Reliable and valid cognitive outcome measures, including examiner-administered and computer-facilitated assessments of processing speed and reaction time, are necessary for future clinical trials that include individuals with Down syndrome (DS). The current study evaluated the score distributions and psychometric properties of four examiner-administered and three computerized processing speed and reaction time measures. Participants included 97 individuals with DS, aged 6 to 17 . Two examiner-administered measures  met most predetermined psychometric criteria. Other assessments demonstrated good test-retest reliability and had negligible practice effects but lacked adequate feasibility. Recommendations for using processing speed and reaction time assessments in research and suggestions for modifications of measures are discussed. Common cognitive features of individuals with Down syndrome (DS) include challenges with executive function, learning, and memory ,4,5,6,7.There is substantial evidence for difficulties with processing speed and reaction time throughout the lifespan in DS, with an emphasis on challenges in this area in adulthood ,14,15. DAlthough there is evidence of challenges with processing speed and reaction time specific to DS, findings related to this cognitive domain have been mixed. For example, similar performance has been found between reaction times in individuals with DS compared to peers with intellectual disability of other etiologies . This suAs new advances in interventions specific to DS continue to be made, reliable and valid outcome measurements are of critical importance in clinical trials to determine intervention effectiveness. NIH INCLUDE (INvestigation of Co-occurring conditions across the Lifespan to Understand Down syndromE) initiatives support the need for evaluation of measures to ensure they are feasible and psychometrically sound for individuals with DS ,26. AlthIndicators of processing speed assess the amount of time to complete tasks or the efficiency  of task completion within a set time while also considering the accuracy of participant responses. This is also what is referred to as Gs in the Cattell-Horn-Carroll Theory of cognitive abilities . Among iThere are also processing speed (Gs) subtests of larger clinical assessments. Rapid Naming is a processing speed measure that is part of the Differential Ability Scales, second edition (DAS-II) and involves labeling colors and animals in timed tasks. The DAS-II Rapid Naming subtest was designated as promising by NIH’s DS outcome measure working group  and a siReaction time can be assessed using a variety of methods as an indicator of Gt in the Cattell-Horn-Carroll Theory of cognitive abilities ,37. OnlyTo prepare for clinical trials, there is a significant need for the evaluation of processing speed and reaction time measures in children and adolescents with DS. Both examiner-administered processing speed  and computer-facilitated reaction time  assessments were evaluated for their appropriateness for use in research involving children and adolescents with DS. The current study aimed to evaluate the feasibility of processing speed and reaction time measures, with specific investigation of floor effects and score distributions. The second goal of the study was to evaluate the psychometrics of the processing speed and reaction time measures . Post hoc analyses were also completed for processing speed and reaction time measures that fell below feasibility criterion to describe the cognitive abilities and age of individuals who were able and unable to complete the tasks. Participants were recruited from two US cities through outreach to DS associations and other local organizations. The study included 97 individuals with DS, aged 6 to 17 years . The average IQ for the sample was 49.1, SD = 5.4, and ranged from 47 to 76 on the Stanford Binet, fifth edition abbreviated battery. Fifty of the participants were male (51.5%) and 47 were female (48.5%). Race and ethnicity were predominately White (85.6%) and non-Hispanic (94.8%). Other participants were Black (5.2%), Asian (5.2%), and other/mixed race (4.0%). Subsets of the participants in the current study were also included in studies investigating working memory, social cognition, short-term memory, and verbal fluency outcome measures ,28,39,40All study procedures were approved using the Single IRB platform at Cincinnati Children’s Hospital Medical Center. Children and adolescents with DS participated in two study visits. The second visit occurred approximately two weeks after the first. During both visits (Time 1 and Time 2), participants completed seven processing speed/reaction time tasks, as part of a larger set of clinical assessments of cognition and language. Caregivers completed a questionnaire rating their child’s adaptive behavior. Each study session was approximately 1.5–2.5 h. Tasks were randomized into blocks to limit the impact of attention or fatigue on performance.Key processing speed measures were selected that have been described by publishers as processing speed assessments or those that place considerable demand on the speed of performance on relatively simple cognitive tasks. Assessments include a variety of types of measures within the Rate of Test Taking (R9) processing speed tasks (Gs). Measure selection was informed by the NIH working group recommendations , and attDifferential Ability Scales, Second Edition (DAS-II) Rapid Naming.The DAS-II Rapid Naming measures fluency in responses to visual stimuli . This me2.Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V) Cancellation.The WISC-V Cancellation assesses processing speed and visual discrimination . The par3.Leiter International Performance Scale, Third Edition (Leiter-3) Attention Sustained.The Leiter-3 Attention Sustained is a task of processing speed, visual discrimination, and fluency . A targe4.Cat/dog Stroop.The Cat/dog Stroop task, originally developed as a measure of inhibition , can alsKey reaction time measures were selected that have been described by publishers as reaction time assessments on relatively simple cognitive tasks. Assessments include a variety of types of measures within Simple Reaction Time (R1) tasks (Gt). Measure selection was performed by using the NIH working group recommendations , and theCambridge Neuropsychological Test Automated Battery (CANTAB) Reaction Time (RTI).The CANTAB RTI assesses cognitive and motor responses through reaction time using a tablet activity . Partici2.Test of Attentional Performance for Children (KiTAP) Alertness.The KiTAP Alertness task measures the reaction time and information processing speed . The KiT3.Conners Continuous Performance Test, Third Edition (CPT-3).The Conners CPT-3 is a measure of attentiveness and impulsivity . ParticiThe Vineland Adaptive Behavior Scale, Third Edition (VABS-3)  was usedhttps://www.proedinc.com/Products/14462/sb5-online-scoring-and-report-system-1-year-base-subscription-includes-5-licenses.aspx) to eliminate floor effects [The Stanford Binet, Fifth Edition (SB-5) abbreviated battery IQ (ABIQ) was used to assess general verbal and nonverbal cognitive abilities . Deviati effects . StandarExpressive vocabulary was assessed using the Expressive Vocabulary Test, Second and Third Editions (EVT-2 and EVT-3) ,54. The Each of the processing speed and reaction time measures was evaluated based on feasibility, score distributions, practice effects, test-retest reliability, validity, and sensitivity/specificity analyses when appropriate. The feasibility  was assessed for the examiner-administered processing speed and computer-facilitated reaction time measures. Predetermined criterion for feasibility was set at ≥80% based on acceptable feasibility used in previous studies ,57. Examt-tests and effect sizes were used to investigate practice effects. Practice effects were considered problematic if there were significant differences between Time 1 and Time 2 and Cohen’s d was greater than 0.20 [The second aim of the study was to evaluate the psychometrics of the processing speed and reaction time measures . Paired samples han 0.20 . Intraclhan 0.20 . Test-reFinally, post hoc sensitivity and specificity were analyzed for measures with feasibility between 20% and 80%. Measures below 20% feasibility were not considered, as such few participants were able to complete the task. Sensitivity ratios describe participants in the study sample who were accurately identified as able to complete a measure. Specificity ratios describe the participants in the study sample who were accurately identified as unable to complete a measure. Benchmarks of age (8 and 10 years) and cognitive abilities  were investigated to determine participant characteristics that increased the probabilities of completion of a measure. Benchmarks were selected based on previous investigations of outcome measure sensitivity and specificity and the ages of children in clinical trials ,27,28.Computer-facilitated reaction time assessments  had low feasibility (8.6–52.1%). For the CANTAB RTI, reasons for non-completion were not understanding instructions (26%), noncompliance (8%), verbal refusal (5%), participant fatigue (10%), and only completing at one visit (4%). For the KiTAP Alertness, reasons for non-completion were not understanding instructions (15%), noncompliance (6%), verbal refusal (3%), participant fatigue (14%), acquiescence , and only completing at one visit (9%). The majority of participants were not able to complete the Conners CPT-3, and reasons for non-completion included not understanding instructions (49%), noncompliance (5%), verbal refusal (5%), participant fatigue (18%), acquiescence (6%), and only completing at one visit (10%). Skew and kurtosis were high for Cat/dog Stroop and the CANTAB RTI. Skew was also high for WISC-V Cancellation scaled score, Leiter-3 Attention Sustained scaled score, and KiTAP Alertness. Floor effects were unacceptable (>20%) for all measures, except for the DAS-II Rapid Naming and Cat/dog Stroop Congruent time see . Floor ed ≤ 0.20 . The WISC-V Cancellation total raw score was also significantly correlated with the Leiter-3 Attention Sustained total raw score (r = 0.75), Cat/dog Stroop Congruent time (r = −0.59), and KiTAP Alertness median reaction time (r = −0.56). Additionally, the Leiter-3 Attention Sustained total raw score was correlated with the Cat/dog Stroop Congruent time (r = −0.52). The CANTAB RTI simple median reaction time was also correlated with the KiTAP Alertness median reaction time (r = 0.59).There were multiple significant correlations among the processing speed and reaction time measures and several of the measures showed evidence of convergent validity  had good test-retest reliability, negligible practice effects, and some convergent validity, despite having only moderate feasibility. Computer-facilitated tasks had low feasibility and the computerized measures selected for evaluation may not be appropriate for individuals with DS. A summary of measures that met/did not meet study criteria is presented in Two measures met predetermined study criterion for feasibility, the DAS-II Rapid Naming and Cat/dog Stroop Congruent time. Although both tasks required verbal abilities, which could be a barrier to completion for some participants, the majority of the sample was able to complete