Physician decision-making skills training is a priority to improve adoption of the cerebral palsy (CP) clinical guideline and, through this, lower the age of CP diagnosis. Clinical guideline implementation aims to improve physician practice, but evaluating meaningful change is complex. Limitations in the validity evidence of evaluation instruments impact the evidence base. Validity frameworks, such as Kane’s, enable a targeted process to gather evidence for instrument scores, congruent to context and purpose. Yet, application of argument-based methodology to implementation validation is rare. Key-features examination methodology has established validity evidence supporting its use to measure decision-making skills, with potential to predict performance. We aimed to apply Kane’s framework to evaluate a pilot key-features examination on physician decision-making in early CP diagnosis.Following Kane’s framework, we evaluated evidence across inferences of scoring, generalisation, extrapolation and implications in a study design describing the development and pilot of a CP diagnosis key-features examination for practising physicians. If found to be valid, we proposed to use the key-feature scores as an outcome measure of decision-making post education intervention to expedite CP diagnosis and to correlate with real-world performance data to predict physician practice.n = 10) and pilot results (n = 10): (1) high internal consistency (0.82); (2) acceptable mean item-discrimination (0.34); and (3) acceptable reliability of examination scorers (95.2% congruence). Decreased physician acceptance of examination time (70%) was identified as a threat and prioritised in case reduction processes. Partial acceptance of generalisation, extrapolation and implications inferences were defensible with: (1) accumulated development evidence following established key-features methodology; (2) high pilot acceptance for authenticity (90%); and (3) plausibility of assumptions of score correlation with population register data.Supporting evidence for acceptance of scoring inferences was achieved through examination development with an expert group (Kane’s approach is beneficial for prioritising sources of validity evidence alongside the iterative development of a key-features examination in the CP field. The validity argument supports scoring assumptions and use of scores as an outcome measure of physician decision-making for CP guideline education implementation interventions. Scoring evidence provides the foundation to direct future studies exploring association of key-feature scores with real-world performance.The online version contains supplementary material available at 10.1186/s12909-023-04631-4. Expediting evidence to practice continues to be a complex challenge for health professions education and health care systems. An average clinical practice time lag of 17 years has been widely reported with apprLimitations in the validity evidence of implementation evaluation instruments have been identified, warranting further investigation . TestingTo address this gap, we applied Kane’s framework to the development of an outcome measure for a tailored implementation intervention targeting an identified research-practice gap in the field of cerebral palsy (CP), the most prevalent motor disability in childhood . Early, The key-features approach to assessment measures a clinician’s essential clinical decision-making skills . Key-feaThis paper describes: 1) the development and pilot of a web-based key-features examination for practising physicians; and (2) Kane’s validation approach of an interpretation use argument for examination scores and evaluating evidence of inferences in a validity argument. An overview of Kane’s validity framework is displayed in Fig.  the deveWe developed a web-based key-features examination to measure clinical decision-making skills in the early diagnosis of CP in practising physicians. The examination was developed so that post-intervention online key feature examination scores could be used as an outcome measure of decision-making skills in a randomised controlled trial (RCT) of e-learning for practising paediatricians in the Australian context. The strength of association of physician key-feature case scores with real-world patient outcomes will be explored through correlation with population CP registers to predict physician performance in diagnosing CP under six-months of age in clinical settings.Based on our proposed use of key-feature examination scores, we articulated assumptions in the interpretative use argument according to Kane’s four-stage chain of inferences , 21. KanTwo previous reviews support the key-features assessment measuring the construct of clinical decision-making , 41. BorEvidence supporting scoring assumptions of internal consistency reliability and test item discrimination can be collected through robust development and piloting phases , 48. An Existing recommendations to optimise reliability and internal consistency support: the use of short menu and write-in responses ; lay lanAlthough the key-features approach is more frequently applied to high-stakes examinations , previouAcceptance of web-based testing conditions for an implementation intervention is also required to support scoring assumptions in our argument. Web-based testing conditions have been explored in practising physicians and need to be considered for construct-irrelevant variance . ScoringGeneralisation inferences refer to the degree to which a single examination score represents all possible performances in the test domain and context . GeneralStrong evidence is required in our validity argument to support extrapolation claims of associations of key-feature examination scores with clinical performance and patient outcomes. No studies exploring the correlation of key-feature examination scores post-educational intervention with impact on future practice or patient outcomes were identified in previous reviews. Tamblyn et al., , 40, 58 Implications evidence is less frequently reported in key-features literature, aligning with validity evidence gaps previously identified in health professions education , 61. TheIn developing an interpretation use argument we considered assumptions of inferences that could be identified a priori on the basis of existing evidence or following established guidelines and those that could be achieved through examination development and piloting phases. For stronger assumptions, such as correlation with external criteria, we have specified the research methodology and other sources of evidence required in future validation studies to support these claims.Determining the strength in the association of examination case scores with other related measures of clinical performance requires plausibility in assumptions and validity evidence of the associated measure. We have identified two population-based CP registries for the purpose of correlation with physician key-feature case scores in future validation studies. Each Australian state and territory has a CP register, with data aggregated into one single population register. Registration is offered to parents after a clinical diagnosis of CP is confirmed or taken as a mandatory report under the public health act. Australia’s National Disability Insurance Agency (NDIA) provides funding for parents to buy early intervention for eligible children with a clinical CP diagnosis. Physician referrals to these national CP datasets have been included in the evaluation framework of the RCT to enable correlation of association with key-feature case scores .The interpretation use argument and evaluation framework outlining the underpinning assumptions, research questions and type of validity evidence required to support the validity argument is outlined in Table Development of a web-based key-features examination with an expert advisory group supervised by a key-features field leader (EF); (2) Pilot of the examination to determine internal-consistency, item discrimination, acceptance with practising physicians, and reliability of examination scorers; and (3) Refinement of the final examination. Our hypotheses for the pilot study given our intended interpretation and use of examination scores are provided in Table The purpose of the exploratory study was to: (1) repurpose the key-features approach to assessment for practising physicians in the field of CP; and 2) evaluate the validity evidence of key-features examination scores. The study was comprised of three phases: (1)  evaluateThe study received ethical approval from The University of Sydney Human Research Ethics Committee (Project number 2020/008).n = 8), medical education (n = 1) and the key-features approach (n = 1). The early diagnosis of CP experts were purposely selected from the authors of the CP guideline [Examination development was conducted between June 2020 and March 2021. The key-features development group comprised a 10-member expert panel involving experts in the early diagnosis of CP  review of published practice guidelines for the early diagnosis of CP , 64, 65;Expert advisory group participants were invited to complete an 8-question demographic survey and attend an online training workshop on the key-features approach. Participants were provided with online resources prior to the training workshop including: video resource lectures and PowerPoint presentations on the conceptual background to the key-features approach and key-feature case writing (available by contacting corresponding author), key-feature writing fact sheets  or ‘write-in’ responses (answer given in short note format) were used. Scoring involved a case score, ranging between 0 and 1, which was comprised of the average of the key-feature questions within each case. Each key-feature was weighted evenly. A total examination score was achieved by the sum of the case scores.During the training session participants were assigned writing partners and broken into writing groups. Each writing group was asked to define key-features for a problem from an examination blueprint domain, source relevant references for key-features and write key-feature cases. Small group writing sessions were followed by whole group discussions for panel agreement on key-features and critical actions of each case. Following the training workshop, writing partners were asked to write a minimum of two further key-feature cases within an 8-week time frame. Authors  facilitated an iterative process via email with panel members to review cases and scoring keys and obtain consensus on key-features. The development group wrote a total of 21 cases with 2–5 key-features per case  to achieve final agreement that key-features assessed critical areas of the case and about wording of questions, scoring keys and authenticity of scenarios. Disagreements were resolved via email. ‘Write-in’ responses for questions assessing communication skills required the greatest number of revisions of scoring keys.n = 3) to affirm comprehensibility. The examination was accessible via a REDCap [Examination instructions were developed, including downloadable fact sheets and video instructions. Instructions included key-features assessment tips, scoring information, and examples of ‘select from list’ and ‘write in’ question formats. Instructions were piloted (a REDCap  survey ln = 3).Usability of the 21-case examination was tested using a think-aloud process  with an Pilot group participants were practising paediatric physicians recruited from across Australia. Participants were invited to participate via an advertisement in the Royal Australasian College of Physicians newsletter and email distribution of opinion leaders in the early diagnosis of CP.Examination piloting was conducted between April and June 2021. Participants were invited to complete a 10-question demographic survey prior to commencing the online examination. They were provided with information about the examination procedure, scoring and testing conditions. Specifically, participants were asked to complete the examination under closed-book testing conditions and told the anticipated time to completion was 90-min. Participants were asked to confirm that they had read the examination instructions and agreed to closed-book testing conditions. Key-feature cases were named, and a progress bar was provided throughout the examination. An email reminder was sent up to three times for participants who partially completed the examination. Upon completion of the examination, participants were invited to complete a 9-question user experience survey. User acceptance questions developed by Bronander et al  were adaExaminee responses were de-identified. An initial scoring meeting was conducted with the research group to review score reports, scoring keys and write-in responses. Each case was reviewed for clarity to gauge if the question was behaving as intended from examinee comments. Refinements to scoring keys and instructions for scorers were actioned.A masked assessor, independent of the research group, conducted scoring on all cases. The masked assessor was an experienced clinician in early CP diagnosis and was provided with a training session on the scoring keys and key-feature fact sheet training resources. A second scoring meeting was conducted with the masked assessor and research team, further refinements were made to scoring keys, and a final round of scoring was conducted by the research group and masked assessor.Descriptive statistics were used to analyse the score distribution on demographic and user acceptance surveys. User acceptance questions comprised five-point Likert scale answer options. The analysis combined the responses ‘strongly agree’ with ‘agree’ and ‘strongly disagree’ with ‘disagree.’ For the question comparing the difficulty of the key-feature examination to a standard multiple-choice examination, the analysis combined ‘much more difficult’ with ‘more difficult’ and ‘less difficult’ with ‘much less difficult.’ Internal consistency was calculated from case scores using Cronbach’s alpha. Case difficulty was estimated from mean averaged case scores. Case score item-discrimination and inter-item total correlation were calculated. A factor analysis was not anticipated due to the small sample size of the pilot but would be considered after inspecting the correlation matrix for a correlation coefficient over 0.30.Twenty-eight participants completed the demographic survey. Nineteen participants commenced the key-features examination; however, data from 9 participants are not included in the main analysis as they did not complete the examination, resulting in 10 records for descriptive and correlation analysis. All these 10 participants completed the user experience survey. Overall, the majority of participants identified as paediatricians (80%), had ten or more years’ experience in CP diagnosis (60%), worked clinically in a hospital setting (90%), and less than 10% of their caseload comprised CP patients 70%). The majority of participants reported awareness of the Novak et al  guidelin%. The maThe cases and key-features of the pilot examination of 21 cases were mapped to the examination blueprint  was 0.83 on the 21-case examination. Mean inter-item correlation was 0.21 and mean item-discrimination was 0.24 (SD = 0.15). The average mean score was 0.56 (SD = 0.24). A factor analysis was not possible with a small sample size and mean inter-item correlation was less than 0.30. Table No statistical analysis was performed due to the small sample size; however mean scores according to awareness of guidelines, clinical caseload, and prior training in the early diagnosis of CP recommended tests were reviewed . Average mean case or question time was not able to be calculated for all participants with accuracy as absence from the platform could not be accounted for.There was strong agreement (70%) that the examination and scoring instructions were clear. Authenticity was well supported, with 90% of participants agreeing that cases resembled problems from clinical practice. The majority of participants (70%) reported that the time taken to complete the examination was not acceptable. In comparing the format to a multiple-choice examination, most participants (60%) reported no difference in difficulty.The range of problems highlighted what I need to learn more about.”In free-text responses in the user experience survey about the online testing format and unsupervised conditions, there were six comments in total, all in favour of the online testing conditions. Participants described the clarity and flow of the examination, the interesting variety of cases that were similar to patients they saw in practice, and the learning value of the examination as aspects they liked best: “In regard to aspects they would most like to change about the examination, the length of the examination was highlighted by four participants. One participant identified a lack of immediate feedback, and that question complexity was difficult for a general paediatrician. One participant advised that the use of the words ‘investigation’ and ‘assessment’ may be misread in questions. Participant feedback responses and pilot data were used to enhance further development of the examination.Reducing the time burden for physicians in practice was prioritised in the refinement phase to enhance acceptance along with exploration of questions or cases for sources of irrelevant variance. A further review of language was conducted for clarity and appropriateness, with particular attention to questions assessing communication skills.Initial reviews focused on case scores with item-discrimination values under 0.2 , key-feaDescriptive statistics for a final examination of 11 cases and 27 key feature questions demonstrated reliability with Cronbach’s alpha 0.82, mean inter-item correlation of 0.30, and an average mean score of 0.54 (SD = 0.28). We estimated the length of examination time as under 1 h. This was confirmed with 3 practising clinicians. The distribution of the 11 cases mapped to the blueprint is described in Supplementary Material File An overarching validity argument was constructed through the synthesis of evidence across the chain of inferences from our specified interpretation and use of key-feature examination scores. The established validity evidence supporting assumptions and organised by each level of inference is summarised in Table Acceptance of scoring inferences are defensible through: (1) appraisal of empirical evidence supporting the key-features methodology measuring the construct of clinical decision-making skills; and (2) collection of prioritised new evidence through examination development, piloting and refinement phases of this study. Experts in CP and the key-features methodology followed a robust process to develop key-features cases backing the scoring assumption that the construct in the newly developed CP key-features examination measures clinical decision-making skills. Piloting of the examination with practising physicians provides sources of evidence to support psychometric test item qualities, reliability of scoring and online testing conditions. Examination pilot data provides supporting evidence for the interpretation-use argument and acceptance of pilot study hypotheses: (1) high internal consistency final examination ; (2) acceptable item-discrimination final examination (2.1) item-difficulty levels between 0.2 and 0.8 in all final 11 cases; (2.2) mean inter-item-correlation of 0.30; (2.3) mean item-discrimination of 0.34; (3) user acceptance (3.1) acceptance of online format through user feedback; and (4) acceptable reliability of examination assessors . The scoring inference not accepted following examination piloting was (3.2) acceptability of examination time for practising physicians (70% reported not acceptable). Further sources of evidence for this assumption were prioritised in the examination refinement phase, justifying acceptance of the final examination time following a robust case item reduction process.Acceptance for generalisation inferences of influence of prior early diagnosis of CP training and years of experience in mean case scores is limited by the small sample size of pilot data, prohibiting statistical analysis. However, differences in mean case scores were observed with CP specialisation and prior training in gold standard early diagnosis of CP tests.Partial acceptance of extrapolation inferences for the context of the use of examination scores in a future RCT to reflect clinical decision-making skills in the real-world is defensible through evidence collected during development and piloting phases: (1) rigorous research prioritisation processes to establish domains; (2) content representation to the domain of clinical decision-making skills in the early diagnosis of CP; (3) expert advisory group consensus of key-feature cases, and (4) pilot data supporting authenticity of cases (90% agreement). The accepted chain of inferences in the interpretation use argument to date provides the necessary foundation to support the plan to gather new evidence of association of examination scores with clinical performance and patient outcome measures in a future RCT.The progression from examination scores to assumptions about individuals’ outcomes and implications was considered from the perspectives of: (1) the physician completing the examination; (2) the infant with a CP diagnosis and their parents/carers; and (3) the key-feature examination developer. Acceptance of key-feature cases as authentic and driving interest in learning was supported with pilot physician feedback. The consequences of the examination driving learning in physicians will be considered in the RCT post-test design to reduce this validity threat. The future RCT will evaluate the association of physician examination scores with physician referrals to CP population registers and the Australian National Disability Insurance Scheme. The RCT methodology enables the collection of new validity evidence to support or refute our assumptions of association of physician examination scores with patient outcomes of age of diagnosis and early intervention and funding supports . The resThrough application of an argument-based approach, validity evidence was collected for the use of key-feature case scores as an outcome of a tailored implementation intervention for physician CP diagnosis. Feasibility of key-feature case development with CP experts was achieved. Validity evidence evaluated through examination development and piloting supports acceptance of scoring assumptions of Kane’s framework and partial acceptance of generalisation, extrapolation, and implications assumptions. Future studies will target sources of criterion relationships validity evidence to strengthen the argument for real-world performance and patient outcomes.The high reliability achieved with low key-feature case numbers was surprising, with up to 40 cases recommended to achieve internal consistency reliability coefficient of 0.8 from previous studies . HeterogOur finding of low acceptance of a 90-min 21-case examination highlights the importance of reducing the time burden for practising physicians. This result is congruent with field leader recommendations that optimisation of time is an essential consideration regarding physician participation in continuing professional development  and reseThe feasibility of the assessment of physician communication skills when delivering a diagnosis using the key-features approach is significant. An increased time burden was identified for ‘write-in’ responses for communication questions by pilot participants and developers, who advised reducing sources of irrelevant variance in scoring key development. Further investigation of key-feature questions assessing communication skills is warranted.That our pilot key-feature cases stimulated an interest in learning is not surprising as it is well accepted that assessment drives learning –80 and tThis study demonstrates strength in providing a worked example of a validity argument in the fields of CP, implementation science and continuing professional development outcome measures. The study methodology has potential for replication in other high-, middle- and low-income country contexts targeting adherence to clinical guidelines in CP diagnosis. This study is limited by the small pilot sample size and by not substantiating all assumptions in the interpretation use argument, however, defensible scoring evidence provides the necessary foundation for Kane’s chain of inferences and the weakest inferences identified are the primary focus in future validation studies.This study answers the call to appraise the validity evidence of health professions education and implementation instrument scores. The key-features approach shows good application in the field of CP. Argument-based validity frameworks can be applied to evaluations of health professional implementation.Additional file 1: Supplementary File 1. Key- Features Writing Fact Sheet.Additional file 2: Supplementary File 2. Key-Features Writing Template.Additional file 3: Supplementary File 3. Example of a cerebral palsy key-features case and questions.Additional file 4: Supplementary File 4. Tables.


