The titration pressure of continuous positive airway pressure (CPAP) is important in patients with obstructive sleep apnea (OSA). This study aimed to understand the difference between drug-induced sleep endoscopy (DISE)-guided CPAP titration and conventional sleep center (CSC) CPAP titration in patients with OSA.In this randomized, controlled, and single-blind crossover trial, we compared the effects of 1-month CPAP treatment in patients with OSA with either DISE-guided CPAP titration or CSC CPAP titration. Twenty-four patients with OSA were recruited for the study. All patients underwent polysomnography, DISE-guided CPAP titration, and accommodation. Initially, patients were randomly assigned to receive either DISE-guided CPAP titration or CSC CPAP treatment for the first month. They were then switched to other treatments in the second month. The Epworth sleepiness scale (ESS) score was recorded at baseline, 1 and 2 months.2O; P = 0.92). The residual apnea-hypopnea index and compliance were also not significantly different between the groups. ESS score significantly improved from baseline to 1 month after CPAP treatment in both groups. Both epiglottis (anterior-posterior collapse) and tongue base collapse were significantly associated with 95% CPAP pressure . After multivariate regression analyses, the epiglottis (anterior-posterior collapse) was an independent factor for 95% CPAP pressure. The incidence rate of bradycardia was 58.3%, which is a safety concern for DISE. Despite the high incidence of bradycardia, all patients with bradycardia recovered with proper management.The upper limit of the pressure of DISE-guided titration and CSC CPAP titration was not significantly different (13.9 ± 0.7 vs. 13.5 ± 0.5 cm HBoth modalities were comparable in terms of establishing the pressure settings required to treat patients. Further large-scale studies are required to confirm these results.https://clinicaltrials.gov/, NCT03523013. Obstructive sleep apnea (OSA) is a prevalent disorder with severe cardiovascular and neurocognitive consequences that can be reduced by effective treatment –4. ContiTraditionally, adequate pressure has been determined by manual titration in a sleep laboratory. However, laboratory-based manual titration of CPAP is time-consuming, expensive, and labor-intensive. Therefore, Auto-CPAP titration at home under new-generation ventilator machine programs is being used to solve this dilemma. A multicenter and randomized study showed that home-based auto-CPAP titration is not inferior to traditional laboratory-based manual CPAP titration in terms of acceptance, adherence, treatment time, and functional improvements . AlthougNo study has compared the results of DISE-guided and doctor-guided CPAP titrations. Therefore, we conducted a randomized prospective controlled crossover trial to examine the differences between DISE-guided and doctor-guided CPAP titrations. Additionally, the relationship between CPAP pressure and location and patterns of upper airway obstruction during DISE has seldom been studied , 14, 15.This prospective, randomized, single-blind, controlled, and crossover study was performed at the sleep center of a tertiary hospital  from March 2018 to December 2019. The local ethics committee of the Chang Gung Memorial Hospital approved the research protocol (NCT03523013), and each patient provided written informed consent.Outpatients with moderate-to-severe OSA were enrolled in the thoracic medicine department of Chang Gung Memorial Hospital. Polysomnography was performed in all patients using standard techniques. Sleep stage and arousal were scored according to the American Academy of Sleep Medicine criteria . All parThis study investigated the effect of CPAP treatment with either DISE-guided CPAP titration or conventional sleep center (CSC) CPAP titration in patients with moderate-to-severe OSA. The protocol used in this study is illustrated in 2O at intervals of more than 2 min to eliminate obstructive apnea or hypopnea. These were determined by the simultaneous observation of flow on the CPAP mode of the bi-level positive airway pressure ventilator  and the DISE monitor screen. Apnea was defined as cessation of flow (from ventilator screen) or complete obstruction of DISE for more than 10 s. Hypopnea was defined as a 50% reduction in flow for more than 10 s, 30% reduction followed by arousal, or >3% decrease in oxygen saturation. After an adequate CPAP pressure level was achieved, sequential observations of the velum, oropharynx, tongue base, and epiglottis were repeated using the video-recorded examination.Our DISE protocol has been discussed in detail previously . In brieThe VOTE classification system was used to characterize DISE findings. It focuses on specific upper airway structures that may contribute to obstruction . At each anatomical level, the configuration of the obstruction was described as anteroposterior, lateral, or concentric. The degree of obstruction had a score for each structure: no obstruction ; partial obstruction ; and complete obstruction  , 15. TheP < 0.05). The Pearson product correlation coefficient was used to examine correlations between variables and AHI or 95% CPAP pressure. Multivariate linear regression analysis was used to determine independent factors for AHI or 95% CPAP pressure. All analyses were performed using the Statistical Package for the Social Sciences software version 13.0 and Prism 5, and a value of P < 0.05 was considered to indicate statistical significance.Data are expressed as group percentages  or mean ± standard error (continuous variables). Categorical variables were compared using the chi-square or Fisher's exact test, where appropriate. The Wilcoxon matched signed-rank test was used for paired samples with non-normal distributions , and tonsil size are listed in The baseline patient characteristics are presented in The VOTE grading during DISE for both sleep and CPAP application is presented in The mean CSC CPAP titration pressure was 13.5 ± 0.5, whereas the mean DISE-guided CPAP titration pressure was 13.9 ± 0.7. There were no statistically significant differences between the CSC CPAP and DISE-guided CPAP titration pressure values . After 1p = 0.04). The 95% CPAP pressure in the epiglottis-AP group was higher than that in the velum-anterioposterior (velum-AP) group  (The 95% CPAP pressure in the epiglottis-anterioposterior (epiglottis-AP) group was significantly higher than that in the oropharynx-lateral (oropharynx-L) group  . In the  = 0.08) ; howeverThe incidence of bradycardia (<60 beats per min) was relatively high  . In contThe present study demonstrated that treating patients with moderate-to-severe OSA with CPAP significantly reduced subjective daytime sleepiness in both groups. There were no significant differences in CPAP pressure, residual AHI, compliance, and ESS between the two groups. Notably, epiglottis (anterior-posterior collapse) was an independent factor for 95% CPAP pressure. Hemodynamic and respiratory parameters were stable during DISE. Although some bradycardia events were noted, no cases of clinically significant bradycardia were observed in the present study. This is the first prospective, randomized controlled, single-blind, and crossover study to compare the effects of DISE-guided and CSC CPAP pressure determination on subjective daytime sleepiness in patients with moderate-to-severe OSA.To the best of our knowledge, the current study was the first to demonstrate that there are no differences between DISE-guided CPAP and CSC CPAP in terms of titration pressure, subjective daytime sleepiness, residual AHI, and compliance. Initially, we assumed that DISE-guided CPAP titration was more efficient to titrate CPAP pressure than CSC CPAP pressure. The first step in CSC CPAP titration is auto-CPAP titration, if patients do not have any contraindications. The titration from auto-CPAP requires weeks to achieve adequate pressure even under the modern ventilator mode . The popThe DISE-guided CPAP titration may also offer an evaluation of the upper airway while patients are struggling with CPAP. It is important to evaluate whether the downstream flows from CPAP further push the epiglottis down into the laryngeal inlet –28. Prevp = 0.04). Additionally, only epiglottis-AP was an independent factor for 95% CPAP pressure in the multivariate stepwise linear regression, which is compatible with the findings of a previous study that found that CPAP pressure had the greatest impact on the lateral collapse of the oropharynx, and then, the velopharynx. The tongue base and epiglottis collapse were more resistant to CPAP pressure  between auto- and DISE-guided CPAP titration is still larger than 1–2 cm of H2O. This may be due to the sedative agents used during the DISE. We selected dexmedetomidine rather than propofol because dexmedetomidine causes less dynamic collapse than propofol (One strength of this study is the controlled sedation level according to both BIS (BIS 65–75) and EEG (N2 sleep stage). Another strength of this study is the use of dexmedetomidine, which has less influence on upper airway muscles  and bettpropofol –50. Howepropofol , which iThis study was limited by its small and selected sample size, and larger studies are warranted. In addition, the study included more male patients than female patients. Therefore, the results of the present study should be interpreted with caution. Additionally, the study population mainly presented with severe OSA (AHI 60 events/h). Therefore, the results of this study may not apply to patients with mild OSA. Furthermore, this study assessed the effect of CPAP over a brief period only (1 month). Thus, further research using a larger number of individuals with a longer evaluation period is warranted.In conclusion, the two modalities are comparable in terms of establishing the pressure settings required to treat patients. Further large-scale studies are required to confirm these results.wang5531@gmail.com).The datasets presented in this article are not readily available because of patient confidentiality and participant privacy. Requests to access the datasets should be directed to TYW  and the Ministry of Science and Technology (MOST−108-2320-B-182-027). The funders had no role in the design of this study; the collection, analysis, and interpretation of data, or the writing of this manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Today's gold standard for treating chronic anal fissure is the Lateral Internal Sphincterotomy (LIS). Botulinum Toxin (BoNT) injection is, on the other hand, an alternative treatment for patients who do not want to have surgical treatment, patients undergoing chemotherapy, patients of high risk for surgery, and those who have the risk of anal incontinence . The aim of this study is to compare the effectiveness of BoNT and redo-LIS for treatment of post-LIS recurrent chronic anal fissure, and reveal differences if any.This study aims to compare redo-LIS and BoNT injection for treating post-LIS recurrent anal fissure.Nineteen patients who received LIS treatment and then redo-LIS or BoNT injection due to recurrence in the follow-up were included in this study. Group I (redo-LIS group) include 11 patients and group 2 (BoNT group) includes 8 patients. Their data on age, sex, anal incontinence scores and pain (VAS score) score as