Physical activity undertaken by stroke survivors is generally low. This trial investigated the feasibility of delivering a high-intensity treadmill and self-management program to people with stroke undergoing inpatient rehabilitation and determine whether physical activity, walking ability and cardiorespiratory fitness could be increased.A phase I, single-group, pre-post intervention study was conducted with stroke survivors undergoing inpatient rehabilitation who could walk. Participants undertook a high-intensity treadmill and self-management program for up to 30 min, three times a week for 8 weeks under the supervision of their usual physiotherapist. Feasibility was determined by examining compliance, satisfaction and adverse events. Clinical outcomes were amount of physical activity, walking ability, and cardiorespiratory fitness collected pre-training (week 0), post-training (week 8), and at follow-up (week 26).Forty stroke survivors participated, completing 10 (SD 6) sessions, 94% at the specified training intensity, with high satisfaction and no adverse events related to the intervention. At week 8, participants completed 2749 steps/day (95% CI 933 to 4564) more physical activity than at week 0. Walking distance increased by 110 m (95% CI 23 to 196), walking speed by 0.24 m/s (95% CI 0.05 to 0.42), and VO2 peak by 0.29 ml/kg/min (95% CI 0.03 to 0.56). At week 26, increases in physical activity, walking distance and speed, and cardiorespiratory fitness were maintained.A high-intensity treadmill training program embedded within a self-management approach during inpatient rehabilitation appears feasible and potentially may offer sustained improvements in physical activity, walking ability, fitness, and quality of life. A randomised trial is warranted.ACTRN12613000764730).This feasibility study was registered with the Australian New Zealand Clinical Trials Registry ( Prior to this study, high-intensity treadmill training had not been embedded in a self-management approach during stroke rehabilitation to enable a transition to sustainable physical activity level follow dischargeA high-intensity treadmill training program embedded within a self-management approach during inpatient stroke rehabilitation appears feasibleGiven this approach may offer sustained improvements in physical activity, a randomised trial is warranted.Stroke survivors, regardless of type, have at least three times the risk of further cardiovascular events than the general population –3. ThereClinical guidelines suggest that for stroke survivors who experience walking difficulties treadmill training should be provided . High-inFurthermore, one of the main findings of studies investigating interventions to cardiorespiratory fitness, is that the benefit does not last beyond the period of intervention . It is tIs it feasible to deliver a high-intensity treadmill embedded in a self-management approach to people with stroke undergoing inpatient rehabilitation and to determine whether it can increase physical activity, walking ability, and cardiorespiratory fitness?Can self-management increase physical activity, walking ability and cardiorespiratory fitness in the short term (2 months) as well as self-efficacy of walking, health-related quality of life, participation and self-reported physical activity in the longer term (6 months)?The aim of this Phase I intervention study, therefore, was to investigate the feasibility of, and potential for, self-management to increase physical activity via an increase in self-efficacy in stroke survivors with mild disability. The specific research questions were:We hypothesised it would be feasible to deliver a high-intensity treadmill embedded in a self-management approach to people with stroke undergoing inpatient rehabilitation to increase physical activity, walking ability, and cardiorespiratory fitness, without incurring adverse events. Additionally, we hypothesised that self-efficacy of walking, health-related quality of life, participation, and self-reported physical activity benefits would be sustained over 6 months.A phase I, single-group, pre–post intervention study was carried out Fig. . Stroke Individuals with stroke undergoing inpatient rehabilitation were screened and invited to participate if they were within 2 months of a stroke ; aged 18 years or older; able to walk 10 m independently ; and able to follow three-stage commands. Individuals with stroke were excluded if they were unable to walk independently prior to current stroke, had co-morbidities relating to the lower limbs that might limit their walking , had unstable cardiac status , were unable to provide informed consent, live too far away to return for post-intervention assessments, or had an anticipated length of stay of < 1 week. All stroke survivors were eligible for inclusion regardless of stroke type. Information was collected to describe the sample included: age, sex, description of the stroke , aphasia, thrombolysis, co-morbidities, and previous living arrangements.The intervention consisted of a program of high-intensity treadmill training plus self-management. The program was performed for up to 30 min, three times a week for up to 8 weeks. The intervention was carried out across inpatient and outpatient departments. The program was performed with the supervision of the usual physiotherapist and replaced a similar period of time of gait training. Usual multi-disciplinary inpatient rehabilitation consisting of task specific training.The high-intensity treadmill training was based on the minimum requirements for training cardiorespiratory fitness (6). This consisted of up to 30 min walking on a treadmill at an intensity between 40 and 60% heart rate reserve or a Borg Rating of Perceived Exertion of 11–14 , and parThe self-management approach was based on the Health Action Process Approach (HAPA)  and Goaln = 4), provision of workbooks, and discussion sessions with new staff and/or students working in the area. Physiotherapists delivering the intervention were the treating physiotherapists. Physiotherapy students supervised by treating physiotherapists were also trained in the delivery of the intervention. Workbooks for the physiotherapists and patients were provided that included educative material, progressions of both treadmill and self-management over 8 weeks, and opportunities for recording, planning, and reflecting on physical activity.Physiotherapists delivering the experimental intervention were trained in high-intensity treadmill training and self-management education via in-services  and self-management components . Intervention fidelity was checked through session audits of treadmill and self-management components. Adverse events  were recorded. Participant satisfaction with the intervention was assessed using a 5-point Likert scale questionnaire (strongly agree to strongly disagree) asking about the treadmill and self-management components of the intervention.2peak) was recorded during the 6-min Walk Test by a fully portable compact metabolic system using breath by breath analysis .Physical activity walking ability and cardiorespiratory fitness were measured at week 0 (pre-training), 8 (post-training), and 26 (follow-up). Physical activity was measured with an accelerometer (ActivPAL) that measured number of steps/day over four days. The accelerometer was placed on the anterior thigh of the unaffected side. This device has been shown to be accurate in recording activity including steps in people following stroke walking at varied speeds, indoors, and out . WalkingSelf-efficacy of walking, health-related quality of life, participation, and perception of physical activity were collected at weeks 8 and 26. Self-efficacy of walking ability was measured using the Ambulatory Self-Confidence Questionnaire . Health-A sample size calculation is not required for a feasibility study . The samt tests. SPSS Version 22.0  was used, with a p value of 0.05 set as the level of significance.Descriptive statistics were used to describe the sample and report on outcomes of feasibility. Within-group differences of clinical outcomes between week 0 and 8, 0 and 26, were analysed using linear mixed effects models to avoid casewise deletion due to missing data. Within-group differences of clinical outcomes between week 8 and 26 were analysed using paired Forty participants were recruited to this study. Participant characteristics are presented in Table n = 40), 25% refused (n = 17), and 17% could not meet study requirements being unable to return for assessments  or follow three stage commands (30%). Sixty-nine people (27%) were eligible. Of these, 58% participated (Participants completed on average 10 (SD 6) sessions over 17 (SD 1) days, averaging 17 (SD 2) min/session on the treadmill alone, i.e. 25% of possible training. Heart rate monitors were not available for all participants for all sessions and intervention intensity was measured using the Borg scale of perceived exertion. Compliance with the intensity of the treadmill training was high, with 94% of completed sessions carried out at the intended intensity (Borg > 11/20). Two participants completed two sessions each below the required intensity. Self-management components were inconsistently reported.Fidelity checking observed accurate reporting of treadmill duration and intensity recorded using Borg. Task self-efficacy was the most common self-management component; discussed in 88% of the audited sessions, initiated by participants 28% of the time and by physiotherapists 88% of the time. Outcome expectance (22%) and action planning (19%) were next most frequently discussed components of self-management. Risk perception and coping planning were infrequently observed. There were four serious adverse events , and all were unrelated to the intervention or trial. No minor adverse events occurred. Participant satisfaction levels were high, with 85% agreeing or strongly agreeing that they felt confident walking on the treadmill and felt it improved their walking. Similarly, 73% agreed or strongly agreed that discussions with the trainer helped them to overcome barriers to exercise and 93% agreed or strongly agreed that they felt confident that they would live an active lifestyle in the future (Table 2 peak by 2.2 ml/kg/min (95% CI − 0.2 to 4.5). At week 26, increases in physical activity, walking distance and speed, and cardiorespiratory fitness were maintained  higher quality of life than at week 8. There were no statistically significant differences in self-efficacy of walking, participation, or perception of physical activity Table .This intervention of high-intensity treadmill training embedded in a self-management approach appears, at least in part, feasible. Approximately 30% of inpatients screened for participation in this study met the eligibility criteria and included stroke survivors with varying stroke severity and type. Physiotherapists delivering the intervention were able to meet the target duration and intensity of the high-intensity treadmill training sessions and include components of self-management in discussions with participants. However, participants received only a quarter of the planned number of treadmill sessions. Participants were satisfied with the intervention and few adverse events occurred; none associated with delivery of the intervention. Physical activity levels, walking ability, and cardiorespiratory fitness all improved immediately following the intervention and these improvements were maintained beyond the intervention. Some modifications to this intervention are needed for further investigation.This intervention of high-intensity treadmill training embedded in a self-management approach appears suitable for a range of stroke survivors. Participants comprised stroke survivors with a variety of types and locations of stroke, and varying motor abilities. Recruiting stroke survivors to research projects is challenging with many trials either not meeting the target sample size or extending the recruitment time period in an attempt to meet the target sample size . CommonlThe dose of intervention was only partially delivered. We had intended to deliver 24 sessions of up to 30 min per session and at a high intensity. On average, 10 sessions were delivered, for approximately 17 min per session, at a high intensity. The intervention was designed to be delivered to participants during the transition from inpatient rehabilitation to living in the community. For many participants, there were limited opportunities to continue the intervention as intended once discharged from inpatient rehabilitation. Participants largely received little or no ongoing outpatient rehabilitation at the participating facilities. Some participants were referred to community-based rehabilitation but these services did not offer high-intensity treadmill training. While the dose of intervention was low, the intensity was delivered as planned. Intensity was planned to be monitored using heart rate. Chest strap type monitors were not available for all participants. However, Borg rating scale was consistently used to monitor intensity and has been shown to be valid for people following stroke to monitor intensity up to 70% peak oxygen uptake , though Participants almost doubled their step count per day, and most importantly, this increase was maintained at 6 months. Similarly, systematic reviews have found immediate improvement in walking speed  and bothThese findings are encouraging for self-management in physiotherapy rehabilitation. Increasing pressure for early discharge following stroke, shorter length of stay  coupled This study is not without its limitations. Our sample was one of convenience and the study was conducted in two rehabilitation facilities in Queensland, Australia. These findings may not be generalisable to other settings and across the broad stroke survivor population. A number of participants (15%) were unable to return for follow-up measurements, potentially biasing our findings. It is important to note that this high-intensity treadmill training intervention embedded in a self-management approach had some challenges to being delivered by treating physiotherapists. Difficulties were noted with completing the required number and duration of treadmill sessions particularly during the transition to living in the community, as well as recording self-management and measuring oxygen uptake.In summary, delivering the high-intensity treadmill training embedded in a self-management approach appears to be feasible for stroke survivors during inpatient rehabilitation. The clinical outcomes of physical activity and walking measured in this feasibility trail suggest this intervention has the potential to be beneficial. Therefore, a randomised controlled trial is warranted. However, some modifications appear necessary including the need to be able to deliver the intervention across the transition from inpatient to outpatient settings, self-management needs to be more structured and recording of components needs further consideration as well as a dedicated metabolic cart is required to optimise measurement of oxygen uptake.