these tasks. The WISC-V Cancellation, Leiter-3 Attention Sustained, and Cat/dog Stroop Incongruent time did not reach adequate feasibility criterion; however, they were approaching acceptable feasibility at approximately 70%. Because these tasks were completed by many participants, it is recommended that they be used with caution in future research, with specific monitoring of the motor components of the WISC-V Cancellation and Leiter-3 Attention Sustained tasks. It is also possible that additional training, practice trials, or simplification of measures would increase feasibility. For example, the WISC-V Cancellation could be modified to have larger pictures or a matrix with fewer pictures and standardized for individuals with DS and other intellectual and developmental disabilities. Modifying cancellation tasks to make them more accessible would be beneficial, as visuospatial assessment modalities are needed to support inclusion of minimally verbal individuals with DS in clinical trials. The evaluated computer-facilitated reaction time measures  all had low feasibility. This suggests that the selected measures were not a good match for the cognitive abilities of the children and adolescents with DS in the current study. Previous findings on feasibility and floor effects on computer-facilitated measures have been mixed ,29, and Floor effects corresponded with feasibility results for raw/ability processing speed scores and reaction times. For all standardized measures, floor effects were greater for standard scores than raw and ability scores. This was particularly apparent for the WISC-V Cancellation and Leiter-3 Attention Sustained scaled scores, and thus, raw scores should be used when scoring these measures for individuals with DS. Additional development of age-corrected standard scores for individuals with intellectual disabilities would be helpful to allow for some form of age correction in scores for these measures. Overall, practice effects were negligible for all evaluated processing speed and reaction time measures, and thus, scores did not improve over the two-week testing period. Test-retest reliability was also good for all processing speed measures, except for Cat/dog Stroop and CANTAB RTI simple median movement time. There was also some evidence of convergent validity among processing speed and reaction time measures see . NotablyCorrelations between the processing speed and reaction time measures and broader developmental domains were also observed. Most of the correlations with age were in the expected direction, such that as performance improved , age also increased. Although this study was cross-sectional, the correlations with age suggest individuals with DS may make age-related gains on measures of processing speed and additional investigation of processing speed measures in adults with DS will be beneficial for evaluating the utility of these measures across the lifespan. For example, the Cat/dog Stroop has been used successfully in groups of adults with DS in previous research ,33, and Many of the examiner-administered processing speed assessments were moderately associated with adaptive behavior. Fewer processing speed and one reaction time measures were correlated with cognitive abilities , suggesting that the processing speed abilities and reaction time are separate from overall cognition. The EVT and PPVT were also significantly associated with some processing speed and reaction time measures that required both verbal and nonverbal responses. Correlations between expressive vocabulary and processing speed measures that did not require a verbal response  were unexpected and warrants additional investigation to better characterize the relation between verbal skills and processing speed and reaction time performance. Examiner-administered processing speed and computer-facilitated reaction time measures both had relatively high sensitivity and specificity for ABIQ Deviation ≥ 30. There were differences based on age, with the computer-facilitated reaction time measures having higher sensitivity and specificity for the age 10 benchmark, indicating that computerized tasks may be better suited for older individuals with DS. These findings should be considered for use as guidelines for inclusion criteria in DS clinical trials if specific measures are required for tracking treatment outcomes. Even with these guidelines, there remains a need to develop measures that are feasible for a wider range of processing speed and reaction time abilities to accommodate the cognitive heterogeneity observed in individuals with DS . In this evaluation of processing speed, study limitations should be considered in the interpretation of results. First, processing speed tasks invariably also call upon other skills (“task impurity”) . For exaThe DAS-II Rapid Naming and Cat/dog Stroop Congruent tasks are recommended as assessments of processing speed for use in future clinical trials. Because these measures both have a verbal component, there remains a need to identify a nonverbal processing speed measure with high feasibility for children and adolescents with DS. Other measures of processing speed require modification , but could still be useful measures for this population as the feasibility was moderate and other psychometric properties were generally good. Adjustments to computer-facilitated reaction time measures are needed to make these assessments accessible to children and adolescents with DS. These findings contribute to the necessary evaluation of cognitive measures in DS and will serve as an important guide for outcome measure selection in future clinical trials that include individuals with DS.


Plasma metabolomic profiles were obtained by using 1H-nuclear magnetic resonance (NMR) spectroscopy, and partial least squares-discriminant analysis (PLS-DA) was applied using the MetaboAnalyst 5.0 platform. Metabolites significantly associated with different cholesterol statuses were identified, and random forest classifier models were used to rank the importance of these metabolites. Their associations with serum lipid profile and functional metabolic pathways related to hypercholesterolemia were also assessed. Cholesterol level was significantly positively correlated with LDL-C and Apo-B level, as well as HDL-C and Apo-A1 level separately, whereas HDL-C was negatively correlated with triglyceride level (p < 0.01). Eight metabolites including tyrosine, glutamic acid, ornithine, lysine, alanine, creatinine, oxoglutaric acid, and creatine were significantly associated with the different statuses of cholesterol level. Among them, glutamic acid and tyrosine had the highest importance for different cholesterol statuses using random forest regression models. Carbohydrate and amino acid metabolisms were significantly associated with different cholesterol statuses, with glutamic acid being involved in all amino acid metabolic pathways (FDR-adjusted p < 0.01). Hypercholesterolemia is a significant health concern among children, with up to 25% having high cholesterol levels. Glutamic acid and tyrosine are crucial amino acids in lipid metabolism, with glutamic-acid-related amino acid metabolism playing a significant role in regulating cholesterol levels.Despite the importance of hypercholesterolemia in children, it is overlooked, and there are currently few metabolomics-based approaches available to understand its molecular mechanisms. Children from a birth cohort had their cholesterol levels measured with the aim of identifying the metabolites for the molecular biological pathways of childhood hypercholesterolemia. One hundred and twenty-five children were enrolled and stratified into three groups according to cholesterol levels (acceptable, <170 mg/dL,  Dyslipidemia is a medical condition characterized by abnormal levels of lipids in the blood, such as cholesterol and triglycerides. It is also known as one of the strongest risk factors for cardiovascular disease, with the increasing fact that atherosclerosis begins in childhood. In clinics, there is growing attention regarding recognizing and treating of dyslipidemia in childhood to prevent or delay cardiovascular events in adulthood ,2,3. TheTotal cholesterol, the sum of non–high-density lipoprotein cholesterol (non–HDL-C) and HDL cholesterol (HDL-C), is the most often discussed factor for pediatric dyslipidemia . Other lIn clinical practice, attention has been given to a hereditary form of pediatric hypercholesterolemia known as familial hypercholesterolemia. This condition is commonly inherited in an autosomal dominant pattern and is believed to affect approximately 1 in 250 individuals globally, rendering it one of the most frequently occurring genetic disorders . FamiliaDespite the few reports, several molecular pathways have been implicated in the development of hypercholesterolemia. One major key mechanism of hypercholesterolemia involves the overproduction of low-density lipoprotein particles by the liver, which can lead to an accumulation of cholesterol in the blood . In addiA new platform of metabolomics has emerged as a powerful tool for studying human health, allowing for the simultaneous measurement of thousands of small molecules in biological samples, such as blood, urine, and tissue . This teMetabolomics is utilized to analyze the specific biochemical molecules and metabolic pathways of an organism. Nuclear magnetic resonance (NMR) spectroscopy is a powerful analytical technique used in metabolomics research, known for its high reproducibility and ability to provide high-throughput molecular identification. Blood contains a wide range of metabolically active compounds and is commonly used to estimate the body’s cholesterol status, making it suitable for investigating the systemic biological metabolism and lipids.1H-NMR spectroscopy. A comprehensive investigation of using a metabolomics-based approach and further functional pathway analysis can not only gain insight into the molecular mechanism of lipid metabolism but also provide potential health strategies for childhood hypercholesterolemia.This study aimed to identify the metabolic signatures of different cholesterol statuses and their relationship with the lipid profile in children using A prospective cross-sectional controlled study was conducted to investigate the metabolomic profiles of blood in children with cholesterol levels. Children recruited in a birth cohort launched in Taiwan and who had completed a 7-year follow-up period since birth were enrolled into this study. Blood samples were obtained at the age of 7 years old. Children with any chronic health conditions including congenital heart disease, congenital chromosome or genetic anomaly, and endocrine disorders such as diabetes or thyroid disease were excluded. In addition, to minimize the potential con-founding effects of genetic familial hypercholesterolemia, children with a family health history of early heart disease or hypercholesterolemia were excluded from the study. Based on the guidelines from the American College of Cardiology (ACC), these children were stratified into 3 groups according to cholesterol level  . InformaBlood samples were collected at the outpatient clinics after the subjects had fasted for at least 8 hours. The collected samples were frozen immediately and stored at −80 °C until required. Total