We investigated the role of three-dimensional (3-D) CT in the diagnosis and management offour bipartite scaphoids in three patients. We computed the volume ratio, moment ofinertia ratio and direction vector from the centroid of the scaphoid to the os centralecarpi. We found that the os centrale carpi was always smaller than the scaphoid and showedan elongated shape in the scaphoid longitudinal axis. Its position was always posteriorcompared with the scaphoid anteroposterior axis. The main morphological feature ofbipartite scaphoids was the continuity of the scaphoid from its proximal to distal aspectalong the longitudinal axis. These criteria from 3-D imaging should be considered usefulin the diagnosis of bipartite scaphoid as it allows differentiation from nonunion. 3-Dsingle-photon emission computed tomography (SPECT)/CT was helpful in the surgicaldecision-making when the patient was symptomatic. 3-D imaging was also used for thepreoperative simulation and planning of bone fusion as it simplifies surgery and makes itmore accurate. Here we provide clear criteria for diagnosing bipartite scaphoids and forthe planning when surgery is deemed necessary. The scaphoid bone is formed by the fusion of the os centrale carpi and the radialchondrification centre in embryos measuring between 28 to 30 mm long . A biparFour bipartite scaphoids in three men with an average age of 34 years  were inc3 afterinterpolation. Wrist bone segmentation was performed using 3-D Slicer software (https://www.slicer.org). Briefly, the thresholding algorithm was used toproduce an initial mask by separating bones from the surrounding soft tissues. Thecompleted masks of each individual bone were used to create 3-D polygon models exported instereolithography (STL) file format. The scaphoid and os centrale carpi polygonal modelswere exported ))b)) demo excised  due to i excised . Figure A 37-year-old, right-handed man presented with pain after a crush injury to his leftwrist. MRI  and 3-Dd region . In thisd region  and (d))d region ) allowedd region  along wid region  and (d))A 19-year-old, right-handed man presented with pain in the left wrist after a snowboardfall on the outstretched hand. 3-D reconstruction from the CT scan  demonstrPrevious publications have reported cases of bipartite scaphoid similar to ours . Others z-axis parallel to that of the scaphoid. The position of the os centralecarpi was always distal to the scaphoid according to the y-axis. Theremaining os centrale carpi was located in the carpus between the capitate, the scaphoid andthe trapezoid. The main morphological feature of bipartite scaphoids was the continuity ofthe bone from the proximal to the distal aspect along the z-axis, a featurenot encountered in case of fracture or nonunion. If the os centrale carpi is removed, thescaphoid morphology appears normal and whole. This is not the case in nonunion oftransverse, oblique and coronal fractures (This case series shows the existence of clear geometric/morphometric features shared by theos centrale carpi in four bipartite scaphoids from our three patients. The os centrale carpiwas clearly smaller than the scaphoid. Its shape was elongated and itsractures . If one Variations of scaphoid shape have been studied by manual measurements between landmarks ondried bones , 3-DmodAdditional ossicles may be found in the foot or the hand and can become painful, usuallyafter trauma .Since mSome authors suggest removing a symptomatic os centrale carpi  especial3-D preoperative planning can simplify surgery and improve the procedure’s accuracy in caseof scaphoid nonunion with marked deformity . Compari


Graphene plasmon resonators with the ability to support plasmonic resonances in the infrared region make them a promising platform for plasmon-enhanced spectroscopy techniques. Here we propose a resonant graphene plasmonic system for infrared spectroscopy sensing that consists of continuous graphene and graphene ribbons separated by a nanometric gap. Such a bilayer graphene resonator can support acoustic graphene plasmons (AGPs) that provide ultraconfined electromagnetic fields and strong field enhancement inside the nano-gap. This allows us to selectively enhance the infrared absorption of protein molecules and precisely resolve the molecular structural information by sweeping graphene Fermi energy. Compared to the conventional graphene plasmonic sensors, the proposed bilayer AGP sensor provides better sensitivity and improvement of molecular vibrational fingerprints of nanoscale analyte samples. Our work provides a novel avenue for enhanced infrared spectroscopy sensing with ultrasmall volumes of molecules. With the ability to probe the vibrational characteristics of inorganic, organic, and polymer compounds samples, infrared spectroscopy possesses the advantages of rapid testing, convenient operation, good repeatability, high sensitivity, and less sample consumption ,2. The bTo address this problem, various types of strategies have been proposed to enhance the absorption signal of molecules. Among these strategies, plasmonic enhancement is one of the most effective approaches to improve light–molecule interaction in the mid-infrared range ,9,10. CoIn this work, we proposed a resonant graphene plasmonic system to far-field excite AGP mode between a bilayer graphene gap for ultra-sensitive molecular infrared spectroscopy sensing. Here the AGPs are excited in the graphene/nano-gap/graphene plasmon cavity instead of the graphene/nano-gap/metal plasmon cavity. The excitation efficiency of AGPs is improved by placing a reflection mirror below the graphene gratings to form an F–P resonant cavity in the vertical direction. In this bilayer graphene plasmonic biosensor, the tightly confined AGP mode inside the bilayer graphene gap provides strong coupling between ultra-compressed mode-volume plasmon cavity mode and molecular vibrational fingerprints mode, resulting in the significant enhancement of the molecular infrared spectroscopy. For illustration, the protein molecules are selected as the sensing analytes in order to evaluate and analyze the biosensing performance of this bilayer AGPs sensor platform. By adjusting the Fermi energy of graphene via external gate voltage, the AGPs’ resonant wavelength can be actively tuned over the infrared region, which enables us to sensitively detect the absorption band of ultra-thin target molecules.p = 82 nm, a width of graphene grating w = 42 nm, and a thickness of nanogap g = 3 nm as shown in e is the elementary charge, ℏ is the reduced Planck constant, c is the speed of light in vacuum, and x-direction and that in the y-direction is infinitely. The refraction index of silicon spacer layer is The ultra-compressed mode-volumes graphene plasmon cavity are formed by graphene/ nano-gap/graphene van der Waals heterostructure with a period of  formula ,33(1)σ(We first investigate the excitation of graphene