Demarcation line in a rhegmatogenous retinal detachment (RD) is a classic finding noted in chronic cases. In this case report, we describe a case of evolution of post-operative demarcation line after pneumatic retinopexy (PnR) in a subtotal rhegmatogenous RD.A 31-year-old male diagnosed with acute, subtotal, macula-off rhegmatogenous RD in the left eye of 15-day duration underwent PnR on the same day. His presenting visual acuity was 6/48 in the left eye. Transconjunctival cryopexy was performed to the retinal break at the same sitting and 0.5 cc of 100% perfluoroproprane (C3F8) gas was injected in the vitreous cavity and right lateral position was advised to the patient.A pigmentary demarcation line was noted extending the nasal part of the macula along the most dependent part of the detachment on the immediate post-operative day and was more obviously visible on the 2nd and then on the 11th post-operative day. The visual acuity at the last follow-up visit improved to 6/18. Successful reattachment of the retina was noted on the last follow-up visit.Post-operative demarcation lines after RD surgery could develop due to subretinal migration of pigments and along the most-dependent part depending upon post-operative positioning of the patient. Careful post-operative positioning, particularly in macula splitting RDs could be important to avoid pigment accumulation along the foveal area. A rhegmatogenous retinal detachment (RD) is a type of RD caused by a retinal tear of full thickness that allows vitreous fluid to enter the subretinal space . In rhegPneumatic retinopexy (PnR) is a non-incisional, minimally invasive technique for repairing RD . It invoThis report describes a case of subtotal acute RRD in which a demarcation line appeared following a successful PnR, and the plausible causes for its development.A 31-year-old male presented to the retinal clinic of a tertiary eye hospital with complaints of sudden loss of vision in the left eye for the last 15 days. He had no history of ocular trauma or any other systemic illness. The present visual acuity of the right eye was 6/6 and the left eye was 6/48, respectively with emmetropic refraction. Examination of the anterior segment and measurement of intraocular pressure in both eyes were normal. A dilated fundus examination of the left eye revealed a clear media, normal retinal vasculature, and a subtotal temporal macula-off RD with retinal corrugations. A large oval retinal break was identified on the temporal aspect of the peripheral retina, anterior to the equator at the 4 o’clock meridian, measuring nearly two-disc diameters laterally and having rolled-up posterior margins. There were no indications of chronic RD, such as demarcation line, retinal cyst, subretinal or preretinal membranes  gas was injected into the vitreous cavity. By repeatedly tapping the eyeball with a cotton applicator, multiple small gas bubbles coalesced into one large gas bubble. The intraocular pressure was measured digitally, and perfusion of the optic disc was observed with an indirect ophthalmoscope. Patient was instructed to assume a right-lateral position for at least 5 days after eye patching.The anterior segment examination and intraocular pressure measurement of the left eye on the first postoperative day were within normal limits. Left fundus dilation revealed a single gas bubble with decreased subretinal fluid. In addition, a faintly visible vertically oriented black pigmentary line was observed at the junction of the attached and detached retina on the nasal aspect of the fovea extending beyond the inferior retinal arcade during the clinical examination, along the most dependent part of the RD. The patient was instructed to maintain the post-operative position and return the next day for a follow-up. The following day, the left eye’s visual acuity had improved to 6/18 and the subretinal fluid had significantly decreased. At this visit, the pigmentary line was prominent. At the final visit 11 days after the procedure, the RD had completely reattached, and the pigmentary line was now clearly visible Fig. A. On theThis report describes a patient with subtotal acute RD who developed a pigmented demarcation line following a successful PnR procedure to reattach the retina along the most dependent part of the RD while maintaining post-op positioning. The location of the retinal break , the characteristics of the RD  and the patient characteristics (young patient with no preexisting glaucoma history and with no problem in maintaining the required post-procedure position) made this an ideal case for PnR. The potential reasons cause for the development of the post-operative demarcation line in this case is provided herewith. The infrared channel’s hyper reflectance confirms the presence of melanin and, by extension, retinal pigment epithelial cells in the subretinal space. Melanin absorbs light with short wavelengths and reflects light with longer wavelengths , 7. The Following the procedure, visual acuity improved in this case as the demarcation line was away from the foveal center. The accumulation of retinal pigment epithelial cells in the foveal neurosensory space could result in diminished visual acuity. To prevent the accumulation of retinal pigment epithelial cells at the fovea, it would be necessary to take certain measures when performing PnR. These include a PnR in which only a small gas bubble is initially injected, followed by retinopexy with not-so-heavy laser burns or cryotherapy around the retinal break as soon as the retina attaches to prevent the release of retinal pigment epithelial cells and close the subretinal space’s entrance . Avoid mIn conclusion, post-operative demarcation lines can develop after PnR along the most dependent part of the RD during post-operative positioning. Steps taken to prevent pigments from entering the subretinal space will prevent this potentially vision-threatening complication.


Functional atrial mapping is an emerging mapping modality to predict potential critical sites with a role in the maintenance of tachycardia. We report a case of atrial late activation mapping under sinus rhythm predicting the critical isthmus of a left atrial tachycardia. Our findings demonstrate the utility of an atrial isochronal late-activation mapping approach to predict the critical isthmus of re-entry. Atrial tachycardia (AT) is a common rhythm disorder, especially in atrial fibrillation (AF) patients with low-voltage areas, attributed to either previous atrial substrate ablation or a de novo scar. High-density activation mapping is a useful method to understand the tachycardia mechanism; however, not all ATs are inducible during the electrophysiological study. Voltage mapping provides important data regarding the underlying atrial substrate to predict critical sites of tachycardia, but the functionality of such a substrate having a role in arrhythmia mechanisms has yet to be confirmed.®; Biosense Webster, Diamond Bar, CA, USA) revealed low-voltage areas in the anterior wall and the roof of the left atrium with isolated pulmonary veins (PVs) . Isochronal late activation mapping (ILAM) during sinus rhythm using a multispline high-density catheter  demonstrated a deceleration zone (DZ) on the anterior wall with continuous fragmented signals in the latest activated zone . Briefly, ILAM was created during sinus rhythm manual annotation at the offset of the latest atrial deflections from the baseline. The total atrial activation window was set between the onset and the offset of the earliest local electrogram (EGM), which was divided into 8 equally distributed isochrones. DZs were defined as the areas with >3 isochronal colors within a 1-cm radius. Programmed stimulation induced a localized figure-of-8 re-entry on the anterior wall with fragmented EGMs at the critical isthmus, which was directly correlated with the DZ of ILAM . During mapping, episodic degeneration of AT into AF was observed. Ablation from this site terminated AT. An anterior mitral line from the mitral annulus to the right superior PV was created, including the DZ of ILAM as well as fragmented EGMs in the low-voltage region . The patient was free of any AT/AF during the 6-month follow-up period.Here, we report a case of recurrent AT/AF in a 65-year-old female patient with previous cryoballoon ablation for persistent AF. Voltage mapping using 3-dimensional electroanatomic mapping (CARTO1 In addition, recent reports have demonstrated the usefulness of atrial late activation mapping during sinus/paced rhythm to reveal the critical isthmus of ATs.3 Similar to these data, our findings corroborated the utility of an atrial ILAM approach to predict the critical isthmus of a re-entry circuit. Functional evaluation of the underlying substrate might be considered to tailor the ablation strategy in re-do procedures with isolated PVs.The utility of functional substrate mapping for ventricular tachycardia has long been known to predict the critical isthmus of re-entry.