C. elegans, male-enriched ascaroside sex pheromone ascr#10, in addition to behavioral effects, expands the population of germline precursor cells in hermaphrodites. Previously, we identified several sensory neurons required for this effect. We also found that feedback from egg laying acts via serotonergic signaling to license the pheromone response in reproducing adults. Here, using newly available reagents, we confirm and extend several of our previous conclusions: a) the ADL neurons are essential for the ascr#10 response, b) phasmid neurons (PHA and PHB) are unlikely to be involved in the ascr#10 response, c) the mod-1 receptor is the main conduit of the serotonergic feedback from egg laying, and d) serotonin remains the only currently known signal of this feedback. Our findings better define the neuronal circuits that mediate the germline response to the major male pheromone.Animals broadcast small molecule pheromones that can alter behavior and physiology in conspecifics. Neuronal circuits that regulate these processes remain largely unknown. In  C. elegans is referred to as the Progenitor Zone . The size of the Progenitor Zone is sensitive to a variety of environmental factors . For example, in the presence of physiological concentrations of ascr#10, the most abundant male-enriched excreted ascaroside , hermaphrodites have an enlarged population of germline precursor cells . A recent single cell RNAseq atlas supports the idea of a narrow overlap between expression patterns of ocr-2 and osm-9, identifying PVD as the only additional neuronal type in the overlap . In the original study, we focused on amphid neurons because loss of a LIM homeobox gene ceh-14 did not appear to alter the ascr#10 response . The ceh-14 gene is thought to be expressed in ~10  to ~20  neuronal types, including phasmid sensory neurons PHA and PHB. It was not clear whether the ceh-14(ch3) allele tested in our original study , caused a complete and stable loss of function. More recently, a new mutant allele ceh-14(ot900), a near complete deletion of the locus, became available . Hermaphrodites carrying this allele had the same germline response to ascr#10 as the wild type animals , our original study focused on ADL because expression of the wild type OCR-2 protein in these, but not in the other three pairs, rescued the ocr-2(lf) inability to respond to ascr#10 . To obtain additional evidence for the role of ADL neurons, we tested a loss-of-function mutation in the HLH-4 transcription factor that defines ADL identity . This gene appears to be expressed exclusively in ADL neurons, as judged by a fosmid-based reporter transgene  and the single cell RNAseq atlas . hlh-4(tm604) animals showed no increase of germline precursor cells in the presence of ascr#10 . Since then, two additional serotonin receptors have been reported: lgc-50 that appears to be exclusive for serotonin and lgc-54 that also responds to dopamine and tyramine . Hermaphrodites carrying mutations in either of these two genes did not discernibly differ from their wild type counterparts . The feedback of active reproduction involves the serotonin signal from the command motoneurons of egg laying, HSN . Previously, we tested mutants in six genes thought to act as serotonin receptors – terparts , furtheret al., 2019). Because feedback from egg laying, mediated at least in part by serotonin, is required for increasing the number of germline precursors in the presence of ascr#10 , we tested whether NLP-3 plays a role in this feedback. We found that neither nlp-3 loss (nlp-3(n4897)), nor overexpression (nlp-3 (vsIs276)), noticeably affected germline response to ascr#10 . Briefly, worms were synchronized by hypochlorite treatment and subsequent overnight incubation in M9, after which the synchronized L1 larvae were placed (in groups of ~30) on agar plates seeded with E. coli OP50. 48 hours later, when worms were young, but pre-reproductive adults, they were transferred to OP50-seeded plates that were either control or conditioned with synthetic ascr#10 (gift of F. C. Schroeder). This protocol ensured that all experiments were paired with a control. On Day 5 of adulthood, hermaphrodites were stained with DAPI  as described  and the germline precursor cells were counted. The boundary between the germline precursor population and the more proximal transition zone is defined by the appearance of crescent-shaped nuclei that have progressed to leptotene/zygotene stages of meiotic prophase . Additional protocol details are available upon request.We used standard


The testing and isolation of patients with coronavirus disease 2019 (COVID-19) are indispensable tools to control the ongoing COVID-19 pandemic. PCR tests are considered the “gold standard” of COVID-19 testing and mostly involve testing nasopharyngeal swab specimens. Our study aimed to compare the sensitivity of tests for various sample specimens. Seventy-five participants with confirmed COVID-19 were included in the study. Nasopharyngeal swabs, oropharyngeal swabs, Oracol-collected saliva, throat washes and rectal specimens were collected along with pooled swabs. Participants were asked to complete a questionnaire to correlate specific clinical symptoms and the symptom duration with the sensitivity of detecting COVID-19 in various sample specimens. Sampling was repeated after 7 to 10 days (T2), then after 14 to 20 days (T3) to perform a longitudinal analysis of sample specimen sensitivity. At the first time point, the highest percentages of SARS-CoV-2-positive samples were observed for nasopharyngeal samples (84.3%), while 74%, 68.2%, 58.8% and 3.5% of throat washing, Oracol-collected saliva, oropharyngeal and rectal samples tested positive, respectively. The sensitivity of all sampling methods except throat wash samples decreased rapidly at later time points compared to the first collection. The throat washing method exhibited better performance than the gold standard nasopharyngeal swab at the second and third time points after the first positive test date. Nasopharyngeal swabs were the most sensitive specimens for early detection after symptom onset. Throat washing is a sensitive alternative method. It was found that SARS-CoV-2 persists longer in the throat and saliva than in the nasopharynx. Coronavirus disease 2019 (COVID-19) is an acute infection of the respiratory tract that appeared in late 2019 . The impHere, we propose a rigorous and in-depth comparison of SARS-CoV-2 detection sensitivity between NP swabs, OP swabs, rectal swabs, pooled swabs, S and TW. Longitudinal sampling was performed to assess assay sensitivity over time. As different clinical presentations may be associated with privileged viral replication sites, we correlated the assay sensitivity with symptoms at the time of sample collection to determine whether symptom-based individualized diagnostic strategies would increase sensitivity.Patients admitted to Liège University Hospital, Belgium, who tested positive for SARS-CoV-2  were invited to participate in the study. Additionally, asymptomatic hospital staff members  enrolled in a prospective study implemented as an active monitoring protocol for COVID-19, aiming to detect SARS-CoV-2 infection at the earliest stage, were invited to participate in the study when they tested positive for SARS-CoV-2.Between 8 October 2020 and 13 December 2020, 61 inpatients with COVID-19 at Liège University Hospital were enrolled in our study. In parallel, 14 staff members agreed to be included in the present study following a COVID-19 diagnosis. Demographics, clinical data and samples were collected after the study participants acknowledged that they had understood the study protocol and signed the informed consent form. The protocol was approved by the ethics committee of Liège University Hospital .For inpatients, samples were obtained during hospitalization. For outpatients (either staff members or follow-up visits after discharge), appointments for sampling were proposed at the hospital’s COVID-19 center. For self-sampling (S and TW), patients were asked to collect specimens in the morning after waking up but before eating, drinking and tooth brushing. The TW was performed with 5 mL of saline and collected into a sterile collection tube after approximately 30 s of gargling. Saliva (S) was collected using Oracol S14 , a simple device for the collection of oral fluid designed to be used in a similar manner to a toothbrush . After cSamples were tested for SARS-CoV-2 infection using the Roche Diagnostics Cobas 6800 SARS-CoV-2 test. The whole process was fully automated, from sample preparation to the detection of the amplified genes (ORF1a/b and E).p < 0.05). All calculations and graphs were performed with SAS version 9.4 and R version 3.6.1.Data are summarized as the means and standard deviations (SDs), medians and interquartile ranges (IQRs), and extreme values for continuous variables, while frequency tables were used for the categorical variables. Cohen’s kappa coefficient (κ) was calculated to measure the inter-rater reliability of categorical items. A logistic regression analysis was conducted to explore the effects of symptoms on detection sensitivity at T1, and a linear mixed model was performed to study the evolution of viral loads over time based on repeated measures in individual patients. The results were considered significant at the 5% critical level  mean and median values are indicated for positive samples in At T1, NP swab specimens (84.3%) exhibited the highest sensitivity, similar to pooled swabs (83%), followed by TW (74%), S (68.2%), OP (58.8%) and R (3.5%) . Viral lThe levels of SARS-CoV-2 RNA decreased after symptoms onset and differed according to sample specimens. Individual evolutions of loads  over time are represented for each sampling method in We observed that the viral loads measured on NP decreased faster than those in other sample specimens . AccordiInterspecimen reliability measurements at the first time point are listed in p = 0.047) (p = 0.041) than in the other groups (p = 0.078). In contrast, the probability of detection with the pooled sample decreased in participants with sore throat (Assay sensitivity was associated with symptomatology. We determined the percentage of positivity depending on the presence of specific symptoms associated with COVID-19  Table 3Table 3. = 0.047) . SARS-Cor groups . Infectie throat .Since the identification of COVID-19 in China, millions of people have been infected in numerous countries, defining the disease as a pandemic. Public health responses have varied substantially between regions. Most countries implemented interventions based on large-scale testing and measures, including wearing masks, quarantine and social distancing. To date, testing for SARS-CoV-2 infection has mostly relied on NP swab sampling. Although alternative approaches have been proposed, some of them are easy to perform without the assistance of health care workers, including saliva or throat wash samples. The self-collection of saliva or throat wash also alleviates the demands for supplies of swabs and personal protective equipment .NP swab specimens have been shown to be superior to OP swab specimens for the detection of SARS-CoV-2 . Indeed,To our knowledge, our study is the first to propose an in-depth longitudinal comparison of various specimen options available to detect SARS-CoV-2 in the same individuals. Overall, we showed that NP swabs were the most sensitive specimens when performed early after symptom onset, although throat washes showed good sensitivity as well. We further revealed a poor correlation between NP and TW, suggesting that a patient suspected of having COVID-19 who tested negative for SARS-CoV-2 through NP may indeed be false negative and should be tested using throat washing.We documented that the duration of symptoms mainly affected the sensitivity of detection using NP swabs. The sensitivity of SARS-CoV-2 detection performed using NP swabs drastically decreased with symptom duration. At the second and third time points of our study, throat washing was the most sensitive sampling method. We determined that throat washing was more sensitive than NP at more than 21 days after symptom onset, which should be considered to improve SARS-CoV-2 testing strategies.Finally, the sensitivity of the sample specimen varied depending on the clinical presentation. SARS-CoV-2 detection in Oracol-collected saliva specimens was lower than that in NP or TW samples but was higher in patients with fever at sample collection. SARS-CoV-2 detection in throat wash specimens was particularly high in patients with rhinorrhea, a phenomenon that might be due to overnight discharge through the throat. Larger studies are needed to confirm that symptom-based testing strategies are also an interesting option.Differences between our study and previously reported results are explained by several factors. First, saliva samples were collected with a specific device in our study. Second, we mostly included hospitalized participants, some of whom had very low saliva production, particularly older mouth-breathing individuals. Third, we showed that the saliva specimens were affected by symptom duration, which was long in our study. We indeed observed that patients often came to the hospital late in the course of the infection.Our study has several limitations. Our results should be interpreted with caution as sensitivity is affected by both the analytical method and the pre-analytical steps. The use of other methods might yield a different outcome. Moreover, the sensitivity of the method was only evaluated and validated using SARS-CoV-2 viral culture spiked in negative nasopharyngeal swab samples.In conclusion, our study showed that NP swab specimens should remain the preferred specimen to detect SARS-CoV-2 infection early after symptom onset. However, alternatives can be used with good efficacy—particularly throat washes—in suspected patients with negative detection using NP swabs, or in settings where the involvement of health care workers is a major bottleneck to efficient testing. Throat wash specimens also appear to be the best option for individuals presenting late during the course of the disease. The detection of SARS-CoV-2 in Oracol-collected saliva specimens was disappointing in our study, with the noteworthy exception of participants presenting with fever. Finally, the finding of higher SARS-CoV-2 detection in throat samples at later time points also has implications for viral persistence studies, with a potential critical effect on quarantine duration and PCR-based lifting of the quarantine strategies. Culture experiments are needed to confirm the infectivity of the virus-identified throat wash samples.


In pediatric inpatient settings, unconfirmed penicillin allergy labels (PALs) are associated with increased broad-spectrum antibiotic use, costs, and adverse events. However, 90% of antibiotics are prescribed in the outpatient setting and 70% of these antibiotics are given for upper respiratory tract infections (URTI.) Little is known about the effect of PALs on antibiotic prescribing in the pediatric outpatient population.st 2010 and June 30th 2020 and seen at one of 91 Texas Children’s Pediatrics or Children’s Hospital of Philadelphia primary care clinics. Children with an ICD10 code for an URTI and an antibiotic prescription were stratified into those with or without a penicillin allergy label at the time of the infection. Rates of second-line and broad-spectrum antibiotic use were compared.A retrospective birth cohort was created of children born between January 1The birth cohort included 334,465 children followed for 1.2 million person-years. An antibiotic was prescribed for 696,782 URTIs and the most common diagnosis was acute otitis media. Children with PALs were significantly more likely to receive second-line antibiotics  and broad-spectrum antibiotics  Children with PALs received more third generation cephalosporins (60% vs. 15%) and more macrolide antibiotics (25% vs. 3%) than those without a PAL. Overall, 18,015 children (5.4%) acquired a PAL during the study period, which accounted for 23% of all second-line antibiotic prescriptions and 17% of all broad-spectrum antibiotic use for URTIs.Multivariable logistic regression for receipt of second-line antibiotics for upper respiratory tract infectionsPALs are common and account for a substantial proportion of second-line and broad-spectrum antibiotic use in pediatric outpatients treated for URTIs. Efforts to de-label children with PALs are likely to increase first-line antibiotic use and decrease broad-spectrum antibiotic use for URTIs, the most common indication for antibiotic prescribing to children.Debra Palazzi, MD, MEd, AAP AHRQ (Research Grant or Support)Elsevier JAMA Pediatrics (Board Member)


The concept implies diagnosis (imaging) and treatment of cells  using the same molecule, thus guaranteeing a targeted cytotoxic approach of the imaged tumor cells while sparing healthy tissues. As the brilliant late Sam Gambhir would say, the imaging agent acts like a 'molecular spy' and reveals where the tumoral cells are located and the extent of disease burden (diagnosis). For treatment, the same 'molecular spy' docks to the same tumor cells, this time delivering cytotoxic doses of radiation (treatment). This duality represents the concept of a 'theranostic pair', which follows the scope and fundamental principles of targeted precision and personalized medicine.theranostic was noted in medical literature in the early 2000s, the principle is not at all new to nuclear medicine. The first example of theranostic dates back to 1941 when Dr. Saul Hertz first applied radioiodine for radionuclide treatment of thyroid cells in patients with hyperthyroidism. Ever since, theranostics has been an integral element of nuclear medicine and molecular imaging. The more we understand tumor biology and molecular pathology of carcinogenesis, including specific mutations and receptor expression profiles, the more specific these 'molecular spies' can be developed for diagnostic molecular imaging and subsequent radionuclide targeted therapy (radiotheranostics). The appropriate selection of the diagnostic and therapeutic radionuclide for the 'theranostic pair' is critical and takes into account not only the type of cytotoxic radiation emission, but also the linear energy transfer (LET), and the physical half-lives. Advances in radiochemistry and radiopharmacy with new radiolabeling techniques and chelators are revolutionizing the field. The landscape of cytotoxic systemic radionuclide treatments has dramatically expanded through the past decades thanks to all these advancements. This article discusses present and promising future theranostic applications for various types of diseases such as thyroid disorders, neuroendocrine tumors (NET), pediatric malignancies, and prostate cancer (PC), and provides an outlook for future perspectives.Although the term  Theranostic is a portmanteau of the Greek words therapo and gnosis, translating to therapy and knowing, i.e., diagnostics 32P) for leukemia in 1941 131I) for Graves' disease published by Saul Hertz in 1942 in vivo, i.e., within the whole body, early detection of disease, disease staging, assessment of tumoral molecular heterogeneity by imaging, therapy selection, treatment planning, and subsequent targeted and tailored treatment based on the diagnostic molecular imaging results. The diagnostic part further allows for early assessment of treatment response and detection of recurrence, long before there are measurable anatomical changes, and plays a critical role in the differentiation between progression and pseudo-progression. The use of dosimetry to predict and determine the specific radiation absorbed doses by the tumor, organs at risk, and healthy tissues of every individual patient ensures the desired goals of efficacy and safety of the treatment. Advances in dosimetric software like voxel-based dosimetry will make dosimetry-guided targeted radionuclide therapies (TRT) more feasible. In pursuing a more personalized medicine, radiotheranostic is slowly moving from a fixed schedule of treatment cycles and dose activity to a more individualized approach based on the patient's specific tumor burden, biology, and dosimetry, which will allow immediate adjustment for toxicity and individualized decision making.The term 123I (single photon emitter) or 124I (positron emitter) can be used for diagnostics and 131I (beta emitter) for treatment of thyroid diseases. These isotopes are chemically 'identical', and only differ in their emissions and physical half-lives, which is favorable for their respective purposes.A radiopharmaceutical consists of three components: the radionuclide (with diagnostic and/or therapeutic properties), a chelator (which links the radionuclide to the ligand/probe), and the ligand/probe (which targets a cancer-specific molecular marker on the tumor cell with high affinity). Sometimes, a radionuclide by itself can serve as a radiopharmaceutical without the need for a chelator or radiolabeling. The purest concept of a 'theranostic pair' consists of a chemically and structurally identical  probe labeled with either a diagnostic or therapeutic radionuclide. This ensures targeting of the same molecular marker for diagnostic imaging and molecular targeted treatment. Radiolabeling is a critical step in the synthesis of a radiopharmaceutical since the receptor binding affinities may be negatively affected by a decreasing degree of similarity between the diagnostic and therapeutic molecule. In that sense, the 'perfect' theranostic pair would be two isotopes of the same element. The prime example is radioiodine, where for instance The diagnostic counterpart can be performed by employing either single photon emission computed tomography/computed tomography (SPECT/CT) or more commonly used positron emission tomography either with computed tomography (PET/CT) or magnetic resonance imaging (PET/MRI) to obtain molecular diagnostic images. The chosen radiopharmaceutical is either a gamma emitter for SPECT or a positron emitter for PET. Both gamma and positron emitting radiopharmaceuticals have high tissue