acoustic plasmons in the proposed bilayer plasmonic system. Under the illumination of transverse magnetic (TM) waves, graphene plasmons can be excited with the assistance of the patterned graphene nanoribbons. According to the F–P resonant model, the resonance condition of such graphene plasmonic modes can be given as following equation:m represents the order of the resonance, Re means taking the real part of the complex quantity, and Here, r system .In order to improve the conversion efficiency of graphene acoustic plasmon, the dielectric spacer layer and gold mirror are further introduced to form an F–P resonance cavity ,34 to eng = 3 nm thickness protein coating over a lossless silicon dioxide substrate is plotted by red line in this picture, and the maximum value of absorption peak are 0.11% and 0.078%, indicating the positions (dash line) of the amide I band  feature of protein vibrational modes after plasmonic enhancement with varying graphene Fermi energy is further extracted and plotted as a function of wavelength in  sensors .To illustrate the advantage of tunable bilayer AGP biosensor, we finally compare the enhancement performance of the proposed bilayer AGP system to that of single-layer GP biosensor by removing top continuous graphene sheet, as shown in The extinction spectra of the GP sensor and AGP biosensor with varying widths of graphene ribbons are shown in  of 4 nm b. While  of 2 nm e. It is Our proposed structure can be fabricated with a similar process as previous literature ,30,34. TIn conclusion, we have suggested a method of probing vibrational fingerprints of extremely ultra-small volume molecules with a bilayer graphene acoustic plasmons biosensor, which is formed by continuous ultra-compressed mode-volume graphene-insulator-graphene plasmon cavity. Compared to graphene-gap-metal AGP structures, the proposed design is expected to solve the difficulty of metal unevenness or surface roughness which significantly attenuates far-field signals and requires a complex fabrication process to realize ultraflat metal surfaces. Furthermore, we have found that strong absorption and tight electromagnetic field confinement are realized in mid-infrared frequency for such a biosensor. The acoustic plasmons modes are squeezed into the nano-metric gap by far-field excitation with high efficiency at normal incidence. By placing protein molecules inside bilayer graphene nano-gap, the molecular fingerprints can be frequency-selectively enhanced by extreme plasmon overlap. The extinction spectra and the absorption band of thin protein molecules can be precisely resolved by sweeping the graphene Fermi energy and extracting plasmon-enhanced excitation peak signals. The maximum enhancement factor can be up to 510 for the amide I band and 560 for the amide II band of enhanced molecular absorption IR spectroscopy. We further demonstrate that the sensitivity of the AGP biosensor is much higher than that of the conventional GP biosensors due to highly confined plasmon mode overlap (<3 nm) and ultra-strong interaction of light and biomolecules. Our proposal provides a new platform to study nanoscale light-matter interactions and ultrasensitive infrared spectroscopy for single-molecule optics, extreme biosensing ,41, and


However, the comparisons between the Bilateral-Mirror and Unilateral-Mirror conditions revealed no significant differences in cortical coherence in all frequency bands. Conclusions. Providing MVF to stroke patients may modulate the lesioned primary motor cortex through visuospatial and attentional cortical networks.Background. Several brain regions are activated in response to mirror visual feedback (MVF). However, less is known about how these brain areas and their connectivity are modulated in stroke patients. This study aimed to explore the effects of MVF on brain functional connectivity in stroke patients. Materials and Methods. We enrolled 15 stroke patients who executed Bilateral-No mirror, Bilateral-Mirror, and Unilateral-Mirror conditions. The coherence values among five brain regions of interest in four different frequency bands were calculated from magnetoencephalographic signals. We examined the differences in functional connectivity of each two brain areas between the Bilateral-No mirror and Bilateral-Mirror conditions and between the Bilateral-Mirror and Unilateral-Mirror conditions. Results. The functional connectivity analyses revealed significantly stronger connectivity between the posterior cingulate cortex and primary motor cortex in the beta band (adjusted  Upper-limb dysfunction after stroke accounts for the majority of neurological deficits, and it critically influences independence in daily activities in stroke patients . Mirror One major reason why mirror therapy promotes the improvement of motor function in patients is mirror visual feedback (MVF). MVF is believed to modulate cortical activations, especially the primary motor cortex (M1), which is directly related to motor function. Several neurophysiological studies using transcranial magnetic stimulation (TMS) have found that providing MVF during unilateral hand movement induces increased excitability in the human M1 or patient’s lesioned M1 ,10,11,12Previous studies suggested that MVF modulated cortical activities in M1 possibly through enriched and various sensory inputs, including visual and somatosensory inputs ,18. In aThe past research described above has revealed that several brain regions are involved in the modulation following MVF; however, the neural mechanism underlying the collaborative work of these brain areas and the temporal relationship among these brain regions still need further investigation. MEG provides the advantages of eminently good temporal resolution while preserving fair spatial resolution , so it iIn our prior work, MVF with either unilateral or bilateral hand movements induced a significant percentage change in beta oscillatory activity in stroke patients. Beta oscillatory activity is generated in M1 after the electrical stimulation ; its strFifteen right-handed, male stroke patients were recruited from the outpatient departments in northern Taiwan. Handedness was measured by the Edinburgh Handedness Inventory . The majThis study had 3 experimental conditions  with theThe patients’ neuromagnetic cortical activities were recorded while the patients executed the 3 experimental conditions inside a whole-head 306-channel MEG . Four head indicator coils were used to localize the head position precisely with respect to the sensors. The relative positions between the coil locations and 3 anatomic landmarks of the bilateral pre-auricular points and nasion were decided with a 3D digitizer. Continuing our prior study, which used electrical stimulation to induce beta oscillatory activity for M1 activity analysis , we furtIn addition, we used surface electromyography (EMG) to monitor patients’ muscle contractions. The