Although relapsing-remitting multiple sclerosis (RRMS) has a chronic course, little information is known about the comparison between the disease-modifying therapies (DMT) for long-term outcomes. We aimed to conduct a systematic review of randomized clinical trial (RCT) extension and observational studies to examine the efficacy and safety of all available DMT for RRMS, compare the evidence with that derived from mid-term studies, and investigate whether the published long-term data are robust and reliable enough to inform clinical decision-making concerning RRMS treatment.PubMed, Scopus, and manual searches were performed until October 2019. The clinical outcomes of long- and mid-term studies were compared. ROBINS-I was used to assess the methodological qualities of the long-term studies. PROSPERO number CRD42019123361.Nineteen long-term studies  were included in the systematic review. All studies presented serious or critical risks of bias that were mainly due to confounding, selection, and missing data biases. The annualised relapse rates (ARR) observed in the long-term studies are lower (better) than those from the mid-term studies for most treatments. The main reason for this ARR decrease could be a selection bias for good responders in the long-term studies, since many studies show a loss of patients between the mid- and long-term phases. The safety profiles depend on the study, follow-up, report, and outcome .The currently available long-term data for patients with RRMS exhibit serious or critical risks of bias that preclude robust comparisons between long-term studies. High quality comparative observational studies with long-term follow-ups or RCT extensions with intention-to-treat analyses are needed to support clinical and regulatory practice. Until reliable long-term evidence is available, neurologists should continue to base their conduct on mid-term studies, patient`s experience and, most importantly, patient`s needs and predictor factors, according to personalized medicine. Multiple sclerosis is a debilitating chronic inflammatory disease that affects the central nervous system . RelapsiDisease-modifying therapies (DMT) are used to improve the course of RRMS and reduce the severity of symptoms . The eviTherefore, we aimed to perform a systematic review of studies reporting efficacy and safety outcomes of long-term DMT use for RRMS, compare the evidence with that derived from mid-term studies (previously published RCTs), and investigate if the published long-term data from cohort and RCTs studies are robust and reliable enough to inform clinical decision-making in RRMS.The systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)  S1 Tabl and CochElectronic searches were conducted in the PubMed and Scopus databases without any time limit or language restriction (until October 2019). Trial registration databases  and the reference lists of reviews and included studies were also searched. Complete search strategies are provided in S2 Table in We included studies that fulfilled the following inclusion criteria according to the PICOS acronym:Patients aged 18 years and older diagnosed with RRMS; studies evaluating RRMS with other forms of multiple sclerosis  were excluded.DMT used as monotherapy (dose comparisons and head-to-head studies against placebo or no treatment), including ALE12/ ALE24: alemtuzumab, 12 or 24 mg/ day per 5 days and 12 months later per 3 days; BG240BID/ TID: dimethyl fumarate, 240 mg, twice-times daily or three-times daily; FING0.5QD/ 1.25QD: fingolimod, 0.5 or 1.25 mg daily; GA20QD: glatiramer acetate, 20 mg daily; IFNA22TIW/ IFNA44TIW: interferon 1a beta 22 or 44 μg three-times weekly; IFNB250EOD: interferon 1b beta, 250 μg, every other day; IFNA30QW: interferon 1a beta, 30 μg weekly; PLA: placebo.Annualised relapse rate , disconProspective, or retrospective comparative cohort studies, randomised phase II or later controlled trials , and multi- or single-arm extensions of RCTs with at least 36 months of follow-up. Equivalence studies were excluded.For studies that evaluated a switch in therapy, we included only the arms with at least 36 months of continuing follow-up. Studies that considered at least one of the aforementioned outcomes were included.Two researchers independently screened the titles and abstracts of the retrieved studies to identify irrelevant records. In a second stage, full-text articles were also independently evaluated by two researchers according to the inclusion and exclusion criteria. Discrepancies were reconciled in consensus meetings using a third researcher as a referee.The following data were independently extracted by two researchers: (i) study characteristics ; (ii) baseline data ; and (iii) clinical outcomes.The baseline data and clinical outcomes of the long-term studies ≥ 36 months) were compared with those from mid-term studies (> 3 and < 36 months) that were recovered from a recently published systematic review Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.Reviewer #1: All comments have been addressedReviewer #2: All comments have been addressed**********2. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: Yes**********4. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********5. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********6. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: (No Response)Reviewer #2: Thank you for your revision. There are some extra minor revisions that you should make. lines 52-54 needs rephrasing, lines 229-232 needs rephrasing, lines 323-325 needs rephrasing. Personalized medicine is not patient's experience in terms of effectiveness and safety. Please see personalized medicine in multiple sclerosis, and the definition of personalized medicine and then rephrase the lines mentioned above. All other corrections were ok**********what does this mean?). If published, this will include your full peer review and any attached files.7. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  28 Mar 2020Dear Aristeidis H. Katsanos,We would like to thank you and the reviewers for the constructive review and for the suggestions for improving our manuscript for publication in Plos One.We send below the responses and comments to the editor and reviewers:Comments to the Author6. Review Comments to the AuthorReviewer #1: (No Response)Reviewer #2: Thank you for your revision. There are some extra minor revisions that you should make. lines 52-54 needs rephrasing, lines 229-232 needs rephrasing, lines 323-325 needs rephrasing. Personalized medicine is not patient's experience in terms of effectiveness and safety. Please see personalized medicine in multiple sclerosis, and the definition of personalized medicine and then rephrase the lines mentioned above. All other corrections were okAuthors: Thanks for the comment. We reviewed the three excerpts (highlighted), considering publications by Giovannoni 2017 and Pellegrini et al. 2019.AttachmentResponse to Reviewers2.docxSubmitted filename: Click here for additional data file. 31 Mar 2020Reliability in long-term clinical studies of disease-modifying therapies for relapsing-remitting multiple sclerosis: A systematic reviewPONE-D-19-31331R2Dear Dr. Lucchetta,We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact With kind regards,Aristeidis H. Katsanos, MD, PhDAcademic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments: 5 Jun 2020PONE-D-19-31331R2 Reliability in long-term clinical studies of disease-modifying therapies for relapsing-remitting multiple sclerosis: A systematic review Dear Dr. Lucchetta:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofDr. Aristeidis H. Katsanos Academic EditorPLOS ONE


Trials in rheumatoid arthritis were successful with respect to efficacy and safety, and currently, three JAKinibs are approved for the treatment of rheumatoid arthritis in the European Union. Although new treatment options  have become available for spondyloarthritis and especially psoriatic arthritis (PsA) within the last years, most of them are biologics and do not address all disease manifestations equally. Therefore, multiple trials were initiated to evaluate JAKinibs in PsA and axial spondyloarthritis (axSpA). A trial of Tofacitinib (OPAL) was successful in PsA and has led to the inclusion of JAKinibs into the treatment algorithm. Currently many trials with JAKinibs are ongoing for PsA and axSpA, with one phase III trial of upadacitinib (selective JAK1 inhibitor) showing good therapeutic response in active radiographic axSpA.Many immune cells and effector molecules  utilize different combinations of Janus kinase (JAK) and signal transducer and activator of transcription (STAT) molecules to transduce signals from the cell surface to the nucleus, where they regulate transcription. This pathway is basically involved in almost all inflammatory diseases and also in the interleukin (IL)-23/IL-17 cascade, which is an essential part of the pathogenesis of spondyloarthropathies (SpA). Upon evidence from  Spondyloarthropathies (SpA) are a group of chronic inflammatory diseases, including axial SpA (axSpA) and psoriatic arthritis (PsA), as well as other less common forms like enteropathic or reactive arthritis. Besides skeletal manifestations , the involvement of extra-articular organs  is a shared feature of these diseases . CurrentJAK and STAT are central signal transducers for a great number of pro-inflammatory  and anti-inflammatory cytokines e.g. IL-10) influencing innate immune responses thought to be essential for the induction of SpA and adaptive immune functions