absorption, a low energy transfer and a long radiation range, resulting in low-level radiation exposure for the patient with optimal imaging condition. In contrast to anatomical imaging like CT or MRI, molecular imaging visualizes tumor molecules and characterizes tumor tissue, function, and biology. This allows not only for disease localization, staging and restaging, but also, and a unique feature of theranostic, the ability to effectively select patients for subsequent TRT based on their chances to have a positive response to therapy. Molecular imaging determines whether there is sufficient expression of the molecular target based on tumor uptake compared to normal tissue and background uptake, and therefore whether the patient will benefit from TRT. This principle indicates that treatment with the same compound will be delivering a tumoricidal radiation dose to the cancer cells.131I, Lutetium-177 (177Lu), Samarium-153 (153Sm), and Yttrium-90 (90Y). They are characterized by a high energy transfer to the tumor cell and a short radiation emission range, which is favorable to spare surrounding healthy tissue cells. Treatment with alpha particles like Radium-223 (223Ra) has been approved by the US Food and Drug Administration (FDA), others like Actinium-225 (225Ac) are being actively researched in human clinical trials. Compared to beta emitters, they are distinguished by a very high LET and an even shorter path length in the dimension of microns (<100 μm). Another group of emitters that have been used in the past for theranostics are Auger electron emitters. However, these radionuclides are generally less effective as they provide very low energy electrons that decay by electron capture. The energy is deposited over a very short distance, so they become most effective strictly intracellularly. Examples of Auger electron emitters are 123I, Indium-111 (111In), Gallium-67 (67Ga), and Technetium-99m (99mTc), which are currently used for SPECT/CT at very low diagnostic doses, but some of them like 123I and 111In have been introduced in clinical trials at high doses for treatment of thyroid diseases and neuroendocrine tumors (NET), respectively TRT is a systemic cytotoxic treatment which is applied either intravenously or orally. The ionizing radiation aims directly at the cancer-specific target and induces deoxyribonucleic acid (DNA) double-strand breaks and subsequently organized cell death through apoptosis. Therefore, choosing the most appropriate radionuclide is key. The higher the linear energy transfer (LET) to the target cell, the higher the damage to the target cell and treatment efficacy. Also, the longer the emission range, which is the tissue penetration range, the larger the perimeter of the irradiated tissue area/treated area (measured in microns up to 2 mm). Preferably, a radionuclide with a relatively long half-life (days to 1-2 weeks) is chosen to prolong the therapeutic effect. The most commonly used radioemitters in the clinic are beta particles like In addition, radionuclides usually have two or more types of emission with different energy peaks. This characteristic makes certain radioisotopes used for therapy to be suitable for non-diagnostic imaging. This non-diagnostic imaging can be of great utility to obtain post-treatment SPECT/CT imaging to confirm molecular targeting of the treatment, rule out pharmacologic interference and stunning. This is usually the case with beta emitters, which tend to have a certain abundance of gamma emission suitable for post-treatment imaging with SPECT/CT. These scans can also be used for dosimetry to determine the absorbed doses of the tumor(s) and healthy tissues.Thyroid cancer is the most prevalent endocrine malignancy, and the incidence of papillary thyroid carcinoma (PTC) has increased over the past few decades due to improved diagnosis Radioiodine treatment utilizes the underlying thyroid physiology of using iodide to synthesize thyroid hormones. Iodide is taken up from the blood stream by follicular thyroid cells through the sodium-iodide symporter (NIS) localized in the basolateral membrane. The NIS cotransports two sodium ions along with one iodide ion into the cytosol whereas the sodium gradient serves as driving force 123I can be used for diagnosis and planning of radioiodine therapy in cases of DTC, hyperthyroidism like Graves' disease and toxic uni- or multinodular adenomas. PET imaging with 124I is also a great diagnostic agent, although not as easily accessible as 123I. 124I is used for staging and restaging of DTC, although its long half-life of 4 days makes it an excellent theranostic pair for dosimetry. Currently, the doses of radioiodine prescribed for radioiodine treatment of DTC are based on disease risk, disease burden and location of metastatic disease. This can lead to under- or overtreatment with subsequent adverse effects. Lesional dosimetry aids in moving towards an individualized treatment approach in order to maximize outcome and minimize toxicity. The feasibility of dosimetry with 124I in predicting and estimating absorbed doses of individual tumor lesions is currently evaluated in various institutions in the United States and Germany .From a diagnostic point of view, SPECT imaging with 131I is given in various settings: In benign hyperthyroidism to ablate uni- or multinodular toxic goiter or whole organ ablation in Graves' disease; in DTC, as adjuvant therapy to irradiate local or distant metastases and thereby reducing the risk of recurrence, or for residual or recurrent disease, or to ablate any normal thyroid remnant after total thyroidectomy to ensure an undetectable thyroglobulin level which subsequently can be used as tumor marker in follow-up 131I 131I From a therapeutic point of view, treatment with Theranostic with radioiodine is an integral part of (re-)staging, therapy, and surveillance of DTC after initial thyroidectomy. Although the prognosis of DTC is usually favorable, recurrence is seen in 5-30% of the cases 90Y-DOTATOC, which targets somatostatin receptors (SSR), has been evaluated. A phase II trial evaluating response, survival, and long-term safety of 90Y-DOTATOC in patients with metastatic MTC and increasing tumor marker calcitonin showed that 29% of patients demonstrated a decrease in tumor marker which was associated with a significantly higher survival 177Lu-DOTATATE 177Lu-octreotate 177Lu-PSMA which is currently used to treat prostate cancer (PC) in clinical trials. Interestingly, a recently published case report showed uptake of 18F-FDG, 68Ga-DOTATATE and 68Ga-PSMA in a patient with radioiodine-refractory, poorly differentiated thyroid cancer 177Lu-PP-F11N in patients with MTC. 177Lu-PP-F11N showed promising biodistribution with accumulation in MTC lesions Medullary thyroid cancer (MTC) derives from C-cells which arise from the neural crest and is therefore considered NET. Primary and curative treatment is surgery. In case of progressive, symptomatic disease, systemic therapy with cabozantinib and vandetanib is recommended 111In-octreotide or 99mTc-Hynic-toc. However, SPECT imaging has been largely replaced by PET due to better image quality and its potential for quantification 68Ga: 68Ga-DOTA-1-Nal3-octreotide (DOTANOC), 68Ga-DOTA-D-Phe1-Tyr3-octreotide (DOTATOC) and 68Ga-DOTA-D-Phe1-Tyr3-Thr8-octreotide (DOTATATE). DOTATATE has a 10-fold higher and selected affinity to SSR2 receptor followed by DOTATOC which also binds to SSR5, whereas DOTANOC is selective towards SSR2, SSR3 and SSR5 68Ga-labeled SSA a powerful tool. In a systematic review and meta-analysis on the impact of 68Ga-SSA PET on patient management including 1,561 patients, a management change due to PET/CT findings was seen in 44%. Most interestingly, 77% were intermodality changes, meaning a change in type of treatment . Recently, the FDA approved Copper-64 (64Cu)-DOTATATE for PET imaging of SSR positive NETs. 64Cu has the advantage of a longer half-life (12.7 hours vs 68 minutes of 68Ga), which makes a central production with long haul distribution possible. In a phase III clinical trial evaluating 64Cu-DOTATATE PET/CT imaging for NET, a 100% sensitivity and 96.8% specificity was found with no adverse events 68Ga-DOTATOC has also been FDA approved based on two clinical trials NETs are a heterogenous group of rare tumors. The majority are gastroenteropancreatic NETs (GEP-NET) (60-70%) and bronchial NETs 30%). Although considered rare, their incidence is rising, which might be due to more awareness and incidental findings, but also related to rapidly developing diagnostic methods %. Althou177Lu and 90Y or more recently with alpha emitters such as 225Ac. Treatment with PRRT has been employed for a quarter of a century now. A magnitude of clinical trials and studies evidence the efficacy of PRRT in terms of decrease in tumor size and tumor marker, symptomatic relief, overall improvement of quality of life, and increase in overall survival (OS). In general, PRRT is known to have a safe profile and possesses little side effects. However, different radioisotopes have different safety profiles. Renal failure due to radiation induced inflammation and fibrosis of the kidneys has been reported, especially when using 90Y, but less since the introduction of nephroprotection with amino acids. Hematological toxicity is usually mild and in the majority of cases reversible 177Lu-DOTATATE. At the data-cutoff date, the median progression free survival (PFS) had not been reached in the PRRT group vs 8.4 months in the SSA group, meaning a 79% lower risk of disease progression or death in the PRRT arm. Partial response of 17% was seen in the 177Lu-DOTATATE arm vs 3% in the SSA group. The patients reported a significant improvement in quality of life compared with high-dose SSA. Adverse events were higher in the PRRT group, however only mild in nature including nausea and vomiting due to the concomitant infusion of nephroprotective amino acids, fatigue or abdominal pain, and diarrhea. Hematotoxicity grade 3-4 was low and included neutropenia, thrombocytopenia, and lymphopenia in 1%, 2%, and 9% of patients, respectively, vs none in the SSA arm 177Lu-DOTATATE for unresectable or metastatic, progressive, well-differentiated, SSR-positive NETs in 2018. As median PFS and OS had not been reached at the data-cutoff date, final analyses are forecasted either after 158 deaths or 5 years after randomization of the last patient and are anticipated soon.The therapeutic counterpart uses the same SSA radiolabeled with beta emitters like 213Bi)-DOTATOC 68Ga-NODAGA-JR11 and 177Lu-DOTA-JR11 (177Lu-OPS201) are currently evaluated in phase I/II multicenter studies .Currently, research is shifting towards PRRT with alpha emitters. Beta emitting radionuclides have a longer range and hence penetration, which impacts adverse events. Alpha emitters not only have a short range but also deliver a high linear dose to the tumor cells, potentially increasing efficacy. Patients with GEP-NET frequently have liver-dominant disease. Liver-directed treatment can deliver a high tumoricidal dose to the hepatic metastases while sparing surrounding healthy liver tissue. A first in human study showed promising results with liver targeted treatment with intraarterial application of Bismuth-213  or alpha emitters  for therapy. 