cholesterol concentrations as well as triglyceride, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) levels were measured by an automated enzymatic colorimetric assay . Apolipoprotein A1 (Apo-A1) and Apo-B levels were measured using an immunoturbidimetric assay with an automatic biochemical analyzer. Serum adiponectin and leptin levels were measured by enzyme-linked immunosorbent assay (ELISA) .1H-NMR spectra were obtained from a Bruker Advance 600 MHz spectrometer  at the Chang Gung Healthy Aging Research Center, Taoyuan, Taiwan.As previously described , plasma 1H-NMR spectra were processed using NMRProcFlow online software to calibrate ppm, correct baseline, bucket spectra, and normalize data. Spectra bucketing was applied using intelligent bucketing and variable size bucketing. Chenomx NMR Suite 9.0 professional software  was then utilized to identify metabolites. According to previously established NMR data analysis methods [1H-NMR spectra data. Partial least squares-discriminant analysis (PLS-DA) in MetaboAnalyst (version 5.0) was used for identifying the metabolites used for discrimination between the groups. Metabolites with a variable importance in projection (VIP) score ≥ 1.0 with a p-value < 0.05 were considered significant. Functional metabolic pathways were pictured based on the Kyoto Encyclopedia of Genes and Genomes (KEGG) database.The raw  methods , generalMurray Hill, NJ, USA, version 4.2.1). Random forest classifier models were used to rank features with the largest contribution toward metabolite and demographic data with the Boruta feature selection algorithm by a 20-fold stratified cross-validation testing procedure. Statistical analysis was performed using the Statistical Package for the Social Sciences . All statistical hypothesis tests were 2-tailed and a p-value < 0.05 was considered significant.Comparisons of baseline characteristics between groups with different cholesterol statuses were performed with univariable parametric and non-parametric tests as appropriate. Differences in metabolites were assessed by Mann–Whitney U test on the MetaboAnalyst web server. A false discovery rate (FDR) of 5% was applied for correcting for multiple comparisons. The correlation coefficients between blood metabolites and serum lipid profiles were calculated using Spearman’s rank correlation test in R software . However, no significant differences were observed in age, height, weight, and BMI in children with different cholesterol statuses.A total of 125 subjects were enrolled into this study, including 42, 52, and 31 children with acceptable, borderline, and high levels of cholesterol, respectively. 1H-NMR data from plasma samples were collected and analyzed. One thousand buckets varied across NMR spectrum, 93 buckets of which corresponded to 39 known metabolites that were identified using the Chenomx NMR Suite. PLS-DA was used to identify metabolites discriminated between groups, and the results are shown in p-value of the permutation test between groups showed no significant differences, the PLS-DA score plots still characterized the differential expressing metabolites .abolites . Metabolp < 0.01). By contrast, HDL-C level was negatively correlated with triglyceride level (p < 0.01). Tyrosine, oxoglutaric acid, ornithine, lysine, and glutamic acid showed strong positive correlations with cholesterol, as well as LDL-C and Apo-B level but not HDL-C and Apo-A1 (p < 0.01).Cholesterol level was strongly positively correlated with LDL-C and Apo-B levels, as well as HDL-C and Apo-A1 level separately . Notably, glutamic acid was involved in all these amino acid metabolic pathways. The metabolic functional pathways related to cholesterol level are shown in Hypercholesterolemia is commonly noted in adults with obesity or metabolic syndrome, and it is a serious health concern. Of note, there is increased prevalence of hypercholesterolemia in the pediatric population and several studies have reported the increased risk of further cardiovascular diseases in these children ,18. A crThe total level of cholesterol varies by age and sex . As in tA lipid profile is a panel of blood tests used to assess several cholesterol health parameters. Total cholesterol is defined as the sum of HDL-C, LDL-C, and very low density lipoprotein (VLDL)-C and is strongly associated with these lipid parameters as in this study. Furthermore, LDL is a high-Apo-B-containing lipoprotein, whereas HDL is rich in Apo-A1; this is the reason why cholesterol was correlated with LDL-C and Apo-B and with HDL-C and Apo-A1 separately in this study. Apart from cholesterol, triglyceride is a type of fat converted by any excess calories from foods and mostly stored in fat cells for a longer-term energy source. A strong inverse correlation for triglyceride with HDL-C levels in this study further supports that hypertriglyceridemia leads to HDL-C consumption via increasing unstable TG-rich HDL particles, which are the more susceptible to clearance . Several studies have targeted the metabolic mechanism of hyperlipidemia and amino acids have been reported as important endogenous signaling molecules of lipid metabolism ,26. In tApart from glutamic acid, tyrosine, a nonessential amino acid synthesized in the body, was also an important amino acid strongly associated with hypercholesterolemia in this study. A longitudinal analysis revealed a relationship between tyrosine metabolism and insulin resistance in obese children , leadingCarbohydrate and amino acid metabolism are both confluent to the energy-producing TCA cycle, which is also a crucial step in the metabolism of fat . Glucose1H-NMR spectroscopy not only ensures a high analytical reproducibility but also a combination with the utilization of the PLS-DA method for metabolomic analysis has been shown to be efficient in identifying a wide range of metabolites associated with variations in cholesterol levels with a high degree of precision. Despite the lack of genetic confirmation for the potential existence of familial hypercholesterolemia, it is relatively low in prevalence and an extreme exclusion by family healthy history minimized its influence on the analytic results in this study. Furthermore, an age-matched design in this study eliminates the largest variability for metabolic profiles among different age groups. Most importantly, the selection of pre-pubertal age children in this study is expected to provide credible results for avoiding the influence of puberty on lipid profiles in relation to hypercholesterolemia.The limitation of this study is primarily attributed to the small sample size and the relatively low sensitivity of NMR-based metabolomic analysis technique employed. However, In conclusion, this study found that as many as 25% of children had high levels of cholesterol (>200 mg/dL), highlighting the significance of hypercholesterolemia as a health concern among the pediatric population. Amino acid and carbohydrate metabolism are both significantly involved in lipid metabolism. However, glutamic acid and tyrosine are the most important amino acids associated with hypercholesterolemia. The metabolic pathways related to glutamic acid appear to be strongly associated with different cholesterol statuses, suggesting that amino acids play a crucial role in regulating lipid metabolism. Nonetheless, further functional studies in independent larger cohorts are warranted to investigate these associations more comprehensively.


The purpose of this meta-analysis is to evaluate the role of high-intensity statin pretreatment on coronary microvascular dysfunction in patients with coronary heart disease undergoing percutaneous coronary intervention (PCI).2 test was used to evaluate heterogeneity. Pooled effects of continuous variables were reported as Standard mean difference (SMD) and 95% confidence intervals (CI). Pooled effects of discontinuous variables were reported as risk ratios (RR) and 95% confidence intervals (CI). Random-effect or fix-effect meta-analyses were performed. The Benefit was further examined based on clinical characteristics including diagnosis and statin type by using subgroup analyses. Publication bias was examined by quantitative Egger’s test and funnel plot. We performed sensitivity analyses to examine the robustness of pooled effects.PubMed, Cochrane, and Embase were searched. This meta-analysis selection included randomized controlled trials (RCTs), involving high-intensity statin pretreatment as active treatment, and measurement of thrombolysis in myocardial infarction (TIMI), myocardial blush grade (MBG) or index of microvascular resistance (IMR) in coronary heart disease (CHD) patients undergoing PCI. IP < 0.0001). The data on MBG < 2 was reported in 3 studies. The rate of MBG < 2 was not different between groups . The data on IMR was reported in 2 studies. High-dose statin pretreatment significantly improved IMR after PCI comparing with non-high-dose statin . There were no significant between-subgroup differences in subgroups based on statin type and diagnosis. Publication bias was not indicated by using quantitative Egger’s test (P = 0.97) and funnel plot. Sensitivity analyses confirmed the robustness of these findings.Twenty RCTs were enrolled. The data on TIMI < 3 was reported in 18 studies. Comparing with non-high-intensity statin, high-intensity statin pretreatment significantly improved TIMI after PCI (RR = 0.62, 95%CI: 0.50 to 0.78, Comparing with non-high-intensity statin, high-intensity statin pretreatment significantly improved TIMI and IMR after PCI. In the future, RCTs with high quality and large samples are needed to test these endpoints.The online version contains supplementary material available at 10.1186/s12872-023-03402-9. Percutaneous coronary intervention (PCI) has been widely used in revascularization therapy for patients with coronary heart disease, especially for acute coronary syndrome (ACS). Early removal of coronary artery stenosis or occlusion and recovery of coronary blood flow play an important role in alleviating patients' symptoms and reducing mortality, which has been unanimously recommended by national guidelines , 2. HoweStatins are the cornerstone of drug therapy for coronary heart disease, and are competitive inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA). It can not only inhibit the synthesis of cholesterol but also reduce the cholesterol level by increasing the low-density lipoprotein (LDL) receptor on liver cells and strengthening the endocytosis of LDL receptor-mediated . In addiAt present, the effects of statin with different dose intensity on the improvement of coronary microcirculation in patients with CHD after PCI have been studied, but the results are controversial. Studies have reported that high-intensity statin before PCI can significantly improve the dysfunction of coronary microcirculation after PCI compared with low-dose statin . HoweverThe meta-analysis was conducted with conforming to Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. (Registration in PROSPERO: CRD42020184732) 、Myocardial blush grade(MBG) and index of microvascular resistance(IMR) .The type of study: Peer-reviewed RCT studies.