EMG patch was attached to the flexor digitorum superficialis of the affected hand for recording muscle twitches, while the patients performed each experimental task. The bandpass filter for muscle signals was set to the range of 20–200 Hz off-line. These EMG signals were then rectified for computing the absolute magnitude and then averaged from the collected artifact-free epochs in each experimental task for quantifying muscle activity over time. The EMG data were captured at a sampling rate of 1000 Hz .x(t) and y(t), in the frequency domain. The magnitude-squared coherence is,The temporal signal space separation method was used to eliminate the magnetic interference from the surroundings in the MEG data . The modThe maximum frequency resolution was 1 Hz, and the highest frequency of interest was 50 Hz . Based oSubsequently, we calculated the coherence values among these areas A. The cop values of 10 comparisons in each frequency band [The differences in functional connectivity between the Bilateral-Mirror and Bilateral-No mirror conditions and those between the Bilateral-Mirror and Unilateral-Mirror conditions were examined by one-tailed nonparametric Wilcoxon signed-rank test. In this study, we selected 5 brain regions and classified the coherence into 4 frequency bands. Therefore, 10 paired comparisons among the 5 brain ROIs in each frequency band were computed. The Benjamini–Hochberg method was applied to adjust the ncy band .p-values was also computed by Benjamini–Hochberg method. The significant level of the adjusted p-value was set at 0.05.In addition, we used the Friedman test to compare the differences in EMG activities between the Bilateral-No mirror and Bilateral-Mirror conditions and Bilateral-Mirror and Unilateral-Mirror conditions. The Wilcoxon signed-rank test was applied for post hoc analysis. The adjustment of p = 0.04) was significantly higher in the Bilateral-Mirror condition than in the Bilateral-No mirror condition (p = 0.08), which might suggest higher functional connectivity between the precuneus and V1 in the Bilateral-Mirror condition compared to that in the Bilateral-No mirror condition , suggesting the similar motor performance of the affected hand under the two conditions. Moreover, the level of EMG activities under the Bilateral-Mirror condition was significantly higher than that under the Unilateral-Mirror condition (adjusted p = 0.002). These results indicated the stroke patients did execute the movement by the affected hand in the conditions with bilateral hand movements.The comparisons of EMG activities of the affected hand are demonstrated in The aim of our study was to illuminate the possible functional connectivity of some brain areas in the mirror neuron network during either unilateral or bilateral MVF in stroke patients. Therefore, we investigated the differences in functional connectivity among five brain ROIs between Bilateral-Mirror and Bilateral-No mirror conditions and between Bilateral-Mirror and Unilateral-Mirror conditions. Our results revealed stronger cortical coherence between the PCC and M1 in the beta band and possibly higher cortical coherence between the precuneus and V1 in the theta band in the patients performing bilateral hand movements with MVF versus without MVF. Since the motor performance of the affected hand did not differ between the two experimental conditions with bilateral hand movements, these findings indicated the involvement of the attentional network and visuospatial processing in cortical modulation from MVF in stroke patients. However, we found no significant differences in functional connectivity between MVF with bilateral and unilateral hand movements.Beta oscillatory activity in the M1 is related to motor function, which is suppressed during movements but rebounds after the movements cease ,48. In aThe possibly higher cortical coherence between the precuneus and V1 in the theta band during bilateral hand movements with MVF versus without MVF suggests that MVF might activate the neural network involving visual perception and visuospatial attention. Several previous studies have pointed out that the precuneus is activated during spatially demanding exercises, whether practically executed or imagined ,57. In aThe comparison of unilateral and bilateral hand movements under MVF revealed no significant difference in functional connectivity in spite of the difference in EMG activities. This result implicates the key factor modulating the functional connectivity among the selected brain areas might be the intervention of MVF but not the movement of the affected hand. In our previous study, facilitated M1 activation in the lesioned hemisphere was found either in moving bilateral hands or the unaffected hand only during MVF . These fSome limitations of this study need to be mentioned. First, the present study recruited 15 individuals with stroke for the analysis. The sample size was relatively modest, and a larger patient group should be enrolled. In addition, a healthy control group should be added. Following the more sophisticated study design, the data analysis should be blinded, and the bias can be eliminated. Second, the stroke characteristics, including the time post-stroke, cortical or subcortical lesions, and ischemic or hemorrhagic type of stroke, may influence the results due to the physiological differences. Subgroup analysis according to different characteristics of stroke should be done in a larger-scale study. Third, we chose the Benjamin-Hochberg method for the adjustment of multiple comparisons due to the relatively small sample size in our study. And, we performed post hoc analysis in each frequency band  separately based on the previous studies ,61 to exThis is the first neurophysiological study to examine the effects of MVF during different motor tasks on brain functional connectivity in stroke patients. Providing MVF during bilateral hand movements may induce higher functional connectivity between the PCC and M1 in the beta frequency band and possibly stronger connectivity between the precuneus and V1 in the theta frequency band than without MVF. However, no difference in functional connectivity was found between the two mirror conditions. In summary, our results may suggest that MVF may facilitate the activation of M1 in the lesioned hemisphere through visuospatial processing and attentional networks, whether during bilateral or unilateral hand movements. Despite some limitations, our results promote current understanding of the neural networks involved in MVF in stroke patients. These pioneering findings also provide more neurophysiological evidence regarding the effects of MT with bilateral or unilateral movements, which may be useful in adjusting the MT protocol to provide individualized stroke rehabilitation. Future studies with a larger scale and a control group are warranted for proving the implications from this study.


