A visceral leishmaniasis outbreak was reported from a village in a low-endemic district of Bihar, India.Outbreak investigation with house-to-house search and rapid test of kala-azar suspects and contacts was carried out. Sandfly collection and cone bio-assay was done as part of entomological study.MH = 39.2, 95% CI 18.2–84.4). The median durations between onset of fever to first contact with any health services, onset to kala-azar diagnosis, diagnosis to treatment were 10 days (IQR 4–18), 30 days (IQR 17–73) and 1 day (IQR 0.5 to 3), respectively, for 50 kala-azar cases assessed till June 2017. Three-fourths of these kala-azar cases had out-of-pocket medical expenditure for their condition. Known risk factors for kala-azar such as illiteracy, poverty, belonging to socially disadvantaged community, migration, residing in kutcha houses, sleeping in rooms with unplastered walls and non-use of mosquito nets were present in majority of these cases. Only half the dwellings of the kala-azar cases were fully sprayed. Fully gravid female P. argentipes collected post indoor residual spraying (IRS) and low sandfly mortality on cone-bioassay indicated poor effectiveness of vector control.A spatially and temporally clustered kala-azar outbreak was found at Kosra village in Sheikhpura district with 70 cases reported till December 2018. Delay of more than a year was found between diagnosis and treatment of the index case. The southern hamlet with socio-economically disadvantaged migrant population was several times more affected than rest of the village (attack rate of 19.0% vs 0.5% respectively, ORThere is need to focus on low-endemic areas of kala-azar. The elimination programme should implement a routine framework for kala-azar outbreak response. Complete case-finding, use of quality-compliant insecticide and coverage of all sprayable surfaces in IRS could help interrupt transmission during outbreaks. Leishmania donovani, a protozoal parasite and is transmitted to humans through the bite of Phlebotomus argentipes sandfly [Visceral leishmaniasis  is a disease caused by  sandfly . Owing t sandfly . India h sandfly , 4. A ta sandfly , 5.Kala-azar has a long history of outbreaks with the earliest recorded outbreak in 1824–25 in Jessore district of present day Bangladesh , 7. It aA kala-azar outbreak was reported by the Bihar state government in March 2017 at Kosra village in Sheikhpura district. This district lies in the fringe of the kala-azar endemic zone in India  was constituted in June 2017. The team consisted of medical officers, a lab technician and frontline health workers associated with the primary health centre. Since the study was within the purview of programme evaluation and was part of an urgent outbreak response, it was exempt from prior institutional ethics committee approval as per national guidelines . ExistinDuring the household visit, those with fever and contacts of known kala-azar cases were referred for rK39 rapid test  at the health sub-centre located in the village. Those with history of an earlier episode of kala-azar were excluded from rk39 test. Contacts were defined as those who resided in the same household as known kala-azar cases and their next-door neighbours. All rK39-positives with history of two or more weeks of fever were invariably referred to the government district hospital. Here they were confirmed as having kala-azar clinically. Those with two or more weeks of fever and finding of palpable spleen were treated with 10 mg / kg single dose liposomal amphotericin B (LAmB), as per programme guidelines . HIV tesA semi-structured questionnaire was developed for assessing kala-azar cases regarding awareness and access to treatment and preventive services. Known risk factors for kala-azar were also assessed among the cases. Interview of relatives of those who had died after prolonged fever was also done using the WHO Verbal Autopsy instrument 2016.Entomological study was conducted by scientists from Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India. Vector density was assessed through sandfly collection using mouth aspirator and CDC light trap in randomly selected households in July 2017, two days after focal indoor residual spraying (IRS) was conducted in the most affected southern hamlet. Species identification was done using taxonomic key described by Lewis . Cone biData was entered and cross-checked for errors. Age-wise, gender-wise and area of residence-wise attack rates were described using numerator of all kala-azar cases reported up to December 2018 Fig. . The genMantel-Haenszel method was used to statistically compare the attack rates of kala-azar for the most affected hamlet as compared to rest of the village, stratified by gender. The spot-map represented all kala-azar cases till December 2018 Fig. . NearestDuring this outbreak investigation, 371 people with fever and contacts of kala-azar patients were tested .Around one-third of the 70 kala-azar cases diagnosed till December 2018 belonged to 0–14-year age group. Age-group wise attack rates were not significantly different (Table p < 0.0001) as compared to rest of the village, while taking gender as stratifying variable.Kala-azar attack-rate in the southern hamlet and its extension was several times higher than in the rest of the village (19.0% vs 0.5%). Mantel-Haenszel adjusted risk ratio for being affected by kala-azar for residents of southern hamlet was 39.2  with the highest expenditure of Rs 50,000 for the index case. Only in 12 of the 50 patients, the first health facility contact was with the government health system on their own or through active case search by frontline workers, with services availed completely free of cost  per labourer in advance to the families under an informal agreement to work in brick kilns. The sum received is used to pay back loans taken from local money lenders at high interest rates. Out of pocket medical expenditure are a major reason for taking these loans. This creates a self-perpetuating cycle of social exclusion, indebtedness, poverty and malnutrition for the migrants , 20.Four children and one adult had died after 2–6 months of prolonged irregular fever, weakness, loss of appetite and pronounced abdominal swelling (only for children) in the most affected southern hamlet of the village. Blackish discoloration of skin was noted in the adult who died. Both genders were affected. The deaths happened between October 2016 – March 2017 before any diagnosis of kala-azar could be attempted. All five deaths could be epidemiologically linked to a family member or an immediate neighbour having been confirmed with kala-azar within 6 months of their death.Regular IRS round was done covering all the houses of the village –during 20–26 March 2017 and 26–31 August 2017. Focal spray was conducted in clusters of 70–200 houses around reported kala-azar cases in the southern hamlet during 15–17 May 2017, on 8 July 2017, 25–27 July 2017 and 20–22 December 2017.Only half the dwellings of the kala-azar cases had been found to be fully sprayed during the most recent IRS conducted in May 2017  also could be ruled out as the village had no prior exposure to DDT for IRS  in the past 10 years. Thus, bioassay findings could be mainly explained by under-dosing of insecticide residue on walls in the three preceding IRS. Under-dosing could have been due to one or more of the following factors - patchy coverage of sprayable surfaces, less than recommended quantity of insecticide being used for suspension preparation, improper spray technique resulting in wider swath or faster spraying or due to less than recommended active ingredient concentration in the insecticide supplied . We coulIn August 2018, the district programme was officially notified regarding 61 batches of Alpha-Cypermethrin wettable powder insecticide which had failed the recommended active ingredient specifications . One of During the outbreak response, rk39-positive individuals providing history of fever without palpable spleen finding were not considered for treatment, as per programme guidelines . Also, sDue to the insidious onset and prolonged fever seen in kala-azar, recall bias could have crept in while assessing duration of fever preceding kala-azar diagnosis.The interruption of transmission in outbreaks must rely on both complete case finding and effective vector control. This could be achieved through coverage of all sprayable surfaces during IRS and use of insecticide compliant with quality norms and plastering the walls of mud houses. Kala-azar, a neglected tropical disease, was found to disproportionately affect the poor and marginalized community.This outbreak revealed the need to strengthen kala-azar elimination programme especially in low endemic and migratory settings so that future kala-azar outbreaks could be prevented and detected early. For example, establishment of routine framework for kala-azar outbreak response is needed owing to risk of outbreaks in low-endemic areas and areas which have hitherto achieved elimination targets .There is scope for further reduction of delay between fever onset and diagnosis through sensitization of government and private practitioners, frontline health workers and active case detection, especially in migratory settings. Reduction of this delay has the potential to not only reduce out-of-pocket medical expenditure, but also to prevent future outbreaks and lead to dramatic reduction of kala-azar incidence in Bihar, India .