68Ga-labeled PSMA inhibitors such as PSMA-11, PSMA-I&T (imaging and treatment) and PSMA-617 are the most commonly used. However, 18F-labeled tracers have the advantage of a slightly longer half-life (110 minutes) which allows a wider distribution along with a high yield production in a cyclotron facility. As highly anticipated, the FDA just recently approved the 18F-labeled PSMA PET agent DCFPyL 177Lu-PSMA for metastatic castration resistant PC (mCRPC) has been introduced nearly a decade ago. Results from prospective phase II clinical trials were pivotal with a decline of PSA levels of greater than 50% in 45% of patients whereas any decrease was observed in 60% of patients. Treatment response was registered in up to 82% according to Response Evaluation Criteria in Solid Tumors (RECIST) and Positron Emission Tomography Response Criteria in Solid Tumors (PERCIST) criteria. PFS and OS were improved, and patients reported pain relief and increased quality of life. Treatment side effects were mild, including fatigue, nausea, and pain. Hematological toxicity was also reported mild and reversible in 90%. However, due to the high uptake in salivary glands, xerostomia was common, however, transient 177Lu-PSMA-617 to chemotherapy with cabazitaxel. A higher PSA response rate (66% vs 37%) and lower adverse events (33% vs 53%) were seen in the 177Lu-PSMA-617 arm compared to cabazitaxel 177Lu-PSMA-617 and standard of care (SOC) to SOC alone, i.e., no active chemotherapy regimen in the control group, in PSMA-positive mCRPC patients who had previously received treatment with next-generation androgen receptor signaling inhibition  and one or two prior lines of taxane chemotherapy. The first results of this international, randomized, open-label phase III study were just presented at the annual conference of the American Society of Clinical Oncology (ASCO) in the beginning of June 2021: The treatment with 177Lu-PSMA-617 plus SOC showed a 60% reduced risk of progression (median PFS 177Lu-PSMA-617 and SOC vs SOC: 8.7 vs 3.4 months), and a 38% reduced risk of death (median OS 177Lu-PSMA-617 and SOC vs SOC: 15.3 vs 11.3 months). The objective response rate was significantly higher in the 177Lu-PSMA-617 plus SOC arm than in the SOC arm (29.8% vs 1.7%), as was the disease control rate (89.0% vs 66.7%) and time to first symptomatic skeletal event (11.5 vs 6.8 months). Despite a higher rate of high-grade (grade 3 - 5) 177Lu-PSMA-617 related adverse events, the treatment was well tolerated. Adverse events included bone marrow suppression, xerostomia, nausea and vomiting 177Lu-PSMA-617 in the US and Europe.PSMA is a transmembrane glycoprotein which is highly overexpressed in prostate cancer (PC) ta 90Y, 1Lu or alp225Ac-PSMA-617 achieved biochemical and radiological complete remission with low hematotoxicity but severe xerostomia, which remains the dose-limiting toxicity 225Ac-PSMA-617 TRT in 73 patients showed a decline in PSA greater than or equal to 50% in 70% of patients, which was associated with a longer OS. The median PFS was 15.2 months and OS was 18 months. Xerostomia was seen in 85% of patients but did not lead to discontinuation of treatment Alpha emitting PSMA agents for treatment have been a field of active research in the last years. In a first in man study, 68Ga-RM2 which has been evaluated for initial diagnosis 68Ga-PSMA-11, to better understand their relationship and potential predictive value of tumor biology and aggressiveness in different types and stages of PC.Gastrin releasing peptide receptor (GRPR) has emerged as a promising novel target. It is highly expressed in PC and shows only low expression in benign prostate tissue 177Lu-RM2 177Lu-RM2 after prior confirmation of GRPR expression through 68Ga-RM2 PET/CT. The highest absorbed doses were seen in bone lesions, followed by lymph node and soft tissue metastases and were all therapeutically relevant. The highest physiologic uptake was measured in the pancreas, which became the dose limiting organ 177Lu-NeoB in patients with GRPR expressing, metastatic solid tumors .Several theranostic pairs were investigated preclinically, however the first compound explored in human is 99mTc-biphosphonates for SPECT and sodium fluoride-18 (NaF18) for PET imaging, and subsequent treatment labeled to an alpha or beta emitter. Bone seeking radiopharmaceuticals accumulate in the bone depending on the degree of osseous metabolism, meaning the higher the bone turnover, the higher the accumulation of the radiopharmaceutical, hence higher affinity to osteoblastic metastases than healthy bone 32P and subsequently other beta emitters such as Strontium-89 (89Sr), Rhenium-186-hydroxyethylidene diphosphonate (186Re-HEDP), 153Sm-ethylenediamine tetramethylene phosphonate (153Sm-EDTMP), 177Lu-EDTMP, and the alpha emitter 223Ra. Bone seeking agents can be grouped into calcium analogs like 89Sr and 223Ra, and radionuclides labeled to a phosphate like 186Re-HEDP and 153Sm-EDTMP. For radiolabeled phosphates and 89Sr, bone palliation has been shown to occur 2 - 10 days after treatment with overall pain relief response rate of 59 - 86%. However, survival is not significantly impacted Many cancers metastasize to the skeleton causing pain, pathologic fractures, and spinal cord compression thus driving morbidity and mortality. Osteoblastic metastases are characterized by increased bone metabolism which can be targeted by bone seeking radiopharmaceuticals such as 223Ra-dichloride is the currently most widely and commonly used bone targeted treatment. It has been FDA approved in 2013 for symptomatic bone metastases in mCRPC without known visceral metastases. 223Ra is a calcium analog, which forms complexes with the bone mineral hydroxyapatite in areas of high bone metabolism. It therefore does not target the tumor cell itself but rather accumulate in between them. The short range of the alpha emitter allows high LET to the tumor stroma, causing DNA double-strand breaks, but minimizes damage to the surrounding normal tissue, especially the bone marrow 223Ra with an interval of four weeks, and a placebo group receiving best supportive care. The key results were a significant delay in time to first symptomatic skeletal event in the 223Ra group vs placebo group (15.6 vs 9.8 months) and better OS (14.9 vs 11.3 months). Adverse events were seen slightly more frequently in the placebo than in the 223Ra group (96% vs 93%). 223Ra related side effects included mainly hematotoxicity, nausea, and other gastrointestinal reactions. Quality of life has been significantly improved in the treatment group 223Ra was safe and effective when used before or after chemotherapy with docetaxel. However, concurrent 223Ra therapy and chemotherapy is not recommended. Adding 223Ra therapy to abiraterone or enzalutamide has been reported safe, however the combination treatment did not improve bone palliation, on the contrary, was associated with increased incidence of pathologic fractures and mortality 223Ra and progressed afterwards can be safely re-treated without serious drug-related adverse events in a two year follow up after re-treatment 223Ra was only approved for PC, 223Ra could target osteoblastic metastases of any malignant origin. A recently published phase II study showed high disease control rate of 49% and tumor response rate of 54% of 223Ra combined with hormonal therapy in hormone receptor‐positive, bone‐dominant metastatic breast cancer 223Ra an ideal systemic therapy for patients with metastatic osteosarcoma. A single phase I dose escalation study has been published hitherto showing feasibility and safety of up to six cycles 223Ra with minimal hematologic toxicity in a small cohort of 18 patients with high-risk osteosarcoma Although 131I 131I-mIBG has been approved by the FDA in late 2018 for the treatment of mIBG positive, unresectable, locally advanced, or metastatic pheochromocytoma or paraganglioma based on the results of an open-label, single-arm, multicenter clinical trial involving 68 patients. Treatment response was achieved in 22% of patients receiving a single dose and increased to 32% in patients who received two doses. Ninety-two percent of patients who received at least one dose, showed partial response or stable disease. The median OS was 36.7 months. Clinical benefit was reflected in a 50% or greater reduction of all antihypertensive medication for at least six months in 25% of patients. Patients without hypertension were not included in this study, however, this might not have an impact on overall oncologic course of disease. The most common side effect was of hematologic nature in 90% of patients, whereas 72% were severe (grade 3-4). Despite the high percentage of severe adverse events, they were transient and resolved without intervention in all but 25% who needed supportive care such as red blood cell and platelet transfusion, granulocyte colony-stimulating factors or erythropoietin for a limited time. In 16% of patients, 131I-miBG treatment had to be discontinued due to persistent severe myelosuppression or other non-hematologic adverse reactions such as nausea. Myelodysplastic syndrome was seen in 4% and acute leukemias in 3% 123I-mIBG scans have been reported 131I-mIBG diagnostic and treatment includes discontinuation of medication that interfere with norepinephrine transporters for at least five half-lives before and seven days after treatment  to avoid any false negative scans or transporter saturation a priori. As mIBG is radiolabeled with 131I, thyroid blockade should be given at least 24 hours prior to treatment and ten days afterward.Neuroblastoma is the most frequent extracranial solid tumor in infancy which derives from primitive neural crest cells from the sympathetic nervous system. These tumors are heterogenous in nature, varying in location, and clinical behavior ranging from spontaneous regression to aggressive, metastatic disease 131I-mIBG showed promising results with a 30% - 40% response rate, especially in high-risk neuroblastoma with refractory, relapsed or resistant conditions For neuroblastoma, therapy with 68Ga-DOTATATE and 177Lu-DOTATATE possible. Especially in patients with metastatic, extra-adrenal primaries or familial PPGL, the sensitivity of mIBG may drop to 53 - 61%. SDHB mutation is the most common germline mutation seen in PPGL. It is characterized by a high malignant transformation (30%), shorter survival  and 20% do not produce norepinephrine As PPGL are also NETs, they express SSR on their cell surface which makes theranostic with Active preclinical research has resulted in the development of new molecular targets with high potential in translating into the clinic and application through theranostics. Here, we present just a few of the many novel targets evolved.68Ga-FAPI-02 and 68Ga-FAPI-04 showed high uptake in several cancers with the highest uptake in sarcoma, esophageal, breast, lung and cholangiocellular carcinoma 225Ac-FAPI-04 showed significant