well.p < 0.01) between groups by pain. No deterioration in the incontinence scores of patients in the group during the 6-month post-surgery period.During the 3-month post-surgery follow-up period, there was statistically significant difference  is a reliable method for patients who received LIS but developed recurrent chronic anal fissure, and achieves successful results in terms of recurrence and relief of pain. The mosRecurrence is rare after treatment of chronic anal fissure by LIS. The reason for recurrency, if it ever occurs, is generally the inadequately performed LIS which does not ensure compete healing and causes patients to develop non-healing fissure or early recurrence. The patient continues to experience, though may be at lower intensity, such pre-LIS symptoms as pain, bleeding, avoidance of defecation, anal spasm and pain for 1 to 2 h following defecation.Some patients avoid surgical treatment because sphincterotomy is influenced by the complication of incontinence. This has called for the application of alternative treatments such as Botulinum Toxin (BoNT) injection for recurrent fissures.In case of anal fissure that recurs or continues following an inadequate/inappropriate LIS, surgeons or patients mostly avoid redo-LIS. The reason is that a redo-LIS will likely exacerbate the damage to anal sphincter which in turn creates a heightened risk of anal incontinence. BoNT inhibits the secretion of acetylcholine at the presynaptic terminal of neuromuscular combination. The injection works by inducing temporary paralysis in the muscle , 15. TheA meta-analysis on 489 patients by Chen et al. revealed that LIS obtained higher healing rates, and a higher rate of incontinence as well; but found no statistically significant difference between LIS and BoNT for other complications. BoNT cases had higher recurrence than LIS. The results of the meta-analysis indicted that LIS was superior in terms of recurrence and healing rates , 19. AnoThe study involves 19 patients who received LIS treatment and then redo-LIS or BoNT injection due to recurrence in the follow-up. Observing the criteria of Helsinki Declaration, approval was obtained from the ethics board. Files of 118 patients who had received LIS and BoNT injection for chronic anal fissure were reviewed. Patients who had inflammatory bowel disease, prior anorectal surgery for non-fissure reasons, underlying hemorrhoidal condition and/or fistula, presence or suspicion of malignity were excluded from the study. The 19 patients who were included in the study in accordance with the methodology had developed post-LIS recurrent anal fissure and received redo-LIS or BoNT injection. These patients were assessed through standardized clinical forms, their medical history and files were reviewed in detail, and anorectal examinations were conducted.Study groups had patients who chose redo-LIS or BoNT. Two groups were formed as Group I including patients who received redo-LIS, and Group II including those who received BoNT application.Using standardized forms, patients' age, sex and complaints  were recorded. The redo-LIS group (Group I) included patients who had received LIS for chronic anal fissure, then were given redo-LIS due to pain or recurrence the 3-month post-surgery follow-up period.Redo-LIS was performed as internal sphincterotomy by incision through LIS scar contra-lateral through fissure apex under sedation and local anaesthesia, in the prone jack-knife position.The BoNT group (Group II) included patients who had received LIS for chronic anal fissure, then developed recurrence or failed to heal, but did not want repeat surgical treatment and had incontinence anxiety. BoNT was applied, under sedation, by injection into the internal sphincter from two laterals in the form of two insulin injectors each containing 0.5 ml of solution containing 100 IU Botulinum Toxin type A diluted with 1 ml of physiological saline solution.After the procedure, patients were instructed, for 2 weeks, to have high-fibre diet and warm sitz-bath three times a day.p < 0.01 within the confidence interval of 95%.The results were accepted statistically significant with Both groups were called in for control in the 1st week, 1st month and 3rd month, and examination findings, pain and continence scores were recorded through standardized forms. The criteria for fissure healing were adopted as fissure epithelization and complete disappearance of pain during and after defecation. The status of continence was assessed using the Cleveland Clinical Incontinence Score (CCIS) system . The datp = 0.89, p = 0.13 respectively). Of the patients, 11 (57.89%) were performed redo-LIS, with 8 being male (73%), and 3 being female (27%). Of the 8 patients who were applied BoNT, 3 were male (38%) and 5 were female (62%).The 19 patients included in the study had previously received LIS for anal fissure. Of the 19 patients, 11 were male (57.89%) and 8 were female (42.10%) with average age of 42.37 ± 5.96. p = 0.008). . In group I healing rate was 100%, while in group 2 (BoNT group) two of eight patients recurrence were assessed.For incontinence, one of the patients in Group I had mild gas incontinence (CCSI = 3), and no patient in Group II had incontinence. The 3rd-month follow-up of patients resulted in complete disappearance of incontinence complaint in Group I as well. There was no statistically significant difference between groups by pre- or post-surgery incontinence (by CCIS) of both groups  or the patient avoids surgical treatment . There is no study in the literature comparing BoNT and redo-LIS for treating recurrent anal fissures. One sole study reports 4% for the recurrence rate following redo-LIS for treating recurrent anal fissure  is a reliable method for patients who received LIS but developed recurrent chronic anal fissure, and achieves successful results in terms of recurrence and relief of pain. BoNT application is less successful for patients group who previously received surgery and developed recurrence than patients who did not receive surgical treatment. The likely reason is the internal sphincter fibrosis related to the previous LIS which reduces the effectiveness of BoNT.This study was limited because it was a single-armed, retrospective analysis of prospectively designed data.


RDH12-retinopathy.To describe the clinical and molecular features of a novel, autosomal dominant Retrospective cross-sectional study. Twelve individuals from a four-generation British pedigree underwent ophthalmic examination, genotyping using next generation sequencing, including whole genome sequencing and multimodal retinal imaging including fundus photography, optical coherence tomography (OCT), autofluorescence imaging and adaptive optics (AO) scanning light ophthalmoscopy were performed. Visual electrophysiology was performed in a subset.RDH12 c.763delG. Visual acuity ranged from −0.1 to 0.2 logMAR. Affected individuals had constricted visual fields. A parafoveal and peripapillary ring of hyper-autofluorescence was seen initially, and with progression the area of perifoveal hypo-autofluorescence increased to involve the parafoveal area. Mild retinal thinning was identified on OCT imaging with reduction in both foveal total retinal and outer nuclear layer thickness. Cone densities along the temporal meridian were reduced in affected individuals compared with normative values at all temporal eccentricities studied. One individual with incomplete penetrance, was identified as clinically affected primarily on the basis of AO imaging. Full-field electroretinography demonstrated a rod-cone pattern of dysfunction and large-field pattern electroretinography identified peripheral macular dysfunction.Eight family members were confirmed as affected by genotyping heterozygous for RDH12 c.763delG is associated with a rod-cone dystrophy with variable expression. Determination of the degree of penetrance may depend on the modality employed to phenotypically characterise an individual. This rare and specific heterozygous (dominant) variant is predicted to result in a gain of function, that causes disease in a gene typically associated with biallelic (recessive) variants.This novel heterozygous variant  RPE65, the most well-known enzyme in this pathway, catalyses one critical step in regenerating 11-cis-retinal in the RPE,RPE65 gene replacement therapy is now available to treat this.trans-retinal, metabolising it in the photoreceptor to generate all-trans-retinol prior to transport to the RPE.The human visual cycle depends on the metabolism and transport of vitamin A molecules (retinoids) in both photoreceptors and the retinal pigment epithelium (RPE). Photons of light, captured in the photoreceptor outer segment, isomerise 11-GUCY2D and a rare RPE65 allele (p.Asp477Gly), which has been observed segregating with a milder, later-onset retinal dystrophy, and transmitted in an autosomal dominant manner.RDH12 allele .RDH12 variant c.759delC;(p.Phe254Leufs*24) and a retinal dystrophy phenotype.RDH12-retinopathy ).Occasionally, rather than causing retinal disease by biallelic loss of function, specific variants may confer a dominant, gain of function. This phenomenon has been observed for a number of LCA genes including RDH12 were identified from a single family attending Moorfields Eye Hospital, UK. Informed consent was obtained from all patients and unaffected family members .Patients with a diagnosis of rod-cone dystrophy and a single, heterozygous, plausibly pathogenic variant in All individuals were examined by slit-lamp biomicroscopy. Retinal structure and function were assessed in more detail in a subset (see below). Individuals were defined as affected if they were symptomatic  and had any evidence of a rod-cone dystrophy .RDH12.The index case , IV-3 unColour fundus photography was performed with TRC-50IX . Spectral domain optical coherence tomography (SD-OCT) horizontal, volume (25 B-scans) and/or line scans covering either 20° or 30° were obtained in six family members . These were automatically registered to simultaneously acquired near-infrared (815 nm) reflectance scanning laser ophthalmoscope fundus images. Automated real-time tracking with at least nine scans was used. The foveal total retinal thickness (TRT) and outer nuclear layer thickness (ONLT) in both eyes were measured in five family members by means of the vendor supplied Heidelberg Eye Explorer (HEYEX) software (V.1.9.10.0) by a single, experienced grader (AK). The TRT was defined as the distance between the internal limiting membrane and the RPE/Bruch’s membrane, while the ONLT was measured as the distance between the outer plexiform layer and the external limiting membrane, following semi-automated segmentation. Longitudinal analysis of foveal TRT was performed in two affected family members in order to ascertain progression. Fundus short wavelength autofluorescence (486 nm) imaging  was performed in a subset of the family members and follow-up images were spatially registered to the baseline ones to aid comparison.2 square regions of interest (ROIs), were cropped and photoreceptors were marked by a single, experienced grader (NS).Photoreceptor mosaic imaging using a custom-built adaptive optics scanning light ophthalmoscope (AOSLO) with both confocal and non-confocal split-detection capabilities,Full-field electroretinography and