Newborn screening (NBS) for congenital diseases is among the biggest achievements of modern medicine in the field of public health . As a seTurkey still has a high consanguinous marriage rate which results in higher incidence of recessively inherited congenital diseases . NeverthClassical congenital adrenal hyperplasia (CAH) is the most common form of of primary adrenal insufficiency in childhood and is a potentially life-threatening condition that requires accurate diagnosis and urgent treatment with glucocorticoid and mineralocorticoid replacement . CAH occIn 2002 the Joint Lawson Wilkins Paediatric Endocrine Society/European Society for Pediatric Endocrinology Working Group recommended biochemical screening for CAH in the newborn period. Neonatal screening for CAH is effective in detecting the salt-wasting form and thereby reducing mortality .th days of life followed by steroid profiling in the same dried blood spots using liquid chromatography-tandem mass spectrometry (LC-MS) method to measure 17-OHP, 21-deoxycortisol, cortisol, 11-deoxycortisol and androstenedione as a second-tier test in those with positive initial screening. The babies with a steroid ratio (21-deoxycortisol+17-OHP)/cortisol of ≥0.5 were referred to pediatric endocrinology clinics for further diagnostic assessment. They found that of the 38,935 infants tested, 2265 (5.82%) had second-tier testing, and 212 (0.54%) were referred for clinical assessment. Final analyses showed that six cases of CAH were picked up . Four cases were identified as salt-wasting 21-OHD , one male baby had simple virilizing 21-OHD, and one male baby had 11-OHD CAH. The incidence of classical 21-OHD in the screened population was 1:7,787.In this issue of JCRPE, Güran et al  present CYP21A2 alleles  giving rise to higher incidence of homozygous biallelic mutations in this population together with compound heterozygotes for two or more different mutant At present, NBS for 21-OHD is carried out in more than 50 countries worldwide. The majority of screening programs use a single screening test which might result in some cases to go undiagnosed even with screening . To imprSingle sample, two-tier screening strategy as used in this study, carries some risk in missing CAH cases with delayed rise in 17-OHP, but obtaining a second sample at a later time would further complicate the screening and cause further delay in obtaining results. As in all screened diseases, a high level of suspicion in patients presenting with signs and symptoms of CAH should still be maintained even if the baby has false-negative screening results. Furthermore, meticulous search for any adrenal-related crises/deaths in the screened area/population is important for evaluation of the efficacy of screening strategy, an activity which requires reliable hospital and/or registry records.Ideally, screening results should be available before approximately two weeks of age, when salt-wasting typically becomes evident. However, in the current study, the initiation of hydrocortisone treatment ranged between 10 to 30 days of life in 4 cases with salt-wasting 21-OHD and the duration from birth to clinical evaluation of abnormal screening test results of false positive cases was 25.8±6.4 days, results which indicate a delay. Fortunately, none of the patients (except one with hyponatremia) were in critical condition despite this delay. The authors rightly identified the reasons for this delay and suggested possible solutions  to optimize screening program, which is the main objective of doing pilot studies.For any screened disease, recall rate should be in a reasonable range since referral of these babies to clinics for further confirmation of the diagnosis and initiation of treatment require considerable work, time and cost. This is particularly important for countries where the healthcare system is overloaded and the sources are limited. In addition, parents of infants with positive screens may suffer significant psychological distress until the final diagnosis is reached. In that respect, recall rate was higher (5.82% in the first and 0.54% in the second tier testing) despite two-tier screening approach in this pilot study compared to previous studies which reported a figure between 0.002% and 1.2% (13). This is due to lower cut-off values the authors used for the first step 17-OHP FIA measurements as well as the second step (21-S+17-OHP)/F ratio to increase the sensitivity of this pilot study. However, based on the obtained results, elevating cutoff values two-fold would seem to reduce false positives dramatically without decreasing sensitivity. (taking 20 instead of 10 ng/mL for the first tier 17-OHP and taking (21-S+17-OHP)/F ratio ≥1 instead of ≥0.5) thus potentially eliminating this problem in the future extended NBS program in Turkey. This observation is in line with that reprted by Janzen et al  who founThanks to the LC-MS method, another “bonus” of this pilot study was diagnosing a male newborn with classical 11 hydroxylase deficency, who might be the first patient with 11-OHD identified directly during NBS for CAH. Second-tier LC-MS also measures 11-S in addition to 17-OHP, 21-S, cortisol and 4AS, which is specifically diagnostic for 11-hydroxylase deficiency. Thus, the method of steroid profiling has a potential to distinguish other rare forms of classical CAH, beyond 21-hydroxylase deficiency. Even though the hormones measured in LC-MS/MS based panels are not specifically diagnostic for the rare forms of CAH, perturbations in simultaneous steroid measurements have the potential to provide preliminary information suggesting the need for further evaluation. This is particularly important for countries like Turkey where “rare” forms of classic CAH are common due to high rate of consanguinity.Analysis of the data from the current study is a big step towards optimization of the 21-OHD screening in Turkey. For no doubt, the incidence of 21-OHD obtained in this study calls for inclusion of 21-OHD screening in the NBS panel in Turkey. It would be interesting to see the figures after the implementation of countrywide screening in the years to come.


Food addiction symptoms were assessed using the Yale Food Addiction Scale. Associations between FA symptoms and activation of the BLA and central amygdala were tested using bilateral masks and small-volume correction procedures in multiple regression models, controlling for BMI. Participants were 24.1 ± 2.6 years, with mean BMI of 27.4 ± 5.0 kg/m2 and FA symptom score of 4.1 ± 2.2. A significant positive association was identified between FA symptoms and higher activation of the left BLA to high-calorie versus low-calorie foods in the fasted session, but not the fed session. There were no significant associations with the central amygdala in either session. This exploratory study provides pilot data to inform future studies investigating the neural mechanisms underlying FA.Few studies have investigated the underlying neural substrates of food addiction (FA) in humans using a recognised assessment tool. In addition, no studies have investigated subregions of the amygdala  and central amygdala), which have been linked to reward-seeking behaviours, susceptibility to weight gain, and promoting appetitive behaviours, in the context of FA. This pilot study aimed to explore the association between FA symptoms and activation in the BLA and central amygdala via functional magnetic resonance imaging (fMRI), in response to visual food cues in fasted and fed states. Females ( There is increasing scientific interest in the possible role of “food addiction” (FA) underlying particular patterns of overeating, dietary relapse and weight gain in vulnerable individuals. Neuroimaging techniques, such as functional magnetic resonance imaging (fMRI), have provided insight into this phenomenon in humans. Visual food cues and consumption of palatable, energy-dense foods have been shown to activate reward-related brain circuits in humans in a similar way to substances of abuse . DespiteIn one neuroimaging study using a recognised FA assessment tool, YFAS symptoms were associated with greater activation in response to a visual milkshake cue in brain areas encoding the reward value of foods and craving , medial orbitofrontal cortex (OFC), and the dorsolateral prefrontal cortex (DLPFC)) in young females . In anotThe amygdala has been implicated in previous FA neuroimaging research  and playThis pilot study aimed to explore the association between YFAS assessed FA symptoms and activation in the central and BLA, assessed via functional MRI, in response to visual food cues in fasted and fed states. It was hypothesised that FA symptoms would be associated with greater activation in the BLA in response to high-calorie vs low-calorie foods in both the fasted and fed states, based on the findings of previous neuroimaging research ,9,10.Australian females aged 18–35 years were recruited to the current study from an existing pool of participants who had completed an online FA survey, which aimed to determine FA prevalence and associations with dietary intake in Australian adults . At the Participants were eligible for the current study if they were female, aged 18–35 years, lived within a one-hour proximity to the imaging facility  and elected to be contacted for future research at the end of the online survey. Eligibility for this pilot study was restricted to females only in order to reduce potential inter-person variation in appetite and neural activation to visual food cues associated with sex-related differences . SeventyThe study procedure is outlined in Demographics: Demographic data including sex, age, indigenous status, marital status and highest qualification were collected. Current and previous dieting history  was alsoYale Food Addiction Scale: The YFAS is a 25-item questionnaire which assesses addictive-like eating according to the diagnostic criteria for substance dependence. The YFAS has been shown to have adequate psychometric properties . The tooAnthropometrics: Height was taken using a BSM370 stadiometer, while weight and body composition  was assessed using the InBody720 bioelectrical impedance analyser  using a standardised protocol. Body mass index (BMI) was subsequently calculated.n = 20; n = 10 high-calorie, n = 10 low-calorie), using a 10 cm visual analogue scale. Participants completed the set of ratings in the fasted state at baseline (prior to Scan 1) and in the fed state (prior to Scan 2). Hunger and appetite ratings included self-reported (i) hunger, (ii) satiety, (iii) fullness and (iv) prospective food consumption [Hunger and Image Ratings: Participants completed a set of ratings related to hunger and appetite, as well as rating a subset of images shown to them in the MRI scanner (sumption . For then = 27). A final sample of 150 single food images were selected for the study including n = 75 high-calorie and n = 75 low-calorie foods. Nutritional composition of the food images can be found in Food images were chosen from a standardised database  and foodVisual stimuli were presented in a block design format using Presentation software  and NordicNeuroLab sync box , and consisted of two 18 min 20 s runs. Each run consisted of 15 epochs each of (i) low-calorie foods, (ii) high-calorie foods and (iii) fixation cross. Within each 20 s epoch of food images, five images were presented for four seconds each. A 20 s central fixation cross was presented as a control, and each epoch was separated by a four second blank screen. Each run consisted of 440 volumes over the scanning period. Images were presented onto an MRI compatible screen via a projector, and viewed via a mirror attached to the head coil. Standardised instructions to remain still focus on the visual stimuli were provided by the radiographer during the scan.Structural and task-related functional scans were acquired using a Siemens 3-tesla MRI . Structural images were acquired with a three-dimension (3D) magnetisation-prepared rapid gradient-echo (MP-RAGE) sequence with the following parameters: TE = 3.5 ms, TR = 2 s, 7° excitation flip angle, 160 slices with 1mm isotropic resolution. Task-related functional MR images were acquired using a T2*-weighted gradient-echo echo planar imaging (EPI) pulse sequence. The