tumor growth delay 90Y-FAPI-04 was administered to one patient with metastasized breast cancer and reduced pain medication significantly. Despite the high uptake in the tumors, a fast clearance was observed A malignant tumor contains not only cancer cells but also non-malignant cells such as inflammatory and vascular cells, and fibroblasts that form the tumor microenvironment, the so-called tumor stroma. Cancer-associated fibroblasts make 90% of the tumor mass and highly express the membrane bound glycoprotein fibroblast activation protein (FAP) in epithelial carcinomas, especially in colorectal, breast, pancreatic and PC 177Lu-3BP-227 in six patients with pancreatic adenocarcinoma. The therapy was well tolerated with reversible grade 2 anemia as adverse event. One patient achieved partial response and significant improvement of symptoms while the other survived 11 months after treatment with 177Lu-3BP-227 177Lu-3BP-227 in solid tumors expressing neurotensin receptor 1 .Neurotensin is a neuropeptide exhibited by the gastrointestinal and central nervous system as well as the myocardium. Neurotensin receptor 1 has been found to be overexpressed in various cancers such as colorectal, small cell and non-small cell bronchial, breast and pancreatic cancer. A first in man study showed the feasibility of treatment with 68Ga-labeled pentixafor has shown promising results for imaging of multiple myeloma and lymphoma. A first in human study explored 177Lu- and 90Y-labeled pentixather for the treatment of relapsed multiple myeloma and showed partial and complete response to CXCR4-directed treatment The CXC-chemokine receptor type 4 (CXCR-4) is highly overexpressed in various human cancers like leukemia, lymphoma, and multiple myeloma 131I-tositumomab and 90Y-ibritumomab tiuxetan have demonstrated efficacy 177Lu-lilotomab satetraxan has been explored in a phase I/IIa study with an overall response rate of 70% whereas 32% showed complete response The anti-CD20 monoclonal antibody rituximab is a standard treatment for B-cell non-Hodgkin lymphoma. In the setting of relapsed or refractory disease, 177Lu-DOTATATE combined with nivolumab  or in mCRPC combining treatment with 177Lu-PSMA-617 with pembrolizumab . Other combinations include TRT with chemotherapy and radiation therapy (65).Future objectives of theranostics not only include the development of new molecular targets, but also improvement of currently available treatments. The implementation of TRT earlier in the course of disease might improve quality of life as reported side effects from chemotherapies and other targeted systemic treatments are higher . Dosimetry estimates cumulated radiation dose and in a personalized medicine fashion will allow for individualized dosing and number of treatment cycles as opposed to current fixed regimen of dose and treatment cycles In this era of precision medicine in oncology, theranostic is the ultimate example of targeted, personalized diagnostic and treatment as we treat what we see. Each tumor's molecular profile is unique and so should the therapeutic approach be. Theranostic allows for imaging these specific tumor markers and patient selection and stratification so that the most beneficial treatment can be chosen. Active research in the field of theranostic will evolve more novel targets and improve radiopharmacokinetics. In the future, dosimetry will pave the way to an even more personalized treatment approach by moving from empiric standardized doses to individualized treatment doses and cycles. Molecular targeted radioligand therapy will become a major part of daily clinical nuclear medicine.


There is limited literature comparing the clinical parameters and treatment outcomes in HIV-infected and HIV-uninfected myasthenia gravis (MG) patients. The aim of the study was to investigate the clinical differences and treatment outcomes in the two categories of patients, particularly the safe use of immunosuppressive therapy in immunocompromised patients. The study was a retrospective analysis of medical records of MG patients from the neuromuscular unit at Inkosi Albert Luthuli Central Hospital in Kwa-Zulu Natal between 2003 and 2019. One hundred and seventy-eight (178) patients fulfilled the clinical criteria for MG. Twenty-four (13.4%) were HIV-infected and 154 (86.5%) were HIV-uninfected. There were 116 (65%) females, median 45 years, (IQR 40–62), 90 (50.5%) black African, 66 (37%) Indian, 20 (11.2%) white, and 2 (1.1%) of mixed ancestry. In the HIV-infected cohort, 20 (87%) had generalized MG, 12 (50%) bulbar, and 14 (60.9%) respiratory onset MG, 12 (50%) presented with MG Foundation of America (MGFA) class five diseases at diagnosis, six (25%) presented with MG crisis during the 5-year follow-up. Thirteen (54%) of the HIV-infected group required rescue therapy using (plasma exchange or IV immunoglobulin) combined with pulse cyclophosphamide compared with 17 (11%) in the HIV-uninfected cohort, respectively. At 5 years, 8 (33%) of the HIV-infected group remained refractory to treatment compared with 10 (6.5%) HIV-uninfected cohort, respectively. No adverse events were documented in HIV-infected patients receiving combination rescue therapy (PLEX or IVIG combined with IV cyclophosphamide). In conclusion HIV-infected MG patients are more likely to require combination rescue therapy with PE/IVIG and IV cyclophosphamide compared with those who were HIV-uninfected. No side effects were documented in the HIV-infected group receiving the above therapy. Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction, with a reported prevalence of 150–250 cases per million individuals and an estimated annual incidence of 8–10 cases per million person years .In South Africa, there are eight million people living with human immunodeficiency virus (HIV) infection . The coeThe use of immunosuppressant drugs including azathioprine and corticosteroids in HIV-infected patients with other neuromuscular diseases has been previously described –22. HoweWe aimed to describe and compare the clinical, demographic features, response to immunosuppressant therapy, in particular PE/IVIG and IV cyclophosphamide in the HIV-infected MG category with the HIV-uninfected MG category.The study was a retrospective chart review of a cohort of patients with MG from the neuromuscular clinic at Inkosi Albert Luthuli Central Hospital (IALCH) in Durban between 2003 and 2019. The study was approved by the University of KwaZulu-Natal (UKZN) Biomedical Research Ethics Committee (ethics number: BE 272/15). This unit provides a service to ~11 million people. An estimated 19% of the South African population is HIV positive in the 15–49 years age category. The province of Kwa-Zulu Natal (KZN) has 40% of the HIV burden in SA  with one or more positive confirmatory tests from the following two categories: (a) AChR-antibody serology and (b) neuromuscular junction dysfunction as evidenced by a positive repetitive nerve stimulation test (RNS) showing a decrement of >10%, positive neostigmine, or edrophonium test, and strongly positive ice pack test. If serology for AChR Ab was negative, neuromuscular junction disorders such as LEMS, botulism, and other neurological diseases were excluded clinically and electrophysiologically   in the HIV-infected category. Response to therapy (number of exacerbations and time to remission), functional recovery scored as Manual Muscle Testing (MMT) , MG qualOur current management protocol for mild to moderate MG (including ocular MG), regardless of HIV status is anticholinesterase inhibitors (pyridostigmine) combined with corticosteroids and/or azathioprine as first-line therapy. Other immunosuppressant therapy  are added if patients were refractory or developed side effects to first line therapy. Patients with myasthenic crisis received PLEX or IVIG. Cyclophosphamide was reserved for patients in crisis, refractory to PLEX or IVIG. Four to six doses of intravenous cyclophosphamide were given at 2 weekly or monthly intervals at a dose of 500–1,000 mg combined with 2-mercaptoethane. Patients were adequately counseled regarding side effects of treatment and informed consent was obtained. The dose and frequency was adjusted at the discretion of the clinician depending on the clinical response and adverse events such as leukopenia, thrombocytopenia, or anemia  or complicating infections. All patients were screened for existing infection with a full blood count and differential white blood count, urine microscopy, and culture, and chest X- ray. They were screened for hepatitis B and C prior to being prescribed methotrexate or rituximab. Maintenance therapy, if required, included pyridostigmine, corticosteroids, used individually or in combination depending on individual patient requirements.The cohort was divided into two categories of HIV-infected MG and HIV-uninfected MG. Within each category patients were further classified according to severity at presentation see . Data atIn this article combination rescue therapy refers to PE/IVIG with IV cyclophosphamide.Anonymized data will be shared by request from any qualified investigator.t-tests used for comparison. A random effects model including HIV status and time point adjustments for repeated measures was then used to examine trends over time between the two groups. A z-test was used to compare groups and time points. To compare the rate of change, the model was run separately for each group and the beta coefficient for time compared. A Kaplan–Meier (KM) curve was subsequently used to determine if time to remission differed between groups. Follow-up time was used to censor patients not obtaining remission , and truncated at 60 months. A log rank test was used to compare the remission curves between groups. Chi-squared tests were used in order to determine if confounders such as demographic factors, and clinical characteristics  associated with HIV status influenced outcome. These factors were examined in the group receiving cyclophosphamide, and only race was found to be significantly different. Medians of MGADL, MGQOL, and MMT score were compared between HIV-infected and HIV-uninfected patients receiving IV Cyclophosphamide at diagnosis, 3 and 5 years using Wilcoxon's rank-sum test. Since all HIV-infected patients receiving cyclophosphamide were black African, the analysis was repeated for black patients only. Stata/IC V1.5 was used for statistical analysis.Characteristics associated with HIV-infected and HIV-uninfected MG patients were compared using Chi Square tests for categorical variables. Functional scores of ADL, QOL, and MMT were initially categorized as positive (>0) and negative (0). Fisher's exact test was used to compare HIV-infected and HIV-uninfected patients at each time point. Overall functional scores were summarized by medians (IQR) and Wilcoxon's rank-sum test used for comparisons at each time point. Because of small numbers, geometric means were used for patients receiving combination therapy (PLEX/IVIG + IV cyclophosphamide) and One hundred and seventy-eight (178) patients fulfilled the clinical criteria for MG of which 116 (65%) were