pattern electroretinography (PERG) were performed on the index patient and the first cousin once removed  using protocols that incorporated the International Society of Clinical Electrophysiology of Vision standards,RDH12 c.763delG.Gene panel-based testing on three individuals  identified a single likely pathogenic variant as the likely cause of autosomal dominant retinitis pigmentosa (adRP) in those individuals ). Subsequent WGS analysis (IV-3) confirmed the absence of additional coding, non-coding or structural variants in known inherited retinal disease genes or likely pathogenic variants in genes previously not associated with retinal diseases. Family testing identified a total of eight individuals  was minimally symptomatic (uniocularly) at the age of 40, with no evidence of pigment migration into the retina. Rather unusually, she had self-identified an asymmetry in scotopic visual function, commenting that in dim light, she could see better out of her right eye compared with her left. Macular structure as assessed by SD-OCT qualitatively appeared normal, however AOSLO imaging revealed a reduction in cone densities  at all R10.1136/bjophthalmol-2020-318034.supp7Supplementary dataRDH12 variant was not identified in four of these individuals who underwent genotyping.Five additional members of the family were examined. All were asymptomatic, and had a normal eye examination. The rare RDH12 variant was also identified.Three other individuals were confirmed from clinical records to have been diagnosed with rod-cone dystrophy, but were not available for examination. One of these three individuals consented for their sample to be genetically tested and the rare The clinical phenotype of the affected index patient and her minimally symptomatic mother are shown in The foveal TRT and ONLT in both eyes for age-matched OCT of children siblings and age-similar adult family members are shown in . In the 10.1136/bjophthalmol-2020-318034.supp1Supplementary dataLongitudinal data on the index patient (IV-3) from the age of 10 years over 4.75 years, and extended family member III-2 from the age of 36 over a 7.5-year period are shown in 10.1136/bjophthalmol-2020-318034.supp2Supplementary data10.1136/bjophthalmol-2020-318034.supp3Supplementary dataRDH12 variant, and unremarkable in all unaffected individuals with imaging available. Qualitative changes included a ring of parafoveal hyper-autofluorescence, patchy perifoveal hypo-autofluorescence, scattered areas of hypo-autofluorescence in mid-peripheral retina and a peripapillary ring of hyper-autofluorescence. All affected individuals had peripapillary sparing.Short-wavelength FAF was abnormal in all affected family members examined who harboured the The mildest change was present in the index patient’s minimally symptomatic mother (III-12), as a subtle region of hyper-autofluorescence in the peripheral macula, evident in the temporal macula of the symptomatic left eye only . This diThe most severe changes were present in the oldest patient, the index patient’s affected maternal grandmother II-7, whose FAF showed extensive parafoveal and temporal macula hypo-autofluorescence bilaterally in area where the outer retina had been lost as noted on the corresponding OCT scans . Analysi10.1136/bjophthalmol-2020-318034.supp4Supplementary data10.1136/bjophthalmol-2020-318034.supp5Supplementary data10.1136/bjophthalmol-2020-318034.supp6Supplementary data2. Both parents’ foveal cones were not fully resolved, therefore their foveal centres were identified by means of overlaying their AO montages on other imaging modalities with the aid of blood vessel landmarks and the foveal pit. These locations served as the starting point for identifying ROIs across the temporal meridian for all three family members where possible  and three degrees for her adult parents. Peak cone density (PCD) for IV-3 (14 years old at the time of the visit) was 109 600 cones/mmpossible . All conet al, temporal meridian, eccentricity bins as per et al compared with our analysis for 3° and 5° temporally, we opted to report the next available eccentricity bin  in order to make our comparisons conservative . Despite the conservative comparison, the cone densities of the index patient were reduced by approximately 20% to as much as 50% compared with the normative density values. The cone densities of the minimally symptomatic mother (III-12) were also outside the previously reported normative cone density ranges. Conversely, the cone densities of the unaffected father were within the normative range.Cooper and colleagues reported normative cone density values using an identical AOSLO system in a cohort of 20 unaffected individuals, including 6 children and 14 adults . Full-field recordings identified a rod-cone pattern of dysfunction in symptomatic individuals (IV-3 and III-2), with evidence of peripheral macular dysfunction using large-field PERG. Electrophysiology testing, including large-field PERG was normal in the index patient’s minimally symptomatic mother (III-12) . This variant is predicted to introduce a frameshift leading to a termination codon, 23 codons downstream of the variant. All family members who reported nyctalopia demonstrated classical features of a rod-cone dystrophy.We describe the clinical and genetic findings in 11 affected individuals, from a four-generation British family with adRP. Genetic analysis, including WGS, identified a deletion of 1-bp in exon 6 of the Quantification of foveal retinal structure by means of SD-OCT was undertaken in two children and three adults . The indSimilarly the age-similar adult relatives also demonstrated a comparable thinner retinal thickness. This was attributed to a thinner ONL of up to 20% compared with the unaffected father of the index patient.Unfortunately, direct comparisons of our data to normative values in the literature is difficult as the majority of studies using Spectralis SD-OCT imaging in adults and in children report average values for the 1 mm diameter central foveal subfield of the Early Treatment Diabetic Retinopathy Study template. The reason we opted to measure a single point foveolar location was to be confident that we had largely excluded the Henle’s fibre layer and obtain a true measure of just the ONL thickness.To the best of our knowledge, we identified only one study with a cohort of 83 unaffected children aged 5–15, that reported the 5th and 95th percentiles of foveal TRT; these were 196.7 µm and 250.2 µm, respectively.As our study was retrospective there were a number of limitations, including the lack of dense OCT volume scans. Consequently our data had a wide inter-scan distance (236 microns), which on occasions may have led to an underestimation of the foveal TRT and ONLT when the fovea was missed. The patients also had variable lengths of follow-up.The index patient’s mother’s (III-12) had normal funduscopy despite being minimally symptomatic at the age of 40, when compared with all other affected family members. Interestingly though, subtle, subclinical endo-phenotypes were detected using short-wavelength FAF and AOSLO . FAF imaRDH12 associated LCA in 2017, and more recently by others.All affected individuals had peripapillary sparing of RPE, usually seen in Stargardt disease,RDH12:c.763delG is a pathogenic allele, and results in rod-cone dystrophy, but with variable expression.Panel-based screening for genes known to be associated with retinal dystrophy was performed on the initial three affected family members who presented (including the index patient), while in nine individuals the specific familial variant was screened for by bidirectional Sanger sequencing. One affected family member (III-2) was also subject to WGS, enabling us to minimise the possibility that non-coding or structural variants undetectable by targeted gene panel testing were causative.RDH12, and the resulting termination codon (TGA) is located 16bp upstream of the final splice donor site  therapy. Carriers of recessive alleles are unaffected by RDH12 disease. Hence being able to switch off the dominant gain-of-function mutant allele using AON targeting would leave affected patients expressing 50% of normal RDH12 like an unaffected parent of an RDH12 LCA child.RDH12-disease association, since we note it is gain of function and not loss of function. Co-segregation of the variant and disease state is one key characteristic that helps to provide confidence in causality, however diagnosing the presence of a disease phenotype may not always be straightforward. Here, this detailed family study, including the index patient, her parents, grandparents and extended family have enabled us to conclude that RDH12:c.763delG is pathogenic, despite the mother, who carries this variant, being minimally symptomatic, and has a normal fundus appearance using conventional techniques. This study also highlights the benefits of detailed clinical phenotyping (using FAF and AOSLO), along with extended family studies, especially when attempting to interpret the significance of genetic variants that may cause inherited retinal disease, a group of conditions known to show incomplete penetrance and variable expression. Asymptomatic patients who are genetically at risk who may not manifest any remarkable abnormalities could be referred to a specialist centre with expertise in advanced AO retinal imaging and analytics.Interpreting the consequences of genetic variants can be difficult when variants in a gene exhibit both dominant and recessive disease, within the guidance set out by the American College of Medical Genetics.RDH12 variant, c.763delG; , as a cause of autosomal dominant rod-cone dystrophy with variable expression, and presents detailed clinical characteristics.This study presents data to support the pathogenicity of a novel


