation of primary treatment response.The majority of recent advances in the management of patients with PTCL has been in the development and use of targeted agents in treating RR-PTCL. A number of drug classes including histone deacetylase (HDAC) inhibitors, monoclonal antibodies, antifolates, kinase inhibitors, and antibody drug conjugates (ADCs) have been assessed with promising results, leading to drug approval for some of these agents based on response rates in this setting .36. While this study led to its accelerated approval, further studies have confirmed the promising effects of pralatrexate in RR-PTCL39. Romidepsin, an HDAC inhibitor, has also been studied as a single agent in this setting with ORR of 25–38%, with the median duration of response ranging from 8.9–28 months across studies41. Belinostat, a pan-HDAC inhibitor, was also examined in a phase II trial of 129 patients with a median of two prior systemic therapies. The ORR was 25.8% with a median duration of response of 13.6 months42. While the response rate to these agents is modest, the duration of response can be sustained in many cases, reflecting a need for predictive markers to identify those patients most likely to benefit. Chidamide, an oral HDAC inhibitor, has also been studied in a phase II trial of RR-PTCL. A total of 83 patients were enrolled with an ORR of 28%, median PFS of 2.1 months, and median OS of 21.4 months43. The anti-CD30 antibody drug conjugate brentuximab vedotin has also shown promising results as a single agent. Pro and colleagues reported their phase II study of 58 patients with RR-ALCL (the majority were ALK-negative), with a CR rate of 66% as per investigator assessment and 57% per central review. Those who had achieved a CR had an OS of 79% and PFS of 57% at 5 years44, leading to approval by the FDA for this indication. Bartlett and colleagues explored the use of brentuximab vedotin retreatment in HL and systemic ALCL patients who had previously responded. While it was only a small group of eight systemic ALCL patients, 88% responded to retreatment. With brentuximab vedotin moving to the frontline for many patients, these results suggest that retreatment should be explored further45.Pralatrexate, an antifolate, was examined in a phase II study in which 111 patients with PTCL who had progressed after at least one line of prior therapy were treated weekly for 6 weeks in a 7-week cycle. Response rate was 29%, which included 11% complete responses and 18% partial responses. Median PFS and OS were 3.5 and 14.5 months, respectively46. Interestingly, the ORR was 35% for gemcitabine, 43% for pralatrexate, and 61% for romidepsin, although the trial was not powered to study individual agents in the comparator arm.Alisertib, a selective, small-molecule aurora A kinase (AAK) inhibitor, was studied in an open-label, phase III trial compared to investigator’s choice in patients with RR-PTCL. Options for the single-agent comparator included pralatrexate, gemcitabine, or romidepsin. While the ORR for alisertib was 33%, the study was stopped early owing to the low probability of alisertib achieving superior PFS with full enrollment, as the control arm ORR was 45%. There was some slight suggestion that alisertib may be better tolerated than its comparators, as 33% required dose modifications on the comparator arm versus 28% in the alisertib arm because of adverse effects47. Duvelisib is another oral kinase inhibitor that inhibits PI3K-δ and PI3K-γ. It has been studied for safety and tolerability both as a single agent and in combination with other novel therapies in patients with PTCL49. Preliminary results of the dose-expansion phase of the PRIMO study, a phase II study of duvelisib monotherapy in RR-PTCL, suggest that duvelisib is clinically active in RR-PTCL with no unexpected toxicities. Further expansion phase data are still pending50. Duvelisib has gained an orphan drug designation and fast track designation for PTCL patients who have received at least one prior therapy.There are also a number of other targeted agents at various stages of investigation in patients with PTCL. Crizotinib is an oral, small-molecule tyrosine kinase inhibitor with binding specificity for ALK and ROS1. This molecule is particularly interesting for ALK-positive ALCL, in which ALK overexpression is constitutively active because of the oncogenic translocation in these tumors. When administered to a small group of ALK-positive ALCL and ALK-positive diffuse large B-cell lymphoma RR patients, there was an ORR of 90.9% with 100% CR in the ALCL group. The 2-year PFS and OS were 63.7% and 72.7%, respectively51. It