maintaining and perpetuating the disease . This in influencIL23R, JAK2, and TYK2 in ankylosing spondylitis (AS)  for tis (AS) . IL-23, tis (AS) . A combitis (AS) , 13. IL-tis (AS) . By bloctis (AS) . IL-22, tis (AS) –18. Grantis (AS) .Respective of the various cytokines relying on JAK-STAT signaling, inhibition of this pathway offers multiple possibilities to modulate the immune and tissue response implicated in SpA. As cells of articular and extra-articular organs are utilizing this pathway, JAKinib will most likely affect the different sites of the disease. However, the protective pathways regulated by JAK-STAT might lead to adverse effects like viral infections by interfering with interferon signaling, as wells as with numbers and function of natural killer (NK) cells, cytotoxic T cells, and ILC .Although animal models for SpA do not fully replicate human disease, they have been useful in examining the molecular disease mechanisms and the role of JAK-STAT signaling. Enthesitis, an early and common feature in all forms of SpA, appears in mice with a myeloid cell-specific A20 (TNF-α-induced protein 3) deficiency , 20. Theex vivo with similar efficacy  was significantly higher in AS patients with lower rates of spinal fusion, providing further evidence that targeting JAK could have effects on ankylosis.JAKinibs of different selectivity were shown to reduce Th17-type responses in CD4 T cells from patients with AS, PsA, and RA efficacy . Small iefficacy . Severalfections . A highlfections . MRI imafections . The frein vitro while sparing osteoclasts  and effector (IL-22) phase of the disease and especially in osteoproliferation . Table 1Tofacitinib  and filgotinib  have been trialed in phase II trials of active AS with an inadequate response to ≥2 or intolerance to non-steroidal anti-inflammatory drugs and high-sensitivity C-reactive protein (CRP) ≥3 mg/L  , 51. UpaAfter 12 weeks of treatment, Assessment in SpondyloArthritis International Society 20 (ASAS20) response rates were significantly higher for 5-mg tofacitinib twice daily (80.8%) and 200-mg filgotinib once daily (76%) compared with placebo  but not for 2 mg (51.9%) or 10 mg (55.8%) of tofacitinib. ASAS40 response was significantly higher for all tofacitinib groups at week 12 and for 15-mg upadacitinib once daily compared with placebo at week 14 (52 vs. 26%). Tofacitinib (5-mg), filgotinib, and upadacitinib additionally lead to a significantly higher change of the mean Ankylosing Spondylitis Disease Activity Score (ASDAS) with rates of −1.4, −1.47 at week 12, and −1.45 at week 14, respectively, compared with placebo . Bath Ankylosing Spondylitis Disease Activity Index 50 (BASDAI50) response rates were significantly higher for all tofacitinib groups and upadacitinib with 42.3 to 46.2 and 45% vs. 23.5 and 23% in the placebo group. Enthesitis was significantly ameliorated by week 12 in 5- and 10-mg tofacitinib versus placebo.The onset of response was slower with tofacitinib (approx. week 4) compared with TNF inhibitors but very rapid for filgotinib (week 1) and upadacitinib (week 2).One limitation of the study of filgotinib is the relatively high proportion of patients with high high-sensitivity CRP at baseline, as elevated CRP is a known predictor of good response to therapy .Spinal mobility measured by Bath Ankylosing Spondylitis Metrology Index (BASMI) improved significantly with filgotinib compared with placebo by week 12 (−0.75 vs. −0.39). In the tofacitinib trial, significant improvement of BASMI was only achieved with 10 mg twice daily. In the upadacitinib trial, consistent improvements were seen with treatment for BASMI but did not meet significance based on multiplicity adjustment per the Hochberg procedure.Five- and 10-mg tofacitinib and filgotinib significantly improved Spondyloarthritis Research Consortium of Canada spine  and sacroiliac joint (SIJ) scores  compared with placebo . Upadacitinib had significant effects on the Spondyloarthritis Research Consortium of Canada spine score (−6.93 vs. −0.22).A recent evaluation of the baseline and week 12 MRI scans from the TORTUGA trial found decreased SIJ erosion scores and increased backfill scores in the filgotinib group with increased erosion scores and no change in backfill scores in the placebo group, supporting the effects of filgotinib on structural lesions in axSpA .Treatment-emergent adverse events (TEAEs) appeared slightly more often with 5- and 10-mg tofacitinib compared with 2 mg and placebo (53.8 and 51.9% vs. 44.2 and 43.1%) and upadacitinib (62 vs. 55% in the placebo group) but were similar in the filgotinib trial (31% both groups). The most common TEAEs in all trials were nasopharyngitis and upper respiratory tract infections. There were no malignancies, opportunistic infections, and cases of active tuberculosis or cases of extra-articular manifestations . Episodes of herpes zoster (HZ) were reported with tofacitinib and upadacitinib, and one non-serious venous thromboembolic event (VTE) with filgotinib.Results from a phase III randomized controlled trial (RCT) of tofacitinib in active AS (NCT03502616) are expected this year.In general, the long-term safety profile of JAKinibs is good and similar among the different inhibitors. Fears of high rates of opportunistic (including tuberculosis) and other infections have not been confirmed. Due to a lack of long-term data for JAKinib in SpA, data reported here are collected from clinical trials and post-marketing surveillance of RA. This seems feasible, as the three performed trials of JAKinibs in AS have so far shown similar safety profiles. However, it cannot be excluded that with longer observation periods and new trials leading to more exposed patients, new safety concerns may arise.Overall incidence rates of serious infections are similar to those with biological disease-modifying antirheumatic drugs and range from 2.5 to 3.8 per 100 patient-years –58. HoweRegardless of a slightly increased risk for overall malignancies for RA patients compared with the general population, so far, no significant effects of JAKinib have been identified, excluding non-melanoma skin cancer . With reAs patients with RA, AS, and PsA generally have an increased risk for deep vein thrombosis (DVT), pulmonary embolism (PE), and venous thrombembolism (VTE) , special interest was given to such events in trials with JAKinibs –72. InciUse of a JAKinib has to be carefully evaluated in patients with risk factors for gastrointestinal perforation such as older age, history of diverticulitis or other gastrointestinal conditions, and use of prednisolone >7.5 mg/day or non-steroidal anti-inflammatory drugs , 79. TheDose adjustments according to the metabolism of each drug should be considered for patients with moderate to severe hepatic or renal dysfunction. Laboratory changes in patients treated with JAKinibs are common and include changes of hemoglobin, lymphocyte and platelet counts. However, it has been hard to separate the intrinsic effects of JAKinibs via concomitant JAK2 inhibition  and disease-driven inflammatory effects on erythro- and thrombopoiesis. Other common laboratory changes include elevation of serum transaminases, creatinine, high- and low-density lipoprotein cholesterols, but usually do not result in treatment cessation.Teratogenic effects of JAKinib have been reported in preclinical animal studies, and so far pregnancy outcomes of 47 patients treated with tofacitinib during RCT are known –83. TherNext to the known TEAEs of conventional synthetic and biological disease-modifying antirheumatic drugs, e.g. infections, a special focus has to be placed on HZ, VTE and PE, and changes in blood cells and lipid metabolism with JAKinib treatment.Although the data from three RCTs of JAK inhibitors in active AS are very promising, studies evaluating patients who have failed TNFi or anti-IL-17 therapy will be of great interest to place JAKinibs in the treatment algorithm of axSpA. Other interesting issues are head-to-head comparisons with TNFi and efficacy in non-radiographic axSpA. For a better assessment of the long-term safety results of the SpA study extensions will have to be awaited. Also the differential effect of more selective JAKinibs on the various disease manifestations of SpA needs to be clarified. Interest focuses on the newly developed specific TYK2 inhibitor, BMS-986165, which has already completed a phase II trial for psoriasis and promises clinical efficacy in axSpA by preclinical data and translational research. It also needs to be elucidated if SpA patients might profit from different dosing strategies for induction and maintenance of remission, such as high loading doses and low maintenance doses. However, these new orally available agents will most likely soon be included in the treatment recommendations for axSpA and provide the clinician with options in patients who are not eligible or have contraindications to TNFi or anti-IL-17, such as allergic reactions, congestive heart failure, or concomitant demyelinating disease (TNFi) and concomitant active IBD (anti-IL-17) , 86. JAKOverall, JAKinibs seem safe when used in a well-screened patient population of SpA and under regular surveillance. They appear equally effective to biologic drugs by current evidence and have advantages besides their oral application and shorter half-life.AH and PM drafted the manuscript. AH wrote the manuscript and created graphical illustrations with the input from GL and PM. All authors approved the final version of the manuscript.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.