We set out to apply IOPW to transport results from an observational study to a target population of interest. We demonstrated the feasibility of this idea with a real-world example using a nationwide electronic health record derived de-identified database from Flatiron Health. First, we conducted an observational study that carefully adjusted for confounding to estimate the treatment effect of fulvestrant plus palbociclib relative to letrozole plus palbociclib as a second-line therapy among estrogen receptor (ER)-positive, human epidermal growth factor receptor (HER2)-negative metastatic breast cancer patients. Second, we transported these findings to the broader cohort of patients who were eligible for a first-line therapy. The interpretation of the findings and validity of such studies, however, rely on the extent that causal inference assumptions are met.Inverse odds of participation weighting (IOPW) has been proposed to  Real-world evidence (RWE) is playing an increasingly important role in clinical decision making, especially when clinical trial data are not available or when trial samples do not represent target populations of interest ,2. Compageneralizability studies and inverse probability of participation weighting is applied. In case when target population does not overlap with the original trial study population, inverse odds of participation weighting (IOPW) can be used for standardization [transportability studies. In addition to standardizing clinical trial results, when applied with rigor, generalizability or transportability methods can be a valuable tool to estimate treatment effects in the target population using observational studies results. However, few studies have done so [Propensity score (PS) methods have been developed to address various sources of bias in observational studies. Specifically, inverse probability of treatment weighting (IPW) is one of the fundamental methods to address confounding bias resulted from nonrandom treatment assignment . It can dization ,20. This done so –23.transportability method to estimate treatment effect in the target population based on results from an observational study. Using a rich observational dataset that contains both per-indication and off-the-label mediation use, our first objective is to compare the efficacy of the two treatments head-to-head using inverse probability of treatment weighting (IPTW) to adjust for confounding in second-line patients. Next, we are interested in using IOPW to adjust for non-representativeness and standardize such results to the population of first-line patients. We will apply PS weighting twice in a row to correct for both nonrandom assignment and non-representativeness of the study sample. We propose this two-step approach as a way of generating RWE especially when few relevant trial results are available. Our study not only explores the opportunity of applying transportability methods to observational study results, it also adds to the body of literature where multi-stage weighting was carried out to account for more than one sources of bias  [Motivated by the use case where we are interested in comparing two existing cancer treatments approved for use in different lines of therapy, we set out to apply s, etc.) ,23–25.Specifically, the two treatments of interest in our study are fulvestrant plus palbociclib and letrozole plus palbociclib. Although they have both been approved for estrogen receptor (ER)-positive, human epidermal growth factor receptor (HER2)-negative metastatic breast cancer (MBC) patients, they were intended for different lines of therapy ,27. FulvThis study used the nationwide Flatiron Health electronic health record (EHR) derived de-identified database. The Flatiron Health database is a longitudinal database, comprising de-identified patient-level structured and unstructured data, curated via technology-enabled abstraction ,30. The Our study used de-identified data from 8,356 ER (+), HER2 (-) MBC patients diagnosed from January 1, 2014, to June 30, 2020, who had at least one line of treatments. Specifically, this general cohort was selected based on the following criteria:ICD diagnosis of breast cancer (ICD-9 174.x or 175.x or ICD-10 C50x)Evidence of Stage IV or recurrent MBC with a metastatic diagnosis date on after January 1, 2014At least 2 documented clinical visits on or after January 1, 2014Evidence of treatment with at least one line of therapy for metastatic diseaseEvidence of ER (+) defined as having ER (+) or PR (+) test before or up to 60 days after the start of first-line treatment.Evidence of HER2 (-) defined by having a HER2 negative test (IH negative (0–1+), FISH negative/not amplified, or negative NOS) and the absence of a positive test (IHC positive (3+), Fish positive/amplified, positive NOS) before or up to 60 days after of the start date of first-line treatment.No greater than 90 days gap between metastasis diagnosis date and first structured activity  after MBC diagnosis date (to identify patients who are likely to be missing treatment)Real world progression was defined as any event with EHR documentation of disease worsening, based on clinicians’ reporting .The cohort of second-line patients were defined based on the following inclusion/exclusion criteria: 1) all female adult patients (at time of second-line therapy initiation) who were treated with fulvestrant-palbociclib or letrozole-palbociclib no later than March 30, 2020 inclusive to allow for at least 90 days of follow-up time 2) excluding patients who were treated with CDK inhibitor , mTOR inhibitors (everolimus), PI3K inhibitors , and any clinical study drug during first-line as a single drug or in combination therapy. Patients were either treated with fulvestrant-palbociclib or letrozole-palbociclib as a second-line therapy. Fourteen days after the start of second-line therapy was used as the index date for all patients in the cohort since an immediate effect of the treatment on the outcome was not expected. Patients who progressed or died before the index date were removed.transportability portion of our study.The following covariates were extracted from the database: age at initiation of second-line therapy, race, stage at initial breast cancer diagnosis, Eastern Cooperative Oncology Group (ECOG) score within 30 days of second-line therapy start date, time from initial breast cancer diagnosis to MBC diagnosis, and medical practice type. Additionally, the number of metastatic sites recorded, visceral disease (whether metastatic disease is in the lung and/or liver), and bone-only metastasis were also determined before or up to 14 days after the initiation of second-line therapy. These covariates were used as confounders among second-line patients based on data availability and clinical significance. Later in Section 2.3.2, the same covariates were used as effect modifiers for the th of each month since death data were only available on a monthly granularity. All patients were censored at the time of last clinical note, or 3 years after the index date, whichever came earlier.Real-world progression free survival (rwPFS) was used as our primary outcome in the study . An evenFig 1). Let A denote treatment, where Ai = 1 indicates fulvestrant-palbociclib and Ai = 0 letrozole-palbociclib. Let C denote the vector of confounders. The conditional probability of receiving fulvestrant-palbociclib, P, was estimated using a logistic regression model. Specifically, Pi = P(Ai = 1|Ci), i = 1,2,3…n1, where n1 denote the number of patients in the second-line cohort. Stabilized weights (Table 1) were estimated for each patient and used to adjust for imbalance of baseline characteristics between two treatment arms [MI-derPassive (missing PS variables were imputed before PS was derived) INT-within (IPTW was carried out within each imputed datasets) were implemented [IPTW was used to adjust for confounding by indication  all female adult patients (at time of first-line therapy initiation) who were treated with a first-line MBC therapy no later than March 30, 2020 inclusive to allow for at least 90 days follow-up 2) no evidence of another primary cancer   within 3Similarly defined covariates as in Section 2.2.2 were considered as effect modifiers among the first-line cohort: age at initiation of first-line therapy, race, stage at initial breast cancer diagnosis, ECOG score within 30 days of first-line therapy start date, time from initial breast cancer diagnosis to MBC diagnosis, and medical practice type. Additionally, the number of metastatic sites recorded, visceral disease (whether metastatic disease is in the lung and/or liver), and bone-only metastasis were also determined before or up to 14 days after the initiation of first-line therapy.Outcome variable was not needed for this analysis.Si = 1) or the target (Si = 0) cohort. Logistic regression was used to estimate the conditional probability of being in the target cohort, Q, given all effect modifiers E. More formally, Qi = P(Si = 1|Ei), i = 1,2,3…n1+n2 where n2 denotes the number of patients in the first-line cohort.First, the extent to which the distribution of potential effect modifiers differ in the two cohorts was assessed using standardized mean differences (SMD) . Next, dQ, Tipton index was computed [p1 and p2 denote vectors of propensity scores estimated in the original and target cohorts respectively [transportability methods will involve less extrapolation, and thus invoke higher confidence of the results [To assess the similarity of the cohorts based on the distribution of computed . Tipton ectively . Tipton ectively . That me results .Fig 1). The weights for adjusting for differential distribution of effect modifiers were estimated as below, where the weights from Section 2.2.4 were multiplied by the odds of being in the original cohort [transport the treatment effect from Section 2.2 to the new target population, Cox proportional hazards model with a robust variance estimator was applied to individuals in the original cohorts only, adjusting for weights V that was estimated using two cohorts combined, including no covariates in the model . Note that neither treatment nor outcome variable from the new target population was used in the analysis. Only potential effect modifiers were used to estimate the weights for the Cox model. Similarly to the IPTW analysis described in Section 2.2.4, MI-derPassive INT-within was used to impute missing data [https://github.com/yling2019/SERD_transportability.Next, IOPW was implemented to adjust for non-representative of the original cohort as compared to the target population of first-line patients , where the two curves are very close to each other, even though the probability of survival was slightly higher in the letrozole-palbociclib arm.There were 752 patients in the original second-line cohort, 397 of which were treated with fulvestrant-palbociclib and 355 with letrozole-palbociclib . CompareTable 3). Compared to the original second-line cohort, this target first-line patient population was younger (Table 3). They also had a larger Black representation, more people diagnosed with de novo MBC, less metastatic sites, and a smaller gap between initial breast cancer diagnosis and MBC diagnosis (Table 3). Mean Tipton index among all m = 25 multiply imputed datasets was 0.81 (SD = 0.01) before weighting, indicating that the two populations are similar enough to carry out a transportability study [Fig 2B), where both median survival times and the overall curves are very similar to each other.The target population consisted of 3,109 patients who were eligible to receive first-line treatment of their MBC  [transportability is still appropriate here. This is because we believe our first-line cohort is still more representative of a typical first-line cohort in the real-world. We also acknowledge that the validity of our findings in the first-line cohort is dependent on the internal validity of results in the first-line cohort, which isn’t as strong as a clinical trial. However, no such trial has been conducted and therefore we have conducted this study to generate RWE. Lastly, we are limited by our dataset and may not capture all potential confounder and effect modifiers in our analyses.There are many limitations to our study. First and foremost, ulation) , our oritransporting results from a cohort study as a way to generate RWE when limited clinical evidence is available. Investigators need to exercise caution in interpretation of the findings that result from such applications. Specifically, assumptions underlying validity of such methods needs to be met and the challenges of achieving this may be higher when transporting from observational findings than randomized clinical trials. As more well designed observational studies have been conducted to emulate clinical trials [We have demonstrated the feasibility of l trials ,42,43, sl trials .