There have been significant advances in the treatment of metastatic renal cell carcinoma (mRCC), with immunotherapy (IO)-based combinations as the standard-of-care treatment in the front-line setting. IO in this setting is paired with another IO agent or with a vascular endothelial growth factor receptor (VEGF-R) tyrosine kinase inhibitor (TKI). One IO/IO combination and four IO/TKI combinations are currently approved. However, the role of the salvage IO in patients with disease progression on TKI monotherapy is uncertain. Here, we present a case series of five patients who were on single-agent TKI therapy for treatment-refractory mRCC and upon disease progression had an IO agent added to their TKI. The median duration of TKI monotherapy was 11.2 months , and the median duration of response after the addition of IO was 4 months . Although IO salvage therapy has a plausible rationale, this case series did not show a clear benefit to this approach. Further clinical trials are needed to determine the clinical utility of IO salvage therapy in mRCC. The standard-of-care first-line treatment for metastatic renal cell carcinoma (mRCC) has changed substantially over the last few decades. The era of targeted therapy saw an emergence of agents targeting the vascular endothelial growth factor receptor (VEGF-R) pathway, including sunitinib , axitiniWith the approval of multiple IO-based combination therapies for treatment naïve mRCC, new questions have arisen for subsequent lines of treatment. One important unanswered question is whether patients on single-agent IO or TKI can benefit from a salvage approach in which the complimentary agent is added at the time of disease progression (PD). There is data demonstrating that the addition of salvage ipilimumab to patients who have PD on nivolumab monotherapy does not produce the same efficacy as when ipilimumab plus nivolumab are given in combination from the onset ,17,18. Hp < 0.001) and median overall survival ) benefit compared with everolimus in patients whose mRCC progressed on antiangiogenic therapy [addition of salvage IO for a patient who develops PD on TKI monotherapy. Herein, we present five cases of patients with mRCC on TKI monotherapy who received salvage IO therapy upon PD.Based on CheckMate-025, single-agent IO with nivolumab has demonstrated a significant objective response rate (ORR) -approved retrospective protocol , five patients with mRCC treated with TKI and subsequent salvage IO therapy were identified. Key features are highlighted in n = 3) or cabozantinib (n = 2). Median duration of therapy on TKI monotherapy was 11.2 months . Patients on axitinib had pembrolizumab added as the salvage IO therapy to align with KEYNOTE-426 [The median number of treatments prior to the TKI for which salvage IO was added was three . All patients had received at least one IO and TKI either alone or in combination as a prior therapy . The TKINOTE-426 , and patNOTE-426 . The besIn this small case series of heavily pretreated patients with mRCC who had disease progression (PD) while on TKI monotherapy, the addition of salvage IO did not appear to provide additional significant benefit beyond what has been seen with single-agent monotherapy ,20. In tAlthough the IO/IO combination of ipilimumab and nivolumab is established as a standard of care for IMDC intermediate and poor risk mRCC, it comes with a significant risk of immune-related adverse events (IRAEs). Therefore, several studies have evaluated the utility of single-agent nivolumab followed by the addition of ipilimumab in order to improve tolerability. In the TITAN-RCC trial, patients with mRCC were treated with nivolumab monotherapy, and those who did not achieve a response as well as those who developed PD received a “boost” with ipilimumab/nivolumab. Included in this trial were 98 patients who received nivolumab as monotherapy following disease progression on TKI. Confirmed objective response rate (ORR) for this population was 17% with nivolumab monotherapy alone. The confirmed ORR in TKI-pretreated mRCC who had PD on TKI and then received a nivolumab/ipilimumab “boost” was 21% [Similarly, the OMNIVORE trial investigated the role of nivolumab monotherapy with the addition of ipilimumab for patients with PD or stable disease (SD) at 6 months. Of 57 patients who met these criteria for salvage ipilimumab, only 2 patients (4%) converted to partial response (PR) and 0 patients converted to complete response (CR) . SimilarWhile the aforementioned trials highlight the relative lack of efficacy with salvage ipilimumab in patients receiving nivolumab, there is no significant data about the role of salvage IO for patients treated with TKI monotherapy. In general, the approach to the patient who has disease progression while on a either a TKI or an IO agent is to discontinue the current agent and switch to a subsequent therapy based on a host of data regarding the efficacy of TKI following IO, and vice versa ,23,24,25There is some rationale to the role of maintaining TKI therapy and adding salvage IO. It is well-established that the tumor microenvironment (TME) contains certain immunosuppressive factors such as regulatory T cells (Tregs) and myeloid-derived suppressor cells (MDSCs). These immunosuppressive components are decreased with VEGF-R inhibition, therefore creating a more immune permissive TME, which is more likely to respond to IO-based therapy ,27. GiveThere are clear challenges to developing a clinical trial of salvage IO. Given the aforementioned data of the poor efficacy of salvage ipilimumab, there will be reasonable hesitance to such an approach. In the setting of multiple approved treatment options in mRCC, trials that investigate the role of IO vs. IO/TKI in patients who develop PD on IO-based therapy are ongoing (NCT04338269). Strategies that investigate salvage approaches remain worthy of consideration.Despite significant advanced in the management of mRCC, a number of questions still remain. Primary among these questions is the role of the addition of salvage therapy at the time of disease progression vs. simply switching to a new therapy. In this small series, there was no clear benefit to the addition of salvage IO therapy in patients with disease progression on TKI. Further trials are needed to define treatment sequencing and the role of salvage therapy in mRCC.