females. The demographic characteristics of the cohort, including gender, age, and ethnic distribution are detailed in Sixty-two (40%) HIV-uninfected patients had T2 diabetes mellitus (T2 DM), and 10 had other autoimmune disorders, whereas only one HIV-infected patient had Lambert–Eaton myasthenic syndrome (LEMS). The diagnosis of combined LEMS and MG was based on clinical findings, positive high-frequency repetitive stimulation studies, and positive AChR-Ab, and voltage-gated calcium channel antibody .Clinical findings at diagnosis are listed in p = 0.047. A greater number of HIV-infected patients had a decremental response (83%) on RNS compared with the HIV-uninfected category (52%). This may reflect more frequent generalized disease in the HIV-infected category.Investigations, treatment, and outcome are listed in There were no significant differences between the two cohorts with respect to the radiological and histological findings of the thymus. Eighty three percent (83%) of the HIV-infected patients, at a median age of 32 years, IQR (26–38), and 63% of the HIV-uninfected patients at a median age of 44 years, IQR (30–48) had a thymectomy performed. Patients were stabilized on IVIG/PE with/without IV cyclophosphamide prior to the thymectomy.Four highly refractory patients in the HIV-uninfected category and three in the HIV-infected category had a thymectomy during the crisis. They had received PLEX and IV cyclophosphamide during the crisis and post thymectomy. In both categories, patients improved 2–4 weeks post-thymectomy. There was no difference in the outcome between the two categories of patients.In the HIV-infected MG cohort on PLEX/IVG and IV cyclophosphamide, the median CD4 count at diagnosis was 110 cells/μl (IQR 96–193 cells/μl) and 88 cells/μl (IQR 68–108 cells/μl) 2 weeks after cyclophosphamide. The median viral load at diagnosis was 47,481 copies/ml . HIV viral loads were not repeated after cyclophosphamide unless indicated.With regard to treatment, 13/24 (54%) of the HIV-infected MG group required rescue therapy using either PE or IVG combined with pulse IV cyclophosphamide compared with 17/154 (11%) in the HIV-uninfected cohort. Maintenance therapy was not significantly different between the two groups.At 5 years, after correcting for baseline severity of disease, eight (33%) of the HIV-infected group remained refractory to treatment and 16 (64 %) obtained remission compared with 10 (6.5%) and 144 (93 %) in the HIV-uninfected cohort, respectively.p < 0.001, compared with the HIV-uninfected cohort. The above scores decrease significantly over time with no statistical difference in the rate of decrease between cohorts. p < 0.001. The Kaplan–Meier curves of survivor function differed significantly by HIV status, p = 0.0007 . This indicates that the time to obtaining remission was significantly shorter for HIV-uninfected patients than HIV-infected patients.p = 0.0014, 0.0018, 0.001, respectively). p = 0.08. Of the 30 patients on the above combination therapy, 13/17 (76.5%) in the HIV-uninfected category obtained remission compared with 5/13 (38.7%) in the HIV-infected category  but this did not reach statistical significance, p = 0.13. The median time to remission for the 13 HIV-uninfected patients was 15 months (IQR 12–36 months) and for the five HIV-infected patients was 24 months. This was not statistically significant (p = 0.68).Confounding factors such as age, gender, thymic pathology, and antibody status were similar in both cohorts receiving IV cyclophosphamide except for race. Since all HIV-infected patients receiving cyclophosphamide were black African, the analysis was restricted to black patients only. However, there were no significant differences in outcome in the black only groups.No adverse events related to therapy were documented in patients receiving combination rescue therapy (PLEX or IVIG + IV cyclophosphamide) in at least the first 6 weeks post-therapy, in particular there were no opportunistic infections in the HIV-infected category during this time period and during the rest of follow-up. In the HIV-uninfected category, two patients experienced hemorrhagic cystitis.In the above study, significant differences are that (a) HIV-infected MG patients were more likely to be young, black females. This is consistent as MG is more common among young females and that HIV is more prevalent among young black South African females, (b) HIV-infected MG presented with more severe generalized disease, as evidenced by MGFA clinical grades and functional scores , and was more likely to present with bulbar-respiratory failure requiring ventilation. This category of patients were managed following the treatment protocol for HIV-uninfected MG patients which includes, respiratory-bulbar support, rescue therapy using either IVIG or PLEX, and IV cyclophosphamide if required, followed by maintenance therapy. The use of a neostigmine infusion in patients admitted to the ICU or a high care setting was useful for symptomatic control of the disease, (c) the rate of functional improvement was significantly lower, time to remission was longer, and response to therapy (number of exacerbation or crises) was higher in the HIV-infected cohort compared with the HIV-uninfected cohort. Time to remission and side effect profile for the group on combination rescue therapy (IV cyclophosphamide/PLEX/IVIG) were not different in the two categories. Patients with milder disease were managed with oral immunosuppressant therapy (AZA and corticosteroids and pyridostigmine) with similar outcomes in both categories.The safe use of IV cyclophosphamide is not well-described in the setting of HIV-infected MG. Clinical guidelines on safe and effective prescription of ARTs with concomitant cytotoxic immunosuppressive agents is limited, except in the setting of AIDS-related B-cell lymphoma , 38. BonVarious autoimmune diseases occur between acquisition of HIV infection and clinical AIDS. These include systemic lupus erythematosus, rheumatoid arthritis, idiopathic thrombocytopenic purpura, and neurological conditions such as AIDP, CIDP, and inflammatory myositis . The mecMG, including anti-MuSK related MG, occurring during immune reconstitution has been reported , 39, 40.Loss of central tolerance, which is pathognomonic of MG, may occur in HIV. Tropism of HIV to the thymus and antigenic mimicry between normal thymic components and core p17 and p24 protein of HIV have been described . McCune In the above cohort, the HIV-infected MG patients with severe bulbar-respiratory failure were more likely to be AChR-Ab negative or have a very low titer of AChR-Ab . This maLimitations of the study are that it is a retrospective, hospital-based study, and therefore, patients may have been missed, and results may not be generalizable to the community. Furthermore, serological testing for MG was incomplete as the tests for anti-MuSK, agrin, LRP4 antibodies are not available in South Africa. One can only draw broad general conclusions regarding the outcome and side effect profile in the two groups due to the discrepancy in numbers, which makes statistical comparison difficult. More symmetrical sample sizes with randomized controlled prospective studies are needed to measure reliable response to therapy and properly assess the safety profile of IV cyclophosphamide in HIV-infected patients with respect to infections and bone marrow suppression. However, this is not possible due to the low frequency of myasthenia gravis in the context of HIV. No infections attributed to recent use of IV cyclophosphamide were documented in the HIV-infected group despite regular follow-up and screening. This may reflect a type 2 statistical error as it is possible that patients with minor infections were not reported or were managed elsewhere. Confounding factors were not found to be significantly different between the HIV-infected and HIV-uninfected groups except for race. Hence, the analysis of outcome was adjusted for race only, and multivariate analysis was deemed unnecessary. Despite the above limitations, the study reflects the real-life experience of managing patients living with MG and HIV in the South African context.HIV-infected MG patients present with more severe bulbar-respiratory signs requiring supportive care in ICU. This study suggests that immunosuppressive drugs, including IV cyclophosphamide may be safe and efficacious in HIV-infected MG. Prospective studies of MuSK or new antibodies, immune function studies, and possibly thymic histology may be valuable to explain the pathogenesis of MG in HIV and perhaps segregate alternate therapeutic avenues. This will allow for the establishment of treatment guidelines of MG in HIV.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by UKZN Biomedical Research Ethics Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.KM developed the concept, collected and analysed the data and generated the manuscript, VP helped develop the concept and reviewed the manuscript and PB reviewed the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the personal payment from research funds of PB.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study builds a coronavirus knowledge graph (KG) by merging two information sources. The first source is Analytical Graph (AG), which integrates more than 20 different public datasets related to drug discovery. The second source is CORD-19, a collection of published scientific articles related to COVID-19. We combined both chemo genomic entities in AG with entities extracted from CORD-19 to expand knowledge in the COVID-19 domain. Before populating KG with those entities, we perform entity disambiguation on CORD-19 collections using Wikidata. Our newly built KG contains at least 21,700 genes, 2500 diseases, 94,000 phenotypes, and other biological entities . We define 27 relationship types and use them to label each edge in our KG. This research presents two cases to evaluate the KG’s usability: analyzing a subgraph (ego-centered network) from the angiotensin-converting enzyme (ACE) and revealing paths between biological entities . The ego-centered network captured information related to COVID-19. We also found significant COVID-19-related information in top-ranked paths with a depth of three based on our path evaluation. The COVID-19 pandemic has caused nearly 1.28 million deaths worldwide (as of 6 December 2020) [This study proposes a framework to merge two independent datasets Analytical Graph (AG) and CORD-19  . We use 27 types of relationships in our KG and natural language processing techniques, such as entity recognition, semantic disambiguation, and knowledge merge. This KG could be used widely in the future. It functions as an essential knowledge base for related scientific research and development, while benefiting from knowledge retrieval and in-depth knowledge mining. This new KG acquires and integrates coronavirus-related information into an ontology and enables researchers to apply reasoning to derive new knowledge according to defined rules.