has also been compared to investigator-chosen regimens in RR-ATLL with encouraging results in this disease with very poor outcomes52. A European study has reported an ORR of only 11% with a disease control rate  of 46%53. Given these encouraging results, further randomized studies are underway.Mogamulizumab is a humanized anti-CCR4 antibody with potent antibody-dependent cellular toxicity. It has been studied in the phase II setting in CCR4-positive PTCL and cutaneous T-cell lymphomas. The overall response rate was 34%, with a median PFS of 2 months for the PTCL group55. A phase II study of 18 patients with RR T-cell lymphoma treated with pembrolizumab was closed early following a preplanned futility analysis in which 18 enrolled patients had an ORR of 33%56. Further study of immune checkpoint inhibitors in T-cell lymphoma is clearly warranted, as there have also been some findings of hyperprogression in various subtypes. It is hypothesized that this rapid disease progression may be related to PD-1 acting as a tumor suppressor in some tumor types, further highlighting the need for clinical studies in biologically distinct subgroups58.Immune checkpoint inhibitors have been studied in most lymphoma subtypes with potential direct anti-tumor effects as well as effects in the tumor microenvironment. While activity in some settings has been modest, anti-PD1 antibodies may be of particular appeal in lymphomas associated with EBV infection (including NK/T-cell lymphoma) as well as other settings, leading to upregulation of the PD1/PDL1 axis, as can be seen in Hodgkin’s lymphoma (HL). A phase I study examined the use of nivolumab in various hematologic malignancies, including five patients with PTCL in which two patients achieved a partial response59. Given these promising findings, a phase II study was initiated and is ongoing. Horwitz and colleagues described a small, parallel phase I study of RR T-cell lymphoma patients, in which there were 21 evaluable PTCL patients who received romidepsin and duvelisib (ORR 55% and CR 27%) or bortezomib with duvelisib (ORR 36% and CR 21%). Transaminitis limited the tolerability of bortezomib with duvelisib, but, given the tolerability and activity of romidepsin and duvelisib, an expansion of that cohort is planned60. Other combinations of novel treatments that are in the early stages of evaluation include pralatrexate with bortezomib61 and romidepsin with pembrolizumab62.Combination strategies also warrant evaluation, whether this involves novel agents in combination with chemotherapy or novel doublets. Chemotherapy combination approaches include the addition of brentuximab vedotin to bendamustine , which has shown early signs of activity in CD30-positive PTCL. Studies of immune checkpoint inhibitors in combination with chemotherapy are also underway. Given synergy in pre-clinical models, pralatrexate was combined with romidepsin in a phase I study to determine safety, tolerability, and maximum tolerated doses in RR lymphomas. The drug combination was found to be safe and reasonably tolerated with an ORR in the RR-PTCL subgroup of 71%65. Hill and colleagues presented the preliminary results of a phase I dose escalation study of a CD5-directed CAR-T cell therapy in RR T-cell leukemia and lymphoma patients as a bridge to allo-SCT66. They treated nine patients (four patients with T-NHL) and showed that treatment is safe and does not appear to induce T-cell aplasia. Some clinical responses were seen in this small and heavily pretreated population. The National Cancer Institute has an upcoming phase I trial assessing the safety and feasibility of an anti-CD30 CAR-T cell treatment in advanced CD30-expressing lymphomas, including ALCL and PTCL-NOS. Other early phase anti-CD30 CAR-T cell studies are currently recruiting67. Also upcoming is a phase I/II study assessing an anti-T cell receptor β-chain constant domain 1 (TRBC1) CAR-T cell therapy in RR, TRBC1-expressing PTCL-NOS, AITL, and ALCL. There are two genes associated with the β-gene constant region of the T cell receptor,TRBC1 andTRBC2. A group of normal T cells will therefore have a mixture of cells, as some expressTRBC1 and others expressTRBC2. Clonality among a group of malignant T cells will therefore result in exclusive expression of one constant domain, making it an attractive target68. These results and others will certainly be helpful to start clarifying the role that CAR-T cell immunotherapy will have in treating patients with RR-PTCL.Chimeric antigen receptor (CAR)-T cell immunotherapies have shown strong results in the treatment of B-cell malignancies. Targeting T-cell