Dry-processed rubberized asphalt mixture has recently attracted a lot of attention as an alternative to conventional asphalt mixtures. Dry-processed rubberized asphalt pavement has improved the overall performance characteristics compared to the conventional asphalt road. The objective of this research is to demonstrate the reconstruction of rubberized asphalt pavement and evaluate the pavement performance of dry-processed rubberized asphalt mixture based on laboratory and field tests. The noise mitigation effect of dry-processed rubberized asphalt pavement was evaluated at the field construction sites. A prediction of pavement distresses and long-term performance was also conducted using mechanistic-empirical pavement design. In terms of experimental evaluation, the dynamic modulus was estimated using materials test system (MTS) equipment, the low-temperature crack resistance was characterized by the fracture energy from the indirect tensile strength test (IDT), and the asphalt aging was assessed with the rolling thin-film oven (RTFO) test and the pressure aging vessel (PAV) test. The rheology properties of asphalt were estimated by a dynamic shear rheometer (DSR). Based on the test results: (1) The dry-processed rubberized asphalt mixture presented better resistance to cracking, as the fracture energy was enhanced by 29–50% compared to that of conventional hot mix asphalt (HMA); and (2) the high-temperature anti-rutting performance of the rubberized pavement increased. The dynamic modulus increased up to 19%. The findings of the noise test showed that at different vehicle speeds, the rubberized asphalt pavement greatly reduced the noise level by 2–3 dB. The pavement M-E  design-predicted distress illustrated that the rubberized asphalt pavement could reduce the IRI, rutting, and bottom-up fatigue-cracking distress based on a comparison of prediction results. To sum up, the dry-processed rubber-modified asphalt pavement has better pavement performance compared to the conventional asphalt pavement. Due to an increase in the number of vehicles on the road, millions of tires are produced each year ,2. An efNumerous researchers have focused on using crumb rubber to enhance the pavement performance in wet processes. Kirk et al.  found thA number of researchers have made contributions to the application of crumb rubber-modified asphalt pavement in the dry process. Some researchers ,14,15 haAccording to the previous study, the study of dry process rubber asphalt mixture performance in the cold and wet regions is limited, and the long-term performance of crumb rubber-modified asphalt pavement still needs more effort and study, especially for the mechanistic-empirical pavement distress prediction for crumb rubber-modified asphalt pavement. The purpose of this study was to demonstrate the reconstruction of crumb rubber-modified asphalt pavement and evaluate the high-temperature and low-temperature properties of dry process rubberized HMA and predict the 20 years’ of service life pavement distress based on the Pavement M-E design. The dynamic modulus test and indirect tensile strength test were conducted, and rheology characteristics were evaluated based on the experimental performance. Additionally, the noise level of the road performance was evaluated before and after the reconstruction.Loose materials were collected from construction on County Road 607 . Rubberized asphalt pavement by dry process and conventional asphalt pavement (without crumb rubber but with the same gradation) are compared in this project. Based on the Michigan Department of Transportation (MDOT) specification, the mix design is based on the Superpave mix design procedure (AASHTO M 323) for both dry-processed rubberized asphalt mixture and conventional asphalt mixture. Details of the aggregate gradation of the HMA are shown in In this project, the crumb rubber was employed, as shown in Traffic input has a great influence on the prediction of road performance. The road construction and thickness are affected by the average annual daily truck traffic (AADTT). Michigan’s low and medium traffic volume was selected. The typical lane’s design life is estimated to be 20 years. The pavement has two lanes with a speed limit of 65 miles per hour (105 km per hour). The truck volume is 51% in this study. In the design lane, 92 percent of the trucks have a medium traffic level, while 65% have a high traffic level. The growth rate of traffic is 2% (compound). The vehicle class distribution, monthly and hourly adjustment factors, and axle load distributions are based on the results from the Michigan Dept. of Transportation’s report .The following are the results of the laboratory mixture experiments: the dynamic modulus (|E*|), the indirect tensile strength of the HMA layer, and the complex shear modulus (|G*|) of the asphalt binder. Then, a sensitivity analysis of the DSR results and dynamic modulus results was estimated by M-E design based on the prediction of pavement distress. Stone, sand, viscous asphalt binder, and additives make up the crumb rubber-modified asphalt mixture, which is a viscoelastic composite material. In the mechanical-empirical pavement design program, dynamic modulus (|E*|) is a critical material attribute. The loose mixture was compacted to 7 percent air void content. The master curve for |E*| was created according to the test results. The test was conducted in accordance with . The appThe IDT strength and failure energy of the field condition obtained from the field core can be reflected using indirect tensile strength. The samples are conditioned for 3 h at −10 °C before the IDT test. The loading speed is 12.5 mm per minute. For the test, at least three field cores should be used. The load and displacement curves are used to compute the failure energy. The test is according to standard AASHTO T 322 . The faifG = failure energy (Joules/m2),fW = work of failure (Joules),D = specimen diameter (mm),t = specimen thickness (mm).The DSR test evaluates the viscosity and elasticity of asphalt binder. DSR is tested at temperatures ranging from 34 to 82 °C, with a 6 °C interval. Glass bottles shaped like cylinders are filled with all of the unaged asphalt, which is then placed within a spinning carriage inside of an oven for 85 min pass, with the carriage turning in the 163 °C oven. The short-term aging process of the samples is according to the rolling thin-film oven (RTFO) procedure. The pressure aging vessel (PAV) simulates a long-term aged asphalt. In the Pavement M-E program, the laboratory test results are used as M-E inputs, and the properties of the mixture are described as a level 1 input. The test results are based on at least three samples, and the DSR results are used to create the complex shear modulus (|G*|) master curve. The test is conducted according to AASHTO T 240  and AASHThe Pavement M-E was applied to determine the pavement performance, particularly considering the cracking and rutting distress . The ratThe noise of asphalt pavements was assessed in this study, it has a 0.1 dB resolution and a 1.5 dB accuracy and it was 15 feet away from the car when the measurement was being made. Different roads’ noise levels were measured, as displayed in Phase angle and G* show the viscous and elastic properties of asphalt binders . The resThe rutting parameter (|G*|/sinδ) and fatigue parameter (|G*|×sinδ) can be used to reflect the rutting resistance and fatigue resistance of asphalt binder. The results of the rutting parameters and fatigue parameters of the asphalt binder are illustrated in The dynamic modulus could reveal the relationship between deformation and load . Figure The stiffness of the HMA was estimated by the rutting parameter. The failure energy could be used to indicate the cracking potential . The craThe predicted pavement distress results at 1000 AADTT level are shown in The field construction process is shown in This study measured the noise levels of three types of asphalt pavement test sections and old asphalt pavement. The noise results are displayed in (1)The dynamic modulus test showed that the rubber-modified asphalt mixture has higher rigidity compared to that of a typical asphalt mixture, in which the dynamic modulus increased up to 19% at a different reduced frequency. The improved dynamic modulus could contribute to a better rutting resistance at various temperatures and frequencies.(2)The indirect tensile test results showed that the rubberized asphalt mixture enhances the cracking resistance compared to the typical asphalt mixture at low temperatures since the failure energy was increased by 29–50% after rubber-modification compared to that of control HMA.(3)The evaluation results of the asphalt binder reveal that compared to conventional asphalt, the rubber-modified asphalt binder shows improved high-temperature and fatigue properties.(4)The noise results illustrated that the rubberized asphalt pavement significantly reduced the noise level by 2–3 dB on the road compared to newly constructed conventional asphalt pavement at various traffic speeds. The noise mitigation effect of rubber-modified asphalt pavement was verified in the field.(5)The pavement M-E analysis showed that the rubber-modified asphalt pavement could reduce the IRI, rutting, and bottom-up fatigue-cracking in comparison with that of the normal asphalt pavement.The objective of this research is to demonstrate the reconstruction of rubberized asphalt pavement and evaluate the pavement performance of dry-processed rubberized asphalt mixture based on laboratory and field tests. Some findings can be summarized below:In conclusion, the use of rubber asphalt mixes that have undergone dry processing during pavement construction increased the pavement’s resistance to permanent deformation, thermal cracking, and fatigue. Meanwhile, the tire noise was also obviously mitigated on rubber-modified asphalt pavement. Consequently, the dry-processed rubber-modified asphalt pavement has better performance than the conventional asphalt pavement.