The aim of the current study was to enlighten the evolution of prostate-specific membrane antigen (PSMA) expression in glioblastoma between initial diagnosis and recurrence in order to provide preliminary insight for further clinical investigations into innovative PSMA-directed treatment concepts in neuro-oncology.via immunohistochemistry and changes between initial diagnosis and recurrence were determined. Immunohistochemical findings were correlated with survival and established clinical parameters.Patients who underwent resection for de-novo glioblastoma (GBM) and had a re-resection in case of a recurrent tumor following radiochemotherapy and subsequent chemotherapy were included (n = 16). Histological and immunohistochemical stainings were performed at initial diagnosis and at recurrence (n = 96 tissue specimens). Levels of PSMA expression both in endothelial and non-endothelial cells as well as vascular density (CD34) were quantified PSMA expression was found to be present in all GBM tissue samples at initial diagnosis as well as in all but one case of recurrent tumor samples. The level of PSMA expression in glioblastoma varied inter-individually both in endothelial and non-endothelial cells. Likewise, the temporal evolution of PSMA expression highly varied in between patients. The level of vascular PSMA expression at recurrence and its change between initial diagnosis and recurrence was associated with post recurrence survival time: Patients with high vascular PSMA expression at recurrence as well as patients with increasing PSMA expression throughout the disease course survived shorter than patients with low vascular PSMA expression or decreasing vascular PSMA expression. There was no significant correlation of PSMA expression with MGMT promoter methylation status or Ki-67 labelling index.PSMA is expressed in glioblastoma both at initial diagnosis and at recurrence. High vascular PSMA expression at recurrence seems to be a negative prognostic marker. Thus, PSMA expression in GBM might present a promising target for theranostic approaches in recurrent glioblastoma. Especially PSMA PET imaging and PSMA-directed radioligand therapy warrant further studies in brain tumor patients. Prostate-specific membrane antigen (PSMA) is a well characterized and validated marker for prostate cancer. PSMA is an enzyme with various physiological functions in non-tumorous tissues and synonymous to glutamate carboxypeptidase II (GCPII), N-acetyl-L-aspartyl-L-glutamate peptidase I (NAALADase I), NAAG peptidase and folate hydrolase 1 (FOLH1) . In oncoHowever, it still remains unclear whether PSMA is expressed both at initial diagnosis and at tumor recurrence and if the PSMA expression is altered under multimodal therapy , 18. Thepars pro toto the feasibility of PSMA PET imaging after multimodal therapy in a glioblastoma patient at recurrence.Therefore, we aimed to fill the knowledge gap on the temporal evolution of PSMA expression and its potential alterations under adjuvant therapy in glioblastoma in order to provide a solid basis for the implementation of innovative PSMA-directed treatment concepts in neuro-oncology. We here present a comprehensive immunohistochemical analysis of tumoral PSMA expression in a strictly selected cohort of glioblastoma patients both at initial diagnosis and at recurrence. Additionally, we demonstrate st 2020. Hematoxylin and eosin (H&E) as well as PSMA and CD34 immunohistochemical stainings were performed for every patient both at initial diagnosis and at recurrence. Immunohistochemical expression of PSMA and vascular density (using CD34 staining) were quantified and changes between initial diagnosis and recurrence were determined. PSMA expression was correlated with survival time as well as established clinical parameters. As a proof-of-principle, a 68Ga-PSMA PET scan was obtained in one patient at the time of tumor recurrence.For the current study, patients who underwent resection for de-novo glioblastoma between Dec 2007 and Nov 2015 and had a re-resection in case of a recurrent tumor following completion of radiochemotherapy and subsequent chemotherapy (at least one cycle) according to the EORTC/NCIC protocol were selected. Time of last follow up was January 1IDH mutation status, MGMT promotor methylation status and Ki 67 labeling index if available are presented in 16 patients in whom tissue from first and second surgery was available for PSMA and CD34 staining were included. Patient characteristics including sex, age, Karnofsky performance status scale (KPS) and survival data as well as tumor characteristics including IDH mutation status, MGMT promoter methylation status). Two H&E-stained slides per patient (primary and recurrent tumor each) were systematically reviewed to confirm the diagnosis of glioblastoma (WHO grade IV) according to the 2016 WHO classification of tumors of the central nervous system  staining and molecular genetic analyses . Finally, PSMA-to-CD34 ratios were calculated for the amount of vessels and for the score of vessel density. In addition to the vascular PSMA expression, the immunoreactive score (IRS) for PSMA expression was assessed in non-endothelial cells within the tumor. The IRS is the product of a score for the intensity of PSMA-staining  and the amount of PSMA-positive cells  as established by Remmele and Stegner . Both fuWilcoxon signed-rank test was used for comparison of means. Correlation of PSMA expression with clinical parameters was tested at primary diagnosis and at recurrence using a two way analysis of variance (ANOVA). Kaplan-Meier estimator, Log-rank test and Cox proportional hazards model were used for survival analyses. Overall survival time was defined as time from first tumor surgery at initial diagnosis until date of last follow up. Post-recurrence survival time was defined as time from