lymphomas with CAR-T cell therapies has some concern given the concept of T-cell fratricide. Anti-CD30 CAR-T cell treatments are in development and have been trialed in small studies thus far. Wang and colleagues included one patient with cutaneous ALCL, and Ramos and colleagues included one patient with cutaneous ALCL and one with systemic ALCL in their series. Grover and colleagues describe their phase Ib/II anti-CD30 CAR-T trial of 24 patients (including one with EATL and one with Sezary syndrome). When using a bendamustine and fludarabine lymphodepleting regimen in this study, they showed significant anti-tumor activity. The majority of patients in these studies had HL. These trials are preliminary but show good tolerability and some modest effects69. Now a distinct entity, ALK-negative ALCLs appear to have further cytogenetic subtypes that manifest varying clinical behavior, although further study is needed72. Newer biologic insights have identified a common T-follicular helper (TFH) cell signature among AITL, follicular T-cell lymphoma (FTCL), and in some cases of PTCL-NOS, leading to a new umbrella category of Nodal T-cell Lymphomas with TFH phenotype in the 2016 WHO classification73. A number of the common genetic changes includingTET2,IDH2,DNMT3A, RHOA, and others are also frequently altered in myeloid neoplasms, most commonly acute myeloid leukemias (AML) and myelodysplastic syndromes (MDS)76. Azacitidine, a hypomethylating agent, as well as enasidenib (IDH2 inhibitor) and ivosidenib (IDH1 inhibitor) via their effects on these altered pathways led to improved outcomes in MDS77 and AML79. Case reports of patients with concomitant AITL and a myeloid neoplasm, as well as a retrospective series of 12 AITL patients, seven of whom did not have concomitant myeloid disease, were treated with azacitidine. With an ORR of 75% in the series and four of the seven patients without a concomitant myeloid neoplasm responding, these data suggest there may be a lymphoma response that is not restricted to those patients with an associated myeloid disease83. This has led to further study, including a phase III trial examining the use of oral azacitidine compared to investigator’s choice in RR-AITL which is currently accruing. A phase I study of oral azacitidine with romidepsin in advanced lymphoid malignancies had an ORR of 73%84. A trial of enasidenib in advanced solid tumors including IDH2-mutated AITL has been completed but is yet to be reported. While gene expression profiling has led to the identification of some similarities among subtypes, it has also confirmed the biologic heterogeneity among others. Overexpression ofGATA3,TBX21, and cytotoxic genes characterized a cohort of PTCL cases into distinct groups with varying clinical behavior85, and next-generation sequencing studies have further characterized the genetic alterations in epigenetic modifiers, signaling genes, and tumor suppressors.PTCL remains a clinically heterogeneous group of diseases, and therapy can only improve from studies that provide biologic insights into these tumors and further identify distinct lymphoma subtypes and targetable alterations. The identification of chromosomal abnormalities has been important in defining specific disease entities. Constitutively active ALK overexpression associated with a genetic translocation in some ALCLs has long been associated with a better prognosisP = 0.0244 and HR 0.71,P = 0.0110, respectively) with an acceptable toxicity profile5. Further studies are needed with adequate power to explore its use in all CD30-positive subtypes given the majority of ALCL patients in this trial. A similar trial comparing CHOP with romidepsin in combination with CHOP has been accrued and results are awaited.Targeted approaches which have shown promise in RR-PTCL have subsequently been brought for evaluation earlier in the disease course, and to date there have been only a handful of such agents. The most successful example is the development of brentuximab vedotin in CD30-positive T-cell lymphomas. Given results of the drug’s efficacy as a single agent in the RR setting and tolerability in combination with cyclophosphamide, doxorubicin, and prednisone (A+CHP) in a phase I study, the ECHELON-2 study was performed, leading to the registration of brentuximab vedotin as part of primary therapy in CD30-positive PTCL. Overall survival and PFS improvement was demonstrated in the brentuximab combination arm  among certain disease subtypes. Selecting the patient or disease subgroups most likely to benefit and eventually moving these drugs earlier in the disease course will require elegant