(1)Non-RCTs, (2)head-to-head comparisons of different statins, (3)studies without PCI as a part of the protocol, (4)studies with revascularization as an exclusion criterion, (5)unavailable data on CMD, and (6)duplicate articles were excluded.The literature was screened separately by two authors. In case of any disagreement, discuss with the third author to reach a consensus on inclusion. According to the inclusion and exclusion criteria, the two authors initially selected the relevant articles by reading the titles and abstracts respectively. After reading the full text of the preliminarily selected articles and clarifying the included articles, the basic data of each study and relevant endpoints of the study were collected, including the first author's last name, research published time, countries, the number of population, diagnosis, the patient's age, sex ratio, statin type, and dosage, studies the endpoints, etc.The two authors used the Cochrane Collaboration Risk Assessment tool to evaluate the quality of the included studies , and if 2 test was used to evaluate heterogeneity, when I2 ≤ 50%, it indicated good homogeneity among various tests, and fixed effect model was used for analysis. If I2 > 50% indicates heterogeneity among trials, random-effects model was used for analysis. Pooled effects of continuous variables were reported as Standard mean difference (SMD) and 95% CI. Pooled effects of discontinuous variables were reported as risk ratios (RR) and 95%CI. Statistical significance was accepted at p < 0.05. Publication bias was examined by quantitative Egger’s test and funnel plot when the number of included studies reaches 10 or more [p < 0.01 [The meta-analysis used STATA 15.1  and Revman 5.3  for statistical analysis. I or more . Benefitp < 0.01 . FinallyA total of 1126 related articles were retrieved from PubMed, Cochrane and Embase databases, and 28 duplicate articles were excluded. The remaining 1098 articles were first read by title and abstract, and then the full text of potentially related articles was read to determine whether the inclusion criteria were fit, and finally, 20 RCTS were included –33. The A total of 3165 patients were included in the study, including 1535 in the high-intensity statin group and 1630 in the control group. Eighteen studies reported postoperative TIMI, three reported postoperative MBG, and two reported postoperative IMR. In terms of population inclusion, 11 studies were included in the diagnosis of ST-elevation myocardial infarction (STEMI), 2 studies were included in the diagnosis of stable coronary artery disease (SCAD), 2 studies were included in the diagnosis of unstable angina (UA), only 1 study was included in the diagnosis of coronary artery disease (CAD), 1 study was included in the diagnosis of non-ST-elevated myocardial infarction (NSTEMI), 2 studies were included in the diagnosis of non-ST-elevation acute coronary syndrome(NSTE-ACS), only 1 study was included in the diagnosis of ACS. And in terms of statins, there were 17 studies using atorvastatin, 2 studies using rosuvastatin, and only 1 study using simvastatin. The study characteristics and patient characteristics of the 20 studies are shown in Tables The risk of bias was assessed in 20 studies. In terms of selection bias, randomization was described in detail and correctly in 14 studies. 2 studies describe the correct method of allocating concealment. As for the blind method, patients and evaluators were blinded in 5 studies, only evaluators were blinded in 5 studies, and patients and evaluators were not blinded in 4 studies. In terms of follow-up bias, 5 studies described the number of missing persons and the causes, which were similar between groups. With regard to reporting bias, seven studies had published research proposals. There was no other risk bias was mentioned in the 20 studies Figs. .Fig. 2Ri2 = 16%, P = 0.26). The results of fixed-effect model analysis showed that 7.0% of patients (101/1453) in the high-intensity statin treatment group had postoperative TIMI c. In the control group, patients with postoperative TIMI < 3 accounted for 12.0% (186/1551). The results showed that high-intensity statin pretreatment significantly improved postoperative TIMI grading  . The results of fixed-effect model analysis showed that 25.1% of patients (42/167) in the high-intensity statin group received postoperative MBG < 2, and 19.5% (34/174) in the control group received postoperative MBG < 2. There was no significant effect on the two groups . The results of fixed-effect model analysis showed that the high-intensity statin group significantly reduced postoperative IMR compared with the control group  . It showed that different statin types did not affect the intervention. According to different clinical manifestations for subgroup difference test, the statistical results (P = 0.27) showed that there was no subgroup effect among patients with different clinical manifestations, indicating that there was no significant difference in intervention effects among different clinical manifestations  also indicate that there was no obvious publication bias.Similarly, funnel plot and Egger check method are used in this study to detect publication bias. As shown in Fig. As shown in Figs. A total of 20 randomized controlled trials were included in this study. TIMI grading was reported in 18 RCTs, MBG was reported in 3 RCTs, and IMR was reported in 2 RCTs. Firstly, the meta-analysis showed that compared with non-high-intensity statins, high-intensity statins significantly improved TIMI grading and significantly reduced IMR after PCI in patients with CHD. There was no significant difference in postoperative MBG between the two groups. Secondly, subgroup differences were detected for TIMI grading according to clinical diagnosis and statin types in the study, and the results showed that there were no subgroup differences in benefits between different clinical diagnoses and different statin types. Thirdly, sensitivity analysis was conducted in this study, the results showed no significant changes in the meta-analysis results, indicating the robustness of the results. Fourthly, this study detected potential publication bias through funnel plot and quantitative Egger inspection method, and the results showed that there was no publication bias.Microcirculation is not only an important determinant of effective restoration of myocardial perfusion after PCI to reduce myocardial cell damage and improve cardiac function in patients with CHD, but also an important factor affecting the prognosis of patients .Statins are competitive inhibitors of HMG-CoA reductase . High-inp = 0.0005) [P < 0.0001). This is consistent with previous findings [P < 0.0004). It also indicates that high-intensity statin can better improve the CMD in patients with CHD after PCI compared with low-dose statin.Due to technical reasons, it is still not possible to directly observe the blood flow of coronary microvessels in the human body. Therefore, most of the previous clinical studies on statin's improvement of CMD mainly used TIMI grading to indirectly reflect the situation of coronary microcirculation perfusion. A meta-analysis of 15 randomized controlled trials showed that high-intensity statins significantly improved post-operative TIMI grading  . A totalfindings , suggestfindings . The metCurrent guidelines recommend that patients with CHD should be treated early with high-intensity statins. However, it is not clear when statins will be given. The results showed that compared with non-high-intensity statin treatment, high-intensity statin treatment effectively improved microcirculation dysfunction after PCI, suggesting that high-intensity statin pretreatment can bring additional benefits to patients, and we should actively give high-intensity statin treatment as early as possible before operation in the absence of contraindications.The meta-analysis has several advantages. First of all, the study focused on comparing the effects of high-intensity statin with non-high-intensity statin treatment on microcirculation function in patients with CHD after PCI. Different from previous studies, TIMI, MBG, and IMR were included in this meta-analysis to evaluate the effects of high-intensity statin pretreatment on coronary microcirculation. Secondly, only RCTs were included in this meta-analysis to minimize the influence of confounding factors on the results and improve the reliability of the results. Finally, subgroup analysis, sensitivity analysis, and publication bias analysis were performed on the results of this study, which all indicated the robustness of the results.However, the study also has limitations. First, the characteristics of the included population in each study may be different, which may lead to the existence of bias and heterogeneity. Although the subgroup difference analysis of clinical diagnosis and statin type in this study showed consistency of results, while the study could not exclude the influence of other factors on the results, including the age, complications, ethnic groups, different statin dosage before PCI in non-high-intensity group, and so on. Second, some of the experiments included in the study did not use the blind method, and some of the studies did not mention whether to use the blind method in the literature, which may have an impact on the research results. Third, the number of RCTs on IMR and MBG is small. Therefore, higher-quality studies will be needed to verify the results through more reliable and rigorous methods in the future.Compared with non-high-intensity statin treatment, high-intensity statin significantly improved TIMI grading and IMR in patients with CHD after PCI, and effectively improved microcirculation dysfunction. More studies with larger samples and higher quality are still needed to verify the results In the future.Additional file 1: Table S1. PRSIMA 2020 Checklist