The global methylation profile of two human metastatic colorectal carcinoma subgroups with significantly different outcomes (primary-resistant versus drug-sensitive tumors) was analyzed and compared with the gene expression and methylation data from The Cancer Genome Atlas COlon ADenocarcinoma (TCGA COAD) metastatic colorectal carcinoma dataset with the aim to identify a prognostic signature of functionally methylated genes. A novel epigenetic eight-gene signature, with hypermethylation of the promoter regions, was identified and validated for its capacity to predict poor outcome, which had a CpG-island methylator phenotype (CIMP)-high status and microsatellite instability (MSI)-like phenotype.Epigenetics is involved in tumor progression and drug resistance in human colorectal carcinoma (CRC). This study addressed the hypothesis that the DNA methylation profiling may predict the clinical behavior of metastatic CRCs (mCRCs). The global methylation profile of two human mCRC subgroups with significantly different outcome was analyzed and compared with gene expression and methylation data from The Cancer Genome Atlas COlon ADenocarcinoma (TCGA COAD) and the NCBI GENE expression Omnibus repository (GEO) GSE48684 mCRCs datasets to identify a prognostic signature of functionally methylated genes. A novel epigenetic signature of eight hypermethylated genes was characterized that was able to identify mCRCs with poor prognosis, which had a CpG-island methylator phenotype (CIMP)-high and microsatellite instability (MSI)-like phenotype. Interestingly, methylation events were enriched in genes located on the q-arm of chromosomes 13 and 20, two chromosomal regions with gain/loss alterations associated with adenoma-to-carcinoma progression. Finally, the expression of the eight-genes signature and MSI-enriching genes was confirmed in oxaliplatin- and irinotecan-resistant CRC cell lines. These data reveal that the hypermethylation of specific genes may provide prognostic information that is able to identify a subgroup of mCRCs with poor prognosis. Colorectal carcinoma (CRC) is among the most frequent causes of cancer-related death in Western countries  and, desAt present, among several proposed biomarkers, NRAS, KRAS, and BRAF mutational status and microsatellite instability (MSI) are the most reliable tools in clinical setting, allowing the selection of RAS/BRAF wild-type tumors that are more likely to respond to anti-EGFR agents ,4 and MSFor a long time, genetic aberrations and mutations in oncogenes and tumor suppressor genes have been considered the only molecular events driving tumor initiation and progression. Nowadays, epigenetic alterations gained consideration as additional crucial events in the multistep carcinogenetic process ,6. Indeep-value < 0.05)  A,B, and  < 0.05) C,D.p-value < 0.05) were used in subsequent analyses. In particular, 19,454 probes, corresponding to 9760 genes, for patients treated with 1st-line FOLFOX and 10,892 probes, corresponding to 7218 genes, for patients treated with 1st-line FOLFIRI, resulted differentially methylated between drug-resistant and drug-sensitive tumors , with a methylation profile consistent with the gene expression profile. Since we could not obtain gene expression data from in-house colorectal tumor samples due to the poor amount and quality of RNA purified from paraffin-embedded specimens, this issue was addressed using a cohort of 33 mCRCs obtained from The Cancer Genome Atlas COlon ADenocarcinoma (TCGA COAD) database, which provides gene expression, DNA methylation, DNA sequencing, and clinical data for each patient . The resp-value < 0.01 and absolute difference of beta value > 0.2) on the FOLFOX_DMGs, we obtained 55 probes further restricted to eight hypermethylated fMET genes when selecting the COAD fMET genes with R2 > 0.5.From the analysis of gene expression and methylation TCGA COAD data, we obtained 741 fMET genes defined as COAD fMET genes. Among these 741 TCGA COAD fMET genes, 542 were DMGs in the FOLFOX dataset and 248 were in the FOLFIRI dataset , and 49 p-value < 0.05 and absolute difference of beta value > 0.1) obtaining 143 genes further restricted to 20 hypermethylated fMET genes (R2 > 0.5)  . In orde2 > 0.5) .p-value < 0.05) separation for Event-Free Survival (EFS), Overall Survival (OS), and RFS curves was observed between hypermethylated/underexpressed tumors, which were characterized by worst prognosis, and hypomethylated/overexpressed tumors using the five-gene FOLFOX signature  separation of the two clusters considering RFS and a non-significant separation considering OS. Based on this evidence, the two cohorts were labeled as “good” and “poor” prognosis clusters.Interestingly, hierarchical clustering on these sets of genes (using both expression and methylation data) allowed us to separate the TCGA COAD samples into two quite homogeneous clusters characterized by over or under expression A,D and hignature . Consistignature . A log-rignature  and FOLFignature  cohorts p-value < 0.05) compared to the cohort with hypomethylation of these genes in both TCGA COAD and in-house cohorts  between the lists of DMGs in the three cohorts , which provided the methylation profile of 24 mCRCs. Upon clustering the GSE48684 samples according to the eight-gene signature, we observed two homogeneous methylation clusters , as prev cohorts . In para cohorts . AltogetThe poor prognosis hypermethylated and the good prognosis hypomethylated clusters were further characterized with respect to their clinical and biological profiles using gene expression and DNA sequencing and gene copy number data from the TCGA COAD database. No major differences were observed between the poor and good prognosis clusters with respect to T and N categories and sites of primary tumor (right versus left colon) . Similarp-value < 0.05 and abs(logFC) > 0.58). Among these, 307 genes were downregulated and 137 were hypermethylated in the poor prognosis cluster and conversely upregulated/hypomethylated in the good prognosis subgroup  in the eight-gene hypermethylated cluster of the GSE48684 and in-house datasets . In our in-house cohort, while all the CIMPs belong to FOLFOX/FOLFIRI-resistant samples, they divide evenly between the eight-gene signature clusters , subdivided in CIMP-high (CIMP-H) and CIMP-low (CIMP-L), and this correlates with the MSI phenotype . Thus, tclusters . Finallyclusters . Thus, tclusters E–G. Altop-value 0.08) and the Nikolsky breast cancer 20q12-13 amplicon  gene sets. These authors reported respectively a correlation between the copy number variation and the expression of 26 genes in lung cancers [Among positional collections, GSA identified enrichments of chromosome 13 arm q and chromosome 20 arm q gene sets A. Intere cancers  and the  cancers . As expeTo validate epigenetic data obtained from FOLFOX and FOLFIRI primary-resistant mCRCs, we generated in vitro drug-resistant cellular models chronically adapted to oxaliplatin  or irinotecan . In preliminary experiments, apoptotic cell death was evaluated in drug-sensitive and drug-resistant cell lines in response to Oxa or Iri in combination or not with the demethylating agent 5-Azacytidine (5-Aza-dC). These experiments confirmed that cell lines chronically exposed to chemotherapeutics are indeed poorly sensitive to Oxa and Iri and that drug resistance is reverted upon treatment with 5-Aza-dC A,B. SincMolecular profiling is a major objective in mCRC in order to define prognostic homogeneous subgroups of patients and deliver personalized therapies . In suchThe CIMP-H status is frequently associated with the methylation of MLH1 promoter region and consequent gene silencing , resultiFinally, GSA enrichment analysis suggests that methylation events are enriched in genes located on arm q of chromosomes 13 and 20 in mCRCs with poor prognosis, supporting the hypothesis that epigenetic remodeling may not occur in a random manner during colorectal carcinogenesis, but rather, it may be a coordinated process with the hypo/hypermethylation of selective genomic regions. This hypothesis is consistent with the evidence that the accumulation of gains/losses in 13q and 20q regions is strongly associated with adenoma-to-carcinoma progression  and thatIn conclusion, this study provides the proof of concept that epigenetic profiling may represent a strategy to predict patients’ prognosis in mCRC and that a novel eight-gene methylation signature may better define a poor prognosis subgroup of mCRCs with CIMP-H status and an MSI-like phenotype.Twenty-four primary-resistant mCRCs treated with 1st-line FOLFOX (16 patients) or FOLFIRI (8 patients) chemotherapy in combination or not with bevacizumab or anti-EGFR agents and 12 drug-sensitive mCRCs (4 treated with FOLFOX and 8 treated with FOLFIRI combined with molecular targeted agents) were selected for this study. Patients’ characteristics are described in Human HT29 and HCT116 CRC oxaliplatin and irinotecan-resistant cell lines were obtained in our laboratory as described in DNA was isolated from formalin-fixed, paraffin-embedded (FFPE) primary CRCs . Five huTo identify a prognostic signature of fMET genes, a multistep analysis was performed as described in In a subsequent step, since gene expression data from in-house tumors were not available, fMET genes were defined based on gene expression and methylation data from the TCGA COAD data collection. To this purpose, the gene expression, methylation, DNA sequencing, gene copy number, and clinical data of 33 patients with mCRC from the TCGA COAD database were downloaded using the TCGA biolink package .Moreover, the methylation dataset GSE48684, containing 24 stage IV mCRCs, was used to validate our methylation and GSA data.All differential analyses were performed applying linear modeling (limma) to the log2 ratio of the intensities of methylated versus unmethylated probe  datasets. We also calculated the beta value as the ratio of the methylated probe intensity and the overall intensity.p-value < 0.05 and absolute difference of beta value > 0.1, if not reported differently.The DMGs from the TCGA, GSE48684, and in-house datasets were all filtered at a Annotation of the methylation datasets is according to illumina R packages. In particular, being the TCGA and the GSE48684 dataset based on Illumina 450k technology, we reduced the considered probes of our in-house dataset to such annotations to make the comparisons meaningful.The overlap between two DMGs or enriched gene sets was simply evaluated by a hypergeometric test, while the overlap among three or more of them was based on a more complex framework implemented in the R SuperExactTest package .p-value < 0.05), and inverse correlation (R Squared > 0.1) between the promoter’s methylation and the gene expression profile in the TCGA dataset. Among these, we selected only the DMGs in the FOLFOX or in the FOLFIRI dataset.We defined as fMET genes those showing a significant , obtaining the final 5-gene signature. The same procedure was performed for the 20 FOLFIRI fMET genes, obtaining the final 4-gene signature. Hierarchical clustering was performed using Ward’s linkage and Euclidean distance.For the FOLFOX in-house dataset, given the 8 fMET genes, we performed a hierarchical clustering on the TCGA mCRCs datasets  obtaining two clusters, one grouping the samples with the hypermethylated genes signature and the other with the hypomethylated gene signature. Finally, we checked if the 8 genes were differentially methylated  was performed on all gene set collections of the mSigDB repository using CluterProfiler R package .Total RNA was extracted using the TRIzol Reagent  from parental and drug-resistant strains of HCT116 and HT29 CRC cells lines. In specific experiments, RNA was obtained from cell lines exposed to 5-Aza-dC , an inhibitor of DNA methyltransferase 1 (DNMT1), at a final concentration of 10 μM for 72 h. Real-Time PCR analysis was described in Parental and drug-resistant cell lines were seeded on day 0 in 6-well plates in triplicate and incubated on day 1 in normal medium or exposed to 10 μM 5-Aza-dC for 72 h. After 48 h, cells were further treated with 3 μM Oxa or 2 μM Iri for 24 h. Apoptosis was evaluated by cytofluorimetric analysis .www.ncbi.nlm.nih.gov/geo/).DNA methylation data generated in this study have been deposited at the NCBI GENE expression Omnibus repository (GEO) and are accessible through the accession number GSE148766 (In spite of significant improvements in the treatment of mCRC, the prognosis remains still poor. Until today drug resistance is the main cause of treatment failure and the main issue is tumor molecular profiling to improve our capacity to predict patients’ prognosis. The data showed in this paper represent the proof of concept that the hypermethylation of specific sets of genes may provide prognostic information being able to identify a subgroup of mCRCs with poor prognosis.