parameters were TE = 24 ms, TR = 2.5 s, 90° excitation flip angle, 47 axial slices 3 mm thick with a 0 mm interslice gap, in-plane resolution of 3 × 3 mm, covering from vertex to cerebellum. Axial slices were angled to the anterior cranial floor for to limit distortions that may impact on imaging of the orbito-frontal region.Participant characteristics, hunger and image ratings were analysed descriptively using Stata13. Differences in hunger and image ratings between the first and second scan were assessed using paired t-tests. Task-related functional MR images were processed and analysed using MATLAB version R2017a  and Statistical Parametric Software . Preprocessing steps involved motion correction, spatial normalization and smoothing using a Gaussian filter (FWHM 8 mm). The realigned functional sequences were coregistered to each participant’s anatomical scan, which had been previously coregistered and normalized to the SPM-T1 template. Normalization parameters were then applied to the coregistered functional images, which were then resliced to a 2 mm isotropic resolution in Montreal Neurological Institute (MNI) space. – Fed scan ) and  – Fasted scan ). The same contrasts were created to explore the between session effects on the activation of low-calorie > high calorie foods. Three regressors were used in these analyses to model conditions separately corresponding to high-calorie and low-calorie foods, and the fixation cross. Furthermore, to correct for subtle in-scanner movements from volume-to-volume scans, we identified the outlier scans present in the realigned task-related functional scans as determined using the CONN toolbox . For each participant, the actual removal of outlier scans was completed by entering the subject-specific variables identifying the outlier scans  in the first-level models as covariates of no interest, so these outlier scans were removed from these and subsequent analyses. We excluded one subject that had 19.8% of outlier scans. A hemodynamic delay of 4 s and a high-pass filter (1/120 Hz) were considered. The resulting first-level contrasts images were then carried forward to subsequent second-level random-effects (group) analyses. One-sample t-tests were used to assess the main task effects in the fasted and fed sessions. Multiple regression models were used to assess associations between FA symptoms and whole-brain activation under the main task effects in the fasted and fed sessions, and the change between sessions. These analyses were controlled for the subject-specific number of outlier scans, BMI, hunger and dieting when the association with FA symptoms was explored. Results were considered significant when surviving a p > 0.001 and a determined cluster-extent using Monte Carlo simulations implemented in the AlphaSim thresholding approach [First-level (single-subject) SPM contrasts images were estimated for each of the fasted and fed scans for the following task main effects of interest: high-calorie > low-calorie foods, and low-calorie > high-calorie foods. Changes in brain activation between sessions were computed by the creation of the following contrasts: approach  ; however, ratings of fullness and satisfaction increased, and prospective food consumption decreased . Image ratings were significantly reduced from the fasted to fed scans (p < 0.05). FA symptoms were not associated with hunger or image ratings (p > 0.05)Participant characteristics can be found in Visual cues of high-calorie vs low-calorie foods activated a cluster in the right amygdala, the left hippocampus, the fusiform gyrus, and in bilateral occipital cortex in the fasted session, and the left amygdala in the fed session . No signpSVC-FWE<0.05 = 0.042) were identified using small-volume correction procedures. Importantly, this association was found regardless of the body mass index of the participants, and it also remained statistically significant after controlling for hunger reported by the participants during the fasted session and current dieting status. No significant associations were identified between FA symptoms and the activation of the central amygdala in the fasted session, and the activation of the basolateral and central amygdala in the fed session . The change in the magnitude of activation from the fasted to the fed sessions of the left BLA showed a significant association with FA symptoms, controlling for BMI   .This is the first study to use fMRI to investigate activation in distinct subregions of the amygdala in response to visual food cues in relation to FA symptoms in both fasting and fed states. In line with the hypothesis, activation in the BLA in response to high-calorie foods versus low-calorie foods was found to be associated with higher FA symptoms in the fasted state, which is consistent with previous research ,9,10. FuThe findings of the current study suggest that those with higher FA symptoms may be vulnerable to environmental food cues of energy-dense, nutrient-poor, high-calorie food when hungry compared to those with lower FA symptoms. This may lead those vulnerable individuals to greater desire to eat, hence leading to food seeking and consumption, which is consistent with previous research ,17. It iThe second hypothesis was not supported, with no significant associations found between FA symptoms and BLA activation in the fed state. This is divergent previous work investigating the role of the amygdala in eating in the absence of hunger and weight gain susceptibility . HoweverThe strengths of the current study include the use of a recognised assessment tool for FA and investigation of participants in fasted and fed states. Food images were informed by previous research and selected from a standardised database , which wThis study demonstrates that activation of the BLA, which has been linked to reward-seeking behaviours and susceptibility to weight gain, was associated with FA symptoms in the fasted state. This study provides pilot data to inform future studies with larger sample sizes investigating the neural mechanisms associated with FA.


The purpose of this study was to examine the impact of epidermal growth factor receptor (EGFR) mutation status and tyrosine kinase inhibitors (TKIs) on the survival of brain metastases (BM) in patients with surgically resected non-small cell lung cancer (NSCLC).We selected the patients who had developed metastatic NSCLC; analyzed the differences between brain metastases and other sites of metastases, including patient characteristics, EGFR status, and survival; and selected the patients who had BM for further investigation. We also compared the treatment effects of first-generation TKIs with those of second-/third-generation TKIs.A total of 785 cases of stage I-IIIa NSCLC were reviewed. Thirty-six (4.6%) patients were identified as having BM. Among them, 14 patients had a mutated EGFR status. No association between EGFR mutation and the incidence of BM was observed (p = 0.199). Patients with mutated EGFRs had significantly longer overall survival and post-recurrence survival than patients with wild-type EGFR mutation (p = 0.001 for both). However, there was no survival difference between patients with exon 19 and exon 21 mutations (p = 0.426). Furthermore, patients who received the second- and/or third-generation EGFR-TKIs had better survival than patients who only received first-generation EGFR-TKIs (p = 0.031). A multivariate analysis indicated that the next-generation TKIs  and a longer interval before BM development  were significant factors in longer survival.EGFR-TKIs were effective in treating NSCLC patients with BM after curative pulmonary surgery, especially in those patients harboring EGFR mutations. Furthermore, the second-/third-generation EGFR-TKIs showed more promising results than the first-generation EGFR-TKIs in treating those particular patients, though larger studies needed to further prove the results. The development of brain metastases (BM) is a devastating consequence of disease progression that affects up to 44% of advanced non-small cell lung cancer (NSCLC) patients, particularly patients with adenocarcinoma , and indst generation of TKIs had limit blood brain barrier (BBB) penetration. In contrast, the 3rd generation TKI, osimertinib, has better BBB permeability and higher clinical activity than other TKIs [®), was introduced in 2003 and first approved by the FDA to treat NSCLC in August of 2014 [EGFR-TKIs have been found to be more effective in the treatment of patients with BM than chemo- and/or radiotherapy ,4; howevher TKIs . Furtherher TKIs . In this of 2014 . TherefoThis study reviewed the database of NSCLC patients who received curative surgery at the Tri-Service General Hospital in Taiwan from July 2004 to July 2017. The institutional Review Board of Tri-Service General Hospital, National Defense Medical Center approved this study and waived individual patient consent. We selected the patients who had developed subsequent BM and analyzed the differences between BM and extracranial metastases, including patient characteristics, EGFR mutation status, and survival. We also compared the treatment effects of first-generation TKIs with those of second-/third-generation TKIs.For survival analysis, we evaluated the overall survival (OS), disease-free survival (DFS), and survival after brain metastases (SVABM). OS was defined as the interval between the first surgery and the last follow-up or date of death. DFS was defined as the interval between the first surgery and the date of recurrence. Tumor recurrence was confirmed by CT or MRI scan. SVABM was defined as the interval between the identification of BM and the last follow-up or date of death. Factors previously reported to influence the survival of NSCLC were all included in the univariate analysis. These included age, sex, TNM stage, lymphovascular invasion, visceral pleural invasion, EGFR mutation, CEA level, tumor size, ground glass opacity ratio, and surgical removal of the metastatic lesion. Those factors that tended to have impacts on survival were then included in the multivariate calculations.P< 0.05 was considered statistically significant.Univariate categorical variables and univariate continuous variables were analyzed using the chi-square test and Mann-Whitney U test, respectively. The Kaplan–Meier method, log-rank test, and Cox proportional hazard models were used for survival analysis. All the prognostic factors were weighted for significance by hazard ratios, and th edition of TNM classification, with those diagnosed before 2009 being restaged according to the new classification. One hundred and fifty-nine of the patients developed metastatic NSCLC and 36 (4.6%) patients were identified as having BM during the period of follow-up, including 19 (53%) men and 17 (47%) women with a median age of 57 years (range: 42 to 86 years). All of the patients were of Asian descent. Among those patients with BM, 21 had a determined EGFR mutation status, and mutated EGFRs were found in 14 . Among 159 patients with relapsed disease, 87 deaths were recorded, and 10 deaths were recorded in 49 EGFR mutant patients. As for the BM group, 20 patients were died during the follow-up period (including 2 patients with mutated EGFR and 5 patients with wild-type EGFR mutation). A total of 785 patients with stage I-IIIa NSCLC who all consecutively underwent curative surgery were included. All of the patients underwent comprehensive clinical assessment based on the 7= 0.161). There were also no significant differences in sex, TNM stage, T factor, and OS  was 41.40 months (7.77–149.55 months). Among the patients with BM, the median follow-up period was 41.53 months (range: 8.21–149.55 months), the median OS was 58.42 months, and the median DFS was 17.18 months. Compared to the patients with wild-type EGFR mutation, the patients with mutated EGFR had significantly longer OS  and SVABM  . In addiUnivariate analyses demonstrated that female sex, mutated EGFR status, and a longer interval to BM development  were favorable factors for OS in patients with BM. Furthermore, to confirm which factors were independently associated with better survival, a multivariate analysis was conducted and showed that longer DFS and the use of next-generation  TKIs were favorable prognostic factors