second tumor surgery at first recurrence until date of last follow up. Significance level was set at p<0.05.68Ga]-PSMA-11 PET scan at recurrence. The PET scan was performed as previously described (68Ga-PSMA-11 were intravenously injected. The acquisition time was 60–80 min post-tracer injection. A low dose computed tomography (ldCT) scan was performed for attenuation correction.Patient #16 received a gallium-68 -PSMA-11 uptake in the area of contrast-enhancement in magnetic resonance imaging (MRI). Although the tumor-to-background contrast is extremely high  due to the very low [68Ga]-PSMA-11 uptake in the contralateral cerebral background  as well as the absolute amount of PSMA-positive vessels significantly decrease after multimodal therapy, whereas the median CD34 score and the median PSMA score remain stable, indicating that less vital tumor tissue might be present in the recurrent situation compared to initial diagnosis. It has already been shown that, especially in the recurrent situation, obtaining sufficient tissue can be challenging and that it is an important prerequisite for conclusive histopathological or further genomic diagnostics  of the German Research Foundation (DFG), project number 68647618. NA thanks the Else Kröner Fresenius-Stiftung for the support of her research.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Such highly efficient SHG from a metal nanocavity also constitutes an ultrasensitive nonlinear nanoprobe to map the distribution of longitudinal vectorial light fields in nanophotonic systems.Efficient frequency up-conversion of coherent light at the nanoscale is highly demanded for a variety of modern photonic applications, but it remains challenging in nanophotonics. Surface second-order nonlinearity of noble metals can be significantly boosted up by plasmon-induced field enhancement, however the related far-field second-harmonic generation (SHG) may also be quenched in highly symmetric plasmonic nanostructures despite huge near-field amplification. Here, we demonstrate that the SHG from a single gold nanosphere is significantly enhanced when tightly coupled to a metal film, even in the absence of a plasmon resonance at the SH frequency. The light-induced electromagnetic asymmetry in the nanogap junction efficiently suppresses the cancelling of locally generated SHG fields and the SH emission is further amplified through preferential coupling to the bright, bonding dipolar resonance mode of the nanocavity. The far-field SHG conversion efficiency of up to  In nanoplasmonic systems symmetry can often suppress the second harmonic generation (SHG) is spite of the highly enhanced fields. Here, the authors demonstrate light-induced symmetry breaking that enables strong SHG enhancement from symmetric nanophotonic systems with certain properties. Both dielectric5 and metallic nanoparticles7 enable strong field enhancement inside and at the surface of a particle, respectively, and offer promising ways to enhance the nonlinear optical processes, including second-harmonic generation (SHG). High-index dielectric nanoparticles support Mie-type resonances with much larger mode volume than plasmonic nanoparticles and exhibit high SH conversion efficiencies9, compared to unstructured materials, capitalizing on a bulk second-order nonlinearity related to their non-centrosymmetric crystal lattice15. For plasmonic materials , the intrinsic inversion symmetry of the crystal lattice forbids the electric-dipole allowed SHG in their bulk, and the second-order nonlinear response mainly originates from the surface where the centrosymmetry is broken16. Such surface SHG is typically weak but much stronger localized than the SHG from dielectric nanoparticles, and very sensitive to the modification of the surface states and used for probing biochemical events, such as chemical reactions17, photocatalytic transformation18, and chemical mapping, potentially at the single-molecule level.Nonlinear nanophotonics has gained rapid appreciation as a route to control light with light at the nanoscale and realize many applications ranging from optical frequency conversion to imaging and biosensing as well as quantum technologies19. This strategy has been extensively implemented in various plasmonic entities to amplify the nonlinear conversion by exploiting mode resonances with stronger near-field localization of fundamental fields, such as the Fano-type resonances21. The antenna efficiency of a plasmonic nanostructure at the SH frequency also plays a significant role in the emission of the locally generated SH light22. Therefore, further improvement of the SHG efficiency resorted to the development of double-resonant plasmonic nanostructures that provide the fundamental field enhancement and the SH emission amplification simultaneously26, demonstrating SHG conversion efficiencies as high as 27, obtaining bright nonlinear nanoscale sources in the ultraviolet-visible spectral range remains a challenge in the absence of suitable plasmonic resonances at the SH frequencies where some metals, such as Au or TiN important for practical applications, do not have plasmonic behavior at all.In the absence of the phase-matching condition important in conventional macroscale nonlinear crystals, efficient SHG in plasmonic nanostructures heavily relies on the enhancement of the fundamental field: 8. At the surface of a symmetric metallic nanostructure, SHG is always associated with an anti-symmetric mode under either symmetric or anti-symmetric plasmonic excitation at the fundamental frequency. Within the electric-dipole approximation, SH emission is, therefore, available only for metallic structures with asymmetric geometries, for example, a small metallic particle with the shape deviating from a perfect sphere28. Beyond the electric-dipole approximation, the nonlocal, bulk