Tobacco use among underage individuals is a public health concern. Timely data about tobacco products, especially emerging products such as novel oral nicotine products (NPs), can provide critical information for the prevention of underage tobacco use. With a recent federal law raising the legal age of purchase of tobacco products from 18 to 21, it is of interest to benchmark awareness and use of tobacco products in the new underage population, young adults 18–20 years old. This study provides estimates on awareness and use of tobacco products among underage individuals 13–20 years old during May 2020 to August 2022 in the United States.Altria Client Services Underage Tobacco Use Survey (UTUS) is a repeated cross-sectional survey conducted every quarter-year. A stratified random sampling approach was used to draw nationally representative samples of household dwelling individuals 13–20 years old. Information about the awareness and use of tobacco products was obtained via online self-administration or phone interviews after a consent/assent process.A sizable portion of underage individuals were aware of NPs (~ 40% among youth and ~ 50% among underage young adults), although past 30-day use was low (< 2%). The lowest levels of awareness and use were observed for heated tobacco products and snus. E-cigarettes were the most used tobacco products among underage individuals. Underage young adults  were more likely to use tobacco products than youth . There was no substantial change over time in the awareness and use of tobacco products during the study period despite a slight increase in past 30-day prevalence of e-cigarette use among youth between quarter 1 of 2021 and quarter 2 of 2022.The awareness and use of tobacco products remained relatively stable between May 2020 and August 2022. There is a notable level of awareness of novel NPs among underage individuals.The online version contains supplementary material available at 10.1186/s12889-023-15610-1. The United States (US) Surgeon General declared youth vaping an epidemic in 2018 . The risIn the meantime, two novel tobacco product categories, oral nicotine products (NPs), which do not contain tobacco leaf, and inhalable heated tobacco products (HTPs), products that heat but do not burn tobacco, have recently emerged in the US market. IQOS®, an HTP, was the first of its kind authorized by FDA for sale in the US in April 2019. Based on data from the 2017 International Tobacco Control Youth Tobacco and E-cigarette Survey, however, 9.1% of 16–19 year olds in the US were aware of IQOS® at that time ; data frIn addition to new, emerging tobacco product categories, the federal minimum legal age to purchase tobacco in the U.S. has recently changed from 18 to 21 years , creating a new underage population of 18–20 year old individuals. Evidence suggests, at least at the state and local level, that raising the minimum legal age to purchase tobacco to 21 years reduces cigarette smoking and vaping among 18–20 year olds –12. CurrGiven the rapidly evolving underage tobacco use landscape and to complement existing government surveys, Altria Client Services (ALCS) launched the ALCS Underage Tobacco Use Survey (UTUS) in May of 2020 to enhance the ability to obtain timely information related to tobacco use that covers a broad range of traditional and novel tobacco products among underage individuals, including the new underage population of 18–20 year olds. The UTUS is a repeated cross-sectional survey that collects data on underage tobacco use every quarter year. Here we present findings from the UTUS between May of 2020 (the second quarter of 2020) and August of 2022 . The data collection period coincides with the COVID-19 pandemic, including a period when multiple national government surveys were disrupted . The main aim of this initial report was to provide data over time on three major tobacco-use-related milestones  of various tobacco products among underage individuals 13–20 years of age during May 2020 to August 2022.UTUS was launched in May of 2020 and has been conducted on a quarter-year schedule. Data from the second quarter of 2020 to the third quarter of 2022 were used in this analysis . In the consent/assent form, it was stated that the survey was sponsored by a tobacco manufacturer. After proper consents and assents were obtained, the selected individuals were directed to complete the questionnaire. Participants received a code to obtain a $20 e-gift card from Amazon or Target upon completion of the survey. For participants 13–17 years of age, a parent code was necessary to obtain the e-gift-card. The study was approved and overseen by Sterling IRB (Protocol #: ALCS-REG-20-10-CCR).https://sciences.altria.com/library/underage-tobacco-use-survey?src=topnav.Most respondents completed the survey via online self-administration (99%) with a few completed via phone interviews 1%) in English or Spanish. The survey consisted of modules for the following nine tobacco product categories: ecigarettes, cigarettes, cigars , smokeless tobacco , hookah, pipe tobacco, snus, HTPs, and NPs  was used for analysis.Table Selected demographic characteristics of the UTUS sample are shown in Table Figure In this study, we provide data from a national survey conducted during the COVID-19 pandemic and found that (a) a sizable portion of underage individuals were aware of emerging tobacco products, such as HTPs and oral NPs; (b) there was no substantial change in the awareness and use of tobacco products during the study period ; (c) e-cigarettes were the most commonly used tobacco products among underage individuals; and (d) underage young adults were more likely to use tobacco, compared to youth.To the best of our knowledge, this is among the first studies to report the awareness and use of emerging NPs, such as nicotine pouches, among household dwelling individuals 13–20 years of age. NYTS, a school-based national survey of middle- and high-school students added nicotine pouches in the assessment in 2021. The estimated awareness of nicotine pouches from this study is comparable to those from the NYTS , 15. In HTPs are another emerging tobacco product category. A few studies have reported the awareness and use of HTPs , 14, 15.The estimated ever and past 30-day use of e-cigarettes in the current study was comparable to those from the most recent NSDUH 2021, another household survey, which showed 12.1% and 25.1% for ever use among 12–17 year olds and 18–20 year olds, and 5.2% and 13.7% for past 30-day use . EstimatThe estimates observed in our study were likely influenced by the effects of the COVID-19 pandemic. A few recent studies have documented a large reduction in e-cigarette use among youth during the COVID-19 pandemic , 25. MulTo the best of our knowledge, the current study is the first to report the awareness, ever use, and past 30-day use among underage 18–20 year olds in 2020–2022 Our estimates were generally in line with estimates from NHIS 2020. For example, estimated ever and current e-cigarette use among 18–20 year olds from NHIS 2020 was 28.3% and 8.3%, respectively, and our estimates ranged from 30 to 36% for ever use and 11–14% for past 30-day use. Previous studies have shown a lag between the enactment of nationwide policies and observed change in behaviors . AlthougSeveral limitations should be considered when interpreting results from the UTUS. First, non-household-dwelling individuals were excluded. Second, the relatively low level of response at the household level (between 6 and 9%) renders the study susceptible to potential selection biases. Nonetheless, the response levels are not distant from other surveys using similar methodology , and we https://sciences.altria.com/library/underage-tobacco-use-survey?src=topnav for details.Taken together, findings from this study and other national surveys highlight the need for continued surveillance of tobacco use among underage individuals, including young adults 18–20 years of age. This is essential for the assessment of potential impacts of foreseeable and unforeseeable changes such as the introduction of new tobacco products, tobacco-related policies, and COVID-19. Recognizing the importance of such data, ALCS has made the UTUS publicly accessible via a data request process. Interested researchers may visit Below is the link to the electronic supplementary material.Supplementary Material 1


Imatinib has an excellent long-term survival rate and significantly ameliorates the treatment of chronic myeloid leukaemia during the past few decades. There is now a concern that first-generation tyrosine kinase inhibitors can cause secondary neoplasms. Here, we describe a case of a 49-year-old non-smoker male who was diagnosed with chronic myeloid leukaemia and treated with imatinib. After 15 years of treatment, an incidental right cervical lymphadenopathy was noted. The fine needle aspiration cytology from the lymph node revealed the small round cell morphology. In order to identify the primary lesion, computerised tomography of the thorax and abdomen was advised, which revealed a diagnosis of small cell carcinoma lung. In the index case report, we will discuss the potential side effects of first-generation tyrosine kinase inhibitors on a long-term basis along with treatment protocols for metastatic small cell carcinoma lung in a disease-free follow-up case of chronic myeloid leukaemia. Tyrosine kinase inhibitors (TKIs) that target the BCR-ABL protein have considerably reduced the progression rate of chronic myeloid leukaemia (CML) . There iA 49-year-old man, a follow-up case of CML diagnosed in the year 2007, was on regular imatinib (400 mg/day) treatment. After 15 years of disease-free time period, he was found to have incidental right cervical lymphadenopathy on physical examination during a follow-up visit on April 2022. The lymph node was of size 1x0.8x0.8 cm and firm, mobile, and non-tender. Abdominal palpation and ultrasonography both did not reveal any organomegaly. There was no history of substance abuse in form of tobacco chewing and smoking. There was no history of cough, haemoptysis, or breathlessness.Fine needle aspiration cytology (FNAC) was performed from the right cervical lymph node, which showed cellular smears composed of atypical cells having round to oval hyperchromatic nuclei and a scant amount of cytoplasm on a haemorrhagic background Figure . On the In order to identify the primary lesion, contrast-enhanced computerised tomography (CECT) of the thorax and abdomen was advised, which revealed heterogeneous enhancing soft tissue mass in the upper lobe of the right lung which measured 35x25 mm. There was no cavitation or calcification seen. No mediastinal lymphadenopathy was noted Figure . For a dHistopathological examination of the Hematoxylin and eosin (H&E)-stained section of the biopsy from the lung mass showed small-sized atypical cells with coarse chromatin, inconspicuous nucleoli, and a scant amount of cytoplasm. A few tumour cells showed nuclear moulding and crush artefacts Figure . ImmunohThe patient was planned for the treatment of metastatic SCLC, and for that, he received six cycles of combined platin-based chemotherapy and radiotherapy. The cervical lymphadenopathy disappeared and the patient progressed favourably and continued on oral dasatinib. The patient was in regular follow-up for six months and currently doing well.Imatinib is a first-generation TKI that inhibits Bcr-Abl tyrosine kinase (TK) and is used in treating CML. It is important for clinicians to be aware of secondary cancers in their daily practice because they have been reported in a number of cases utilising TKIs . A studySecondary malignancies were found in 4.2% (64/1525) of the CML cases treated with TKI in a study by Miranda et al. Prostate, non-Hodgkin's lymphoma (NHL), colorectal, lung, malignant melanoma, non-melanoma skin tumours, and breast cancer were the most prevalent malignancies. They found lung carcinoma in 0.39% (6/1525) of CML cases that were treated with imatinib . Most paIt was found that imatinib contributes to secondary cancer risk. French investigators, who observed 3.2% (6/189) cases of patients treated with imatinib over a five-year period, found that they developed a second malignancy but none developed lung carcinoma . In addiMore than 70% of patients who are diagnosed with SCLC present with metastasized disease . Cancer In the present case, the patient had no symptoms of pulmonary disease despite having metastasis to the cervical lymph node. This made it challenging for the clinician to search for a primary lesion in a disease-free follow-up case of chronic myeloid leukaemia on long-term imatinib treatment.Considering the improved survival and longevity of patients with chronic myeloid leukaemia, age-appropriate cancer screening with meticulous physical examination is essential. Long-term follow-up is needed for patients receiving imatinib as front-line therapy in cases of chronic myeloid leukaemia.