for OS in patients with BM  . As for et al. reported the overall frequencies of EGFR mutations were 47% in Asian patients, 15% in European patients, 22% in North American patients, and 36% in South American patients [In this study, in which we included 785 surgically resected NSCLC patients and identified 36 patients among them who developed postoperative BM, we sought to explore the predictive factors for overall and post-recurrence survival, with a particular focus on EGFR mutation statuses and treatment with different TKIs. The EGFR mutation rate in NSCLC varies according to patient characteristics, including sex and ethnicity. More specifically, it is well known that EGFR mutation incidence is higher in female patients than in male patients, and higher in Asian patients than in Western patients [patients . The patet al. reported a significant association between mutated-EGFR status and risk of BM at the time of initial diagnosis, as well as during the follow-up period after curative resection of pulmonary adenocarcinoma [in vitro exploration showed that mutated EGFR tumors trigger mesenchymal-like phenotype transformation and induce cancer cell dissemination [et al. included 209 consecutive patients with treatment-naïve NCSLC and sought to explore the biological behaviors influenced by the different activations of driver oncogenes, finding that patients with EGFR mutations were more likely to have liver metastases than patients without such mutations [The association between EGFR mutation status and BM in NSCLC patients has previously been investigated, although no clear conclusions could be drawn from those investigations –14, witharcinoma . A similmination . In contutations . Howeverutations . Given tet al. [et al. [Furthermore, we found that the patients with BM in the current study were younger and more likely to have pN1 and pN2 disease than the patients with extracranial metastases . A nomoget al.  showed t [et al. . Our ownet al. [One of the latest upgraded prognostic assessments for NSCLC patients with BM was introduced in a study by Sperduto et al.  that incet al. . Moreoveet al. .This study could not definitively determine which EGFR mutation subtype resulted in better survival in patients with postoperative BM under EGFR-TKI treatment due to the small sample sizes of patients with the relevant subtypes , although there was no survival difference evident in our results . A meta-Based on the results of previous clinical trials –27, EGFRThe LUX-Lung clinical trials further focused on a second-generation EGFR-TKI, afatinib, performing a comprehensive survey of treatment effects in patients with advanced EGFR-mutated NSCLC. A subgroup analysis of the LUX-Lung 3 and 6 results demonstrated a significantly better PFS in the setting of first-line afatinib versus chemotherapy in patients with BM  .In our database, there was one patient (no.10) who sustained long-term survival under osimertinib treatment after developing a T790M mutation under erlotinib treatment (41.5 months after the diagnosis of BM). The abilities of the different generations of EGFR-TKIs to penetrate the blood-brain barrier (BBB) may directly reflect their different intracranial antitumor effects. That said, while the penetration ability of gefitinib was previously reported to be approximately 1% of serum level and that of erlotinib was previously reported to range from 2.5% to 13%, very little is known about the BBB penetration ability of afatinib . NeverthThe present study had some limitations. First, it was a retrospective study of a single center with a relatively small number of patients, and some of the patients lacked EGFR mutation data. Second, further EGFR mutation surveys of surgical brain tissue should be conducted to clarify the exact molecular changes in metastatic lesions, given that genetic heterogeneity between the primary tumor and CNS metastases may exist. Third, the inconsistent treatment strategies used for postoperative BM patients may obscure the real intracranial antitumor effects of EGFR-TKIs. Previous studies have shown that upfront radiotherapy will disrupt BBB tight junctions and cause elevated drug concentrations in the CSF; thus, a study with a unified post-recurrence treatment setting should be conducted to eliminate this bias. Finally, we did not include the functional status of patients in our analyses. Patients with better functional status were more likely to receive aggressive therapy, whereas patients with poorer functional status tended to be treated more conservatively. Nevertheless, our study focused on patients of East Asian ethnicity who underwent curative pulmonary surgery, with the results providing the clinical implication that more strictly brain surveillance should be undertaken for younger patients and patients with positive pN disease, and next-generation of EGFR-TKIs should be strongly considered for the treatment of NSCLC patients with subsequent BM.S1 Table(DOCX)Click here for additional data file.S1 Fig(TIFF)Click here for additional data file.S2 Fig(TIFF)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.


In recent years, immunotherapies have been clinically investigated in AML and other myeloid malignancies. While most of these are focused on stimulating the adaptive immune system (including T cell checkpoint inhibitors), several key approaches targeting the innate immune system have been identified. Macrophages are a key cell type in the innate immune response with CD47 being identified as a dominant macrophage checkpoint. CD47 is a “do not eat me” signal, overexpressed in myeloid malignancies that leads to tumor evasion of phagocytosis by macrophages. Blockade of CD47 leads to engulfment of leukemic cells and therapeutic elimination. Pre-clinical data has demonstrated robust anti-cancer activity in multiple hematologic malignancies including AML and myelodysplastic syndrome (MDS). In addition, clinical studies have been underway with CD47 targeting agents in both AML and MDS as monotherapy and in combination. This review will describe the role of CD47 in myeloid malignancies and pre-clinical data supporting CD47 targeting. In addition, initial clinical data of CD47 targeting in AML/MDS will be reviewed, and including the first-in-class anti-CD47 antibody magrolimab. The clinical relevance of CD47 expression was then evaluated in AML patients. Primary AML patient samples displayed increased expression of CD47 on the cell surface compared to normal cell counterparts  developed for clinical use demonstrated similar leukemic eradication and long term survival in vivo  is a transmembrane protein that mainly functions as an anti-phagocytic or “do not eat me” signal, enabling CD47-expressing cells to evade phagocytic elimination by macrophages and other phagocytes. Inhibition of phagocytosis occurs by CD47 binding to its cognate receptor Signal Regulatory Protein Alpha (SIRPα) on macrophages leading to tyrosine phosphatase activation and inhibition of myosin accumulation at the phagocytic synapse site, thereby preventing phagocytosis . CD47 waterparts . Furtherterparts . Given t in vivo . While C in vivo . This prApart from AML, similar pre-clinical findings were observed in MDS patients . While Cin vitro. In vivo, anti-CD47 antibody therapy significantly reduced the frequency of CD34+ LSC progenitors in the bone marrow compared to control treatment. Lastly, bone marrow cells harvested from mice treated with anti-CD47 antibody failed to transplant into secondary mouse recipients thus demonstrating inhibition of LSC function in vivo. In summary, pre-clinical data demonstrate that CD47 is an LSC marker in AML. Thus, anti-CD47 therapies that eradicate LSCs may lead to long term remission in the clinic (AML is organized as a cellular hierarchy initiated and maintained by a subset of self-renewing leukemia stem cells (LSC). These LSC have been hypothesized to be a disease-initiating cell population and thus eradication of disease-initiating clones is presumably required for cure. LSC phenotype and function have been well-characterized in AML . Cle clinic .It is important to note that while CD47 is expressed on most cancers, it is also expressed on most normal cells. This widespread expression of CD47 on normal cells may cause concern about toxicity when considering a therapeutic approach to targeting CD47. Interestingly, in pre-clinical studies (described above), anti-CD47 antibody therapy eliminated leukemic cells, but not normal cells via phagocytosis. Thus, therapeutic targeting of cancer cells was observed with CD47 blockade. Given that CD47 is widely expressed on normal cells, what is the mechanism of this tumor selectivity? It is now known that the therapeutic targeting of CD47 depends not only on the anti-phagocytic CD47 signal, but also the expression of pro-phagocytic or “eat me” signals. During the process whereby normal cells become damaged , they induce expression of pro-phagocytic signals that lead to their homeostatic removal by phagocytosis . This isin vitro. While calreticulin is one identified pro-phagocytic signal, there are likely others including proteins involved in DNA damage and stress responses, aberrant cell surface phospholipid exposure, and aberrant cell surface protein glycosylation. In summary, pre-clinical data demonstrate that the tumor selectivity of certain anti-CD47 antibodies is based on the relative expression of the anti-phagocytic signal CD47 and pro-phagocytic signals. The scientific basis for this rationale is key for the safe and effective development of CD47 targeting therapeutics.Calreticulin is a multifunctional protein that serves several functions including calcium homeostasis, stress response, and acting as a protein chaperone, that normally resides in the endoplasmic reticulum. Upon a cell damage or stress response, calreticulin translocates to the cell surface and serves as a pro-phagocytic signal, marking cells for clearance. Calreticulin binds to its ligand low-density lipoprotein-related protein (LRP) on macrophages which leads to engulfment of the target cell. While calreticulin can be induced on cancer cells, macrophages can also secrete calreticulin that binds to cancer cells leading to macrophage phagocytosis . As a prin vitro  CD47 signal while enhancing the positive (pro-phagocytic) signal, leading to increased leukemic phagocytosis . It has in vitro . The comnt alone . Important alone . These pSince the discovery of CD47 as a therapeutic target in AML, subsequent studies have validated the role of CD47 across multiple cancer types. Consequently, several CD47 targeting agents have entered the clinic for a number of cancer indications spanning both hematologic malignancies and solid tumors . While mCD47 is ubiquitously expressed on normal cells, which can present a major concern for potential toxicity with CD47 targeting agents. As mentioned previously, selective elimination of cancer cells is dependent on the presence of pro-phagocytic signals, like calreticulin, on cancer cells that are absent on normal cells. Among normal cells, red blood cells (RBCs) are a notable exception, in that they express pro-phagocytic signals in certain settings and can be susceptible to elimination by CD47 blockade. CD47 was previously identified as a major homeostatic regulator of RBC turnover and a marker of self and protective mechanism against RBC clearance . As RBCsTo date, three CD47 targeting agents have been evaluated clinically in AML and MDS. These include magrolimab (previously known as 5F9) , TTI-621 (Trillium Therapeutics), and CC-90002 (Celgene) . MagroliMagrolimab was first evaluated in a first-in-disease multi-center Phase 1 trial as monotherapy in R/R AML conducted in the United Kingdom. Clinical data was reported as of June 2018 . 