electric quadrupole, and bulk magnetic dipole interactions can contribute to SHG by breaking the lattice centrosymmetry, but they are weaker than the contributions of the surface SHG19. Plasmonic excitations, which provide resonantly enhanced surface electric fields, can significantly amplify the SH conversion near a nanoparticle surface. Although composite plasmonic nanoantennas with a nanogap, such as a nanosphere or nanoparticle dimers or metal film-couped nanoparticles, are able to provide stronger near-fields to enhance the nonlinear polarization33, the far-field SHG efficiencies are limited by the degree of their structural symmetry36.The effective second-order nonlinear susceptibility of metal nanoparticles, which determines the far-field radiated SHG, strongly depends on the geometric symmetry of a nanoparticleHere, we demonstrate that a nanostructured plasmonic system, featuring extremely narrow gaps with an asymmetric geometry, exhibits exceptionally strong SHG in the ultraviolet-visible band. This nanostructure having a plasmonic response at a fundamental frequency consists of a single gold nanosphere closely separated from a gold film Fig. , forming37. The vertical dipolar mode of interest in this work features a strong electromagnetic field enhancement in the gap region with the dominant electric field component oriented in the vertical direction  the local SHG polarization , which produces the focal field distributions as presented in Fig. To validate the advantage of the VND configuration for SHG superior to a RND, we performed nonlinear confocal scanning measurements on both the single gold NPoMs and the nanodimers  is produced to illuminate the nanoparticles. The scattered light from the individual nanostructures is collected by the same objective with a smaller collection angle (53°) and then delivered to either the spectrometer for spectral analysis or the camera for wide-field imaging.The SHG spectroscopy of the plasmonic nanostructures is implemented on a commercial laser scanning confocal microscope system  combined with a Ti: sapphire femtosecond laser . The laser beam  is tightly focused on the sample with a high NA 0.95) objective. The emitted second harmonic photons from the plasmonic nanostructures are collected by the same objective in an epi-reflection configuration and then sent to high-sensitivity hybrid detectors (HyDs) for photon counting. The confocal image reconstruction within the SH band and spectral analysis are performed by a prism-based light dispersion module inserted in the detection path. To minimize the laser damage, the laser power used is 5 objectiThe SH near-field polarization fields of the nanodimer structures were simulated numerically using a commercial finite-element solver (COMSOL Multiphysics) in the frequency domain. A perturbative approach within the undepleted-pump approximation  was employed to run the simulations. The SH responses from plasmonic metals originate from the free-electron currents induced by both bulk and surface effects, but here we only consider the dominant ones normal to the metal surface in the simulations. The far-field SH radiation patterns of individual plasmonic nanostructures were derived by performing a near-to-far-field transformation of the simulated fields at the SH wavelength (Supplementary Note Supplementary Information


Eph receptors are the largest family of receptor tyrosine kinases and by interactions with ephrin ligands mediate a myriad of processes from embryonic development to adult tissue homeostasis. The interaction of Eph receptors, especially at their transmembrane (TM) domains is key to understanding their mechanism of signal transduction across cellular membranes. We review the structural and functional aspects of EphA1/A2 association and the techniques used to investigate their TM domains: NMR, molecular modelling/dynamics simulations and fluorescence. We also introduce transmembrane peptides, which can be used to alter Eph receptor signaling and we provide a perspective for future studies. Erythropoietin-producing hepatocellular carcinoma receptors (Ephs) represent the largest superfamily of tyrosine kinases receptors (RTKs). Ephs are expressed in most tissues during embryogenesis and are essential for a large variety of developmental processes.  They plaN-terminal globular domain for ephrin binding known as the ligand-binding domain (LBD), a cysteine-rich EGF-like domain (CRD) and two fibronectin III repeats .The solution NMR structure of the TMD homodimer of EphA1 was obtained in lipid bicelles under two different conditions: at pH 4.3 (PDB ID: 2K1K) and pH 6.3 (PDB ID: 2K1L). The EphA1 sequence is unique by comparison to the other Eph family receptors because of the presence of a membrane-embedded ionogenic residue (Glu547) at the  packing . This inIdentification of several characteristic dimerization motifs in the TM region sequences of Eph receptors indicates that TMD associations in the plasma membrane are dynamic and independent of ligand-induced dimerization/clustering events. The NMR structure of the dimeric TMD of EphA2 was also obtained in lipid bicelles at pH 5 (PDB ID: 2K9Y) . CompareIn general, the association of transmembrane (TM) α-helices is controlled by many factors in the cell, such as the primary structure of interacting helices, lipid composition of their local environment, binding of external or internal ligands, and general physicochemical properties of the membrane. However, as a membrane is highly dynamic environment for proteins and peptides this might locally induce or stabilize one out of several possible TM structures. As mentioned above, experimental techniques for the determination of TM helical dimer spatial structures by NMR spectroscopy in detergent micelles, or more complicated membrane mimics (bicelles)  typicall3-G form of this