trial design using novel biomarkers and improved disease classification.Further exploration into the biological heterogeneity of disease subtypes will allow the development of rationally designed therapeutic agents, with directed clinical trials to specific subtypes or patients who are most likely to respond. Unique trial designs with multiple arms and baskets will allow the study of these targeted agents in rare disease subtypes. The rational combination of novel agents and/or chemotherapy will be possible as more knowledge is gleaned regarding the biological mechanisms of action and which patients are most likely to benefit. It is with these improved techniques and personalized approaches that we can aim to improve outcomes for patients with aggressive T-cell lymphomas.


PETO, 2.81 ). The long-term benefits of second-generation TKIs are restricted to surrogate outcomes and do not translate into prolonged survival compared to imatinib. Given the long-term use, frontline therapy should be chosen carefully, with special attention to the patients’ quality of life and cardiovascular risks.Large randomized clinical trials and prior meta-analyses indicate that second-generation BCR-ABL tyrosine kinase inhibitors (TKIs) improve surrogate biomarkers in patients with chronic myeloid leukemia (CML) without providing survival benefits. The objective is to evaluate the long-term efficacy and the occurrence of vascular occlusion with second-generation BCR-ABL TKIs compared with imatinib in patients with CML. Three scientific databases, a clinical registry and abstracts from congress were searched to identify all randomized controlled trials that compared a second-generation BCR-ABL TKI to imatinib in patients with CML. Outcomes extracted were overall survival, major molecular response and complete cytogenetic response, arterial occlusive events and venous thromboembolism. These data were synthesized by odds ratios using a fixed-effect model. This meta-analysis included 4659 participants from 14 trials. Second-generation BCR-ABL TKIs did not improve overall survival compared with imatinib, even at longer follow-up ). They improved surrogate biomarkers at 12 and 24 months but increased the risk of arterial occlusion (OR Treatment of chronic myeloid leukemia (CML) has significantly changed over the last two decades with the development of tyrosine kinase inhibitors (TKIs) targeting BCR-ABL. Today, five BCR-ABL TKIs are approved to treat CML . Four of them are indicated for use in newly diagnosed chronic-phase (CP) CML patients . The optDespite their benefit in molecular and cytogenetic responses, second-generation TKIs have not demonstrated survival benefits over imatinib in clinical trials ,7, possiThe study proposed is the first meta-analysis aimed at assessing the long-term overall survival, major molecular response (MMR) and cytogenetic response (CCyR) of second-generation BCR-ABL TKIs compared with imatinib in patients with CML in RCTs. This meta-analysis also compares the occurrence of arterial and venous occlusion with first-line BCR-ABL TKIs in CML patients.The literature search yielded 918 records. After title and abstract screening, 113 full texts were considered for further investigation. The full-text screening excluded 93 articles. Major exclusion reasons were the lack of pertinent data, outdated data or an inappropriate study design. Finally, we identified 14 clinical trials reported in 20 abstracts and articles that met the inclusion criteria, involving a total of 4659 participants ,36,37,38The risk of bias for each of the 14 included studies is shown in 2 = 0%; Of the 14 included studies, 12 reported overall survival data. There was no significant difference between second-generation TKIs and imatinib in the outcome of overall survival ; 2 = 20% and 0%), but the I2 statistic indicated moderate heterogeneity for CCyR at 12 months (I2 = 48%). This inconsistency was mainly due to the heterogeneity between nilotinib (I2 = 81%) and bosutinib trials (I2 = 64%). Differences between these study designs were related to TKI dose and population ; MMR 24 months: OR, 1.40 (95% CI: 1.17–1.67)); CCyR 12 months: OR, 1.50 (95% CI: 1.31–1.72); PETO, 2.81 (95% CI: 2.11–3.73); PETO, 1.74 (95% CI: 0.82–3.66); The risk of AOEs was increased with second-generation TKIs compared with imatinib ) and dasatinib ). Only bosutinib was not associated with a significantly increased risk of AOEs compared with imatinib ). However, this result became significant when simulating recruitment similar to that with dasatinib and nilotinib . Arterial occlusive events (AOEs) occurred more frequently