18 patiMagrolimab was then investigated in a Phase 1b study both as a monotherapy safety run-in in R/R AML/MDS in the United States and in combination with azacitidine in untreated AML patients ineligible for induction chemotherapy and untreated MDS patients who are intermediate to very high risk by Revised International Prognostic Scoring System (IPSS-R)  NCT0324 with mosSome initial correlative analyses were presented. First, given that CD47 is an LSC marker, putative CD34+CD38– LSC frequency in the bone marrow was assessed. LSC frequency was significantly reduced or eliminated in the majority of responding patients. Thus, magrolimab + azacitidine as a potential LSC targeting combination may lead to durable remissions, although longer clinical follow-up is needed. Second, magrolimab + AZA treatment led to a significant increase in CD4 and CD8 T cell infiltrates in the bone marrow of AML patients, suggesting that this combination activates an adaptive T cell anti-leukemic response. Lastly, magrolimab + AZA efficacy was reported for AML patients with a TP53 mutation, a particularly poor prognosis population. The CR/CRi rate in 9 TP53 mutant AML patients was 78% with 44% achieving CR and 33% achieving CRi. In addition, complete cytogenetic responses were observed in 67% of responders. Minimal residual negativity was observed in 57% of responders. Median duration or median survival was not reached with a median follow-up of 6.9 months. TP53 mutant variant allele frequencies were dramatically reduced or eliminated in all patients. While patient numbers and follow-up are limited, these data are encouraging as current available therapies are not effective in TP53 mutant AML. For example, for venetoclax + azacitidine, a current new standard of care in induction chemotherapy ineligible AML, the response rate was 47% with a median duration and overall survival of only 5.6 months and 7.2 months, respectively . OverallWhile the clinical experience of CD47 targeting agents in AML and MDS is early, initial data with magrolimab + AZA demonstrates clinical proof-of-concept in these disease settings. While these data are encouraging, they raise a number of additional questions. First, which patients may preferentially respond to magrolimab + AZA? This question can be divided into three types of investigations: (1) biomarkers of response relating to the CD47/SIRPα pathway; (2) immunologic biomarkers; and (3) correlation of response by mutational profile. With regards to immunologic biomarkers, given that magrolimab activates several immune cell effectors , the correlation of response to frequency and activation state of immune cell effectors in the bone marrow tumor microenvironment is important to characterize. Correlation of response with CD47/SIRPα expression, mutational profiling, frequency of macrophage and T cell effectors in the bone marrow microenvironment, and activation state of T cells in the bone marrow microenvironment are key to assess, and such studies are ongoing.Second, what novel combinations will maximize efficacy with CD47 targeting agents? Given the broad mechanism of action of CD47 targeting agents as macrophage checkpoint inhibitors and potential leukemia stem cell targeting, this raises the question of whether additional combinations incorporating anti-CD47 agents will be effective. While multiple combination modalities can be pursued, it is worth highlighting three potential approaches. Such combination approaches will be emphasized with magrolimab given available clinical data, but may apply to other CD47 targeting agents. First, for magrolimab, significant enhancement of activity when adding azacitidine likely occurs due to the upregulation of pro-phagocytic signals on leukemia cells by azacitidine . This prin vivo with several therapeutics in clinical development. While the clinical data of such agents in myeloid malignancies has been limited, initial data with magrolimab, a first-in-class anti-CD47 antibody, has been shown to be well-tolerated with encouraging efficacy results when combined with azacitidine in AML and MDS patients. These data highlight the clinical importance of targeting immune checkpoints such as CD47 and the critical role for macrophages in the pathophysiology of leukemic disease. As the scientific and clinical understanding of CD47 targeting agents matures, key questions are likely to be addressed including biomarker strategies for patient selection and the identification of effective therapeutic combinations with CD47 blockade. The next several years should prove fruitful in increasing the scientific and clinical understanding of CD47 targeting in myeloid malignancies.CD47 is a novel macrophage immune checkpoint that plays a broad role in cancer immune evasion across multiple cancer types and particularly in myeloid malignancies. In addition, CD47 has been identified as an LSC marker in AML. Therapeutic blockade of the CD47-SIRPα pathway has led to robust pre-clinical efficacy MC, J-PV, CT, and DF were employees of Forty Seven, Inc. KM and PG were employees of Forty Seven, Inc. at the time this work was conducted. IW and RM were co-founders, consultants, and serve on the Board of Directors of Forty Seven, Inc. The authors declare that this study received funding from Forty Seven, Inc. and were conducted with employees of Forty Seven, Inc.MC, CT, J-PV, IW, and RM wrote the manuscript. DF, KM, PG, and JL performed experiments included in the manuscript.This study received funding from Forty Seven and was conducted with employees of Forty Seven, Inc., MC, CT, DF, KM, PG, JL, and J-PV. Since employees or affiliates of Forty Seven conducted experiments and wrote the manuscript, the funder was involved in the study design, collection, analysis, interpretation of data, and writing the article. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The demand for TKA continues to rise within the United States, while increasing quality measures and cost containment became the basis of reimbursement for hospital systems. Length of stay is a major driver in the cost of TKA. Early mobilization with physical therapy has been shown to increase range of motion and decrease complications, but with mixed results in regards to length of stay. We postulate that initiating physical therapy on post-operative day zero will decrease length of stay in an urban public hospital. Retrospective chart review was performed at a large, urban, public academic medical center to identify patients who have had a primary TKA over the course of a 3-year period. Groups who underwent post-operative day zero therapy were compared with those who initiated physical therapy on post-operative day one. Length of stay was the primary outcome. Patient demographic characteristics and discharge disposition were also collected. There were 98 patients in the post-operative day-one physical therapy cohort and 58 in the post-operative day zero physical therapy group. Hospital length of stay was significantly decreased in the post-operative day zero physical therapy group. ( The demand for total knee arthroplasty (TKA) in the United States is increasing annually and projected to rise to 3.48 million annually by 2030 . The incHospital length of stay is a major driver of cost to the healthcare system in patients who undergo total knee arthroplasty ,4. The aNumerous studies have established patient and surgical factors that affect LOS including age, gender, medical comorbidities, anesthetic type, blood transfusion, and surgical day of the week ,12,13,14The purpose of this study is to investigate the effect of same day physical therapy on length of stay following primary TKA in a single, large, urban public hospital in the United States. A retrospective chart review was performed at a large, urban, public academic medical center to identify patients who have had a primary TKA over the course of a 3-year period (2014–2017). The institution performed elective total joint arthroplasty one day per week throughout the course of the study period. We collected length of stay, whether the patient received post-operative day zero (POD-0) PT or post-operative day one (POD-1) PT, baseline patient demographics , American Society of Anesthesiologists (ASA) score, and race), and discharge disposition. Inclusion criteria included patients who were greater than or equal to 18-years-old and were undergoing elective primary TKAs. Exclusion criteria included any patients less than 18-years-old at the time of the surgery, revision surgery, infection and patients undergoing non-elective TKAs . Patients received the same therapy protocol regardless of day of initiation of therapy. Physical therapy was conducted once on POD-0 for those in the POD-0 group and one to two times daily thereafter for both groups under the direct supervision of a physical therapist. A detailed description of the graduated therapy protocol can be found in p-value < 0.05 was used to determine statistical significance of a finding.Data was collected and de-identified using Microsoft Excel software. All statistical analyses and calculations were conducted using SPSS v23 software. A simple Poisson regression and Fisher’s exact test were used for simple bivariate comparisons between length of stay or baseline patient demographics and same-day PT. A multivariable Poisson regression was used to compare length of stay, baseline patient demographics, and same-day PT. A From January 2014 to May 2017 we identified 156 patients who underwent primary TKA at Bellevue Hospital and met our inclusion criteria. Ninety-eight patients received physical therapy on postoperative day one (POD-1), fifty-eight patients received physical therapy on POD-0. There were no significant differences in age, sex, BMI, ASA class, or race between the two groups. Detailed demographic data can be found in Length of stay was significantly decreased for the POD-0 physical therapy group compared with those receiving physical therapy on POD-1.Average length of stay for patients receiving physical therapy on POD-1 was 3.97 days (±2.66), the average length of stay for patients receiving physical therapy on POD-0 was 2.05 (±1.09), Female gender was associated with a significantly increased length of stay. This was found to be significant with multivariable regression analysis Multiregression analysis can be found in There were no differences in the discharge disposition of patients as determined by POD-0 physical therapy p = 0.286. There was a trend towards increased discharge to home, but did not reach clinical significance. Safe ambulation after TKA is a major determinant of discharge disposition and hospital length of stay. Post-operative day zero physical therapy after TKA has been proven to be safe ,18. NumeHowever, there are conflicting reports of the effect of early postoperative rehab for TKA. Karim and colleagues found that POD-0 PT did not affect LOS in TKA but did in THA . While oThe present study supports the findings of Chen and Den Hertog, who found decreased length of stay with initiation of physical therapy on POD-0 ,23. HoweThis study did not find a significant difference in discharge destination for patients who underwent initiation of therapy on POD-0-. There was a trend towards increased discharge home however the difference was not statistically significant. Sarapong et al and others found that patient were significantly less likely to be discharged to a rehabilitation facility when initiating physical therapy on POD-0 ,26,27,28An intensive physical therapy protocol with initiation of physical therapy POD-0-, and one to two daily sessions was examined by Moses et al . While tThis study has several limitations including those inherent to its retrospective design, potentially exposing the study to selection bias as patients where not randomized to receive PT on POD -1 or POD-0 but rather naturally occurred secondary to case timing, patient readiness, and staff availability. Furthermore, retrospective design exposes the study to potential confounding variables including institutional changes over the course of the study period. Another limitation is the lack of validated patient outcome score both pre and postoperatively. A prospective design in which these variables as well as longer term patient outcomes and complications may benefit the literature. Despite these limitations, the study indicates that initiating PT on postoperative day zero can reduce length of stay by a significant factor regardless of patient baseline demographics.Initiating Physical Therapy on POD-0 decreases hospital Length of Stay by almost a full day regardless of age, race, sex, and pre-existing comorbidities. Initiating POD-0 physical therapy significantly decreased length of stay and trended towards increased discharge to home after TKA.