Synchronous cancer in patients with abdominal aortic aneurysm (AAA) increases morbidity and mortality after AAA repair. However, little is known about the impact of the history of cancer on mortality after AAA repair.Patients with intact AAA who were treated with endovascular aneurysm repair or open surgical repair were selected from the Health Insurance and Review Assessment data in South Korea between 2007 and 2016. Primary endpoints included the 30- and 90-day mortality and long-term mortality after AAA repair. The Cox proportional hazards models were constructed to evaluate independent predictors of mortality.P = 0.0038, 6.14% vs. 2.69%, P = 0.0016). Furthermore, the mortality rate at the end of the study period was significantly higher in AAA patients with a history of cancer than in those without a history of cancer .A total of 1999 patients  were diagnosed with cancer prior to the AAA repair. History of cancer generally had no effect in short-term mortality at 30 and 90 days. However, short-term mortality rate of patients with a history of lung cancer was more than twice that of patients without it (3.07% vs. 1.06%, The history of cancer in AAA patients increases long-term mortality but does not affect short-term mortality after AAA repair. However, AAA repair could increase both short- and long-term mortality in patients with lung cancer history, and those cases should be more carefully selected. An asymptomatic abdominal aortic aneurysm (AAA) is usually found incidentally during workup for other clinical problems or on ultrasound during regular check-ups. Because cancer patients often undergo periodic imaging studies with computed tomography scan or ultrasound examinations, they have an increased diagnosis of AAA . TherefoMany studies have analyzed the effect of AAA repair in patients with synchronous malignancy and showed increased short-term mortality and morbidity after both endovascular aortic repair (EVAR) and open surgical repair (OSR) . In addiDespite improvements in short-term outcome after AAA repair, long-term survival is still not favorable –7. End-sThe purpose of our study was to investigate the effect of cancer history on the outcome of AAA repair. In this retrospective study using big data, we first determined the incidence and types of cancer history in patients who underwent AAA repair. We then evaluated how cancer history affects short- and long-term mortality after AAA repair.The Health Insurance Review and Assessment Service (HIRA) reviews the accuracy of claims and renders reimbursement decisions for the National Health Insurance, covering approximately 98% of the entire South Korean population. We used the claims data of HIRA, comprised of detailed health care service information, including diagnosis, treatment, procedure, surgical history, and prescription drugs, along with the International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes .From the HIRA data, a study cohort of patients diagnosed with AAA  between January 1, 2007 and December 31, 2016 was created. Of the 79,880 eligible patients, 68,095 who were diagnosed with ruptured AAA , untreated by EVAR or OSR, or had an unverified date of death were excluded. The death of a patient was designated as an “event,” and living patients were censored on December 31, 2016. The final sample included 11,785 patients with intact AAA treated by EVAR or OSR.Patients with a history of cancer were defined as those diagnosed with malignant neoplasms (ICD-10 C00–97) more than two times prior to the EVAR or OSR. The main outcome measure was the all-cause mortality at 30 days, 90 days, and at the end of the study period following AAA repair in patients with and without a cancer history.The demographic variables included age  and sex . Health insurance coverage was categorized into the National Health Insurance Program, a mandatory enrollment scheme, and the Medical Aid Program for low-income citizens. The hospitals where EVAR or OSR were performed ranged from small general hospitals with 100–300 beds to mid-sized general hospitals with 300–1000 beds to tertiary research university hospitals with over 1000 beds. The hospital locations were divided into urban and rural areas. The comorbidities were selected using the Charlson Comorbidity Index (CCI), a method of categorizing comorbidities based on the ICD-10 codes, and grouped based on the CCI scores 0–1, 2, and ≥ 3 . SpecifiThe statistical differences in the patient characteristics based on the history of cancer were computed using the Chi-square test. We compared the prevalence of all-cause mortality in AAA patients with and without a cancer history. All-cause mortality was calculated at 30 days, 90 days, and at the end of the study period after AAA repair. We used the Kaplan-Meier curves to depict the cumulative incidence of all-cause mortality. The statistical comparison between the survival of AAA patients with and without cancer history was performed using the log-rank test.To estimate the effect of cancer on death in AAA patients treated by EVAR or OSR, we conducted univariate (crude) and multivariable (adjusted) Cox-proportional hazards regression analyses with respect to the occurrence of all-cause deaths. Hazard ratios (HRs) and 95% confidence intervals (CIs) for the outcome were calculated in AAA patients with and without a cancer history. The Cox-proportional regression models were adjusted for the demographic variables  in Model 1 and then further adjusted for all covariates  in Model 2. All analyses were performed using the SAS 9.4 software , and the statistical significance level was set at α = .05.A total of 11,785 patients with intact AAA were included in this study, of which 1999 patients (17.0%) had preexisting cancer. The distribution of different types of malignancy is shown in Table Table P = 0.0010) and OSR . Regardless of EVAR or OSR, there were no differences in 30-day and 90-day mortality between the two groups (P > .05).Table P < .0001) than in those without a cancer history. In contrast, 30-day and 90-day mortality rates in patients who underwent AAA repair did not differ based on the presence of cancer history.Fig. Table We also calculated HR according to the history of intra-abdominal and digestive cancers and lung cancers. There was a significant increase in HRs for long-term but not short-term mortality in patients with intra-abdominal and digestive cancer history Tables  and 6. IOf the 11,785 patients surgically treated for intact AAA, 1999 (17.0%) had a history of cancer. Stomach cancer (21.5%) was the most commonly diagnosed cancer, followed by colorectal (19.1%), prostate (18.4%), and lung cancer (11.5%). History of cancer did not affect 30- and 90-day mortality after both OSR and EVAR. However, long-term mortality after AAA repair was significantly higher in patients with cancer history than in those without cancer history .Cancer patients are more likely to have imaging studies done during the course of treatment and thus incidentally found to have AAA. Our results showed that about 17% of patients who underwent AAA repair had a cancer diagnosis, and most of them were intra-abdominal cancers (74%). The types of cancer diagnosis in patients with AAA repair were similar to those in the general population , 14. TilAs the progression in cancer treatment have been decreasing overall deaths related to cancer, vascular surgeons will more commonly see cases of AAA in cancer patients. Their history of cancer would become an important factor to consider in determining the treatment strategy.Both OSR and EVAR of the intact AAA did not increase mortality in patients with a history of cancer. In contrast, previous study by Kouvelos et al. of AAA repair in patients with synchronous malignancy showed higher mortality and morbidity . Since wWe hypothesized that previous abdominal surgery interferes with OSR and results in a worse outcome. Additional analyses were performed with codes corresponding to intra-abdominal and digestive cancers. Interestingly, there was no difference in short-term mortality after OSR (1.12%) versus EVAR (1.12%). While EVAR is considered the preferred choice for AAA repair in patients with a history of abdominal surgeries, OSR also seems to be safe if well planned.Generally, elective AAA repair shows poor long-term survival despite improved short-term outcomes , 8. LongPatients with a history of lung cancer had increased short-term mortality as well as long-term mortality after AAA repair. Among all cancers, lung cancer is well known to have the worst prognosis at an advanced stage in most cases. 80% of lung cancer is non-small cell type, and lobectomy or pneumonectomy is performed in operable patients , 18. TheStudies using big data are helpful in revealing an overall understanding when the specific diagnosis code is reliable, and the endpoint is well defined. In our study, HIRA data allowed analysis of a vast number of patients and specific variables, such as mortality, and ensured accuracy by using diagnosis codes.Due to the inherent limitations of HIRA data, the cause of death, cancer stage, and types of cancer surgeries could not be determined. The cancer stage will affect long-term survival rather than a short-term result. When we analyzed the cause of death based on patient code at the finial hospitalization, the patients with cancer history had cancer-related code as a major diagnostic code. However, this result has not reported this study because it came from an indirect estimation. Further studies are needed to determine the exact cancer recurrence and death in patient with cancer history.Patients and their family will suffer from double jeopardy due to cancer and AAA and wish to understand the short- and long-term prognosis . In addiMalignancy in AAA patients can complicate the disease course and treatment as well as outcome. History of cancer increases long-term mortality after AAA repair, but there is no difference in short-term mortality after both OSR and EVAR. Well-planned OSR and EVAR can be safely performed even in patients with intact AAA and history of intra-abdominal cancer. However, in patients with history of lung cancer, AAA repair could increase both short- and long-term mortality, and therefore, cases should be carefully selected.