To cope with the persistence of the COVID-19 epidemic and the decrease in antibody levels following vaccination, a third dose of vaccine has been recommended in the general population. However, several vaccine regimens had been used initially for the primary vaccination course, and the heterologous Vaxzevria/Comirnaty regimen had shown better efficacy and immunogenicity than the homologous Comirnaty/Comirnaty regimen.We wanted to determine if this benefit was retained after a third dose of an mRNA vaccine.We combined an observational epidemiological study of SARS-CoV-2 infections among vaccinated healthcare workers at the University Hospital of Lyon, France, with a prospective cohort study to analyse immunological parameters before and after the third mRNA vaccine dose.Following the second vaccine dose, heterologous vaccination regimens were more protective against infection than homologous regimens (adjusted hazard ratio (HR) = 1.88; 95% confidence interval (CI): 1.18–3.00; p = 0.008), but this was no longer the case after the third dose . Receptor-binding domain-specific IgG levels and serum neutralisation capacity against different SARS-CoV-2 variants were higher after the third dose than after the second dose in the homologous regimen group, but not in the heterologous group.The advantage conferred by heterologous vaccination was lost after the third dose in terms of both protection and immunogenicity. Immunological measurements 1 month after vaccination suggest that heterologous vaccination induces maximal immunity after the second dose, whereas the third dose is required to reach the same level in individuals with a homologous regimen. What did you want to address in this study?Different vaccine combinations were initially used to immunise populations against COVID-19. Others and we previously found that the mixed Vaxzevria/Comirnaty combination was more effective and immunogenic than the matched Comirnaty/Comirnaty one. We wanted to determine if this benefit was retained after the third vaccine dose.What have we learnt from this study?In a study of SARS-CoV-2 infections among vaccinated healthcare workers, we confirmed that mixed vaccination regimens were more protective against infection than matched regimens, but this was no longer the case after the third dose. Antibody titres and neutralising capacity were higher after the third dose than after the second dose in the matched regimen group, but not in the mixed group.What are the implications of your findings for public health?A third dose of mRNA vaccine significantly improves the antibody response against SARS-CoV-2, and mixed combinations of vaccines are not required to reach good immunity if a third dose is administered.In response to the COVID-19 pandemic, several vaccines were rapidly designed and administered to the population, inducing a protective immunity composed of both neutralising antibodies and virus-specific T lymphocytes. As multiple vaccines were available, different heterologous combinations of prime/boost doses have been used in patients. This mixing of vaccines was motivated first by the necessary adaptation to limited vaccine supply, but also by the rare observation of vaccine-induced severe adverse reactions with some vaccines. Most studies have reported similar or higher immunogenicity following heterologous primary vaccination involving Vaxzevria  and the mRNA vaccines Comirnaty ) and Spikevax  compared with homologous vaccination composed of mRNA vaccines only (either Comirnaty and Spikevax) . For exaRecent reports demonstrate that most COVID-19 vaccines delivered as a third dose booster significantly enhanced both humoral and cellular anti-SARS-CoV-2 immunity . NeverthTo address this question, we compared spike-specific immunity and protection against infection conferred by a second and third dose of mRNA vaccine in healthcare workers (HCW) primed with either adenovirus-based Vaxzevria or a COVID-19 mRNA vaccine.https://github.com/genepii/seqmet). Clades and lineages were determined on samples with genome coverage > 90% using Nextclade and PangoLEARN, respectively.Testing of HCW for SARS-CoV-2 was performed using routine diagnostic procedures in the virology laboratory of the University Hospital of Lyon  and included: transcription mediated amplification (TMA) , loop-mediated isothermal amplification (LAMP)  and RT-qPCR with different kits . To determine the prevalence of SARS-CoV-2 variants of concern (VOC) in HCW, available positive samples with quantification cycle (Cq) < 28 were sequenced using COVIDSeq (Illumina) as previously described . LibrariWe extracted data from the occupational medicine database of the HCL. A total of 13,489 HCW working at HCL throughout the study period (15 December 2021–21 March 2022) were included. Only subjects who (i) had never contracted COVID-19, (ii) were primed with Vaxzevria or an mRNA vaccine and (iii) had received the second or third dose of an RNA vaccine were included in the epidemiological analysis. We provide the details of the recruitment in Eighty-eight HCW naive for COVID-19 and vaccinated with Comirnaty and/or Vaxzevria and/or Spikevax were included in a prospective longitudinal cohort study conducted at the HCL. Blood sampling was performed before vaccination, before and 4 weeks after the second and the third dose of vaccine. The absence of previous SARS-CoV-2 infection was confirmed using the Abbott SARS-CoV-2 anti-N Ab total assay in all samples .Serum specimens were immediately stored at −80 °C after blood sampling. Receptor-binding domain (RBD)-specific IgG antibodies were measured using the Vidas SARS-CoV-2 IgG diagnostic kit . For standardisation of these assays to the first World Health Organization international standard, the concentrations were transformed into binding antibody units per mL (BAU/mL) using the conversion factors provided by the manufacturer.50) was ≥ 20 PRNT50 for neutralising antibodies. All experiments were performed with a subset of serum specimens collected longitudinally from 15 subjects in each group. The different viral strains that were used were sequenced and deposited in GISAID (https://www.gisaid.org/)A plaque reduction neutralisation test (PRNT) was used for the detection and titration of neutralising antibodies as previously described . NeutralThe descriptive statistics generated appropriate figures and parameters according to type of variable . The comparisons between groups were done using the chi-squared test for categorical variables and non-parametric test or Student’s t-test according to the distribution for continuous variables. The cumulative probability of COVID-19 was based on the Kaplan–Meier survival analysis, and survival distributions were compared using the LogRank test. A univariate and multivariate Cox proportional hazard model was performed to identify the determinants independently associated with onset of COVID-19 according to their hazard ratio (HR) and their 95% confidence intervals (CI). All p values were two-tailed. A value of p < 0.05 was considered as statistically significant. To compare clinical parameters in the immunological study, Wilcoxon–Mann–Whitney two-sided tests were used for quantitative variables and chi-squared or Fisher’s exact test were used for qualitative variables when appropriate. Adjusted p values were calculated using the Benjamini–Hochberg method. To analyse biological data in the immunological study, we used a multiple linear regression model, with adjustment variables .Using the extracted database from the occupational medicine database of the HCL, we compared the risk of SARS-CoV-2 infection following a second or third dose of COVID-19 mRNA vaccine (Comirnaty or Spikevax) in subjects who received a priming dose of Vaxzevria or Comirnaty vaccine. As the third dose was mandatory for healthcare workers 6 months after the second dose, most of them had received their third dose before the start of the study, i.e. by 15 December 2021. This explains the lower proportion of HCW with two doses at the start of the study. We focused on individuals not previously infected with SARS-CoV-2 (PCR or antigenaemia-positive diagnosis) before vaccination to avoid any bias linked to hybrid immunity .We monitored infection rates in HCW after the second or the third booster dose in each group. We extracted SARS-CoV-2 infection incident events documented by positive antigen or RT-PCR tests that occurred between 15 December 2021 and 21 March 2022. This period corresponded to the Omicron  wave, succeeding the Delta variant  and preceding the appearance and increase of the Omicron sub-lineage BA.2 (Clade 21L) . The proCovid-Ser cohort that we have previously described and which includes a subset of voluntary HCW in whom anti-SARS-CoV-2 immunity is measured longitudinally over time  . We thenIn We previously showed in a real-world observational cohort study in HCW that the heterologous Vaxzevria/Comirnaty combination confers better protection against SARS-CoV-2 infection than the homologous Comirnaty/Comirnaty combination . Here, wOur results show that (i) the third dose with an mRNA vaccine equalises the levels of effectiveness of heterologous or homologous COVID-19 vaccine regimens and (ii) that serum neutralisation capacity against different SARS-CoV-2 variants is comparable in both groups 4 weeks after the booster. Indeed, the third vaccine dose did not increase antibody levels and neutralisation capacity beyond those observed 1 month after the second dose in the heterologous group, which suggests that a maximal immunity level 1 month post vaccination is already reached after the second dose in this group and cannot be boosted further, at least with an mRNA-based vaccine. While we cannot exclude that either a shorter or a longer delay between the second and third doses would have a different impact in the heterologous vs homologous group, our results are in line with those of Accorsi et al. who showed that a single booster dose of an mRNA Covid-19 vaccine in individuals who had received primary vaccination with a single dose of the adenovirus-based COVID-19 Vaccine Janssen , provided protection close to that of the three-dose mRNA vaccine regimen . In addiOur results address the question of how many vaccine booster doses are needed to reach maximal humoral immunity in both anti-RBD IgG level and neutralisation capacity against SARS-CoV-2, including its numerous variants. We confirm that, using the heterologous combination performed in our study, a single boost was shown to be enough in our study to reach this plateau. By contrast, the homologous scheme using an mRNA vaccine needs two boosters for reaching the same level of protection. Of course, this maximum immunity is temporary and decreases with time, which makes the third dose necessary in the heterologous group as well. The recent study of Regev-Yochay et al. that evaluated the benefit of a third booster in a homologous mRNA immunisation scheme suggests that maximum immunity is reached after the third dose with homologous mRNA vaccination. The fourth mRNA vaccine dose seems to be able to restore the level of immunity after waning but does not quantitatively and qualitatively improve the humoral immunity conferred by the first three doses .Surprisingly, our data highlighted a higher risk of infection in women between 30 and 50 years compared with older HCW. This group of individuals mainly corresponds to active nursing staff with higher exposure to pathogens. Indeed, at the HCL, contacts between nurses and patients and among nurses are longer and more frequent than for other professionals , and thiSome limitations of the present study should be acknowledged. Firstly, these results were obtained from observational data and not from a randomised clinical trial. As a result, there were some inherent differences between the compared groups. For example, subjects vaccinated with a heterologous schedule were on average younger than those vaccinated with a homologous schedule. This difference is explained by the recommendations for vaccination according to which individuals under 55 years of age who received a first dose of Vaxzevria should receive a booster of COVID-19 mRNA vaccine. Yet, our statistical analysis did not show a significant impact of age in infection risk or vaccine-induced immune parameters. Secondly, the HCW might differ slightly from the general population since they are repeatedly exposed to SARS-CoV-2 and closely monitored for vaccine coverage and COVID-19 incidence. Thirdly, in our study, the advantage of the heterologous regimen observed after the second dose may be impacted by the delay between the first and second dose which was only 4 weeks between the first two doses in the homologous scheme. A study by Payne et al. reported that an extended delay of 10 weeks between the first two doses of Comirnaty allowed the development of better humoral immunity . FourthlOur data provide evidence to understand the number of vaccine booster doses needed to reach the maximal level of both antibody titre and neutralisation capacity against SARS-CoV-2 in heterologous or homologous vaccine scheme. More studies will be needed to determine if another vaccine type should be given to boost SARS-CoV-2 immunity even further.