® and PubMed Central® (PMC) texts [We evaluated the KG’s usability for information extraction using our pathfinding framework, which retrieves several paths with different depths. It calculates the path score based on the similarity distance between two nodes in every relationship found in the path. First, we transform nodes into vector values using a word vector transformation model. Then, we calculate the similarity distance between nodes using cosine similarity. We use a pre-trained word2vec model built using PubMedC) texts .http://blender.cs.illinois.edu/covid19/, accessed on 6 December 2020), through August 2020, has been updated daily. Ge et al. [Since the coronavirus outbreak in 2020, many researchers have focused on building a coronavirus KG. Domingo-Fernández et al.  built a e et al.  proposedRichardson et al.  establisWhen building a KG, researchers often rely on multiple sources instead of just one. For example, Sun et al.  extracteIn graph theory, the shortest path problem aims to identify path problems between two nodes in a graph using the minimum sum of weights. We can obtain the possible paths between the two entities in the KG using the shortest path problem. Those paths symbolize two nodes’ relatability, knowledge fundamental for further research. The shortest path problem relies on edge weight initialization in the graph. Edge weight can represent either the amount of effort required to travel or the capacity to be transported. Because the KG structure depicts the relationship between entities, we assume the edge weight as the cost or similarity between entities. Previous studies calculated entity or term similarity using the Jaccard index  and termOur research differs from the existing literature because we produce a larger and more updated coronavirus KG. Furthermore, we demonstrate that the nodes in our retrieved ego network are highly correlated with COVID-19 and use case studies to confirm the possibility of using our proposed KG for further knowledge discovery.We incorporate an existing KG and bibliographic dataset—AG  and CORDAG is a subgraph generated from multiple chemogenomics repositories. In AG, compound data are obtained from ChEMBL , PubChemThis study adopts the latest version of AG. In March 2020, the Allen Institute of AI and other leading research groups released a COVID-19 Open Research dataset, covering coronavirus-related scientific publication bibliographic metadata (COVID-19 Open Research Dataset ). AccordFor these publications, we extract biological entities mentioned in their titles and abstracts using PubTator , a web-bBefore merging the two KGs, we must disambiguate biological entity names carefully. We used two external data sources to help with the disambiguation process: Wikidata and ref.txt. Wikidata is a large-scale, multilingual encyclopedia knowledge base that contains over 25 million entities (as of 2017) and their relationships . RecordsFirst, we extracted entities and their types from both AG and CORD-19. Then, we grouped entities based on their types. Next, we mapped each entity to terms mentioned in Wikidata and ref.txt based on string similarities. Since there might be uncertainty and variability issues in the merging process, we ensured that we only merged entities of similar types. In addition, we carried out several evaluations by manually checking similarity measurement results to obtain the best threshold value for string similarity score.If two or more entities link to the same term, we merged those entities into one. We mapped 161,324 entities from AG and CORD-19 with terms from Wikidata and ref.txt. We present examples of disease and gene synonyms in After disambiguating medical entities in AG and CORD-19, we merged those KGs and built a new KG. https://covid-19.aminer.cn/kg/?lang=en, accessed on 1 May 2021). The second case presents the path details of two biological entities.Based on the built KG, we present two cases to demonstrate KG usage. The first case illustrates an ego-centered network, a subgraph of the established KG (We illustrate a subgraph from our established KG in We chose the angiotensin-converting enzyme (ACE) gene, encoded as ACE, which has 40% overall identity to ACE-2 and is positively related to COVID-19 . ACE-2 cThis section evaluates each path by scoring it using the similarity distance between nodes and verifying the information given in the top-ranked paths. We calculated the similarity distance using cosine similarity on vector representation from the vector transformation model . First, Second, for each path, we calculated and summed the cosine similarity between nodes. Third, we measured the cosine similarity between nodes using their vector values obtained from . FinallyIn this example, we analyzed two paths: (1) between IL-6 receptor and hydroxychloroquine and (2) between STAT1 and chloroquine. IL-6 receptor and STAT1 are both related to immune systems and COVID-19. We found one path with a depth two, 202 paths with a depth of three, and 600 paths with a depth of four for IL-6 receptor and hydroxychloroquine. We also found 62 paths with a depth of two, 642 paths with a depth of three, and 435 paths with a depth of four between STAT1 and chloroquine. We found evidence of gene–gene, gene–disease, and compound–disease relationships from those paths. We analyzed the evidence found in top-ranked paths for each depth and compared them with DisGeNet  and DrugThis section discusses the characteristics of paths between two entities: IL-6 receptor and hydroxychloroquine. IL-6 is Interleukin 6, an interleukin that functions as both a pro-inflammatory cytokine and an anti-inflammatory myokine. IL-6 inhibitors may ameliorate severe lung tissue damage caused by cytokine release in patients with severe COVID-19 infections. Hydroxychloroquine is a medication used to prevent and treat malaria in areas where malaria remains sensitive to chloroquine. Other usage includes the treatment of rheumatoid arthritis (RA), lupus, and porphyria cutanea tarda (PCT).Common side effects of hydroxychloroquine consumption include vomiting, headache, changes in vision, and muscle weakness. Severe side effects may include allergic reactions, vision problems, and heart problems. Although we cannot exclude all risks, it remains a treatment for rheumatic disease during pregnancy. Companies sell hydroxychloroquine under the brand name Plaquenil (among others).The list of top-ranked paths (top 95 percentile) with a depth of two, three, and four based on the shortest path algorithm of the graph to find and calculate the score of all paths from IL-6 receptor to hydroxychloroquine is presented in We concluded that the Ebola virus infection co-occurs with IL-6 receptor and hydroxychloroquine from the evidence found in paths with a depth of two. We assume the first relationship between IL-6 receptor and the Ebola virus is accurate because experiments in  concludeBased on the Drugbank dataset , we alsoThere are ten paths in the top-ranked path category with a depth of three. We found twenty-one different relationships (node–relationship–node). In addition to the Ebola virus, we found another disease that appeared in top-ranked paths: autoimmune diseases. We found that the relatedness between COVID-19 and autoimmune disease is more substantial compared to the Ebola virus. A recent report found autoimmune diseases in COVID-19 patients . We alsoWe found three more compounds in top-ranked paths with a depth of three: chloroquine, amodiaquine, and quinoline. Drugbank  reportedThere are 29 paths in the top-ranked path with a depth of four and 54 different relationships. Based on top-ranked paths with a depth of four, we found two types of diseases: HIV infections and malaria. HIV infection is an autoimmune disease that may have a higher risk in COVID-19. For malaria, there is a probability of misdiagnosis in COVID-19 and malaria . CompareSTAT1 is the primary transcription factor activated by interferons (IFNs) vital to normal immune responses, particularly viral, mycobacterial, and fungal pathogens . An innaChloroquine is an aminoquinoline primarily used to prevent and treat malaria in areas where it remains sensitive. Chloroquine is also vital as an anti-inflammatory agent in RA and lupus therapy. The list of top-ranked paths (top 95 percentile) with a depth of two, three, and four is presented in In contrast to IL-6 receptor–hydroxychloroquine, there are three paths with a depth of two in the STAT1–chloroquine case. We found six different relationships in paths with a depth of two. However, it is challenging to obtain information from paths with a depth of two. We found a “chloroquine–co_occur–weight loss” relationship in paths with a depth of two, but we could not find supporting evidence. The information obtained from paths with a depth of two is more related to mice.In top-ranked paths with a depth of three, we found 31 paths and 15 different relationships. We found eight different gene nodes between the head and tail nodes in top-ranked paths with a depth of three. The gene nodes are MX1, MX2, ISG15, OAS1, OAS2, JAK1, OASL, and EIF2AK2. According to , the MX1When we evaluated the top-ranked paths with a depth of four in the STAT1–chloroquine case, we found 51 paths and 56 different relationships. We found other genes in the top-ranked paths with a depth of four, such as USP18, A226V, SOCS, and LY96. USP18 is a differentially expressed gene (DGS) in COVID-19 cases . HoweverIn COVID-19 cases, there is a higher incidence of bilateral pneumonia and pleural effusion . The mosAs with the IL-6 receptor–hydroxychloroquine case, we can find more information using a higher depth (depth four) but obtain fewer significant paths than using depth three. However, results from STAT1–chloroquine are slightly different as chloroquine is also related to many other diseases. Therefore, in the STAT1-chloroquine case, there are more irrelevant nodes and information to COVID-19 extracted from top-ranked paths.This study built a coronavirus KG by merging two existing datasets: AG and CORD-19. The combination of the two datasets enriches the KG with more entities. However, further analysis is needed to illustrate that those entities contribute to understanding the COVID-19 disease context. We analyzed our built KG using an ego network analysis for nodes, such as ACE, SARS, and PaO2. From the retrieved ego network, we can discover the high relatedness between those nodes and COVID-19.We attempted pathfinding using a defined head and tail node to confirm KG usability for further knowledge discovery. We found that we could obtain paths with significant relationships using word-embedding and distance similarity between nodes. We also found that using a depth of three in both IL-6 receptor–hydroxychloroquine and STAT1–chloroquine cases resulted in more information related to COVID-19.In the future, we plan to update this KG with more recent coronavirus publications. We also plan to include more related knowledge resources to enrich the graph. We will perform a further experiment in the COVID-19 domain query search for knowledge discovery using the built KG. We will explore more paths on scoring methods and missing link prediction.