with nilotinib 400 mg BID than with nilotinib 300 mg BID (300 mg BID: 3.32 (95% CI: 1.56–7.09); 400 mg BID: 5.19 (95% CI: 3.14–8.57); The analysis of the risk of bias is reported in the This is the first meta-analysis of second-generation BCR-ABL TKIs that provides long-term estimates on efficacy and safety compared to imatinib. The major finding of this meta-analysis of 14 RCTs including 4659 CML patients was that second-generation BCR-ABL TKIs did not significantly improve short- or long-term overall survival compared with imatinib. Except for nilotinib, for which survival superiority was suggested in the ENESTnd trial . UnsurprBased on the higher rate of surrogate outcomes with second-generation TKIs, numerous recent studies have concluded that second-generation TKIs are superior for frontline treatment of CML, challenging the position of imatinib ,9,10,12.As imatinib and second-generation TKIs confer similar survival probability, their vascular safety is important to consider avoiding premature non-CML-related deaths or vascular-related disabilities. Our meta-analysis confirms that the risk of AOEs is higher with second-generation TKIs than with imatinib. Of 1000 CP-CML patients, 38 more patients  will develop an arterial occlusive disease with second-generation TKIs compared with imatinib. In accordance with real-life studies, the risk of arterial occlusion has reportedly been higher with nilotinib, dasatinib and ponatinib. Bosutinib has the safer vascular profile and is currently not associated with a significant increase of the risk of vascular occlusion ,44. HoweThe potential long-term duration of BCR-ABL TKI treatment led patients and physicians to pay more attention to treatment long-term risks and the impact on patients’ QoL. However, the latter has rarely been studied in clinical trials. The few such studies report similar QoL with imatinib as in the general population among older patients (older than 59 years) . HoweverImatinib and second-generation BCR-ABL TKIs are all highly effective in treating CP-CML and provide survival close to that of the age-matched population. Imatinib has demonstrated reassuring long-term safety and efficacy . At 10 yThe induction of faster and deeper molecular responses with second-generation TKIs compared to imatinib in treatment-naïve patients has generated interest over the last few years for these drugs because of the increasing number of candidates for TKI discontinuation  . HoweverDue to the safety profile of second-generation TKIs, particularly the vascular issue damage from these treatments , the frontline treatment choice should not focus solely on the objective of treatment-free remission. Arterial occlusion occurred more frequently in patients with prior cardiovascular risk factors. Therefore, an estimation of 10-year arteriosclerotic cardiovascular disease risk, as recommended by the ACC/AHA, should be applied to CML patients before making a treatment decision .The treatment choice should then be made individually by carefully weighing the benefits and the risks of each TKI. These results support the current NCCN guidelines, particularly to limit the use of second-generation TKIs as frontline drugs for young patients. Finally, the treatment cost should be taken into account. A recent study demonstrates that the one-year health care expenditures were significantly higher among patients treated with second-generation BCR-ABL TKIs as first-line, compared with those treated with imatinib .Modification of the TKI dose regimen has already been proposed as a potential measure to minimize the risk of AOEs, but data were insufficient to provide formal recommendations . The res2+ release by activating the calcium channel [Several measures have already been recommended in the literature to minimize the risk of arterial occlusion ,58. Thes channel ,63. The A major limitation of this meta-analysis is the use of aggregate data from the studies because of the lack of access to individual data. This precludes additional calculations such as overall survival analyses based on patients’ Sokal score and age and the integration of patients’ comorbidities in the analysis of AOEs. In addition, access to individual data would provide the advantage that statistical analyses could be standardized between but also within studies, and allow the computation of the number of patients eligible for treatment discontinuation. Progression-free survival was not analyzed in our meta-analysis as its definition differs between studies . AnotherA major strength of this meta-analysis is the integration of both published and unpublished data that limit