Acute myocardial infarction (MI) is one of the leading global healthcare emergencies, contributing to over three million global deaths. The purpose of this study is to investigate further the efficacy of sacubitril/valsartan over angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in reducing the risk of heart failure (HF) in post-MI patients and providing a clear evidence-based medicine guideline for future use.An electronic database search was conducted on English databases. Eight articles were included, fulfilling our inclusion criteria, i.e., adult patients of ≥18 years with a recent diagnosis of acute MI. Pooled analysis was done using Review Manager version 5.4.1 , and the data for each outcome were analyzed as dichotomous variables.A total of eight clinical trials were included in the meta-analysis. Six studies analyzed the sacubitril/valsartan and ACEI combination. The pooled analysis reported a significant increase in the risk of hypotension  in the sacubitril/valsartan compared to the ACEI alone group. In addition, a significant increase was observed in the left ventricle ejection fraction (LVEF) after using the sacubitril/valsartan combination compared to using ACEI alone . Furthermore, no significant difference was observed between the groups in terms of mortality rate , the risk of heart failure , the frequency of recurrent MI , and the mean difference of N-terminal pro-B-type natriuretic peptide (NT-proBNP)  between both the groups. However, the sacubitril/valsartan combination proved to be beneficial in significantly reducing the risk of major adverse cardiac events (MACE)  and rehospitalizations  as compared to ACEI post MI. Additionally, sacubitril/valsartan and ARB's combination was reported in two studies. This led to a significant decrease in NT-proBNP concentration  post MI in the sacubitril/valsartan combination group compared to the ARB usage alone. However, no significant difference was observed in the improvement of LVEF  between both groups.Although the sacubitril/valsartan combination has no difference in mortality and outcomes compared to ACEI, there is evidence that using it proves to be more beneficial post MI compared to ACEI and ARB usage alone. Acute myocardial infarction (MI) is a significant global healthcare crisis, resulting in over three million deaths worldwide, with more than one million of these fatalities occurring in the United States . The morOne commonly observed complication after myocardial infarction is heart failure (HF), a significant predictor of mortality. The increasing incidence of heart failure following myocardial infarction has imposed a significant burden on healthcare systems globally. In recent decades, heart failure (HF) has been acknowledged as a progressive medical condition in which cardiac remodeling plays a crucial role in its initiation. The activation of multiple neuroendocrine systems significantly influences the remodeling process. The sympathetic nervous system (SNS), renin-angiotensin-aldosterone system (RAAS), and natriuretic peptide system (NPS) are recognized as the critical neuroendocrine systems involved in the pathophysiology of heart failure. These systems can have beneficial and detrimental effects -5.Angiotensin-converting enzyme inhibitors (ACEIs) have traditionally been considered the primary treatment for reducing mortality after acute myocardial infarction (MI), preventing the development of heart failure, and potentially preventing subsequent MIs . MultiplIn this meta-analysis, a thorough search and systematic evaluation of the current literature was conducted to examine the comparative effectiveness of ARNI versus ACEI in mitigating the risk of heart failure after acute myocardial infarction. Our objective is to develop a comprehensive and evidence-based medical guideline for future clinical application, focusing on elucidating ARNI's potential advantages in this vulnerable patient population.MethodsSearch StrategyClinicaltrials.gov were searched for any studies that had not yet been published but had reported their results online. There was no language barrier, as all the studies retrieved in the search were in the English language. Two reviewers independently screened the search results. A third reviewer was consulted in case of discrepancies. Duplicates were removed, and studies were initially shortlisted based on title and abstract, after which the full text was assessed for eligibility. The references of the selected studies were also reviewed thoroughly to prevent any risk of selection bias.A systematic literature search was conducted up until May 30, 2023, on the PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) databases with the following subject keywords and their Medical Subject Heading (MeSH) terms:  OR (neprilysin inhibitor) AND (angiotensin receptor inhibitor) AND (angiotensin converting enzyme inhibitor) AND . Google Scholar and Data ExtractionTwo independent reviewers performed article identification and screened for titles and abstracts for inclusion in all potential studies. The results were retrieved and reviewed by a third investigator. Any possible inconsistencies within the lists were resolved through discussion and if needed by the third-party investigator. We retrieved full-text manuscripts of the initial inclusion criteria, and the same two independent reviewers screened them thoroughly. The reviewers only included the studies that satisfied the entire inclusion criteria, and for the articles that were excluded, a valid reason was recorded. We identified and excluded all duplicate articles for our final list.Inclusion and Exclusion CriteriaThis study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, as shown in Figure Statistical Analysis2 metrics .All statistical analyses were performed using Review Manager version 5.4.1 (2020) . The data for each outcome were analyzed as dichotomous data. All tests were two-sided, and statistical significance was based on the 95% confidence interval (CI). Sensitivity analyses to assess the robustness of the results were conducted using the Mantel-Haenszel statistical method with a random-effects analysis model. Heterogeneity across the RCTs was assessed using IQuality Assessment of the Included RCTsThe risk of bias for RCTs was calculated by the Cochrane risk-of-bias tool version 2 (RoB2) . The tooResultsStudy CharacteristicsOur meta-analysis included eight prospective RCTs, which consisted of 7,318 participants in total, as shown in Figure OutcomesSacubitril/valsartan versus ACEI: This combination of intervention and control was analyzed by six studies. The pooled analysis of five studies reported a significant increase in the risk of hypotension  in the sacubitril/valsartan combination as compared to the ACEI alone group. In addition to this, when the improvement in the LVEF was compared between the intervention and control groups, a significant increase was observed after the usage of the sacubitril/valsartan combination as compared to using ACEI alone  post MI as given in Figure Furthermore, no significant difference was observed between the groups in terms of an increase in the mortality rate  and the risk of heart failure  post MI, as shown in Figure However, the sacubitril/valsartan combination proved to be beneficial in significantly reducing the risk of major adverse cardiac events (MACE)  and rehospitalizations  post MI, as shown in Figure Moreover, an insignificant difference was observed in terms of the frequency of recurrent MI  and the mean difference of NT-proBNP  between both groups post MI, as shown in Figure Sacubitril/valsartan versus ARBs: A total of two studies analyzed this combination of intervention and control between sacubitril/valsartan and ARBs post MI. This led to a significant decrease in NT-proBNP concentration  post MI in the sacubitril/valsartan combination group as compared to the ARB usage alone, as illustrated in Figure However, no significant difference was observed in the improvement of LVEF  between both groups, as given in Figure DiscussionIn this extensive meta-analysis, our objective was to provide insights into the comparative outcomes of administering sacubitril/valsartan versus ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) to individuals who have suffered from acute myocardial infarction (MI). Our analysis provides valuable insights into the potential benefits of sacubitril/valsartan in enhancing post-myocardial infarction (MI) outcomes, specifically in relation to the left ventricle ejection fraction (LVEF), N-terminal (NT) pro-B-type natriuretic peptide (BNP) levels, rehospitalization rates, and major adverse cardiac events (MACE).One of the significant findings from our meta-analysis is the notable improvement in the left ventricle ejection fraction (LVEF) observed in the experimental group that received sacubitril/valsartan, in comparison to the control group that received angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). This discovery is consistent with prior research conducted by Zaid Iskandar and Lang , Lui et Our study additionally illustrates a significant decrease in the levels of NT-proBNP in the experimental group compared to the control group. This finding aligns with previous research conducted by Lui et al.  and XionThe meta-analysis revealed a noteworthy decrease in rehospitalization rates among the experimental group receiving sacubitril/valsartan. Additionally, no significant heterogeneity was observed. The results presented are consistent with the research conducted by Xiong et al.  and ZhanThe findings of our study indicate a significant decrease in major adverse cardiac events (MACE) among the experimental group. These results align with the consistent findings reported in previous studies conducted by Lui et al. , Xiong eOur study had some limitations that added up to the heterogeneity in outcomes such as heart failure and NT-proBNP. The main contributing factor can be different doses of sacubitril/valsartan in the intervention group in different studies along with the different timings of the introduction of the intervention in the participants. Some of the studies introduced the intervention after primary PCI, whereas some introduced it before PCI just after the MI along with patients having different comorbidities before MI in each study that could have overall led to heterogeneous results.In conclusion, our meta-analysis presents strong evidence supporting the efficacy of sacubitril/valsartan as a promising therapeutic approach for reducing major adverse cardiac events (MACE) and rehospitalizations and improving left ventricle ejection fraction (LVEF) in patients following acute myocardial infarction. In addition, the significant decrease in NT-proBNP levels observed in the experimental group highlights the potential of sacubitril/valsartan in reducing the risk of heart failure. These findings add to the increasing amount of evidence supporting the clinical usefulness of sacubitril/valsartan in managing patients after a myocardial infarction. They highlight the significance of timely and effective pharmacological interventions in promoting the recovery of cardiac function and improving patient prognosis. However, it is necessary to conduct additional research, including carefully planned clinical trials, to validate and build upon these encouraging findings. This will also help refine the treatment guidelines for patients who have experienced a myocardial infarction.