Extranodal natural killer/T(NK/T)-cell lymphoma (ENKTL) is a rare subtype of non-Hodgkin lymphoma that typically presents with an isolated nasal mass, but a sizeable minority present with advanced stage disease and have a significantly poorer prognosis. Those with limited disease are standardly treated with chemotherapy and radiation while those with advanced stage disease are treated with L-asparaginase containing chemotherapy regimens. The addition of modern radiation therapy techniques and the incorporation of L-asparaginase into chemotherapy regimens have significantly improved outcomes in this disease, but relapses and death from relapsed disease remain frequent. Given the high rate of relapse, several novel therapies have been evaluated for the treatment of this disease. In this review, we explore the current standard of care for ENKTL as well as novel therapies that have been evaluated for its treatment and the biologic understanding behind these therapies. Extranodal NK/T-cell lymphoma is a rare subtype of non-Hodgkin lymphoma strongly associated with Epstein-Barr virus (EBV) . The mosENKTL is most prevalent in Asia  and in Central and South America where EBV infection in early childhood is common ,6. It isDemonstration of EBV positivity in malignant cells is required for the diagnosis  and likeThe typical immunophenotype of ENKTL is similar to that of an NK cell: CD45(+bright), CD2(+), surface CD3(−), cytoplasmic CD3 epsilon(+), CD56(+bright), CD16(−/+), T-cell receptor (TCR) (−), and cytotoxic granule molecules such as granzyme B, TIA-1, and perforin(+) . TCR genThe prognosis for ENKTL is variable but it is especially poor for patients with high-risk disease as defined by the prognostic index for natural killer cell lymphoma (PINK-E) . This prThere is currently no defined standard of care even for front line therapy in limited or advanced stage ENKTL. However, traditional regimens used in many lymphomas such as CHOP  are inadequate due to high expression of P-glycoprotein in malignant cells resulting in chemotherapy resistance . In factRadiotherapy (RT) is the most important treatment modality in the treatment of limited stage ENKTL, and patients with localized ENKTL should not receive chemotherapy without RT. For patients receiving RT alone, or receiving sequential chemoradiotherapy, the recommended dosage is 50–54 Gray (Gy), whereas patients who receive concomitant chemoradiotherapy, the RT dose varies depending on the intensity of the chemotherapeutic regimen. Intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) are the current standards of care for patients with ENKTL, though novel approaches such as the use of proton therapy, may prove helpful in future studies ,36. For The current paradigm for the treatment of limited stage disease, i.e., stage I(E) or contiguous stage II(E) generally confined to the nasal and paranasal cavities, consists of RT, combined with platinum containing chemotherapy concurrently or L-asparaginase containing chemotherapy given sequentially or as a “sandwich” with RT. In addition to the gains made in outcomes with the incorporation of L-asparaginase as above, the use of adequately dosed radiotherapy (>50 Gy) with a large enough clinical target volume improves local disease control as well as survival for patients with limited stage disease ,38.Commonly used concurrent chemoradiotherapy (CCRT) regimens include RT-2/3DeVIC  and RT-Cis, VIPD . RT-2/3DeVIC concurrently starts radiotherapy and chemotherapy at the same time . RT-Cis,Nonconcurrent chemoradiotherapy can be given in one of two ways: (1) sequentially with chemotherapy followed by radiation or (2) “sandwich” with a limited number of chemotherapy cycles prior to and following a course of radiation. Modified SMILE is one of the more commonly used regimens, although its use is generally limited to younger, more fit patients given its toxicity profile ,43. OtheFor elderly or frail patients with limited stage disease, radiotherapy alone can be used. Early studies have shown a high rate of systemic relapse , howeverFor limited stage ENKTL, our current standard of care is to utilize modified SMILE for two cycles, followed by 50 Gy of IMRT to the site of disease in younger, fit patients. For patients unable to tolerate SMILE therapy, we utilize a ”sandwich chemotherapy” approach, with two cycles of GELOX, followed by 50 Gy IFRT, followed by two additional cycles of GELOX.For those with advanced stage disease (stage II (E) with non-contiguous involvement to stage IV) or relapsed, similar chemotherapy regimens as for limited stage disease are often used in the front-line setting. Many of these have L-asparaginase in the regimen as the prior standard of care regimen. CHOP has shown an OS of only 30–40% . In the Given the generally poor outcomes in this disease, especially for those who present with advanced stage disease, several novel therapies have been evaluated with the hopes of improving outcomes in this disease .The identification of the immune checkpoints was a revolution in understanding the mechanism of cancer evasion and immune escape phenomena. The programmed cell death protein 1 (PD1) is an immune checkpoint protein which manipulates the host immune response by regulating T-cell function. The binding of PD1 ligand (PDL1), present on cancer cells or other non-malignant cells within the immune system, to PD1 on cytotoxic T-cell, leads to T-cell inhibition rendering the cancer cell invisible to the immune system. PDL1 has been found to be overexpressed in EBV + lymphoma (particularly NK lymphoma) as compared with EBV negative lymphomas and is associated with worse prognosis ,61. Thisn = 7) with relapsed/refractory disease after failing multiple regimens, including pegaspargase, pembrolizumab was given at 100 mg every 3 weeks [In a small trial of seven patients with ENKTL with relapsed disease after failing multiple regimens, including L-asparaginase and HSCT, single agent pembrolizumab was given with doses ranging from 100 to 200 mg for a median of 7 total cycles (range 2–13) . Impress 3 weeks . The med 3 weeks , pembrol 3 weeks , a CR waCD38, otherwise known as cyclic ADP ribose hydrolase, is a surface glycoprotein found on the surface of T-cell, B-cells, and natural killer cells. CD38 has a wide range of functions, including modulating cell differentiation, regulating cell recruitment, cytokine release, and regulation of NAD . Over 50Given the high expression rate in mature T-cell lymphomas and Hodgkin lymphoma ,68, CD30PI3Ks are a family of intracellular signal transduction kinases that phosphorylate the 3′ position of the inositol ring of phosphatidylinositol present in the lipid membrane . This giA Phase I study is currently recruiting patients to evaluate CC-486  with duvelisib for patients with lymphoid malignancies (NCT05065866). Another study is currently recruiting patients to evaluate ruxolitinib and duvelisib in patients with lymphoma (NCT05010005). Finally, a future trial is planned to evaluate doxorubicin, CC-486, romidepsin, and duvelisib in patients with T-cell lymphoma, including ENKTL. (NCT04639843). While results in ENKTL specifically are limited, it will be important to follow up on these studies to determine if there is a role for PI3K inhibition in ENKTL.n = 45) and MF (n = 7) [The Jak/Stat pathway is a central signaling pathway within normal T and NK biology, responsible for growth and proliferation in response to cytokine signaling. Not surprisingly, the Jak/Stat pathway has been found to be dysregulated across multiple lymphoma subtypes, including ENKTL. In a series of 84 ENKTL lymphomas sequenced for JAK3 and STAT3, JAK3 mutations were discovered in 7% of cases, while STAT3 mutations were less common, with only one case found to be mutated . However (n = 7) , patientEBV is a ubiquitous herpesvirus that infects >90% of adults . EBV priExtranodal NK/T-cell lymphomas arise in immunocompetent individuals and are strongly associated with EBV infection . ExpressEBV proteins expressed by ENKTL are relatively weak immunogenic targets, and they present a potential for cytotoxic EBV-specific cytotoxic T lymphocyte (CTL)based therapy for ENTKL treatment . Six ENKLytic cycle induction using the histone deacetylase inhibitor nanatinostat in combination with the antiviral agent valganciclovir has also been attempted at targeting relapsed/refractory EBV-positive ENKTL . AntivirTargeting the effects of EBV on the immune system has also shown potential. EBV is known to induce immune response evasion and was associated with high PD-L1 expression in 15 of 28 tested ENKTL samples . PatientStem cell transplant (SCT) has been evaluated for the treatment of patients with ENKTL. However, due to the rarity of the disease, and given most patients have limited stage disease (>60%), no prospective, randomized clinical trials exist, so evidence is based primarily from small trials and retrospective studies, mostly in Asian populations. For patients with early stage (IE-IIE) disease, treatments with standard chemoradiotherapy approaches provide cures in most patients, and therefore, SCT is only considered for patients with advanced stage (III-IV) or relapsed/refractory disease.p = 0.027), though this was not observed for those who were not in CR [p = 0.013 on univariate analysis. This benefit was not confirmed on multivariate analysis, though this study is limited by small numbers [There are limited data on the role of consolidative auto-SCT in ENKTL. Consolidative auto-SCT is used routinely in many centers for patients with peripheral T-cell lymphomas (PTCLs) with chemo-sensitive disease, and therefore, this approach has been utilized in patients with ENKTL. In a retrospective study in Asian populations, patients treated without auto-SCT were compared to results from three published series of patients treated with