Outcomes in well-resourced, intensive care units (ICUs) in Kenya are thought to be comparable to those in high-income countries (HICs) but risk-adjusted mortality data is unavailable. We undertook an evaluation of the Aga Khan University Hospital, Nairobi ICU to analyze patient clinical-demographic characteristics, compare the performance of Sequential Organ Failure Assessment (SOFA), delta-SOFA at 48 hours and Mortality Prediction Model-III (MPM-III) mortality prediction systems, and identify factors associated with increased risk of mortality.A retrospective cohort study was conducted of adult patients admitted to the ICU between January 2015 and September 2017. SOFA and MPM-III scores were determined at admission and SOFA repeated at 48 hours.2 = 17.1, 24.2 and 26.5 respectively; p<0.001). Admission SOFA, MPM-III and 48-hour SOFA were well calibrated (p >0.05) while delta-SOFA was borderline (p = 0.05).Approximately 33% of patients did not meet ICU admission criteria. Mortality among the population of critically ill patients in the ICU was 31.7%, most of whom were male (61.4%) with a median age of 53.4 years. High adjusted odds of mortality were found among critically ill patients with leukemia , tuberculosis , post-cardiac arrest , admissions from the step-down unit , acute kidney injury  and metastatic cancer . The area under the receiver-operating characteristic (ROC) curve of admission SOFA was 0.77 , MPM-III 0.74 , delta-SOFA 0.69  and 48-hour SOFA 0.83 . The difference between SOFA at 48 hours and admission SOFA, MPM-III and delta-SOFA was statistically significant (chiMortality among the critically ill was higher than expected in this well-resourced ICU. 48-hour SOFA performed better than admission SOFA, MPM-III and delta-SOFA in our cohort. While a large proportion of patients did not meet admission criteria but were boarded in the ICU, critically ill patients stepped-up from the step-down unit were unlikely to survive. Patients admitted following a cardiac arrest, and those with advanced disease such as leukemia, stage-4 HIV and metastatic cancer, had particularly poor outcomes. Policies for fair allocation of beds, protocol-driven admission criteria and appropriate case selection could contribute to lowering the risk of mortality among the critically ill to a level on par with HICs. Intensive care mortality rates in low and middle-income countries (LMICs) are significantly higher than those in high-income countries (HICs), ranging between 35.1% and 53.6% .Kenya is a lower middle-income country  with a pAs in many parts of Sub-Saharan Africa, there is substantial heterogeneity in resources consistently available in the ICU. The national referral hospital ICUs are predominantly managed by anesthesiologists, but staffing may vary across smaller county and private hospital ICUs . Core ICThe Aga Khan University Hospital Nairobi (AKUHN) is a private 280-bed Level 6 facility situated in the capital city of Nairobi, accredited by the Joint Commission International since 2013 for its quality of care . The hosNo study to date has assessed ICU outcomes in well-resourced private institutions in Kenya that provide care at standards equivalent to the best academic tertiary care teaching facilities in HICs. Benchmarking efforts are hampered by insufficient evidence to support the use of existing severity of illness scoring systems to guide the generation of risk-adjusted mortality data. Severity of illness scoring may be performed once at admission, daily or at given intervals during the course of care –20. DiffThis was a retrospective cohort study, conducted at the AKUHN ICU, an 11-bed mixed general, open unit with approximately 450 admissions per year. SOFA scoring at admission and daily thereafter has been performed here since 2016. The unit is staffed by a multidisciplinary team of physicians, including full-time critical care physicians, 85% of whom had formal training in intensive care at the time of this study. Being an open ICU, care is coordinated by the admitting physician or surgeon, with intensivists playing a predominantly advisory role. The nurse-to-patient ratio in the AKUHN ICU ranges between 1:1 and 1:2 based on staff availability, and 30–50% of ICU nurses have a Higher National Diploma in intensive care nursing.The unit provides both invasive and non-invasive mechanical ventilation, invasive hemodynamic monitoring, inotropic support, invasive neuro-monitoring and bedside renal replacement therapy including continuous renal replacement therapy (CRRT). Evidence-based protocols and pathways guide the full spectrum of intensive care, adherence to which is monitored by hospital leadership. Paper records are maintained at this hospital, in addition to an electronic medical record system that is mainly used for laboratory and radiology data.Housed within AKUHN and staffed by the same team of physicians is a mixed, general, 16-bed step-down unit (the high dependency unit) for lower acuity patients, averaging 1,500 admissions annually. Nurse-to-patient ratios here are 1:2, stretching to 1:3 occasionally depending on staff availability. Admission to the AKUHN ICU is limited to patients in need of multiorgan support and/or invasive ventilation, whereas the step-down unit admits those with single organ failure only. Despite having clear ICU and step-down unit admission criteria however, patients are often admitted to a unit with a higher or lower level of care than required (ICU instead of a step-down unit and vice versa), depending on bed availability, the frequency of which is audited. In addition, the institution does not have a policy for withholding ICU care from terminally ill or palliative care patients, except where an advanced directive is in place, or the legal next of kin decline such care.Our primary objective was to analyze the difference in the area under the receiver-operating characteristic (ROC) curves of the scoring systems under investigation. Secondary objectives were to evaluate ICU mortality and to investigate the association between clinical and demographic factors and mortality among the critically ill. Patients who died or were discharged before 48 hours were excluded from delta-SOFA calculations but included in MPM-III and SOFA calculations. A minimum sample size of 677 critically ill patients was required to give the study 80% power to detect a difference of at least 10% between the area under the ROC curves of SOFA, delta-SOFA and MPM-III –23, adjuThe ICU admission register was used to identify patients admitted to the ICU, and their files retrieved by the medical records team. Consecutive sampling was performed until the desired sample size was achieved. A comprehensive review of patient files was conducted, and clinical and demographic variables entered into a spreadsheet using Microsoft Office ® Excel 2010 . Where files were not available for review, a minimum dataset consisting of age, sex, admission and discharge data was extracted from the ICU admission register. Patients admitted with burns, those for cardiac surgery and readmissions during the same hospitalization were excluded, as is standard practice for the MPM-III scoring system. Patients who were boarding in the ICU due to unavailability of beds in the general wards and overflow from the step-down unit were excluded from analyses of ICU outcomes as they did not meet the pre-specified ICU admission criteria.Demographic and outcome variables were analyzed as percentages for categorical variables and medians with interquartile ranges for continuous variables. Non-parametric data for other outcomes were analyzed as medians (interquartile ranges) or means (standard deviation) for parametric data. Chi square or Fisher’s exact tests were used to evaluate risk factors independently associated with mortality and multivariate logistic regression analysis used to control for confounders. Missing data for SOFA and MPM-III were assumed to be normal and absent respectively, as is standard practice with these scoring systems . SOFA scThe area under the ROC curve was used to evaluate the discrimination of the models. An ROC curve with an area of 0.7–0.8 was considered fair, 0.8–0.9 good and >0.9 excellent . The areThere were 1,342 admissions to the AKUHN ICU between January 2015 and September 2017, 1,088 (81.1%) of whom had complete records available for review . A furthData from 723 critically ill patients of the 1,342 admissions to the ICU during the study period were analyzed . Most of these were male (61.4%), with a median age of 53 years . Among tMost critically ill patients had more than one indication for ICU admission, with 51(9.4%) admitted following a cardiac arrest . The mosMore than one co-morbidity per critically ill patient were recorded where present . The mosMedian predicted mortality among 723 critically ill patients with limited or complete records was 10–15% based on admission SOFA, and 19.4% based on MPM-III (IQR 5.5–47.8%). Observed mortality in this population was 229 (31.7%), with a median ICU length-of-stay (LOS) of 4 days . Among the 543 critically ill patients with complete records, mortality was 32.4% (n = 176) with a median LOS of 4 days . There was no difference in ICU LOS between survivors  and non-survivors . Overall, 190 (26.3%) of 723 critically ill patients were in the ICU for less than 48 hours, with 76 (40%) dead and 114 (60%) discharged to a lower level of care within that time.A greater proportion of non-survivors than survivors was found among critically ill patients with leukemia, metastatic cancer, HIV and tuberculosis . Mortali2 41.2, p = 0.002)  of 543 critically ill patients, 38% of whom survived, while vasopressors were administered in 110 (20%), 89% of whom survived. The highest mortality at 48-hours and overall was found in critically ill patients admitted to the ICU from the step-down unit, who also had higher SOFA scores at admission than the unit average (chi= 0.002) .SOFA points ≥2 for a given organ system were associated with increased odds of mortality among the critically ill: hematological system odds ratio, OR 4.79 , cardiovascular system, OR 3.58 , central nervous system, OR 2.30  and respiratory system, OR 1.68 . Median delta-SOFA was 0 (IQR -2-+2). A baseline SOFA score of 16 or more at admission among critically ill patients admitted to the ICU was associated with 100% mortality while 74 (47.7%) of 155 patients with a rising SOFA score at 48 hours died, OR 4.5 .Critically ill patients with leukemia, tuberculosis, post-cardiac arrest, acute kidney injury (AKI), sepsis, metastatic cancer and stage-4 HIV had the highest adjusted odds for mortality . Mean ad0 and delta-SOFA in this population was statistically significant . Admission SOFA, MPM-III and 48-hour SOFA were well calibrated (p >0.05) while delta-SOFA was borderline (p = 0.05).The area under the ROC curve of admission SOFA was 0.77 , MPM-III 0.74 , delta-SOFA 0.69  and 48-hour SOFA 0.83  among critically ill patients . The difThe objectives of this retrospective study were twofold. Our primary objective was to examine the performance and utility in our setting of three commonly used mortality prediction models. Our results show that while admission SOFA and MPM-III had fair discrimination and were well calibrated among critically ill patients admitted to the AKUHN ICU, delta-SOFA performed poorly. SOFA at 48-hours had the best overall performance in this cohort. While the area under the ROC curve for MPM-III in our study was similar to that from a study from Rwanda . The pooOur second objective was to identify factors associated with higher risk of mortality among critically ill patients in a well-resourced private ICU in a lower middle-income country. We found that mortality was surprisingly high for such a well-resourced ICU. The crude mortality rate of 31.7% among the population of critically ill patients admitted to the AKUHN ICU was substantially greater than the reported range of 8–19% in HICs –30. WhilThe public ICU cohort was younger  compared to our critically ill  [Our results also highlight the impact of HIV in critical care in Kenya and on the outcomes of critical care in our region reported here and elsewhere. An analysis of critical care outcomes in LMICs would be incomplete without a discussion of outcomes in HIV. In 2018, 1.6 million people were living with HIV, with a prevalence in adults of 4.9%, and 28,200 people had died from an AIDS-related illness . While aLimiting ICU care for those unfortunate patients who will not benefit from critical care at the end of life is a worldwide problem but one which is greatly accentuated in both the public and private sectors in Kenya and possibly worsened by the relatively rapid expansion of critical care in this country . A fair Looking beyond patients admitted to critical care with marginal expected benefit, we make note of a subset of patients which indirectly contribute to poorer outcomes , 33. In Although we cannot make statistical inferences about the finding of mortality risk at the midpoint between reported outcomes in HICs and LMICs, we can enumerate likely health system and structural challenges to improving ICU outcomes. These factors, such as the “open model” discussed above, underscore important issues confronting most ICUs in LMICs.Potentially important structural factors impacting outcomes among the critically ill in our institution include bed-allocation policies and capacity limitations. Thirty three percent of patients in the AKUHN ICU did not meet our institution’s ICU admission criteria and were admitted to ICU solely due to unavailability of beds in the general wards and in the step-down unit. Bed capacity limitations and allocation issues have a ripple effect in our institution and indeed in most ICUs in LMIC. Patients who do require ICU care are either not admitted to the ICU directly or receive a sub-optimal level of care in step-down units until a bed becomes available in the ICU. Predictably, such patients admitted from the step-down unit in our cohort had a particularly high mortality.We can identify several limitations in our study. Firstly, this was a single center study and as such, the results may not be applicable across all patient populations in Kenya or other well-resourced ICUs in LMICs. This is largely because different hospitals have different ICU admission criteria, staffing ratios, management protocols and management policies. Secondly, we could not verify what proportion of critically ill patients stepped up to the ICU from the step-down unit were admitted to the step-down unit due to lack of an ICU bed, as data on the appropriateness of the initial step-down unit admission were unavailable. Thirdly, this was a retrospective study and it was difficult to gauge the diagnostic accuracy of the documented indications for admission from case notes and some case files were missing. However, the retrieval rate of complete case files at our institution was high (81.1%); higher than that in the public ICU study (67%) . This liOur analysis of mortality prediction models concluded that 48-hour SOFA performed significantly better in predicting outcomes among critically ill patients admitted to the AKUHN ICU than admission SOFA, MPM-III and delta-SOFA. We found that mortality in this cohort was higher than we expected in this well-resourced ICU. Critically ill patients with advanced co-morbidities and individuals stepped-up from the step-down unit were unlikely to survive their ICU stay. Critical care capacity building efforts in other LMICs should be informed by the implications of this analysis. We suggest that achieving good outcomes in intensive care depends on more than the provision of world-class resources. Policies for fair allocation of beds, protocol-driven admission criteria and appropriate patient selection could contribute to lowering the risk of mortality among the critically ill to a level on par with well-resourced ICUs in HICs.S1 Data(XLSX)Click here for additional data file.