The accurate large-scale mapping of cerebral microvascular blood flow velocity is crucial for a better understanding of cerebral blood flow (CBF) regulation. Although optical imaging techniques enable both high-resolution microvascular angiography and fast absolute CBF velocity measurements in the mouse cortex, they usually require different imaging techniques with independent system configurations to maximize their performances. Consequently, it is still a challenge to accurately combine functional and morphological measurements to co-register CBF speed distribution from hundreds of microvessels with high-resolution microvascular angiograms.We propose a data acquisition and processing framework to co-register a large set of microvascular blood flow velocity measurements from dynamic light scattering optical coherence tomography (DLS-OCT) with the corresponding microvascular angiogram obtained using two-photon microscopy (2PM).We used DLS-OCT to first rapidly acquire a large set of microvascular velocities through a sealed cranial window in mice and then to acquire high-resolution microvascular angiograms using 2PM. The acquired data were processed in three steps: (i) 2PM angiogram coregistration with the DLS-OCT angiogram, (ii) 2PM angiogram segmentation and graphing, and (iii) mapping of the CBF velocities to the graph representation of the 2PM angiogram.We implemented the developed framework on the three datasets acquired from the mice cortices to facilitate the coregistration of the large sets of DLS-OCT flow velocity measurements with 2PM angiograms. We retrieved the distributions of red blood cell velocities in arterioles, venules, and capillaries as a function of the branching order from precapillary arterioles and postcapillary venules from more than 1000 microvascular segments.The proposed framework may serve as a useful tool for quantitative analysis of large microvascular datasets obtained by OCT and 2PM in studies involving normal brain functioning, progression of various diseases, and numerical modeling of the oxygen advection and diffusion in the realistic microvascular networks. It is the preferred method to acquire accurate capillary morphology in vivo, across the mouse cortical layers  obtaining accurate cerebrovascular angiograms with microscopic resolution that will include a majority of or all arterioles, venules, and capillaries over a large field of view (FOV) and (ii) acquiring volumetric blood flow velocity data from the majority of the microvascular segments over the same FOV. Several imaging modalities, such as multiphoton microscopy (MPM)In this work, we developed a computational framework to co-register large-scale microvascular blood flow velocity measurements from DLS-OCT with the high-resolution microvascular angiograms obtained using 2PM over the same FOV. We first performed a global 3D coregistration and a multilayer 2D coregistration to transform the 2PM angiogram onto the DLS-OCT angiogram. Then we segmented the original 2PM microvascular angiogram, obtained its mathematical graph representation, and transformed the vectorized angiogram onto the DLS-OCT image space based on the transformation matrices computed in the first step. Finally, the DLS-OCT flow velocity measurements were mapped onto the 2PM angiogram and mean microvascular segment velocities were extracted. The developed framework was implemented to process the datasets acquired from the three mice cortices. The distributions of mean CBF velocities in arterioles, venules, and capillaries as a function of vessel type and the branching order from precapillary arterioles and postcapillary venules have been retrieved. The framework proposed here will facilitate the numerical modeling of CBF and oxygen transport within cerebral microvascular networks and help us improve our understanding of the microvascular blood flow regulation in normal brain and in various brain conditions.22.1Three healthy, young-adult female C57BL/6 mice  coordinate direction is defined, and the maximal intensity on each line is identified. If the mean of the six maxima exceeds the intensity at the given voxel, the intensity of the given voxel is increased, by an amount that decreases exponentially with the coefficient of variation of the six maxima. This method ensures that a voxel that is surrounded in multiple directions by voxels of higher intensity receives a maximal boost in intensity. (iv) Segmentation. Using Amira, the stack was thresholded to obtain a 3D solid representing the network. (v) Skeletonization. Using Amira, the solid was skeletonized, to yield a graph consisting of nodes and edges with defined diameters. (vi) Refinement. The skeleton was further processed to combine short, connected edges and to remove tight loops, which occur as artifacts of the skeletonization. The result is a representation of the network as a set of nodes and edges, with several edges forming a segment between vessel branching points. Segment diameters were estimated as the median of edge diameters in the segment. In this study, the graphs that represent the 2PM angiograms of three animal subjects were able to enclose in a connected network more than 99.9%, 99.3%, and 99.5% of the total vessel segments, respectively. A version of the custom software used is available online (https://github.com/secomb/StackEnhanceV1).For quantitative modeling and analysis of cerebral microvascular networks, graph-based representations of the structure are needed.,The vessel type  was associated with each segment by a combination of manual and automated vessel labeling.The capillary branching order starting from precapillary arterioles was computed by first assigning branching order zero to all pial and diving arterioles and subsequently assigning branching orders to the rest of the graph network starting from zero-order segments .49 The s2.5,,Supplementary Material for detailed results of the comparisons). In addition, our method enables a considerable degree of manual, user control over the coregistration process, which may be helpful to deal with sometimes significant deficiencies in acquired datasets, such as large shadows below the vessels or missing data in large sub-ROIs.Angiogram coregistration was performed by transforming the volumetric intensity images obtained by 2PM to the DLS-OCT space. To account for the non-linearity of image spaces caused by distortions, such as field curvature across those two imaging modalities due to the implementation of different optics, an initial global 3D coregistration was combined with multiple regional 2D coregistrations. The global 3D coregistration was implemented over the whole 3D 2PM and OCT stacks with an affine transformation matrix computed based on 2.6Based on transformation matrices, all nodes from the graph-based network obtained from the 2PM angiogram were co-registered with the DLS-OCT volumes at different depths . This enSupplementary Material for details) and led to a pronounced decrease in the goodness of DLS-OCT flow velocity fitting. Therefore, we chose 35 deg as a conservative threshold for the axial tilt angle of capillary edges in data analysis to maintain a high-accuracy standard in DLS-OCT measurements while still enabling the measurements of velocities in a large number of capillary segments. Only the vascular edges with strong DLS-OCT signals were included in the data processing. However, vascular segments typically contain tens of graph edges and mean segment velocities could be obtained even if some edges within these segments needed to be removed from analysis. Examples of mapping the blood flow velocities onto a graph-based network are shown in DLS-OCT measurements of the Vz component of the RBC velocity exhibit the largest and the smallest SNR when RBCs are travelling parallel and perpendicular to the optical axis (Although most data analysis steps have been performed automatically by the custom-written software, a certain amount of manual corrections and adjustments are still needed in the graphing and coregistration procedures for refined blood flow speed mapping, which is time consuming. In the future, machine learning-based methods may be developed to assist with the manual-correction steps.3The mean center-line flow velocity distributions in cortical arterioles, capillaries, and venules based on measurements in three mice are shown in The mean flow velocity distributions in capillaries of the first four branching orders from precapillary arterioles and postcapillary venules are shown in 4in vivo. We anticipate that this technique will be helpful for quantifying the microvascular blood flow velocity distributions in a broad range of studies involving normal brain functioning, progression of various microvascular diseases, and numerical modeling of the oxygen advection and diffusion in the realistic microvascular networks.We have proposed a method to combine the high-resolution cerebral microvascular angiograms obtained by 2PM and large-scale microvascular blood flow velocity measurements based on DLS-OCT for a comprehensive analysis of cerebral microvascular blood flow network down to capillary level in mice. The developed methodology was applied in proof-of-principle experiments to retrieve the distributions of mean blood flow velocities from several hundred arterioles, capillaries, and venules Click here for additional data file.