Extended treatment is preconized in a significant proportion of patients with unprovoked venous thromboembolism (VTE). However, limited direct/indirect comparisons are available to appropriately weight the benefit/risk ratio of the diverse treatments available. We aimed to compare the rate of symptomatic recurrent VTE and major bleeding (MB), the net clinical benefit (VTE+MB) and death on vitamin-K antagonist (VKA), direct oral anticoagulants (DOAC) and antiplatelet drugs for extended anticoagulation.A systematic literature search through September 2018 identified randomized trials studying these pharmacologic therapies for extended anticoagulation following VTE. Treatment effects were calculated using network meta-analysis with frequentist fixed-effects model.18 trials  were included in the analysis. All treatments reduced the risk of recurrence compared to placebo/observation. Nonetheless, VKA  and DOAC  were more effective than aspirin, whereas low-dose VKA was less effective than standard-dose VKA . The efficacy of DOAC was globally comparable to standard-adjusted dose VKA. Low-  and standard-dose  VKA also increased the risk of MB, which was not the case for any DOAC. Low-dose VKA and low-dose DOAC had similar effects on MB compared to standard-doses. Although there was a trend for reduced MB and enhanced net clinical benefit for DOAC compared to VKA, this was not statistically significant. The specific anticoagulant therapies had no significant effects on deaths.Standard-dose VKA and low/standard-dose DOAC share similar effects on VTE recurrence and MB, whereas aspirin and low-dose VKA were associated with lower benefit/risk ratio. Pulmonary embolism (PE) and deep venous thrombosis (DVT), collectively referred as venous thromboembolism (VTE), are a leading causes of death and disability worldwide, affecting 10 millions of individuals annually . In patiUntil recently, the main option for long-term anticoagulant therapy was vitamin-K antagonists (VKA) with a standard-adjusted dose  between 2 and 3) . In ordeUnfortunately, there are limited direct comparisons between treatments, and many regimens were not evaluated using the same comparator. For example, low-dose apixaban was compared to placebo , whereasThis systematic review was conducted in accordance with the methodological guidelines for systematic reviews of randomized controlled trials from «Cochrane Handbook for Systematic Reviews of Interventions» . No ethiThe primary efficacy and safety objectives of the study were to compare the effects of VKA, DOAC  and antiplatelet drugs for the secondary prevention of VTE on the rate of symptomatic recurrent VTE and major bleeding (MB), respectively. Secondary objectives were to assess their effects on the net clinical benefit, a composite endpoint defined as recurrent VTE or MB, as well as on fatal VTE and fatal MB.th 2018 (see online supplement) using a filter for randomized controlled trials. Publications from potentially relevant journals were also searched by hand. There were no restrictions on language.We updated the systematic review of Castellucci et al. , searchiThe primary efficacy and safety outcome measures were recurrent VTE and MB episodes, respectively. Recurrent VTE was defined as an objectively confirmed occurrence of new DVT on ultrasound imaging, on venography or on the impedance plethysmography test, as well as a new PE suggested by a new high probability on ventilation/perfusion scanning, or a new filling defect on computed tomography or pulmonary angiography. A MB episode was defined according to International Society on Thrombosis and Haemostasis definition  and inclStudies were independently selected and data were extracted by two reviewers (V.M. and S.J.) using a standardized data abstraction form. Studies were included in the systematic review if they met inclusion criteria defined a priori: 1) prospective enrolment of consecutive patients previously treated for a minimum of three months with anticoagulant treatment for an objectively confirmed, symptomatic DVT or PE; 2) patients randomized to receive an antiplatelet drug, a VKA or a DOAC versus placebo or observation; 3) report one of the outcomes of interest of the present systematic review. Studies recruiting patients with asymptomatic VTE were excluded. Studies’ methodological quality was assessed using the risk of bias assessment tool from the Cochrane Handbook for randomized trials . The rev2 statistic was used to assess between study heterogeneity and was considered high at I2>50%. Fixed-effect model was used in regard to negligible or moderate heterogeneity . We then calculated the probability that each drug had the most efficacious regimen by the p-score, which can be considered as a frequentist analogue of the surface under the cumulative ranking curve for Bayesian approach [Frequentist network meta-analysis and direct pairwise meta-analysis were conducted for all outcomes to compute relative risk (RR) and their 95% confidence interval (95%CI). Network meta-analysis combine direct (pairwise) and indirect comparisons for the same outcome, allowing estimation of the relative effectiveness among all interventions and rank ordering of the interventions. For a given comparison (e.g. VKA versus placebo), direct evidence is provided by trials that compare these drugs directly. Indirect evidence for VKA versus placebo can be provided by synthetizing studies that compared VKA versus aspirin and placebo versus aspirin. Network meta-analysis combines both direct and indirect evidence across a network of studies into a single effect size for a given medical condition. This method is similar to electrical network, where variance corresponds to resistance, treatment to voltage, and weighted treatment effects to current flows . We asseapproach .We systematically tested the presence of significant interaction between the estimate of treatment effects derived from direct and indirect meta-analysis. A sensitivity analysis was planned a priori, adding drugs are not commercialized for the treatment of VTE  from the evidence network. The pooled prevalence of events and its 95%CI was estimated using the arcsine transformation. All analyses were performed using R .Fig 1. Patients and study characteristics are shown in Table 1. Number of events for each main outcome are reported in S1 Table. Ten studies recruited patients with unprovoked VTE only [Fig 2). The mean follow-up duration was 24±11 months. Overall, included trials were generally at low risk of bias (S2 Table). Although independent, blinded outcome assessments were described for all trials, lack of blinding was noted for four trials of them [The primary reviewers included 18 independent trials that contributed to 17 separate publications , 22–31, VTE only , 30, 31,VTE only , 24, 29 VTE only  study, rVTE only , DOAC  and 11.2%  in patients with and without active anticoagulation, respectively . The estimates of the treatment-effect derived from the direct and indirect meta-analysis were not different. Overall, all treatments reduced the risk of recurrence compared to placebo or observation . In multiple pairwise comparisons (Table 2), however, VKA and DOAC were more effective than ASA and standard-dose VKA was more effective than low-dose VKA. Standard- and low-dose DOAC also tended to be more effective than low-dose VKA, whereas their efficacy was globally comparable to standard-dose VKA. Sensitivity analysis including unmarketed drugs  yielded similar results . Frequentist network meta-analyses suggested that standard-dose VKA was associated with the highest probability of being the best treatment for VTE reduction (82%)  that contributed to 16 publications , 25–31, 2 = 78%) and 0.3%  in patients with and without active anticoagulation, respectively . Overall, low- and standard-dose VKA and idraparinux significantly increased the risk of MB compared to placebo or observation . DOAC tended to be associated with a decreased risk of MB compared to VKA (Table 2). This was statistically significant for apixaban 5mg only. Apixaban 5 mg (89%) and 2.5 mg (79%) were associated with the highest probability of being the best treatments in terms of MB risk (Table 3).The analysis of MB also included 17 trials  that contributed to 16 separate publications , 22–30, Fig 4A). However, results from the network meta-analysis showed that standard-dose VKA and DOAC were associated with significantly higher net clinical benefit than ASA and low-dose VKA . Apixaban 5mg (84%) and 2.5mg (81%) were also associated with the highest probability of being the best treatments for the net clinical benefit (Table 3). Conversely, none of the treatment was associated with a reduction in fatal outcome due to recurrent VTE or MB  within the 13 trials  [Table 4). This analysis was limited by the overall low mortality due to fatal VTE  and MB .The analysis of net clinical benefit included 17,895 patients from 17 independent trials that contributed to 16 separate publications , 25–31, atients) , 28, 29,The present network meta-analysis confirmed that extended