The new coronavirus disease 2019 (COVID-19) has become a world health emergency. The disease predominantly effects individuals between 30 and 79 years of age with 81% of cases being classified as mild. Despite the majority of the general population displaying symptoms similar to the common cold, COVID-19 has also induced alveolar damage resulting in progressive respiratory failure with fatalities noted in 6.4% of cases. Direct viral injury, uncontrolled inflammation, activation of coagulation, and complement cascades are thought to participate in disease pathogenesis. Patients with COVID-19 have displayed kidney damage through acute kidney injury, mild proteinuria, hematuria, or slight elevation in creatinine possibly as consequence of kidney tropism of the virus and multiorgan failure. The impact of COVID-19 on patients with pre-existing kidney impairment, including those with chronic kidney disease, kidney transplant recipients, and individuals on hemodialysis (HD) has not yet been clearly established. No specific treatments for COVID-19 have been found yet. Research has revealed several agents that may have potential efficacy against COVID-19, and many of these molecules have demonstrated preliminary efficacy against COVID-19 and are currently being tested in clinical trials. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first described in humans in December 2019 in Wuhan, China  proteins . There aThe spike protein is key to its high-virality as the RNA virus enters cells through binding between the S protein and its host receptor. The virus efficiently binds to the angiotensin converting enzyme 2 (ACE2) receptor  which isAfter binding to ACE2, the cellular transmembrane protease, serine 2 (TMPRSS2) mediates the S protein priming allowing the virus to enter the host cells through clathrin-dependent endocytosis  13). Th. Th13). There are two phases to the immune response induced by SARS-CoV-2 , 15: (1)The complement system is an important component of innate immunity that is essential to respond rapidly to infection. During inflammation, both acute and chronic, activation of the complement system promotes the elimination of pathogens. Dysregulation of the complement system may lead to acute lung disease after a highly pathogenic viruses infections .Complement activation through the lectin pathway has already been described in SARS-CoV-2 infected patients. Gao et al.  showed tIn general, altered hemostasis due to viral infections often leads to vascular complications like thrombosis and or hemorrhage. Vascular and endothelial changes by the virus as well as inherited host factors help define the clinical presentation. Some viral contributions to the ischemic and thrombotic environment include procoagulant factors, hemodynamic changes, and pro-inflammatory cytokines. The pro-inflammatory response also directly induces plaque rupture –25. ThisRecently, anti-phospholipid antibodies and infarcts in multiple vascular territories have been reported in three COVID-19 patients with thrombocytopenia. It is known that these antibodies can increase during several infections, and critical illness and may lead to thrombotic events .Based on this data, a prophylactic dose of low molecular weight heparin has been advised to hospitalized COVID-19 patients, despite abnormal coagulation tests, and the thrombotic risk associated with prolonged bed resting .SARS-CoV-2 rapidly spread throughout the world since its first case and very few countries to date have not reported at least one case of the disease within their borders. One infected patient may transmit the virus to 2 or 3 other individuals, and asymptomatic patients may also spread the virus , 30. TheApproximately 80% of patients infected by SARS-CoV-2 present with mild disease and can recover spontaneously . The othThe main risk factor for mortality due to COVID-19 is advanced age. In patients with comorbidities, such as chronic kidney disease, hypertension, chronic obstructive pulmonary disease, diabetes, tumor, and obesity, advanced age was the strongest predictor of a poor outcome with infection , 35, 37.Li et al.  analyzedAKI is more common among patients with more severe disease, particularly in those recovering in the ICU, and is considered a negative prognostic factor for survival . In a reIn a single-center, retrospective, observational study of 287 patients, 55 patients presented with AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO). These patients were significantly older, more likely male, and with other comorbidities, including chronic renal insufficiency, hypertension, and cerebrovascular disease, and tended to have more severe pneumonia (not peer-reviewed) . Of thesIn another study of 701 patients, 11.9% of those with elevated baseline creatinine developed AKI compared to 4.0% in patients with normal baseline creatinine . In-hospHigh dose diuretics and K-binding resins have been used to delay the need of dialysis –46. CareThe current management of COVID-19 associated AKI includes supportive treatment, avoiding nephrotoxic drugs, and early start, when possible, of renal replacement therapy . SARS, MProne positioning, already known to reduce mortality in other causes of severe ARDS, should be applied early. Although there is no available data on patients with COVID-19 , SARS-CoDue to the hypercoagulability state associated with COVID-19, systemic anticoagulation with unfractionated heparin or regional citrate anticoagulation is advised . Since tIn a single-center retrospective observational study of 287 patients, Xiao et al.  found th+ macrophages in the tubule-interstitium  and the pathogenesis that could led to AKI. Unfortunately, this is very difficult to obtain given the respiratory and hemodynamic instability of AKI patients and the use of anticoagulation which increases the risk of bleeding. In addition, non-essential procedures in infected patients are not being done in most hospitals given significant risk of exposure to personnel.Patients with chronic kidney disease (CKD) are known to have a higher risk of upper respiratory tract infection and pneumonia due to their persistent proinflammatory state with functional defects in innate and adaptive immunity . No studChronic immunosuppression is a well-known risk factor for viral and bacterial infections, but it is also crucial to prevent graft rejection and to contrast the uncontrolled antiviral inflammatory response. Therefore, the transplant community is puzzled in trying to understand the best therapeutic approach, in the absence of any strong clinical data .So far, initial presentation in transplant recipients has been reported heterogeneous to other hosts and many patients did not report contact with infected individuals. Common symptoms at disease onset have been fever, cough, asthenia, myalgias, and diarrhea . In a stUntil more data is available, the rules to prevent viral infection in the general population apply to transplant patients  . TransplAccording to the European Renal Association—European Dialysis and Transplant Association (ERA-EDTA) guidelines , in patiIn critically ill patients, withdrawal of immunosuppression could be done while converting those patients to hydrocortisone/solumedrol. This approach may improve viral clearance but could lead to immune reconstitution and kidney's rejection , 75. It In some patients, tacrolimus reduction may be preferred over complete withdrawal , 69 becaIn countries with widespread community transmission, living-donor kidney programs have been temporarily suspended. In countries where community transmission is lower, living donations should not be performed if the donor or recipient have lived in a place with high incidence or have been in contact with confirmed or suspected COVID-19 patient within 14 days.Transplantation can be considered in highly selected cases when required as a life-saving procedure.In countries with sporadic COVID-19 infection, deceased donor transplants should continue. However, donors at risk of infection should not be accepted since RNAemia was reported in at least 15% in one case series, and, transmission from the donor is possible .Suspension of all transplants that require T or B cell depletion  should be considered even in countries where the incidence of COVID-19 positive individuals is low.In countries with widespread infection, temporary suspension of the deceased donor program for non-life-saving organs should be considered in order to prevent infection of the recipient during the post-transplant period. Even then, each kidney transplant should be considered case-by-case.Although it is known that diabetic nephropathy is an important comorbidity and AKI is one of the main risk factors for poor outcome during COVID-19 infection, the impact of the infection on other kidney diseases, like end-stage renal disease, is still unclear .Wang et al.  describeCirculating CD4 and CD8 T cells, NK cells, and proinflammatory cytokines are significantly lower in COVID-19 HD patients, compared to non-HD COVID-19 individuals . ConsistAn interim guidance for outpatient HD facilities has been recently released by the Centers for Disease Control and Prevention (CDC) . Early rPatients on peritoneal dialysis should be managed from home, using telemedicine assistance or other systems for communication whenever possible .Currently, no specific treatment against SARS-CoV-2 has been developed, but research thus far has revealed several agents that may have potential efficacy against COVID-19 . Severalin vitro. Lopinavir was also used against MERS-CoV because it has inhibitory activity against the virus both in vitro and in an animal models  in patients with SARS-CoV-2 infection showed that treatment with lopinavir–ritonavir added to standard supportive care was not associated with a statistically significant difference over standard care alone in the time to clinical improvement or mortality .In vitro data indicate that the antimalarial drug chloroquine exerts antiviral effects by increasing endosomal pH and abrogating virus-endosome fusion. Antiviral effects in vivo of hydroxychloroquine may be enhanced by the immune-modulating activity that this drug offers  inhibitor. It inhibits viral polymerase activity because it can enter the cell and be recognized as a substrate by RNA polymerase when it