Olfactory and gustatory dysfunction, including anosmia, parosmia, ageusia, and dysgeusia, are common long-term symptoms of coronavirus disease 2019 (COVID-19) infection. These symptoms can have a severe impact on quality of life of a patient, including psychological well-being. Stellate ganglion block (SGB) has recently been explored as a potential therapeutic intervention for these symptoms. In this case series, we present six patients with long-term COVID-19 symptoms and we detail how their symptoms evolved after an SGB. All SGB were performed under ultrasound guidance by the same physician. Patients had a right SGB during the initial visit, followed by a left SGB at a subsequent visit. All but one patient reported improvements in olfaction and gustation after the SGB. Our findings suggest that SGB may be a promising therapeutic intervention for patients with olfactory and gustatory dysfunction related to long-term COVID-19 symptoms. Further research is needed to confirm these findings and to explore the optimal treatment protocol. Long-lasting impairment of smell and taste, encompassing anosmia, parosmia, ageusia, and dysgeusia, is frequently observed in individuals who have experienced coronavirus disease 2019 (COVID-19) .Stellate ganglion block (SGB) has recently been explored as a potential therapeutic intervention for olfactory and gustatory dysfunction in patients with long-term COVID-19 symptoms . SGB invThis case series aims to add to the growing body of evidence on the efficacy of SGB in treating olfactory and gustatory dysfunction in patients with long-term COVID-19 symptoms. We present six patients with persistent olfactory and gustatory dysfunction who underwent a series of SGB injections and 83% of the patients experienced significant improvements in their symptoms. This case series highlights the potential of SGB as a therapeutic intervention for long-term COVID-19-related olfactory and gustatory dysfunction and calls for further research to confirm these findings and explore the optimal treatment protocol.Procedural techniqueUltrasound-Guided Stellate Ganglion BlockAfter obtaining informed consent, the patients were brought to the procedure room and placed in Fowler's position. Blood pressure, heart rate, oxygen saturation and visual and verbal monitoring were established. A time out was performed. The area was prepped with 2% chlorhexidine gluconate and 70% isopropyl alcohol and draped in a sterile fashion. Next, after skin infiltration with 3 mL of 1% lidocaine, a linear ultrasound probe was placed in the anterior part of the neck to identify the stellate ganglion, which is located between the carotid artery and longus coli muscle at the level of the C6 transverse process in 80% of patients. A 10cm 22 Gauge nerve block needle  was inserted using an in-plane approach, next to the stellate ganglion. After negative aspiration of blood, 7 mL of 0.5% bupivacaine or ropivacaine were slowly injected with alternating periods of aspiration that were negative for blood. In Video The patients were monitored up to 15 minutes after the procedure and were called for a follow-up the next day to assess symptom severity or changes if any. Additional follow-up times varied between one month and four months following the second SGB, with the specific timing varying for each patient.This report presents six patients who experienced persistent anosmia, parosmia, ageusia, and dysgeusia after recovering from COVID-19 and underwent SGB injections to manage these symptoms. It is important to note that the improvement assessment is based on self-reported patient feedback.Case 1A 57-year-old male, weighing 95.0 kg, reported prolonged anosmia and ageusia persisting for five months following recovery from COVID-19 in August 2022. The patient reported that his sense of smell has been more affected than his taste. He also noted neuropathy in his left thumb, predominantly characterized by numbness. However, he has no complaints of neck pain. His past medical history reveals that he is pre-diabetic. He currently does not take any medications and has no known allergies. The first SGB, administered on the right side, resulted in an 80% improvement in taste and a 25% return of smell. Subsequent left-sided SGB led to a slight enhancement in both senses. At the three-month follow-up, the patient reported a greater improvement in taste compared to smell.Case 2A 48-year-old female weighing 63.5 kg reportedly contracted COVID-19 four times, with dysgeusia and anosmia occurring after her most impactful episode in November 2020. She reported experiencing dysgeusia and anosmia approximately 50% of the time, with altered sensations during episodes when taste and smell are restored. The patient has no significant medical history other than her COVID-19 infections. She does not take any medications and has no known allergies. The patient has explored acupuncture, aromatherapy, and hypnotherapy to relieve her symptoms, but these interventions have not led to any noticeable improvements.The patient first received a right-sided SGB, and she self-reported a substantial 90% improvement in taste and a modest 10% return of smell based on her previous experiences. After the second left-sided SGB, she experienced a complete return of taste and a 30% return of smell. Case 3A 36-year-old female weighing 56.7 kg, with a history of rheumatoid arthritis, contracted COVID-19 in August 2021. Since her recovery, she has been grappling with long-term symptoms such as anosmia, parosmia, ageusia and dysgeusia. She reported a total loss of smell for two weeks after a COVID-19 infection. Upon its return, she found that most smells had become unpleasant, faint, and seemed chemical in nature; her taste was altered as well. The patient has previously attempted smell retraining therapy which she states has led to minor improvements in her sense of smell. Additionally, the patient had undergone an MRI of the brain prior to receiving therapy, and no significant results were reported.After her first right-sided SGB treatment, she reported a 70% return of smell and a 15% improvement in taste after the first right-sided SGB. The subsequent left-sided SGB resulted in an 80% return of smell and a 30% improvement in taste. At her one-month follow-up, the patient reported a cumulative 85% improvement in smell and a 50% improvement in taste, with continuous daily progress. At the three-month follow-up, she says that her smell has remained at 85% improvement, but she has experienced an 80% improvement in taste.Case 4A 20-year-old female weighing 52.2 kg, with a history of migraine headaches, with no long term medication use, contracted COVID-19 in December 2020. The patient initially experienced ageusia that lasted for six months; upon return of taste the patient had complaints of dysgeusia that lasted for over 1.5 years. The first SGB on the right side resulted in a 50% improvement in her symptoms. The second left-sided SGB led to an additional 30% improvement of her symptoms. After the initial follow-up, patient could not be reached for further follow-ups.Case 5A 55-year-old female, 62.1 kg, with dyslipidemia treated with atorvastatin, had anosmia and ageusia for 1.5 years following a week of respiratory symptoms due to COVID-19. An otolaryngologist had ruled out any anatomical abnormalities. She tried smell training without any improvement. Despite experiencing no initial improvement 24 hours after the right-sided SGB, a subsequent left-sided SGB was performed without complications. At the three-week follow-up period the patient says she has not noticed any improvement in her sense of smell or taste.Case 6A 55-year-old male, 95.0 kg, with a medical history of hypertension managed with losartan and depression managed with citalopram, reported anosmia and ageusia for 1.5 years after a COVID-19 infection. Antihistamines and consultations with an otolaryngologist were not helpful. After a right-sided SGB, the patient reported 80% improvement in smell, with a less significant improvement in taste. One week later the patient underwent a left-sided SGB. After the left-sided SGB the patient could not be reached for further follow-ups.This case series showcases six patients who had SGB for the management of prolonged olfactory and gustatory dysfunction associated with long-term COVID-19. Five out of six patients demonstrated varying degrees of taste and smell perception improvement following the SGB. These findings offer preliminary evidence supporting the potential effectiveness of SGB as a therapeutic strategy for this cohort of patients, thereby paving the way for more rigorous investigations in the future -7.Post-viral olfactory and gustatory dysfunction are increasingly recognized sequelae of COVID-19, with significant implications on quality of life. It is hypothesized that these symptoms could be due to the bilateral cervical sympathetic chain being affected during these viral infections, and that dysautonomia could play an important role in the pathophysiology of long COVID. Dysautonomia is not specific to COVID-19 infection, it has been reported with other viral illnesses such as HIV, Epstein-Barr virus, mumps, and coxsackie B . Other cDue to this pathophysiology, SGB-mediated sympathectomy has been used as a therapeutic option in this patient population. It is hypothesized that SGB attenuates sympathetic hyperresponsiveness, and this causes a recalibration of the autonomic nervous system towards its pre-COVID state. Another mechanism described in other studies is that after SGB, there is increased cerebral blood flow . This quThere is limited published literature on the use of SGB for long-term COVID-19 olfactory and gustatory dysfunction, and our case series adds to this growing body of evidence -8,10-11.Considering the potential side effects and complications associated with SGB is noteworthy, as observed in our case series. These include temporary ptosis, conjunctival erythema, dysphonia, dysphagia, and hypopharyngeal anesthesia, among others. While the symptoms were transient and well-tolerated in our patients, it is essential for practitioners to counsel patients about these potential risks before performing the procedure.It is also important to investigate the optimal timing and frequency of SGB for maximum therapeutic benefit. In our series, patients received one SGB on each side, but the time between procedures varied between patients. The variable times of doing contralateral SGB was governed by patient's ability to return for a subsequent visit, physician availability and distance between the physician's office and patient's residence. The timing of SGB administration in the course of disease progression may also influence outcomes, a facet not explored in this case series. These factors should be addressed in future research to optimize the therapeutic protocol.This study demonstrated promising results for SGB as a potential intervention for persistent olfactory and gustatory dysfunction following COVID-19. Among the six patients treated, five experienced considerable restoration of their taste and smell capacities. The self-reported patient improvement varied, from moderate to nearly full recovery of these senses, with an interesting trend of taste recuperation often preceding smell. Most of the positive outcomes were observed after bilateral SGB administration. However, the treatment did not lead to observable improvements in one out of six cases. While our findings highlight SGB as a possible remedy for the sensory dysfunctions associated with post-COVID-19 symptoms, they also underscore the need for more comprehensive research. Future studies must involve larger sample sizes and controlled experimental conditions to substantiate and broaden our understanding of this treatment's efficacy.