anticoagulation significantly reduced the rate of recurrent VTE following an acute DVT or PE. This effect was mostly apparent for standard-dose VKA and DOAC, which were associated with a ≈80% and ≈75% relative risk reduction compared to placebo and aspirin, respectively. Consistently, individual pairwise comparisons confirmed that VKA and DOAC were more effective than ASA, whereas standard-dose VKA prevented more effectively recurrent VTE than low-dose VKA. DOAC also tended to be more effective than low-dose VKA. On the other hand, DOAC tended to be associated with a lower risk of MB. Consequently, standard-dose VKA and DOAC were associated with the highest net clinical benefit in the secondary prevention of VTE. Conversely, low-dose apixaban and rivaroxaban were not associated with differences in VTE recurrence, MB or net clinical benefit compared to full-dose DOAC.Following the initial three months of anticoagulation for acute VTE, both physicians and patients face the important question of whether long-term anticoagulation should be maintained to prevent recurrent VTE. With the exception of patients with cancer and antiphospholipid syndrome, the risk for recurrent VTE after discontinuation of anticoagulation is mostly related to the characteristics of the index event, the recurrence rate averaging 2.5% and 4.5% per year after provoked and unprovoked VTE, respectively , 32. ThiIn this regard, the present results add to the current literature by providing more specific estimates of VTE recurrence and MB with the diverse treatment strategies for the long-term management of VTE. Intriguingly, the present meta-analysis did not provide evidence of differences in efficacy and bleeding during extended anticoagulation between treatments, either as drug class (i.e. standard-dose VKA versus DOAC), dosage (standard- versus low-dose DOAC) or as individual agents, except for ASA that was associated with an increased risk of recurrence. These results differ from previous phase 3 trials comparing DOAC to low molecular weight heparins/VKA for the acute management of VTE that reported a decreased risk of bleeding associated with edoxaban, rivaroxaban and apixaban –42. WhetMore recently, the net clinical benefit of anticoagulation therapy, a composite endpoint defined as recurrent VTE or MB, was proposed as an attempt to fully capture the overall effects of anticoagulation in the secondary prevention of VTE . The netContrary to two previous network meta-analyses , 46, theTaken together, the present meta-analysis supports current guidelines suggesting that standard-dose VKA (INR 2 to 3) and DOAC are appropriate treatment strategies to prevent VTE recurrence. While apixaban, edoxaban, and rivaroxaban have a better safety profile over VKA for the acute management –42, DOACConversely, the place of ASA appears to be limited, being associated with a lower reduction of recurrent VTE compared to VKA or DOAC without a significant reduction in MB. ASA should thus be reserved to the minority of patients refusing to take or not tolerating any form of anticoagulants. It is noteworthy, however, that in the absence of direct effects on mortality, extended anticoagulation aims to mitigating the risk of non-fatal complications such as recurrent VTE, or post-thrombotic syndrome . UnfortuThere are several limitations to this study that should be considered. Firstly, the magnitude of treatment effect may be affected by the design of the included trials. Overall, the risk of bias was considered low, although length of follow-up that varied widely from one study to the other. However, this variation did not modify the treatment effect of VTE prevention using a Bayesian approach . SecondlIn conclusion, standard dose VKA and DOAC shared similar effects on VTE recurrence and MB, whereas ASA and low-dose VKA were associated with the worst risk/benefit ratio. While DOAC were associated with a trend for reduced risk of MB compared to VKA, this effect remained non-significant during extended anticoagulant therapy. Conversely, low-dose apixaban and rivaroxaban were also associated with a similar risk of MB compared to standard-dose, as previously documented for low-dose VKA.S1 PRISMA Checklist(DOC)Click here for additional data file.S1 TextMedline and embase search strategies.(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(XLSX)Click here for additional data file.


Human herpesvirus 6 (HHV-6) is a double-stranded DNA virus part of the Herpesviridae family that colonizes nearly 100% of the human population. The virus is known to be the etiologic agent of roseola infantum, a self-limited disease in childhood and reactivation of the virus later in life is linked to potentially severe manifestations, including encephalitis, in immunosuppressed patients. It is rare in immunocompetent patients, but there have been several reports of encephalitis due to HHV-6 reactivation. We describe here a case of altered mental status and multi-organ failure in an immunocompetent woman, whose cerebrospinal fluid (CSF) was positive for HHV-6 DNA by polymerase chain reaction (PCR). Human herpesvirus 6 (HHV-6) is a double-stranded DNA virus part of the Herpesviridae family. All herpesviruses can establish a lifelong latent infection after the viral genome integrates into host cell DNA. HHV-6 colonizes nearly 100% of the human population . It's ocA 93-year-old woman with history of hypertension, diabetes mellitus, coronary artery disease, and atrial fibrillation presented with fever, altered mental status, and reported seizure-like activity. She was, at baseline, able to ambulate with a walker. She had been seen the previous day at an outside hospital for a mechanical fall, with negative computed tomography (CT) scan of the head. The patient was discharged early in the morning and later that morning was unable to be woken up, with the family noting seizure-like activity. She was subsequently brought to the emergency department.The patient was febrile (temperature 100.4), tachycardic (heart rate between 90-110s), hypoxic , and noted to have a left-sided paresis on physical exam. Her initial National Institute of Health (NIH) Stroke Scale score was 24. Laboratory results were significant for creatinine , troponin (3.21 ng/ml), and lactic acid (4.7 mmol/L). Non-contrast CT of the head was negative. CT scan showed bilateral lobar pneumonia, dilated esophagus with a debris level , and asymmetric opacification of the middle cerebral artery branches without corresponding asymmetry on CT perfusion. She was deemed not a candidate for tissue plasminogen activator or endovascular revascularization.The patient was intubated for airway protection and admitted to the medical intensive care unit for altered mental status, cerebrovascular accident (CVA), non-ST elevation myocardial infarction (NSTEMI), and respiratory failure secondary to bilateral aspiration pneumonia. She was started on aspirin, high intensity atorvastatin and minocycline for CVA, levetiracetam for seizure prophylaxis, and intravenous vancomycin, ceftriaxone, metronidazole and ampicillin for broad coverage given possible meningitis as well as aspiration pneumonia. An EEG was performed with no evidence of seizure activity. A lumbar puncture was performed by interventional radiology on day five of admission and revealed in the CSF 14 white blood cells/μl , 155 red blood cells/μl, glucose 82 mg/dl, and protein 50 mg/dl; no opening pressure was documented. HHV-6 DNA was detected in the CSF, viral load was 395 copies per ml. A Magnetic Resonance Imaging (MRI) was never performed. Given the patient’s gradually improving mental status, antiviral treatment was deferred. The patient was extubated on day ten of admission and transferred to the medical floor, where she was ultimately discharged to hospice care per the family’s wishes.HHV-6 is well known to cause roseola infantum and clinical manifestations in immunosuppressed patients, in particular after hematopoietic stem cell transplant. However, HHV-6 meningoencephalitis in immunocompetent patients is rare, although there are increasing numbers of reported cases. The presumed pathogenesis is reactivation of the virus. It has been established that HHV-6 has a tropism for central nervous system tissues . One stuThe significance of HHV-6 in the CSF has been debated. It is difficult to distinguish between latent and active viral infection. The high CSF viral load supports the possibility of HHV-6 as the etiologic agent of disease in the case series by Isaacson et al . There iThere are currently no therapies approved for treatment. Small studies and case reports describe success with drugs such as cidofovir, ganciclovir, foscarnet, and new small molecule inhibitors are being developed . For exaWe believe this case report will help physicians to consider HHV infection early in the list of differentials of altered mental status and in the management of this patient. Even if the HHV-6 virus is a co-condition and other conditions in the patient could explain alteration in sensorium, we should keep this virus as a differential.