is phosphoribosylated. It is capable of blocking the replication of several RNA virus . One ranRemdesivir has broad-spectrum antiviral activity because it is an adenosine analog that can determine pre-mature termination of viral RNA , 112. ItIn a cohort of 53 severely ill COVID-19 patients treated with remdesivir and observed for 18 days, 68% of patients improved in oxygen-support status, with a mortality of 13% overall . In a prThe use of convalescent plasma was recommended as an empirical treatment during outbreaks of Ebola virus in 2014 and as a protocol for treatment of MERS .Shen et al.  administSeveral other ongoing trials are testing the safety/efficacy profile of convalescent plasma transfusion in patients with SARS-CoV-2.Camostat mesylate is a TMPRSS2 inhibitor. TMPRSS2 is a cellular protease that, together with ACE2, allows SARS-CoV-2 to enter target cells . CamostaEarly reports, mainly from China, suggested that over 60% of severely ill COVID-19 patients presented with additional organ dysfunction syndromes . This haThe World Health Organization does not recommend the use of steroids because they could inhibit viral clearance and prolongate viremia . StockmaJAK-STAT inhibitors, like baricitinib, fedratinib, and ruxolitinib are potent anti-inflammatory drugs that are approved for rheumatoid arthritis and myelofibrosis. Patients infected with SARS-CoV-2 often present increased levels of pro-inflammatory cytokines and may benefit from the use of these drugs. A case series reported clinical improvement in COVID-19 patients treated with baricitinib . These dIntravenous immunoglobulin (IVIg) may reduce SARS-CoV-2-induced inflammatory response by blocking FcR activation on monocytes. There are several clinical trials that will evaluate the efficacy and safety of IVIg therapy in patients with pneumonia caused by SARS-CoV-2. In a retrospective study of 58 COVID-19 patients, the use of IVIg within 48 h of admission increased in-hospital recovery and reduced 28-day mortality rate .Mesenchymal stem cells (MSC) have immunomodulatory properties because they can inhibit T cell and macrophage activation and induce the formation of regulatory T cell and anti-inflammatory macrophages , 122. ThTocilizumab, a drug used to treat rheumatoid arthritis, is a monoclonal antibody against the IL-6 receptor. Since elevated IL-6 levels are commonly found in COVID-19, tocilizumab is now under evaluation by a multicenter randomized controlled trial (ChiCTR2000029765). The preliminary clinical results are encouraging . In an uOther IL-6 inhibitors are being tested to treat COVID-19, including sarilumab and siltuximab. The latter showed a decrease in inflammatory markers in a study of 21 COVID-19 patients (not peer-reviewed) .Ulinastatin is a serin protease inhibitor with anti-inflammatory effects approved in China and Japan for the treatment of acute pancreatitis and sepsis . There iAnakinra has been approved by the FDA for the treatment of rheumatoid arthritis and neonatal-onset multisystem inflammatory disease. It is a recombinant human interleukin-1 receptor antagonist (IL-1Ra), and it is currently being tested in ongoing trials with COVID-19 patients to contrast the uncontrolled inflammatory response. In one retrospective study of 29 patients with COVID-19, those that received high-dose of Anakinra in combination with standard treatment had a faster respiratory improvement compared to 16 patients who received standard therapy alone  .The receptor for SARS-CoV-2, angiotensin-converting enzyme 2 (ACE2), is a membrane-bound aminopeptidase whose function is to cleave angiotensin I and angiotensin II into two peptides, angiotensin-(1–9), and angiotensin-(1–7) . AngioteExperimental animal models showed that, although ACE inhibitors and ARBs do not directly affect ACE2 activity, these agents can upregulate the expression and activity of the receptor in heart and kidney tissue . These dThe European and American Cardiology Societies, remarked that there is no evidence of a noxious effect of RAS inhibitors in patients affected by COVID-19 , 129. MoSARS-CoV-2 effects on the kidney and in patient with underlying kidney disease is not well-characterized. Preliminary data has indicated that previous kidney disease could represent a risk factor, especially in elderly patients, for a more severe disease course. SARS-CoV-2 infects the kidneys and may induce acute kidney injury. While there is no current specific therapy, many drugs both antiviral and/or anti-inflammatory are being actively tested in randomized trials. Further studies are necessary to better understand disease pathology, acute kidney injury associated with infection, long-term renal consequences, and potential therapies. Rigorously controlled interventional studies and international registry analyses will be crucial to define risk factor and the best therapeutic approaches to resolving COVID-19 disease outcomes.CB wrote manuscript the initial draft. MW, GZ, and LR participated in the manuscript writing. PC supervised the manuscript. All authors contributed to the article and approved the submitted 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. The reviewer UM declared a past collaboration with one of the authors PC to the handling editor.


Background: Therapy monitoring of cancer treatment by contrast-enhanced CT (CECT), applying response evaluation criteria in solid tumors criteria version 1. 1 (RECIST 1.1) is less suitable for neuroendocrine tumors (NETs) which, when responding, tend to show stabilization rather than shrinkage. New methods are needed to further classify patients in order to identify non-responders at an early stage and avoid unnecessary adverse effects and costs. Changes in arterial tumor attenuation and contrast-enhancement could be used to identify the effect of therapy, perhaps even in early stages of treatment.Methods: Patients with metastatic pancreatic NETs (PNETs) receiving peptide receptor radionuclide therapy (PRRT) with 177Lu-DOTATATE underwent CECT at baseline, mid-treatment (PRRT cycles 3–5) and at follow-up, 3 months after the last PRRT cycle. At baseline CECT, the liver metastasis with the highest arterial attenuation was identified in each patient. The fold changes in arterial tumor attenuation , contrast-enhancement (HU), and transversal tumor area (cm2) between CECT at baseline, mid-treatment and follow-up were calculated. Correlation of the tumor metrics to outcome parameters such as progression-free survival (PFS) and time to best response was performed.Results: Fifty-two patients were included , median age 60 years (range 29–80), median Ki-67 8% (range 1–30). Six patients had grade 1 PNETs, forty had grade 2 and four had grade 3 tumors. As an internal control, it was first tested and established that the tumor contrast-enhancement was not merely related to that of the abdominal aorta. The mean ± SD arterial attenuation of the liver metastases was similar at baseline, 217 ± 62 HU and at mid-treatment, 238 ± 80 HU and then decreased to 198 ± 62 HU at follow-up, compared to baseline  and mid-treatment . The transversal tumor area decreased 25% between baseline and follow-up . Tumor contrast-enhancement increased slightly from baseline to mid-treatment and these fold changes correlated with PFS  and with time to best response .Conclusions: Early changes in contrast-enhancement and arterial attenuation in PNET liver metastases may for CECT monitoring of PRRT yield complementary information to evaluation by RECIST 1.1. The pancreatic neuroendocrine tumor (PNET) constitutes a subgroup of the gastroenteropancreatic neuroendocrine tumors (GEP-NETs) which derive from local multipotent gastrointestinal stem cells of the diffuse neuroendocrine cell system (DNES). They are relatively rare and due to a lack of consensus on their classification, the epidemiology has been difficult to ascertain. In a European population, the incidence for a wide spectrum of GEP-NETs ranges from 1 to 5 per 100,000 persons per year .PNETs are divided into functional tumors, giving rise to a hormonal syndrome, and non-functioning tumors which do not, although hormonal activity can be detected biochemically. Among the functioning PNETs, insulinomas are the most frequent and are often benign, whereas gastrinomas and glucagonomas, frequently metastasize to the liver, lymph nodes and bone. In general, PNETs are large at diagnosis and approximately half of them have metastasized. Patients with functional PNETs are, however, usually detected at an earlier stage because of hormonal symptoms. Non-functioning tumors may cause some abdominal discomfort, but typically give little or no symptoms , 7–9.Contrast-enhanced computed tomography (CECT) is the most readily available modality for the primary diagnostic workup and staging of PNETs, for surveillance and to monitor therapy. Magnetic resonance imaging (MRI) is recognized as superior to CT for evaluation of the liver, bile ducts, and pancreas, and allows for diffusion-weighted imaging (DWI) and the use of hepatocyte-specific contrast media. Nevertheless, CT is generally sufficiently effective for imaging of PNETs and as the availability of CT is much higher than that of MRI, even at academic institutions, CT is the golden standard for therapy monitoring , 9–12.68Ga-DOTA-somatostatin analogs (68Ga-DOTA-SSAs) have in conjunction with PRRT of GEP-NETs been shown to detect new lesions earlier than CECT, but changes in tumor 68Ga-DOTA-SSA uptakes over time have not yet convincingly been shown to reflect therapy outcome  , 14. For outcome , 11.177Lu-DOTATATE is increasingly used when other therapies have failed. Treatment may be repeated after a few years in case of disease progression, so called “salvage therapy” administering a reduced number of cycles  may be treated with somatostatin analogs and tumors of higher grade with chemotherapy or targeted molecular agents, such as mTOR inhibitors and tyrosine kinase inhibitors. During recent years, PRRT with f cycles –19.177Lu-DOTATATE on tumor size are at best discreet and generally appear late, with best response often seen after about a year. There is therefore a need to develop new methods to assess therapy outcome, if possible at an early stage, in order to stop inefficient treatments and avoid undesirable side effects and costs. Tumor cell death