auto-SCT. All patients were matched for NK-IPI between the two groups. In this study, patients in CR at the time of auto-SCT had improved disease-free survival at 5 years . Interestingly, this series included four patients who received a prior auto-SCT. In a large series from the Center for International Blood and Marrow Transplant Research (CIBMTR), of mixed racial backgrounds , 82 patients received allo-SCT of which 30% received up-front allo-SCT, and 60% received salvage therapy after relapse; 45% of the patients were in CR, 30% in PR, and 12% unknown or refractory disease. In this series, 3-year OS and PFS were 34% and 28%, respectively, and the 3-year cumulative incidence of NRM was 30% and relapse mortality was 42%. No relapses were observed beyond 10 months. There was no difference in outcomes in those who received up-front versus salvage allo-SCT, though the favorable outcomes with salvage allo-SCT should be interpreted with caution as many patients will not reach allo-SCT due to refractory disease or rapid progression. These results suggest that allo-SCT is an effective salvage therapy for patients with relapsed/refractory ENKTL, even with just a PR, and can be considered to be a consolidative therapy up-front for highly selected fit patients.Allo-SCT has been utilized in both the consolidative and salvage setting in ENKTL. Evidence of a graft-versus-lymphoma (GVL) effect in ENKTL comes from numerous studies in which patients attained long-term remissions even with refractory ENKTL ,115. In The current data available provides evidence that consolidative auto-SCT may be considered for patients with advanced stage III/IV ENKTL at diagnosis, and a CR after chemotherapy, particularly if they are unfit for an allo-SCT. Allo-SCT should be considered for extremely fit patients in CR1, or those patients who do not attain a CR with initial therapy or with relapsed/refractory disease, but its efficacy is limited by non-relapse mortality.Our current approach for patients with advanced and relapsed/refractory ENKTL is to start with L-asparaginase containing chemotherapy. For younger, fit patients, from two to four cycles of modified SMILE, followed by auto-SCT for those in CR is utilized. For less fit patients, ffrom four to six cycles of GELOX chemotherapy is utilized, with consolidative auto-SCT utilized for fit, older patients. The timing and best use of novel agents in ENKTL is not known, and most of these agents are unavailable. For patients who received prior SMILE, GELOX is a good option. For patients that are refractory to chemotherapy, we utilize immunotherapies such as the PD-1 inhibitor nivolumab. Novel agents such a Nstat or EBV-targeting T-lymphocytes are currently unavailable outside of a clinical trial, but at our center these are the primary strategies we use to treat these patients. Allo-SCT should be considered for any patients with multiply relapsed ENKTL, particularly if they failed auto-SCT, even if the patient is only in a partial remission.ENKTL is a rare disease with relatively poor outcomes, especially for patients with advanced stage disease at diagnosis. Outcomes have significantly improved with the addition of modern radiotherapy techniques and the addition of L-asparaginase into chemotherapy regimens. Despite these improvements, relapses remain frequent and novel therapies such as those discussed here are urgently needed. As we continue to grow in our understanding of the pathogenesis of this disease, we anticipate that novel therapies targeting these drivers will steadily improve the quality of life for patients afflicted with ENKTL.


Introduction: Cancer survivors are increasingly diagnosed with a syndrome of neurocognitive dysfunction termed cancer-related cognitive impairment (CRCI). Chemotherapy and radiation therapy have been implicated in CRCI; however, its underlying pathogenesis remains unclear, hindering effective prevention or treatment.Methods: We used the hairless strain SKH1 (11–12-week-old) and treated the mice with radiation to the right hindlimb, doxorubicin (a chemotherapy agent), concurrent radiation, and doxorubicin, or no treatment (control). Neurocognition was evaluated via standardized behavioral testing following treatment. Mice were subsequently humanely euthanized, and plasma and brains were collected to identify inflammatory changes.Results: Mice treated with radiation, doxorubicin, or both radiation and doxorubicin demonstrated equivalent hippocampal dependent memory deficits and significant increases in activated microglia and astrocytes compared to control mice. Doxorubicin-treated mice had significantly increased plasma IL-6 and failed to gain weight compared to control mice over the study period.Discussion: This study demonstrates that non-brain directed radiation induces both gliosis and neurocognitive deficits. Moreover, this work presents the first characterization of SKH1 mice as a relevant and facile animal model of CRCI. This study provides a platform from which to build further studies to identify potential key targets that contribute to CRCI such that strategies can be developed to mitigate unintended neuropathologic consequences associated with anticancer treatment. Advancements in cancer therapy have improved cure rates and increased the life span of cancer patients  and activate microglia which may lead to neurocognitive changes  with subsequent cognitive impairment compared to control mice . Female SKH1 mice were purchased from Charles River Laboratories . The SKH1 mouse was selected because this strain has been previously used, by us and others, to evaluate the detrimental effects of extracranial radiation , extracranial hindlimb radiation treatment (RT), both doxorubicin, and radiation (DOX-RT) or anesthesia only (Control) groups. The time period for the study was chosen based on consultation with the University of Minnesota Mouse Behavior Core and literature review of chemotherapy only treated mice studies. Mice were 11–12-week old at the start of the study. Mice were weighed on the day of treatment and every other day for the duration of the 16-day study period. Mice were euthanized by carbon dioxide proceeded by exsanguination following the University of Minnesota IACUC Criteria for Carbon Dioxide Euthanasia Guidelines.2) and irradiation in humans may lead to unacceptable toxicity, we elected to use a single dose of 5 mg/kg , just below the postulated acute lethal dose in mice of 7–10 mg/kg IP  during radiation therapy  to verify the prescribed dose was as expected and that dose was undetectable in non-target sites  and a custom 2 × 2 cm cutout. Tissue equivalent bolus (1 cm) was placed on the surface of the skin to provide sufficient dose build-up to the level of the skin. The proximal edge of the field was palpated to ensure the caudal spine was not within the treatment field. Mice were anesthetized with ketamine (90 mg/kg) and xylazine (4 mg/kg) administered IP to ensure immobilization for treatment. Live video monitoring of each mouse was used to monitor positioning and anesthesia during treatment. Radiation dose at the level of the irradiated skin on the right hindlimb, unirradiated skin on the left hindlimb, and skin over the calvarium (indirect measure of brain exposure) was quantified Mice were assimilated to the testing room for 30 min before testing. The open field test evaluates the general motor function and anxiety-like behavior , and novel object recognition (NOR) testing. The NLR test evaluates spatial learning and memory  at 80°C for 1 h with sodium citrate buffer pH 6. Tissue sections were blocked with Biocare Background Punisher  for 30 min in a humidity chamber at room temperature. Sections were immunostained for activated microglia  overnight, and activated astrocytes  for 2 h. Tissue sections were subsequently stained with a secondary antibody, goat anti-rabbit Alexa-Fluor 488 . Slides were stained, omitting the primary antibody for negative controls. Slides were counterstained with 4’,6-Diamidino-2-Phenylindole, Dihydrochloride  for 20 min in the dark.Seven regions of the brain were analyzed: the caudal cortex, cerebellum, hippocampus, medulla, midbrain, rostral cortex, and striatum. These regions of the brain have been shown to be affected by cancer treatment . Following the manufacture protocol, the BD Cytometric Bead Array (CBA) Mouse Inflammation Kit  and BD FACSCelesta flow cytometer were used to quantify IL-6, IL-10, IL12p70, IFN-γ, MCP-1, and TNF in each mouse. The data was analyzed using the Flowjo CBA plugin .Blood was collected post-hoc test was used to evaluate differences between groups for behavioral tests, IHC, and cytokine analysis. Student t-tests were used to determine differences in discrimination ratio between groups and chance for NLR and NOR tests. For the discrimination ratio, the chance was defined as a discrimination ratio of 0. Two-way ANOVA with the Tukey post-hoc test was used to determine differences in body weight change over time between treatment groups. Significance was set at a p-value < 0.05 with one asterisk (*) representing p value < 0.05 and two asterisks (**) representing p-value < 0.01.Data were presented and analyzed using Prism 8.0 . One-way analysis of variance (ANOVA) with the Tukey Doxorubicin, whether it was given as a single agent or in conjunction with irradiation, induced a significant decrease in body weight change over time compared to control mice . DOX-treNeurocognitive deficits are the hallmark of cancer-related cognitive impairment in cancer patients after therapy , particularly as these molecules are known to be produced by irradiated cells and can cross the blood-brain barrier .KD-D, JL, EL, and DS designed, performed experiments, and analyzed data. AR analyzed data. KD-D, JL, and DS secured funding. All authors contributed to the article and approved the submitted version.