the risk of publication bias. As much as possible, we confront the data from the different sources and use a conservative approach to select the data that have been included in the quantitative analysis. Another strength of our analysis is that we assessed the rates of molecular and cytogenetic responses at specific time points . Most clinical trials have investigated these surrogate outcomes over a period of time, also called the cumulative response, and the reporting of these data is often unclear . Due to the rapid variation of the molecular response, the cumulative incidence is frequently higher than the response rate at a specific time point. Loss of molecular or cytogenetic responses can be the consequence of lack of compliance, treatment intolerance and drug resistance, three factors that are revealed by the analysis of responses at specific time points rather than cumulative response.This meta-analysis was performed in accordance with the protocol for meta-analyses published in 2015  and compTwo researchers (HH and JD) independently screened all titles and abstracts identified from the literature search to determine potentially eligible studies. We included RCTs that compared a second-generation TKI approved for first-line CML treatment with imatinib in patients with CML. The full texts of these potentially relevant articles were then assessed independently by the same researchers (HH and JD) based on predefined inclusion and exclusion criteria. Disagreements were resolved through discussion with a third author (JMD).The data extraction was performed for each study independently by 2 researchers (HH and JD) using a standard data extraction form. The outcomes extracted were overall survival, MMR and CCyR at predefined time points , as well as AOEs and VTEs. Method S2 presents the list of terms considered as AOEs and VTEs. Reviewers took special care to extract responses at a specific time point rather than the cumulative response . The number of patients alive was also preferred over the estimated overall survival , and the overall survival with the longest study follow-up was included.When discrepancies occurred between sources a conservative approach was adopted. For AOE and VTE analyses, data were extracted from the adverse event report rather than from secondary analyses performed by the study sponsor  when possible, to limit the risk of bias.https://training.cochrane.org/online-learning/core-software-cochrane-reviews/revman/revman-5-download). In addition to ORs, anticipated absolute effects were computed using a GRADE profiler . This measure was expressed as a risk difference with its 95% CI and is based on the baseline risk  and the relative effect of the intervention.We conducted meta-analyses of dichotomous variables with the fixed-effect model (FEM) by computing odds ratios (ORs) and 95% confidence intervals (CIs). For the AOE and VTE analyses, ORs were computed using the Peto method because the rate of events was low . Statist2 statistic, with an I2 value < 25% reflecting mild heterogeneity, 25%–50% reflecting moderate heterogeneity and > 50% reflecting severe heterogeneity.Stratification per treatment was performed, as well as per TKI dose when data were available. Heterogeneity among trials was quantified by the ISensitivity analyses were performed as a repeat of the meta-analysis by substituting previously treated patients in order to explore their impact on MMR and CCyR. Sensitivity analyses were also performed by subtracting trials with high-dose imatinib .The risk of bias was assessed using the Cochrane Collaboration’s risk of bias 2 (RoB 2) tool for RCT . To asseSince the introduction of BCR-ABL TKIs, patients’ and physicians’ concerns have shifted because of their high efficacy, and more attention has been paid to treatment toxicity and patients’ QoL. Even with long follow-up, there is no direct evidence of a survival benefit associated with second-generation BCR-ABL TKIs. Given the long-term use of BCR-ABL TKI treatment, the therapeutic option should be selected individually and based on multiple factors, including cardiovascular safety and QoL. Future research should focus on these two last points. To date, the cardiovascular safety of bosutinib is reassuring. In light of the present results, it is anticipated that an in-depth reanalysis of the clinical trials by the marketing authorization holders together with the regulatory bodies would be needed to update the product information with the most recent data analysis. This would provide health care professionals with updated recommendations on the benefits and risks of these medicines.