Cell, Rahim et al. show that a subset of progenitor exhausted CD8+ T cells (Tpex) in uninvolved, regional lymph nodes (uiLNs) are clonally related to exhausted CD8+ T cells (Tex) in tumors of patients with head and neck squamous cell carcinoma (HNSCC) and following adjuvant immune checkpoint blockade (ICB) these clones expanded in the tumor suggestive of migration from the uiLNs and differentiation into an exhaustion state.1 The work by Rahim et al. underscores the great value of neoadjuvant ICB clinical trials to better understand the dynamics of T cell responses in patients.In a recent study published in + T cells were enriched in the tumor. Combining single-cell RNA sequencing with TCR-seq and/or single-cell protein expression to assess matched LN and tumor tissues from HNSCC patients revealed CD8+ T cell clonality between the TME and the LNs. Shared T cell clones in the uiLNs belonged to the Tpex phenotype, whereas their counterparts in the TME were more likely to exhibit an intermediate exhausted CD8+ T cells (Tex-int)/terminally exhausted CD8+ T cells (Tex-term) phenotype. Multiplexed ion beam imaging revealed that in uiLNs from patients treated with surgery only, Tpex and Tex-int were found in cellular neighborhoods with CD4+ T cells, regulatory T cells (Tregs), CD4+ CD8+ T cells and dendritic cells (DCs). Pre-clinical mouse studies have shown that cDC1s  in tumor-draining LNs (tdLNs) maintain a reservoir of proliferative tumor-reactive Tpex and that boosting cDC1s increases Tpex cell frequencies and decreases tumor burden.2 Rahim et al. show that neoadjuvant ICB decreased frequencies of Tpex cells and increased frequencies of Tex-int in uiLNs and altered the spatial organization of the uiLNs increasing the numbers of neighboring DCs of both Tpex and Tex-int cells. Moreover, Tpex localized in closer proximity to Tex-int cells indicating activation and differentiation toward a Tex-int phenotype.Rahim et al. comprehensively profiled immune cells in the tumor microenvironment (TME) and in matched uiLNs and/or metastatic lymph nodes (metLNs) of patients with metastatic HNSCC using mass cytometry. Tpex were found at a higher frequency in the uiLNs compared to matched tumor tissue, while Tex and effector memory CD8+ T cells in the blood has been associated with clinical responses to ICB in various tumor entities. After ICB treatment, Tpex cells were detected in the blood and in the primary tumor tissue only at low levels, implying that the overall decreased frequency of Tpex in treated uiLN is not caused by cell egress from the LNs. Instead, circulating Tex-int and terminally differentiated CD8+ effector memory cells with enhanced proliferation were detected in the blood and significantly increased after neoadjuvant ICB. This is in line with other literature describing CD8+ T cells from tdLNs as developmental precursors of the Tex cells in tumors maintained by continuous migration.3 By protecting T cells from terminally differentiating, the tdLNs have a critical function in maintaining anti-tumor CD8+ T cell immunity.Expansion of activated CD8+ T cells giving rise to T cells involved in the anti-tumor immunity. This represents an opportunity to critically discuss the clinical practice of LN dissection, in particular in the context of ICB-based regimens. LNs are frequently dissected during tumor surgery as LN involvement is an important prognostic factor and an essential element for disease staging. However, for some cancer entities such as melanoma, breast or gynecologic cancers, LN dissection often provides little to no therapeutic benefit. It is beyond the scope of this publication but it raises the question whether it is always beneficial to remove non-metastatic LNs.This paper highlights that uiLNs contribute to a successful anti-tumor immune response as they harbor a pool of stem-like CD8+ T cell phenotype and spatial organization of uiLNs and metLNs from non-treated and ICB-treated patients. Tpex cells were almost non-existent in metLNs, whereas Tex-term were more abundant. Moreover, Tpex and Tex-int reside in an immunosuppressive cellular niche in metLNs, characterized by the abundance of proliferative Tregs and CD4+ T cells with a more naïve or quiescent phenotype, and DCs expressing immune regulatory molecules. Patients with metLNs had a more blunted response to neoadjuvant ICB. Other literature has shown that LN metastases are epigenetically rewired harboring a tumor intrinsic interferon response program that promotes NK cell evasion and LN colonization. LN metastases induce antigen-specific Tregs and resist T cell-mediated cytotoxicity resulting in metastasis-promoting tumor-specific immune tolerance.4Rahim et al. also addressed the impact of metastasis on LN functionality. They compared CD85 This is however difficult to model in mouse models.It still remains unclear whether lymph node dysfunction is the cause or consequence of metastatic tumor spread and increased disease burden. These questions could be addressed by refined pre-clinical tumor models implementing spatial and longitudinal analysis of anti-tumor immunity. Improved pre-clinical models ideally show slower growth and spontaneous metastasis to better recapitulate human disease. However, the majority of mouse studies rely on fast-growing transplantable syngeneic models and outgrowth of the primary tumor is often a limiting factor. One solution could be surgical removal of the primary lesion allowing the investigation of an ongoing immune response and still offering an opportunity for clinical intervention. Moreover, extensive analyses of various murine and patient LNs would allow an in-depth characterization of the heterogeneity of LN architecture. It has been shown that LN dissection in mice reduces immunotherapy efficacy suggesting that tumor-antigen-specific immunity is not just limited to the tdLN but may extend to other secondary lymphoid organs.+ T cell dynamics and cellular interactions in the context of human cancer, which is well supported by various pre-clinical studies. The publication illustrates how valuable a good clinical trial design allowing the collection of longitudinal matched tissue samples can be for understanding human cancer in greater detail. With the advent of multiplex approaches, tissues from LN dissections could help guide future treatment strategies by evaluating the T cell repertoires and cellular interactions. It is an opportunity to investigate to which extent immunity extends beyond the tdLN. In summary, we propose that neoadjuvant ICB clinical trials and translational studies like Rahim et al. are instrumental to guide the development of improved pre-clinical models that in turn allow the exploration of novel therapeutic concepts and refine the clinical trial design (Fig. Despite the limited number of patients showcased, the data in this paper describes novel insights into CD8ign Fig. .Fig. 1Ne


Patients with a bipolar disorder (BD) may experience one or several episodes of major depression before transitioning into a manic phase. Given that treatment with common antidepressants may exacerbate symptoms of mania in patients with BD, initial diagnosis of major depressive disorder (MDD) is a significant issue affecting BD patients. Currently, a family history of BD is used as an early identifier for BD, but as genetic factors associated with BD confer susceptibility to a wide range of psychiatric illnesses, this approach lacks specificity. Thus, there is a pressing need for a biomarker which specifically predicts development of bipolar symptoms in patients with MDD, rather than a trait vulnerability to psychiatric disorderThe aim of this study is to assess alterations in fronto-limbic function that exist prior to the manifestation of the first manic episode in BD patients without familial predisposition for BD.To identify a biomarker for conversion to BD we performed a study in a naturalistic sample of MDD patients without a familial risk for BD, which were followed for 9 years. We used a seed-based functional connectivity analysis to assess differences in resting-state fronto-limbic connectivity between MDD patients who converted to BD during the follow-up period (n = 11), and non-converting MDD patients (n = 56).Clusters of significantly reduced functional connectivity were found in the fronto-limbic network of prospective converters relative to non-converters.Findings suggest that alterations of fronto-limbic functional connectivity during episodes of depression predate and associate with conversion to BD later in life, in the absence of familial risk. These fronto-limbic functional connectivity disturbances may be of interest for diagnosing early-stage BD, and may offer insight in the mechanisms that drive conversion in the absence of familial predisposition. Findings from this study need to be verified through large-scale longitudinal imaging studies in naturalistic cohorts of MDD patients.None Declared


Multiple causative mutations have been identified, including mutations in the beta-B2-crystallin gene (CRYBB2), gamma-D-crystallin gene (CRYGD), V-MAF avian musculoaponeurotic fibrosarcoma oncogene homolog gene (MAF), the major intrinsic protein of lens fiber gene (MIP). The treatment is surgical and consists of the removal of the cataract, if the visual acuity is reduced, with the placement of an artificial lens.We report a case of a 34-year-old woman with a medical history of diabetes type 1 presented to our ophthalmology department due to a progressive diminution of vision in both eyes during the last year. No history of ocular trauma was reported. Her best corrected visual acuity was 20/50 in both eyes. Slit lamp examination of the lenses of both eyes revealed white tiny opacities forming concentric layers and a dense posterior subcapsular cataract . The posterior segment was unremarkable in both eyes with no sign of diabetic retinopathy. The patient underwent cataract surgery of the right eye and three months later of the left eye. The two surgeries proceeded without complications with a final visual acuity of 20/20 for both eyes. Cerulean cataract is a rare form of congenital cataract which usually presents as bilateral, blue-white opacities in the lens arranged in concentric layers. Armitage MM