The total joint replacement is recognized as one of the most effective medical arbitrations leading to increased mobility, pain relief, and an overall restored function of the joint. Unfortunately, prosthetic debris accumulates after long-term wear of the implant leading to activation of the innate immune response and periprosthetic osteolysis. Understanding the intricate biological mechanisms underlying the innate immune response to implant debris would support the development of novel pharmacological treatments to prolong the life span of the implant. This article provides a detailed description on the role of the innate immune system in response to implant debris, emphasizing the most recent research and outstanding questions. Furthermore, a critical discussion is presented on the novel pharmacological treatments currently under investigation to prevent implant failure. Examples of such surgical interventions include the total knee arthroplasty, which is projected to increase by 601% from 2005 to 2030 . AsepticSubstantial evidence suggests the involvement of cells, such as osteoblasts, lymphocytes, fibroblasts, and others, in the underlying mechanisms of osteolysis. The inflammatory response is mainly driven by the innate immune system, specifically macrophages ,13. The Our knowledge of orthopedic implantology and the potential infectious consequences have been extensively investigated, but non-infectious immune rejection reactions against implanted materials still need to be thoroughly examined. The main focus of this review is to understand the role of the innate immune system in response to orthopedic implant failure in relation to debris accumulation.2.Implant debris-induced inflammation has been a central cause of long-term implant failure. Aseptic implant failure due to inflammation is responsible for over 70% of hip arthroplasty revisions . Peri-imMacrophage response to wear particles and subsequent release of cytokines is determined by Pattern Recognition Receptors (PRRs) ,12. PRR Pathways activated by TLRs are classified into myeloid differentiation factor 88 (MyD88)-dependent and My-D88-independent. Signaling by MyD88 results in the activation of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) and production of TNF-α, IL-1, and IL-12 . TLRs arThe NOD, LRR, and pyrin domain-containing protein 3 (NLRP3/NALP3) inflammasome is an intracytoplasmic sensor that assembles into a protein complex within inflammatory cells upon infection (PAMPs) or tissue damage (DAMPs), leading to maturation of inflammatory cytokines such as IL-18 and IL-1β ,30,31. AImplant wear debris and its various chemical attributes induce different responses from macrophages. In the following sections, the uses of different materials in orthopedic joint implants are discussed along with the ways the innate immune system responds to them.3.The complement system is a crucial component of the innate immune system and plays a crucial role in inflammation. The complement system recognizes DAMPs and is part of the humoral defense system of the innate immune system ,36. ActiOrthopedic biomaterials are considered foreign substances and can activate the complement system . Macroph4.The most successful hip and knee replacements have used UHMWPE biomaterials which have been the gold standard due to their high wear resistance and biocompatibility relative to other materials ,41. Long5.The generation of metallic particles has become a matter of concern regarding the activation of the immune system and eventual aseptic loosening. Macrophages take up particles through pinocytosis and endocytosis and internalize larger particles through the lysosomal pathway . DespiteAlthough biomaterials made of metals such as titanium have been deemed biocompatible, corrosion and subsequent particle release remain an issue . TitaniuThe complex interplay between the immune system and different biomaterials for orthopedic implants has yet to be fully understood. Aseptic loosening secondary to wear particles is a serious health issue in orthopedics today and will continue to have an impact on patients in the coming decades. The initial response to joint implants is a sudden inflammatory response that progresses over many years, provoking many chemokines in the process. Many of these cytokines are involved in the differentiation of osteoclasts contributing to osteolysis. Clarifying the molecular details and chemokines involved in the inflammatory response against prosthetic wear debris will present an enormous therapeutic benefit when implementing potential therapies against these pathways.6.Chemokines are a central component of orthopedic implant failure and are expressed by fibroblasts, macrophages, and osteoblasts. Chemokines help enhance the migration of leukocytes to and from sites of implant debris accumulation. The chemokines specific to orthopedic implant aseptic loosening include monocyte chemotactic protein 1 (MCP-1), IL-8, MIP-1, CCL22/monocyte-derived chemokine (MDC), CCL17/thymus and activation-regulated chemokine (TARC) all of which have been implicated in implant debris reactivity  Table 1Table 1.6.1IL-8 is released from macrophages, mast cells, and endothelial cells. IL-8 is a well-established chemokine present in peri-implant tissues and is used as a biomarker for peri-implant osteolysis . IL-8 re6.2Release of chemokines by macrophages in response to wear debris around the bone-implant interface may lead to chronic inflammation and implant failure. Peri-implant tissues from failed arthroplasties expressed chemokines such as MCP-1 (CCL2), MIP-1 α (CCL3), and MIP-1β (CCL4) . Upon ex7.TLRs have been observed on many cells, including monocytes, macrophages, osteoclasts, and fibroblasts. Studies reveal that TLRs are found in peri-prosthetic tissues and play a significant role in implant failure . Steel rTLR-4, a receptor for Lipopolysaccharide (LPS), has become critical in understanding aseptic loosening. In tissues around loosened replacement implants, there was an increase in TLR-4 expression . When TLFurther research has yet to be conducted to understand the mechanisms involved in the biological response to implant wear debris. A comprehensive understanding of the innate immune system can support the creation of therapeutic modalities to control inflammation and consequent implant failure.8.A multitude of pharmacological methods has been researched to reduce implant debris-induced osteolysis. Some strategies include reducing the activity of pro-inflammatory cytokines, blocking the NF-kB pathway, and modulating macrophage polarization.As previously mentioned, macrophage response to implant particles leads to a release of a host of cytokines and chemokines that elicit osteolysis and implant failure. Inhibiting this reaction may mitigate the inflammation in the periprosthetic tissue. TNF-α is a critical pro-inflammatory mediator in wear-induced inflammation, and its inhibition has been researched as a potential therapeutic target.Progranulin, a peptide that antagonizes the binding of TNF-α to TNFR1/2, inhibited the inflammatory response against titanium particles in an air pouch model as well as osteoclastogenesis and osteolysis in vivo, ex vivo, and in vitro ,70. FurtBlockage of titanium particle-induced osteolysis using adalimumab (anti-TNFα), anakinra (anti-IL-1β), and tocilizumab (anti-IL-6) antibodies in vivo effectively abolished titanium-induced osteolysis . ResveraThe NF-kB pathway is activated in macrophages when exposed to implant debris, suggesting that the modulation of this mechanism can have a robust therapeutic impact in preventing implant failure ,27. OsteRegulating IKB Kinase (IKK) was identified as another potential mechanism to inhibit the NF-kB pathway. A short peptide NEMO-Binding Domain (NBD) inhibited NF-kB activation by reducing IKK complex assembly, ultimately inhibiting RANK-L-induced osteolysis . MoreoveOsteoclast activity can be regulated to avoid bone resorption using bisphosphonates. These drugs suppress osteoclast precursors from differentiating and can also promote macrophage apoptosis .The inhibiting effect of Pamidronate, a member of the bisphosphonate family, on UHMWPE-induced TNF-α release from murine macrophages was studied. Pamidronate suppresses the PMMA-induced bone resorption in a co-culture model of murine calvaria and macrophages ,83. Simi9.In recent decades, the immunological reaction to implant wear particles has been researched, and macrophages have been identified as the offending cells. The precise biological mechanism by which wear debris induces macrophages has yet to be fully understood. Recent research reveals wear particles from implants are identified by several PRRs. Activation of TLRs has also been elucidated as one of the most integral mechanisms in macrophage reactivity to prosthetic debris. The initiation of these mechanisms generates an inflammatory response that promotes aseptic loosening and ultimately implant failure.Currently, no biological treatments effectively manage the immune response to periprosthetic debris. However, several therapies have been identified in ongoing research, including neutralizing pro-inflammatory cytokines, inhibiting the NF-kB pathway, and using bisphosphonates to modulate osteoclast activity. Further research has yet to be conducted to assess their safety and therapeutic efficacy. A thorough understanding of the biological mechanisms involved in implant wear debris, and the innate immune system will further support identifying potential targets for future therapeutic models.