Furthermore, a passively mode-locked erbium-doped fiber laser based on GNRs SA with femtosecond pulse is demonstrated. Thanks to the excellent properties of GNRs, by adjusting the cavity polarization direction with the proposed GNRs SA, soliton molecules operation with spectrum modulation period of 3.3 nm and pulse modulation interval of 2.238 ps is directly obtained. For the most important, 9th-order harmonic soliton molecules have been generated in the laser cavity for the first time. It is demonstrated that GNRs can be a novel type of non-linear optical (NLO) device and have potential applications in the field of ultrafast photonics.Gold nanorods (GNRs) has been investigated in the field of chemistry, optoelectronics, and medicine for their tenability, compatibility, electromagnetics, and excellent photonics properties. Especially, GNRs, used to generate ultrashort pulse, have been studied recently. However, multiple pulses evolution based on GNRs needs to be further explored. In this article, GNRs are synthesized by seed-mediated growth method, characterized systematically and been chosen as saturable absorber (SA) to apply in ultrafast photonics. The GNRs SA presents a saturable intensity of 266 MW/cm Many researchers have been attracted by noble metal nano-materials, such as gold, silver, due to the strong non-linear optical (NLO) effects which caused by their surface plasmon resonances (SPR) , dissipative solitons, stretched pulse, self-similar pulse , hexadecyltrimethyl ammonium bromide (CTAB), sodium borohydride (NaBH4), silver nitrate (AgNO3), hydrochloric acid (HCl), ascorbic acid (AA). All the glass wares are cleaned with deionized water by ultrasonic cleaning machines prior to the experiments.Chloroauric acid (HAuCl4 (marked solution B) is added to 8 mL CTAB (marked solution A) and mixed in a magnetic stirrer at 35°C, NaBH4 is added to the mixture with continuous stirring for 2 min. The color of the solution immediately changes from luminous yellow to dark brown. This change suggests that gold nanoparticles are successfully synthesized. The formed gold nanoparticles dispersion is sat in an incubator for 2 h to grow into seed solution and the seed solution are stable for a couple of weeks.GNRs are synthesized by using the seed-mediated growth method reported previously. Briefly, HAuCl3 (marked solution c) and HAuCl4 (marked solution b) are added, respectively, to 20 mL CTAB (marked solution a), then added HCl to the solution (a) and mixed on a magnetic stirrer at 35°C (marked solution 1), AA is added to growth solution. Adding seed solution to growth solution and setting the mixture in an incubator for 12 h. Using deionized water to wash resulting solution repeatedly and centrifuging the resulting solution at 8,000 revolutions per min for 10 min once a time. Keeping the resulting solution in cold storage for further characterization. AgNOThe SEM  and TEM  images of samples are shown in The fabrication processes of GNRs SA are described in 2, the modulation depth is ~0.6%, and the non-saturable loss of 51%. Based on these experimental results, we apply GNRs as a SA in fiber laser for implementing mode-locking.In order to further investigate the characteristics of GNRs, the non-linear absorption is measured by using balanced twin detector measurement technology. To check the laser performance of GNRs SA, it is incorporated into a laser cavity to generate ultrashort pulse. The schematic of the passively mode-locked EDF ring laser is shown in 2 pulse shape is assumed. There is a formula to describe the relationship between spectrum modulation period (Δλ) and pulse modulation interval (ΔT) of soliton molecule:Then simply increasing the pump power to 153 mW, the self-started soliton molecule mode-locking operation occurs. For further exploring the mode-locking operation, the pump power is increased to 314 mW. 0 and c mean center wavelength of mode-locked laser operation and speed of light. Their values are 1,560 nm and 3 × 108 m/s, respectively. Through theoretical calculation, our experimental results are consistent with the theoretical predictions.Here, λAfter increasing the pump power gradually to the maximum of laser diode, fiber laser is still working in the mode-locked state. Moreover, the soliton molecule could maintain stable operation well at the maximum pump power of 350 mW, which means the optical damage threshold of GNRs SA is considerable high. As we know, not only the soliton molecules and harmonic mode-locking solution but many other kinds of pluses could also be generated in a fiber laser, such as soliton rain and noise-like pluses. Nevertheless, in our experiments, only two multi-soliton states are observed. Thanks to the high optical damage threshold of GNRs we would do more research on composite mode-locked operations based on GNRs SA and investigate the coexistence of multi-soliton dynamics.In conclusion, GNRs are prepared by seed-mediated growth method and characterized by the technology of SEM, TEM, VIS-NIR absorption which noticed the micro-structure and the absorption of GNRs. By measuring the NLO response of GNRs, the obvious saturable absorption effect is identified which shows a modulation depth of 0.6%. And then, GNRs are used as a high-performance SA in a fiber laser for generating soliton molecule mode-locked pulse. By the GNRs SA, the 740.6 fs stable soliton molecule mode-locked pulse easily produced from the fiber laser. And 9th-order harmonics mode-locked soliton molecules obtained in the laser cavity for the first time. It turns out that the GNRs SA could be a really wonderful NLO material for preparation of saturable absorption device for ultrafast lasers. And has the great potential in many applications.All datasets generated for this study are included in the article/supplementary files.YS do experiment and write paper. XL providing guiding ideology and experimental equipment. PG process data and draw experimental images. GL provide materials needed for the experiment. PW participate in the preparation of gold nanorods. GS purchase reagents for the experiment. JL modify the article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Arabidopsis thaliana have shown that glutathione donates the sulfur atoms that are present in these compounds, and this further suggests that specialized glutathione S-transferases (GSTs) are involved in the biosynthesis of glucosinolates and sulfur-containing phytoalexins. In addition, experimental evidence has shown that GSTs also participate in glucosinolate catabolism. Several candidate GSTs have been suggested based on co-expression analysis, however, the function of only a few of these enzymes have been validated by enzymatic assays or with phenotypes of respective mutant plants. Thus, it remains to be determined whether biosynthesis of sulfur-containing metabolites in Brassicaceae plants requires specific or nonspecific GSTs.Plants in the Brassicaceae family have evolved the capacity to produce numerous unique and structurally diverse sulfur-containing secondary metabolites, including constitutively present thio-glucosides, also known as glucosinolates, and indole-type phytoalexins, which are induced upon pathogen recognition. Studies on the glucosinolate and phytoalexin biosynthetic pathways in the model plant  S-transferases (GSTs) constitute a family of multifunctional enzymes that catalyze the nucleophilic attack of the sulfur atom of the tripeptide glutathione (GSH) on electrophilic centers of low-molecular weight compounds , glucosyltransferases (UGTs), and sulfotransferases (SOTs)  mutant, which has a reduced GSH biosynthesis rate, suggested that GSH is the alkylthiol that conjugates with the products of CYP83 activity -GSH, the predicted GSH conjugate -GSH level suggesting that this intermediate is not a substrate of SUR1. This was confirmed by additional expression of γ-glutamyl peptidase 1 (GGP1) or GGP3, enzymes cleaves γ-Glu from GSH conjugates, which resulted in depletion of the S-(phenylacetohydroximoyl)-GSH intermediate along with a significant increase in the rate of benzyl glucosinolate production in transgenic N. benthamiana  Figure . Decreasactivity . In lineonjugate . Introduthamiana , 2011. Ie mutant .myb28 knock-out and MYB28-overexpressing cell cultures showed that GSTF11 and GSTU20 expression is regulated by the MYB28 transcription factor, which controls the AG biosynthetic pathway  showed that GSTF9 and GSTF10 are dispensable for conjugation of the product of CYP83B1 activity with GSH in this microorganism. Additional introduction of GSTF9 in the engineered yeast strain boosted the level of glucosinolate by only 25%  biosynthesis in sis GSTs . Moreovesis GSTs . Similaronly 25% . These rbidopsis . Thus, iin planta functions. For instance, in a yeast two-hybrid screen, GSTU20 interacted with Far-Red Insensitive 219, a jasmonate-conjugating enzyme linked to phytochrome signaling, and a partial loss of GSTU20 function resulted in hyposensitivity to continuous far-red light. Moreover, under the same condition GSTU20 was differentially expressed in suppressor of phytochrome A-105 1 and constitutive photomorphogenic 1 mutant plants  or overexpressed GSTF10 showed wild type (WT)-like growth in the presence of brassinolide (a brassinosteroid) or brassinazole (an inhibitor of brassinosteroid biosynthesis), thus GSTF10 is probably not involved in brassinosteroid signaling. In addition to the compact rosette phenotype, GSTF10/9 RNAi plants had higher anthocyanin levels and a lower tolerance for NaCl or N-acetylcysteine, a pharmacological reagent that scavenges free radicals , a leucine-rich repeat receptor-like kinase involved in brassinosteroid signaling and plant defense . RNA intradicals . Similareostasis . It has urvature . Collectin planta requires their conjugation with GSH   metabolizes IGs to several end products, including indol-3-yl methyl amine (I3A), raphanusamic acid (RA), and 4-) Figure . The redependent . In addiependent . Howeverependent . Thus, tependent . This sebstrates . The red pathway . Because pathway , in addiBrassica species that consists of an indole ring conjugated with an S-methylated dithiocarbamate group , a benzyl-type structural analog of brassinin was formed indicating that brassinin and related metabolites can be produced from IGs via corresponding ITCs , the label was incorporated into wasalexins, which are structurally related to brassinin , putative myrosinases that may hydrolyze IGs during biosynthesis of this phytoalexin  cascade, which includes MAPKK9 , GSTF6 expression appears to be regulated by the PAP1 transcription factor that controls anthocyanin biosynthesis (GSTF6, also known as Early Responsive to Dehydration 11, was identified as a gene that is induced strongly in response to dehydration (gstf12, gstf6 mutant plants did not display any defects in anthocyanin accumulation (Despite the reported defect in camalexin accumulation in ynthesis . In addiydration , a condiydration . These fydration . Howevermulation .Recent experimental evidence indicated that GSH-conjugates are intermediates in the biosynthesis of sulfur-containing secondary metabolites in Brassicaceae plants, thus there has been a search for the GSTs responsible for the formation of these intermediates. Several candidate GSTs have been identified based on co-expression with enzymes involved in the corresponding biosynthetic pathways. From those, so far only GSTF6 and GSTU13 have been shown to be required for the formation of the corresponding end products. Metabolic engineering of the Brassicaceae biosynthetic pathways in other organisms suggests that GSTs from Brassicaceae plants, with the possible exception of those involved in the conjugation of unstable indolic ITCs, are generalists rather than specific in their catalytic properties and substrate specificity. However, distinct spatial and temporal distributions of enzymes linked with IG biosynthesis and metabolism suggest that the specificities of GSTs involved in biosynthesis of sulfur-containing phytochemicals may result from their expression patterns and from their cellular and sub-cellular localizations. Therefore investigation of GSTs involved in the production of sulfur-containing phytochemicals from Brassicaceae should also address these aspects in a greater detail.PC drafted the manuscript. PB supervised the writing, revised the manuscript, and prepared its final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.