and micro-necrosis, with related effects on tumor vascularity, are likely to occur much earlier than tumor shrinkage. Changes in the arterial tumor attenuation  and contrast-enhancement on CECT, reflecting tumor vascularity, may therefore be suitable early markers of therapy response (or lack thereof), in parallel to monitoring of tyrosin kinase inhibitor therapy of gastrointestinal stromal tumors (GIST), according to the Choi criteria .In this report, we evaluated the fold changes of the arterial attenuation and the contrast-enhancement in hypervascular PNET liver metastases on CECT during and after 177Lu-DOTATATE at Uppsala University Hospital between 2006 and 2018 (n = 151) were identified in the hospital's radiological information system (RIS) and picture archiving and communication system (PACS). Only patients with at least one hypervascular liver metastasis on CECT were included. Those with partly calcified metastases or metastases with extended tumor necrosis were excluded, due to the risk of partial volume effect in the attenuation measurements. Also, patients lacking relevant CECT before and/or after treatment were excluded as were those in which the timing of the CT scanning in relation to contrast medium administration was inadequate . Furthermore, patients who had received insufficient amounts of contrast medium were excluded. In general, patients examined with a CECT of poor technical quality were excluded.The study was approved by the Local Ethics Committee for Human Ethics in Uppsala, Sweden (reference number: 2010/177) and all patients provided written informed consent. The declaration of Helsinki was followed. All patients with a PNET diagnosis who had undergone PRRT with Baseline CECT was performed within 1 month before PRRT, which comprised 7,4 GBq per treatment cycle, and the number of cycles were tailored according to kidney and bone marrow dosimetry . During Data on Ki-67 and tumor grade were collected from the pathologists' reports on the biopsies of the liver metastases, if available. Data on chromogranin-A at baseline was collected from the laboratory reports.2) was noted. This was also transferred to the corresponding non-contrast-enhanced images.For each patient, the liver metastasis with the highest attenuation in the late arterial contrast-enhancement phase at baseline CECT  was outlined manually using an irregular region of interest (ROI) and its mean attenuation (HU), maximum attenuation (HU) and transversal surface area (cmThe fold changes (%) of the arterial tumor attenuation, contrast-enhancement and transversal tumor area on CECT at baseline to follow-up, between baseline and mid-treatment and between mid-treatment and follow-up were calculated. The combined fold changes in arterial tumor attenuation and transversal tumor area between these time points were also assessed.A ROI was also placed in the abdominal aorta at the level of the coeliac trunk to achieve an approximate measurement of the attenuation in the hepatic arterial branches, from which the tumor vessels of the liver metastases are derived. Aortic contrast-enhancement was assessed at baseline and at follow-up, in order to exclude that the fold changes in arterial tumor attenuation and contrast-enhancement not merely reflected those in the aorta. Thus, it was established that the changes in lesion attenuation and contrast-enhancement reflected biological effects, such as changes in vascularity, as a response to PRRT, and not merely variations in aortal attenuation.The CECT measurements were correlated with the outcome parameters best response (BR) according to RECIST 1.1, time to BR, progression-free survival (PFS) and overall survival (OS). OS was defined as the interval from initiation of therapy until death or the last day of follow-up.The patients underwent clinical, biochemical and radiological assessment by CECT at least every 3–6 months following PRRT. CECT from baseline was assessed according to RECIST 1.1 and the maximum percentage decrease/increase in the sum of tumor diameters  was calculated (BR RECIST 1.1) as well as the time to BR. A twenty percent increase in the sum of tumor diameters and/or the appearance of new tumor lesions was categorized as progressive disease and, together with the patients' clinical and biochemical data, allowed for establishing PFS.Only hypervascular liver metastases were assessed for fold changes in arterial attenuation, contrast-enhancement and size. The complete RECIST 1.1 measurements were used as a means to evaluate outcome.Statistical analysis was performed with JMP 14  software. Wilcoxon's non-parametric test was used to analyze differences in the fold changes between baseline and follow-up in arterial attenuation and contrast-enhancement, respectively, in the liver metastases. Correlations between CECT data and BR RECIST 1.1, time to BR, PFS, and OS were tested by linear regression.n = 45), Ki-67 was reported from biopsies of liver lesions, otherwise from the primary tumor (n = 5). Six patients had grade 1 PNETs, 41 had grade 2, and three subjects harbored grade 3 tumors. As the vast majority of patients harbored grade 2 tumors, and only a few had grade 1 or grade 3 tumors, no subsequent subgroup analysis was performed.Out of the original 151 patients, 52 had liver metastases that were available for inclusion . Thus, tn = 20), bone (n = 9), adrenal glands (n = 3), ovaries (n = 1), peritoneum (n = 1), and bile ducts (n = 1). Direct extension of the primary PNET with tumor infiltration of the stomach (n = 2) and the spleen (n = 2) was also found.The patients harbored at least one hypervascular liver lesion  and exceChromogranin-A was available in 48 patients, median 21 nmol/L (range 2 nmol/L to a 168-fold on the upper reference limit). All patients showed high tumor uptake on somatostatin receptor imaging (Krenning score 3–4).n = 32) underwent three to five cycles of therapy. Nine patients received six cycles of therapy, whereas three went through seven cycles and a single patient was given 10 cycles. Among the remaining seven patients, the majority (n = 6) underwent two cycles of therapy. One patient underwent received only a single cycle of PRRT.The majority of patients  or before the 5th therapy cycle (n = 20)  .p = 0.025, n = 52) and also from mid-treatment, 238 ± 80 HU, to follow-up 197 ± 64 HU , but not between baseline and mid-treatment . Interestingly, there was a slight increase in arterial tumor attenuation from baseline to mid-treatment (p > 0.05)  .2) to follow up (12 ± 15 cm2) .There was a significant decrease in the transversal tumor area in the arterial phase from baseline  and between PFS and OS , whereas no correlation was found between BR RECIST% and PFS or BR RECIST% and time to BR (data not shown).A strong correlation was found between PFS and time to BR . Similar results were found between the combination of fold changes in arterial attenuation and tumor area and PFS and time to BR, but no convincing correlations were found.The therapy outcome parameters BR RECIST 1.1, time to BR and PFS were correlated to arterial attenuation, contrast-enhancement and tumor area. Regression analysis between BR and the fold changes in transversal tumor area from baseline to follow-up yielded no convincing correlation . No reliable correlation could be found between the fold changes in contrast-enhancement and OS .The arterial tumor attenuation and the contrast-enhancement were found to increase between baseline and mid-treatment, although not significantly. However, the fold changes in contrast-enhancement between these examination points were found to correlate with both PFS and time to best response  and PFS   , 6.177Lu-DOTATATE is increasingly used when other regimens, such as chemotherapies or targeted molecular agents, have failed   .p = 0.024, n = 52). Interestingly, this effect was not distinguished as an early sign of response during ongoing therapy, but instead appeared later, from mid-treatment to follow-up, after PRRT . This suggests that the major biological effects of PRRT were possible to assess only in the later stages of the therapy.In an attempt to refine therapy monitoring in PNET patients undergoing PRRT, the present CECT study assessed the fold changes in arterial tumor attenuation, contrast-enhancement and transversal area of hypervascular liver metastases in correlation with the therapy outcome parameters BR RECIST 1.1, time to BR and PFS. As expected, the maximum arterial tumor attenuation decreased from baseline to follow-up  and with the time to BR . One possible model for explaining the slight increase in contrast-enhancement in the liver metastases during early therapy could be parenchymal or vascular damage from the 177Lu beta radiation. The irradiated liver has previously been quite extensively studied and seems to mimic a form of veno-occlusive disease with hypoattenuating areas, but with none or little actual vessel occlusion , as opposed to the decreased arterial attenuation seen in the later stages of the therapy. This early increase of the contrast-enhancement was found to correlate moderately with PFS . While it may be possible to relate differences in contrast-enhancement to progression-free survival, it would be much more challenging to argue that these early changes in lesion vascularity could influence overall survival. Thus, one should be careful when interpreting any correlations between therapy monitoring and overall survival.The observed fold changes in contrast-enhancement were also tested for correlation with OS. This yielded no convincing results  but could not be used to monitor early responses.Treatment response was also evident from a decrease in the transversal tumor area from baseline to follow-up  and all patients provided written informed consent.AS and OP: conception or design and manuscript writing. KF-B and AS: provision of patients. OP, KF-B, and AS: collection and/or assembly of data. OP, KF-B, JC, and AS: data analysis and interpretation and final approval of the manuscript.AS has received lecture honoraria from Ipsen and honoraria for external imaging expert work from Advanced Accelerator Applications (AAA). JC has received lecture honoraria from Novartis and educational honoraria from NET Connect (funded by IPSEN). 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.