Cancer patients have a significantly higher risk of developing venous thromboembolism during their disease course when compared with the general population. During routine staging or follow-up imaging studies, incidental venous thromboemboli, including incidental pulmonary embolisms, can be identified. Identifying factors associated with incidental or unsuspected venous thromboembolism is important and can improve the management plan. In the current study, we found that 20.9% of patients with unsuspected pulmonary embolisms had concomitant deep vein thrombosis, and most of these patients were asymptomatic. In addition, we found that concomitant deep vein thrombosis increases the odds of venous thrombosis recurrence in cancer patients presenting with unsuspected pulmonary emboli. Therefore, for patients with isolated incidental subsegmental pulmonary embolism and concomitant deep vein thrombosis, initiating anticoagulants if no contraindications exist is recommended. In addition, the presence of concomitant deep vein thrombosis among cancer patients with unsuspected pulmonary embolisms is associated with poor short- and long-term outcomes in these patients.p = 0.007). The mortality rates among C-DVT were significantly higher than in patients without. C-DVT was associated with reduced overall survival in patients with unsuspected PE . In conclusion, C-DVT in cancer patients who present with unsuspected PE is common and is associated with an increased risk of VTE recurrence and poor short- and long-term survival. Identifying other venous thrombi in cancer patients presenting with unsuspected PE is recommended and can guide the management plan. For patients with isolated incidental subsegmental pulmonary embolism and concomitant deep vein thrombosis, initiating anticoagulants if no contraindications exist is recommended.Incidental venous thromboembolism (VTE) is common in cancer patients and identifying factors associated with these events can improve the management plan. We studied the characteristics of concomitant deep vein thrombosis (C-DVT) in cancer patients presenting with unsuspected pulmonary embolism (PE) and the association of C-DVT with VTE recurrence and survival outcomes. Patients presenting to our emergency department with confirmed unsuspected/incidental PE between 1 January 2006 and 1 January 2016, were identified. Radiologic reports were reviewed to confirm the presence or absence of C-DVT. Logistic regression analyses and cox regression modeling were used to determine the effect of C-DVT on VTE recurrence and survival outcomes. Of 904 eligible patients, 189 (20.9%) had C-DVT. Patients with C-DVT had twice the odds of developing VTE recurrence (odds ratio 2.07, 95% confidence interval 1.21–3.48,  Venous thromboembolism (VTE) is a common and well-known concerning complication linked to the existence of cancer (occult or overt) and its progression ,2,3,4. CRemarkable advances in medical imaging studies, including computed tomography (CT), have allowed for improved visualization of the pulmonary arterial tree, which has led to an increase in the detection of PE as an incidental finding ,18. DuriDetermining the characteristics and clinical presentation of an incidental PE is important to establish the optimal diagnostic and management plan including imaging studies, follow-up, and anticoagulation. Several studies have already examined incidental or unsuspected PEs in cancer patients and identified the characteristics, management, and outcomes of PE in these patients ,28,29,30To identify all consecutive cancer patients who visited our institution’s emergency department with unsuspected PE, we queried The University of Texas MD Anderson Cancer Center institutional billing databases for the period between 1 January 2006 and 1 January 2016, for the diagnosis of PE in patients who had undergone CT studies of the chest with intravenous contrast  within 24 h before or during the emergency department visit. The records of the identified patients were manually reviewed by trained abstractors to confirm the presence of acute unsuspected PE. Radiology reports were used to confirm the presence of acute PE incidentally found on a chest CT study with contrast. Central PE was defined as acute PE within the main (including saddle embolism) and interlobar pulmonary arteries up to the lobar level. Advanced cancer stage was defined as stage IV for solid tumors based on the American Joint Committee on Cancer anatomic stage/prognostic groups, grade IV for brain and spinal cord tumors based on the World Health Organization groups, or hematologic malignancies in relapsed or refractory phases. An expert thoracic radiologist reviewed the images where reports stated questionable findings of PE (54 reports) and determined whether an acute incidental PE was present.All imaging study reports  for patients with confirmed unsuspected PE were reviewed to determine the presence or absence of C-DVT. C-DVT was defined as acute DVT reported on any imaging study carried out within 72 h (to assure the concomitant status) after the emergency department presentation. The institution’s electronic medical record system was used to collect demographic, clinical, and radiologic data for each patient. The institution pharmacy database was used to identify patients who had anticoagulants prescription prior to their emergency department visit. Exclusion criteria were as follows: (1) non-cancer patient, (2) absence of acute incidental PE , (3) clinically suspected PE , (4) prior diagnosis of VTE within one month before incidental PE discovery, and (5) incomplete medical records. A data dictionary, collection form, and biweekly meetings were used to ensure accurate and uniform abstraction. A random sample of 46 final charts (5%) was reviewed by different abstractors to assess interrater agreement. This analysis yielded a kappa value of 0.843, implying almost perfect agreement among the abstractors. p < 0.05 was considered statistically significant.Standard descriptive statistics were used to analyze and report patient demographics and clinical characteristics. The chi-square test was used to compare frequencies for the categorical data, and the nonparametric Wilcoxon-Mann-Whitney test was used to compare continuous variables because the normality assumption was not met for all continuous variables. Univariate logistic regression analysis was used to identify associations between clinical factors, including the presence of C-DVT and VTE recurrence within 6 months of presentation. Next, a multivariable logistic regression model that included all the statistically significant variables from the univariate analysis was constructed, reporting the odds ratio (OR) with 95% confidence interval (95% CI). For this analysis, the site of cancer was grouped based on their previously reported risk stratification for VTE: Very high risk ; high risk ; and low risk  . The 30-http://www.r-project.org accessed on 29 May 2021). The Institutional Review Board of MD Anderson approved the study and granted a waiver of informed consent. Anonymized patient-level data that are compliant with Health Insurance Portability and Accountability Act regulations will be shared upon acquiring MD Anderson Institutional Review Board approval.All statistical analyses were carried out using R software version 4.0.2 . The final analysis included 904 eligible patients with unsuspected PE . Of thesThe top four sites for C-DVT were femoral (45.0%), popliteal (23.3%), iliac (22.8%), and inferior vena cava (9.0%), and most C-DVTs (56.6%) were found in CT imaging studies of the abdomen and pelvis . The remp = 0.004) of C-DVT compared with patients with a peripheral unsuspected PE. The presence of C-DVT was confirmed in 28.7% of the patients with a saddle or main unsuspected PE, 19.8% of patients with an interlobar or lobar unsuspected PE, and 16.9% of patients with a segmental or subsegmental unsuspected PE (Most the patients (82.5%) with C-DVTs had no symptoms related to the DVT at the time of the DVT diagnosis . Patientected PE . Most paected PE .p = 0.002) and multivariable analyses , as shown in p = 0.037), while it was 2.11  for the high-risk cancer sites . Other predictors of VTE recurrence in the multivariable analysis were age  and advanced cancer stage , p = 0.097).In this case, 71 patients had acute VTE recurrence within 6 months after presenting to the emergency department with unsuspected PE. Of these, 59 (83.1%) had DVT, 9 (12.7%) had PE, and 3 (4.2%) had both PE and DVT as their recurrent acute VTE events. The presence of C-DVT at initial presentation was associated with more than twice the odds of developing VTE recurrence within 6 months in both the univariate . In another subgroup analysis, patients with peripheral unsuspected PE with C-DVT (p = 0.006).Similar results were observed in a subgroup analysis that included only patients who were prescribed anticoagulants at discharge ; in thisth C-DVT  had almop < 0.01 for both) than in cancer patients without C-DVT . A similar effect  was observed in the multivariable analysis after controlling for cancer type, cancer stage, and Charlson comorbidity index . In this case, 30-day and 90-day mortality rates were also significantly higher among patients with C-DVT  when compared with patients without C-DVT . C-DVT was also associated with reduced overall survival . Malignancy by itself is a main risk factor for the development of VTE, but cancer patients have multiple other clinical risk factors, including chemotherapy, multiple surgeries, and immobility ,32,33,34In cancer patients with VTEs, an estimated 35–50% of the VTEs are discovered incidentally . In contThe American Society of Clinical Oncology guideline recommends treating incidental PEs much the same as symptomatic ones, except for isolated subsegmental PEs, which the guideline recommends treating on a case-by-case basis . The mosp = 0.855) [Various studies for suspected PE have shown that concomitant DVT alters short-term mortality, and its presence can be used to improve risk stratification in patients with intermediate to low risk for short-term complications from PE ,46,47,48= 0.855) . HoweverWe also found that the odds of VTE recurrence within 6 months of PE presentation were more than two times higher in patients with C-DVT. To the best of our knowledge, ours is the first study to show such an association. Given the lack of firm evidence or guidelines on the proper management of incidental PEs ,26,37,38For the therapeutic plan in these patients, therapeutic anticoagulants are recommended by the current guidelines regardless of the presence of symptoms related to VTE ,24,49. TThe main limitations of the current study are related to its retrospective nature. Particularly important is the true incidence of C-DVT in cancer patients with unsuspected PE, which could be different than the 20.9% reported in the current study. In this retrospective study, identifying C-DVT events depended highly on the types of imaging studies carried out around the time of the incidental PE discovery, and thus our reported rate can be an underestimation. This limitation can be overcome only by a prospective study in which imaging studies to detect other thromboses are supported by funding for the study if not already carried out in the course of standard clinical care. Additionally, although we reported whether patients were discharged with anticoagulants, the rate of compliance and duration of treatment could not be effectively assessed retrospectively. Similarly, for patients identified to have anticoagulants prescription within 90 days prior to presentation, an important factor that could have influenced the risk of VTE, nonadherence to anticoagulants, and if some patients had prescriptions from outside our institution could not be assessed due to the nature of this study. However, for patients who could be safely given anticoagulants upon discharge, we expect a similar or longer duration of treatment for patients with C-DVT compared with those without C-DVT, which further supports our VTE recurrence analysis. Another limitation of the current study is identifying the incidence of recurrent VTE, which could have been detected and treated outside our institution and thus not included in our dataset. To minimize the impact of this limitation, we reviewed the follow-up physician notes to look for VTE events diagnosed and treated outside our institution, along with all imaging studies carried out at MD Anderson to check whether any VTE occurred outside our institution. In summary, C-DVT in cancer patients presenting with unsuspected PE is common, and C-DVT is associated with poor short- and long-term outcomes in these patients. The 30- and 90-day mortality rates among patients with C-DVT are significantly higher than those for cancer patients without C-DVT. In addition, our results showed that the presence of C-DVT is a predictor of VTE recurrence, resulting in twice the odds of developing VTE recurrence within 6 months from the initial presentation. Proper identification of C-DVT in cancer patients presenting with incidental or unsuspected PE, especially in patients with peripheral PE, is critical and can help guide anticoagulation management and oncology care to improve patient outcomes. Initiating anticoagulants if no contraindications exist is recommended for patients with isolated incidental subsegmental PE in the presence of C-DVT.