Awake prone positioning has been widely used in non-intubated patients with acute hypoxic respiratory failure (AHRF) due to COVID-19, but the evidence is mostly from observational studies and low-quality randomized controlled trials (RCTs), with conflicting results from published studies. A systematic review of published high-quality RCTs to resolve the controversy over the efficacy and safety of awake prone positioning in non-intubated patients with AHRF due to COVID-19.Candidate studies were identified through searches of PubMed, Web of Science, Cochrane, Embase, Scopus databases from December 1, 2019 to November 1, 2022. Literature screening, data extraction and risk of bias assessment were independently conducted by two researchers.Eight RCTs involving 2657 patients were included. Meta-analysis of fixed effects models showed that awake prone positioning did not increase mortality, length of stay in ICU , total length of stay , or incidence of adverse events  compared with usual care, but significantly reduced the intubation rate . Similar results were found in a subgroup analysis of patients who received only high flow nasal cannula . All eight RCTs had high quality of evidence, which ensured the reliability of the meta-analysis results.Awake prone positioning is safe and feasible in non-intubated patients with AHRF caused by COVID-19, and can significantly reduce the intubation rate. More studies are needed to explore standardized implementation strategies for the awake prone positioning.CRD42023394113.The online version contains supplementary material available at 10.1186/s12879-023-08393-8. The ongoing global pandemic of COVID-19 has led to significant morbidity and mortality, and poses unique challenges to medical system, including severe shortages of medical staff, funding, ICU beds, and the number of mechanical ventilators –4. Such Awake prone positioning mainly involves rotating the patient from supine to ventral position while awake and not intubated to allow for greater expansion of lung tissue in the dorsal area . Prior tAlthough there have been several systematic reviews/Meta-analyses (SRs/MAs) exploring the effects of awake prone positioning on patients with AHRF caused by COVID-19, these studies have the following problems and inconsistent results. First, previous SRs/MAs combined data from different types of studies , resulting in high heterogeneity among different studies and reducing the reliability of meta-analysis results , 13. SecIn this study, we aimed to conduct an updated meta-analysis to systematically explore the efficacy and safety of awake prone positioning in patients with AHRF caused by COVID-19, with a view to providing the latest and most reliable evidence for the treatment of patients.www.crd.york.ac.uk/prospero).This systematic review and meta-analysis followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) . The proNon-intubated patients with AHRF caused by COVID-19. The diagnostic criteria of hypoxic respiratory failure are PaO2:FiO2 ratio ≤ 300 mmHg, or no specific diagnostic criteria have been reported in the study, but patients with hypoxic failure are clearly described.The patient is in the awake prone positioning for at least 6 h a day and is in the awake prone positioning for as long as possible .Patients receive only usual care and no restrictions on postures.1) Primary outcomes: intubation rate, mortality. Mortality is defined as the number of deaths caused by COVID-19 during treatment divided by the total number of patients receiving treatment. 2) Secondary outcomes: hospital length of stay and incidence of adverse events.1) Patients with AHRF due to bronchial asthma, heart failure or pulmonary embolism, or patients with COVID-19 who received endotracheal intubation, were excluded. 2) Observational studies and studies without a control group were excluded. 3) Excluded studies that did not report expected outcome indicators. 4) Editorials, narrative reviews, letters, and conference abstracts were excluded. 5) Studies without full text or primary data that could not be obtained were excluded.Candidate studies were identified through searches of PubMed, Web of Science, Cochrane, Embase, Scopus databases from December 1, 2019 to November 1, 2022. The following terms were combined to design the search strategy: (SARS-CoV-2 OR SARS-CoV2 OR ‘severe acute respiratory syndrome coronavirus 2’ OR 2019-nCoV OR 2019nCoV OR coronavirus OR covid-19 OR COVID19 OR COVID-19) AND . Further details of the search strategy are shown in Supplementary Table First, titles and abstracts were reviewed to identify studies that met the inclusion criteria. Second, full texts were obtained to determine the final required studies. After identifying the studies that ultimately met the inclusion criteria, we first contacted the corresponding author of the paper by email to obtain raw data. If there is no response, we will extract the required information from the paper according to the information extraction table made in advance, including, 1) Basic information: Author, year of publication, country, type of study, disease, oxygen supply pattern, location, sample size for trial and control groups, age, details of care. 2) Primary and secondary outcome indicators. 3) Key information for bias risk assessment. Finally, the Cochrane bias risk assessment tool was used to assess the risk of bias in included studies . The abo2 ≥ 50%), subgroup analysis, sensitivity analysis and meta-regression were used to further analyze the sources of heterogeneity. When heterogeneity was found to exist even after all methods were taken to reduce heterogeneity, a random effects model was used to analyze the data. Conversely, when heterogeneity was not present, the fixed-effects model was used for data analysis. In addition, when less than 10 studies were included, it was difficult to judge whether there was publication bias according to the symmetry of the funnel plot, so Egger’s test was used to quantitatively detect publication bias.Statistical analysis was performed by RevMan 5.4.1 software. Intubation rate, mortality and adverse events were measured by odds ratio (OR), and the length of stay in hospital was measured by weighted mean difference (WMD). All effects were expressed by 95% confidence interval (95% CI). When there was a large heterogeneity between the included studies , so the fixed effect model was used. The results of meta-analysis showed that, whether for all patients or only patients who received HFNC, awake prone positioning did not reduce the mortality of patients with AHRF caused by COVID-19 compared with routine care  and total hospital stay  between awake prone positioning group and usual care group (Fig. A total of six studies reported adverse events of 13 types of patients during treatment. The results of meta-analysis of fixed effect model showed that there was no significant difference in the incidence of total adverse reactions, vomiting, indwelling needle displacement, cardiac arrest at any time and skin breakdown between awake prone positioning group and usual care group Fig. . In addiP value was 0.182, which indicated that there was no publication bias.Publication bias was measured quantitatively by egger's test. The results showed that the The use of awake prone positioning can be traced back to 1977. Douglas et al.  performePrevious meta-analysis of cohort studies and RCTs showed that awake prone positioning significantly reduced mortality compared with usual care, but did not reduce intubation rate . The res2 of heterogeneity test is zero, and P > 0.05 proves this point. Therefore, the current conclusive evidence suggests that awake prone positioning can significantly reduce the risk of endotracheal intubation in patients with AHRF caused by COVID-19 without increasing mortality.In fact, among the eight high-quality RCTs included in our meta-analysis, there were differences in the results of different studies. For example, in an analysis based on 60 patients with AHRF due to COVID-19, Jayakumar et al. found no statistically significant differences in any outcomes such as intubation rate and mortality between patients who received awake prone positioning and usual care . HoweverAnother interesting aspect of awake prone positioning is safety. Possible complications in prone positioning include indwelling needle displacement, transient hypotension, vomiting and pressure sores . Our resRecent studies suggest that longer durations of prone positioning are associated with better patient outcomes , 19, 38.As the first meta-analysis of RCTs data in the current field, the quality of the studies we included is very high, and the statistical heterogeneity between different studies is within an acceptable range, which ensures the reliability of meta-analysis results to a great extent. Although statistical heterogeneity is acceptable, the impact of clinical heterogeneity and methodological heterogeneity on meta-analysis results cannot be estimated. For example, the source of patients includes ICU, general ward, and high-acuity units, and the severity of disease varies among patients in different locations. The amount of time patients were given prone ventilation also varied considerably across studies (Prone positioning for at least 6 h , 16 h 3, or encoThe latest evidence from high-quality RCTs suggests that awake prone positioning is safe and feasible for non-intubated patients with AHRF caused by COVID-19 and does not lead to more adverse events than usual care. Awake prone positioning can significantly reduce the intubation rate without increasing the mortality. However, the implementation strategy of awake prone positioning still needs more research.Additional file 1:Table 1. [Search strategies].


The paradigm of early phase dose-finding trials has evolved in recent years. Innovative dose-finding designs and protocols which combine phases I and II are becoming more popular in health research. However, the quality of these trial protocols is unknown due to a lack of specific reporting guidelines. Here, we evaluated the reporting quality of dose-finding trial protocols.ClinicalTrials.gov in 2017–2023. A checklist of items comprising: 1) the original 33-items from the SPIRIT 2013 Statement and 2) additional items unique to dose-finding trials were used to assess reporting quality. The primary endpoint was the overall proportion of adequately reported items. This study was registered with PROSPERO (no: CRD42022314572).We conducted a cross-sectional study of oncology and non-oncology early phase dose-finding trial protocols posted on A total of 106 trial protocols were included in the study with the rule-based 3 + 3 being the most used trial design (39.6%). Eleven model-based and model-assisted designs were identified in oncology trials only . The overall proportion of adequately reported items was 65.1% (95%CI: 63.9–66.3%). However, the reporting quality of each individual item varied substantially (range 9.4%–100%). Oncology study protocols showed lower reporting quality than non-oncology. In the multivariable analysis, trials with larger sample sizes and industry funding were associated with higher proportions of adequately reported items .The overall reporting quality of early phase dose-finding trial protocols is suboptimal (65.1%). There is a need for improved completeness and transparency in early phase dose-finding trial protocols to facilitate rigorous trial conduct, reproducibility and external review.None. Despite its broad applicability to many types of trials, SPIRIT 2013 and its extensions do not comprehensively cover the characteristics of early phase dose-finding trials and the quality of these protocols in an era with more adaptive designs is unknown.Clearly written protocols, with provision of sufficient detail to help the reader understand the trial methodology and know what is pre-specified, are of paramount importance. The SPIRIT  2013 Statement provides evidence-based recommendations for the minimum content of a clinical trial protocol. A PubMed search using the terms “This study provides a comprehensive assessment of the reporting quality of early phase dose-finding trial protocols (from 2017 to 2023). The results identified i) the reporting quality of contemporary early phase dose-finding protocols, ii) the least frequently reported items, and iii) the type of trial protocols that need more surveillance actions. Additionally, this study assessed the prevalence of the most common trial designs used in phase I and I/II oncology and non-oncology trials.The findings can be used by the trial community to identify areas that have been poorly reported and/or require substantial improvement. Persistent and collaborative efforts from journals, editors, reviewers, regulators, funders and investigators are necessary to enhance the comprehensiveness and transparency of such protocols. This study highlights the need for an international consensus-driven protocol guidance for early phase dose-finding trials, and paves the way for creating recommendations of essential contents to be included in such protocols.dose-finding” or “dose escalation” studies, early phase trials (phase I or I/II) are a critical step in clinical development. The primary objective of such trials is to assess the safety of an experimental treatment and finding recommended dosing regimen(s). They have historically been designed using classical rule-based approaches. However, as many innovative model-based designs for dose finding have been developed, more sophisticated designs have been implemented and protocols combining phases I and II are becoming more popular in health research.,The paradigm of early phase dose-finding trials has dramatically evolved in recent years. Often termed “The current landscape of early phase clinical trials includes a broad variety of study designs. Typically involving several dose levels for evaluation, dose-finding trials feature the use of accumulating trial data for adaptive decision making. Dose assignment decisions are based on safety considerations, pharmacokinetic and pharmacodynamic data, biological markers or a combination of these parameters. Incomplete or unclear information on the design, conduct and analysis in dose-finding protocols would hinder their interpretability and reproducibility. This may impact on timely clinical development and can lead to inadequate reporting and erroneous conclusions on safety and efficacy data. In some circumstances, patient safety and ethics of the trial can be jeopardised, exposing patients to subtherapeutic or even harmful doses.The SPIRIT  2013 Statement provides evidence-based recommendations for the minimum content of a clinical trial protocol.Considering this background, we performed a methodological study to assess the quality of contemporary dose-finding trial protocols. The aims of this study are 1) to determine the reporting quality of early phase dose-finding protocols, based broadly on the SPIRIT 2013 Statement with added items specific to early phase dose-finding trials, and 2) to determine whether the reporting quality differs by trial characteristics.This methodological cross-sectional study evaluated the reporting quality of early phase dose-finding protocols. The study was registered in the international prospective register of systematic reviews PROSPERO (registration no: CRD42022314572).ClinicalTrials.gov. No restrictions were applied to limit types of intervention or setting. To identify the potential full protocols, an electronic systematic search was performed via ClinicalTrials.gov. Details of the systematic search can be found in To be included in this study, protocols had to meet the following criteria: 1) phase I or phase I/II trials that include a dose (de-)escalation component, 2) treated living humans, 3) had their full protocols in English, and 4) posted between 01/01/2017 and 08/02/2023 in Clinicaltrials.gov identifier, study title, first author , study sample size , area of research, protocol year, research funding, multi-centre or single-centre study and type of the dose-escalation design.A standardised Excel spreadsheet was created to extract data from the included protocols. The following variables were collected for all protocols if available: Yes" or "No". For some items, there was the option to select "Not applicable" and these items were not evaluated. For composite items, the option "Partially" was also available .Additionally, to evaluate the reporting quality of the protocols, a checklist of items was created as a combination of 1) original items from SPIRIT 2013 and modified items tailored to dose-finding trials and 2) additional items unique to dose-finding trials considered useful by the review team. The complete list of all 68 items can be found in All included protocols were randomly allocated to at least one member of the study team. Thirteen protocols (12.3%) were reviewed by more than one member to check for discrepancies or potentially spurious data. To standardise the assessment criteria, two roundtable discussions were held during the evaluation period. The first roundtable took place among all authors to discuss the first 8 double-reviewed protocols, where each protocol had been independently reviewed by two authors beforehand. The second roundtable took place when 24 protocols had been assessed in order to review and discuss discrepancies. As a result of these meetings, an internal document was created with examples of good reporting for each item to provide guidance in the subsequent individual protocol assessment . Explicitly, this metric was defined as the number of adequately reported items in all evaluated protocols divided by the total number of applicable items. High proportions would suggest high reproducibility and quality of dose-finding trial protocols. The study also had the following secondary endpoints: 1) percentage of protocols that had reported each item adequately, 2) factors associated with the quality of the protocol and 3) prevalence of the most common statistical designs used oncology and non-oncology in phase I or phase I/II trials.Yes” or “Partially” were combined as ‘adequately reported’ to facilitate result interpretation. Univariable linear regression models were used to study the association between factors of interest and the overall proportion of adequately reported items. A multivariable linear model was evaluated to further identify attributes of the quality of protocol, where the least absolute shrinkage and selection operator (LASSO) regression was used for variable selection. No data imputation was performed and a significance level of 0.05 was set for a two-sided test. All analyses were performed using R statistical software version 4.1.2.The overall proportion of adequately reported items and the percentage of protocols that had been adequately reported per individual item were reported, alongside its corresponding 95% confidence interval (CI) calculated using the Clopper-Pearson method. Items evaluated as “No funding was received for this work.A total of 106 trial protocols were included in the study  and a suOverall, the most used design was the rule-based 3 + 3 design , followed by personalised rule-based designs  and Single/Multiple Ascending Dose (SAD and MAD) designs . There were differences in the types of designs used in the oncology and non-oncology setting . The SADIn the 106 trial protocols included in the study, the overall proportion of adequately reported items was 65.1% (95% CI: 63.9–66.3%). The percentage of protocols with more than 70% of items reported adequately was 22.6% (n = 24) and only 1.9% (n = 2) reported more than 80% adequately. Interestingly, the reporting quality of each individual item varied substantially: the percentage of protocols that reported a specific item ranged from 9.4% to 100% . On the To better characterise the potential differences resulting from funding source or disease area, we compared the reporting quality of each item by i) industry versus non-industry trials and ii) oncology versus non-oncology trials . Overall,The classical paradigm of drug development in health research consisting of three separate phases (I-III) has left its place to a more dynamic paradigm with less barriers between phases. In oncology, the current early-to-late transition, the strategy to move from a promising phase I/II trial directly to a confirmatory phase III trials, highlights the importance of correctly selecting treatment dose level to maximise the chances of a successful further development. Moreover, specific examples of drugs that were evaluated using a potential suboptimal dose have reinforced the necessity to design efficient, robust and replicable early phase trials.,,Although a well-reported dose-finding trial protocol is vital even for simple designs, as the trial designs evolve and get more complex, they are technically more complex to implement than conventional designs. This is especially so to assist in the conduct of trials that require the use of sophisticated and adaptive methods to achieve various objectives simultaneously. The SPIRIT 2013 Statement emerged as a guide to improve the reporting quality of trial protocols. However, the recommendations provided by SPIRIT were created in an era with less personalised and adaptive trial designs and the current quality of early phase trial protocols is unknown due to a lack of specific reporting guidelines.This methodological review evaluated early phase dose-finding protocols from 2017 to 2023 showing a suboptimal quality in the reporting (65.1% of the items were reported adequately). Results from this study are consistent with those previously reported in RCTs trials (56.7%),The items used for evaluating the reporting quality of early phase dose-finding protocols were based broadly on SPIRIT 2013, with additional protocol-related items drawn from the comparison guidance for trial reports of early phase dose-finding trials (in development),Subgroup analysis helped to better identify the type of trial protocols, according to study characteristics, that need more surveillance actions. Non-industry studies with a relatively small sample size presented the lowest reporting quality, and conversely, industry-funded studies, with the use of novel designs and a generally larger sample size, presented a higher reporting quality. In particular, the better reporting quality of industry-funded studies in some sections  could be explained by the fact that these protocols are more likely to be reviewed by regulatory agencies. Non-oncology protocols also showed better reporting quality than oncology protocols. However, this should be interpreted alongside the fact that types of early phase dose-finding designs are notably different across therapeutic areas. Specifically, most of the non-oncology dose-finding trial were randomised studies (66.7%), including a median of 48 patients in the dose-finding part. Whereas randomisation was rarely used in oncology trials (5.2%) and the number of patients evaluable per dose levels was smaller.Although model-based and model-assisted designs had shown better operating characteristics in the dose selection process than rule-based designs,This study has some limitations. First, subjectivity on the part of the reviewers could occur when the reporting was unclear to draw any conclusions, even though an assessment strategy was prepared to minimise the risk. And second, the study was based on a random sample of 80% of eligible protocols. Though it is considered sufficiently large to provide an overall assessment of reporting quality of dose-finding protocols, the number of protocols with some specific trial characteristics could be too small to extract robust conclusions. Strengths include being the first study to comprehensively assess the reporting quality of early phase dose-finding trial protocols, and its wide scope covering both oncology and non-oncology therapeutic areas. Additionally, we have considered a list of additional items that address design features specific to dose-finding procedures to complement the SPIRIT checklist.In conclusion, the current reporting quality of early phase dose-finding trial protocols is suboptimal. These results could be used by the trial community to identify areas that have been poorly reported and require substantial improvement. Additionally, it paves the way for creating a consensus-driven guidance of the minimum essential content to be included in early phase dose-finding trial protocols. This guidance could improve reporting practices and transparency to facilitate the rigorous conduct of future trials.Specific author contributions are as follows. Guillermo Villacampa: Methodology, Validation, Investigation, Data curation, Formal analysis, Visualization, Writing - original draft, Writing - Review & Editing, Project administration. Dhrusti Patel: Methodology, Validation, Investigation, Data curation, Writing - original draft, Writing - Review & Editing, Project administration. Haiyan Zheng: Methodology, Investigation, Data curation, Writing - original draft, Writing - Review & Editing. Jessica McAleese: Investigation, Data curation, Formal analysis, Visualization, Writing - review & editing. Jan Rekowski: Methodology, Investigation, Data curation, Methodology, Writing - review & editing. Olga Solovyeva: Methodology, Investigation, Data curation, Methodology, Writing - review & editing. Zhulin Yin: Methodology, Investigation, Data curation, Methodology, Writing - review & editing. Christina Yap: Conceptualization, Methodology, Investigation, Data curation, Writing - original draft, Writing - Review & Editing, Project administration, Supervision.The findings, interpretations and conclusions expressed in this paper are entirely those of the authors. The funding source did not have a role in the writing or decision to submit for publication. All authors have full access to the full data in the study and accept responsibility to submit for publication.christina.yap@icr.ac.uk).All reasonable requests for data sharing will be considered and should be emailed to Christina Yap (Guillermo Villacampa has received a speaker's fee from MSD, Pfizer, GSK and Pierre Fabre, has held an advisory role with AstraZeneca and received consultant fees from Reveal Genomics. All other authors declare no competing interests.