motif  is mostly observed to participate in oligomerization. Smaller residues in GAS motifs allow for close proximity between opposite helical backbones and hence, enable interhelical backbone or main chain hydrogen bonds . Th. Th74]. In other systems, for example in plexin-A1 interacting with its coreceptor neuropilin, a neuropilin TMD-like peptide was found to inhibit the function of the plexin receptor . Generalin cis [in trans, all features which contribute to-, if not comprise the regulatory mechanism of Eph receptor signaling. This review discussed studies on the transmembrane domain (TMD) of EphA1 and -A2 which have been studied so far and provided an overview of the experimental and computational techniques used. From the reported results it is clear that the TMD has a significant role to play in signal transduction across the plasma membrane. Particularly understanding the relationship between how TM helix dimerization motifs predispose the TMD to populate particular configurational states and the associated level of dimerization and the activity of the whole length receptor is of key importance for its further characterization. This importance is suggested by the finding that a TMD-like peptide can critically influence the TMD configurational structure and whole receptor function [We are still in the process of understanding the structural components involved in Eph receptor dimerization/oligomerization and also Eph-ephrin interaction, possibly in cis  as well function . The nexfunction . It may


Recently, electric cigarettes with liquid (e-liquid) were introduced as an alternative to tobacco smoking. They were promoted as possible cessation aids and were considered to be potentially less harmful than traditional tobacco-based cigarettes. However, there is little information on the toxicants present in e-liquids and their possible carcinogenic effects.Western blot analysis was performed to identify the protein levels of cancer progression related signal transducers. Patient-derived brain tumor cells (CSC2) were injected into mouse brains and tumor growth was then observed by performing magnetic resonance imaging (MRI) and hematoxylin and eosin (H&E) staining of the whole brain. Immunohistochemistry (IHC) staining and Immunofluorescence staining were performed to study the expression of pEGFR and pERK.Western blotting revealed that e-liquids increased pEGFR and pERK expression in a dose dependent manner. Animal experiments revealed that the e-liquid treated group had accelerated tumor growth and poor prognosis compared to the vehicle group. Histological staining showed activation of pEGFR and pERK in the e-liquid treated group.Our study revealed that e-liquid activates pEGFR and pERK, leading to accelerated brain tumor growth and poor prognosis. Tobacco use is a major threat to health worldwide and several epidemiological studies attribute tumorigenesis and tumor progression to the use of tobacco –3. DiffeHowever, recent epidemiological evidences suggested that exposure to even low doses of tobacco increases the risk for health impairments such as lung cancer, and the overall death rate. Some studies have suggested that nicotine itself has harmful effects and stimulates the expression of some well-known oncogenes, such as epidermal growth factor receptor (EGFR), in cancer cells, which leads to poor prognosis and survival in patients –20. CertCurrently, there is a lack of general information on the contents of e-liquid mixtures and the harmful effects of even the low dosage use of e-cigarettes. A study is, therefore, necessary to understand the effects of using e-cigarettes. Thus, the present study was conducted to reveal that e-liquid mixture can boost proliferation and malignancy of brain tumor cells by increasing EGFR phosphorylation, resulting in poor prognosis in an orthotopic animal model.http://primejuice.kr/shopinfo/company.html) product in the Korean E-cigarette market based on the development of an analytical method and survey for hazardous substances in liquid phases of new types of electric cigarettes . Major compounds of Prime nico10 mild e-liquid are combined congener, glycerin, propylene glycol, and nicotine .We selected a prevailing Prime nico10 mild e-liquid  was diluted in 1 mL culture medium and then a volume of 12.5 μL(19.7 ng/ml nicotine concentration), 25 μL(39.5 ng/ml nicotine concentration), and 50 μL(79.1 ng/ml nicotine concentration) per well was added to each respective well for 24 hours. For the vehicle treatment, we have used propylene glycol, the major substance described by the company and another researches ). There were 185 low EGFR expressing patients (EGFR < 8.965-fold) and 155 high EGFR expressing patients (EGFR > 8.965-fold). Kaplan–Meier survival analysis was used to estimate the survival distributions. The log-rank test was used to assess the statistical significance between the stratified survival groups using Graphpad Prism six statistical software.t-test. P < 0.05 or P < 0.01 was considered statistically significant.Results of multi-dataset mouse experiments were compared by analysis of variance using the log-rank  test. The results of the two-dataset experiments were compared using a two-tailed Student EGFR is observed to be overexpressed in 30–40% of higher grade glioma patients. Thus, we first investigated the relationship between EGFR expression and the survival of glioma patients using the REMBRANDT database of the United States National Cancer Institute. The Kaplan-Meier survival plot showed that the EGFR mRNA level was negatively correlated with patient survival  : 41 days for vehicle group mouse and 20 days for e-liquid group mouse after CSC2 cell injection. Although the vehicle as well as e-liquid treated mouse developed brain tumor by the end time point, pEGFR expression in e-liquid treated mouse was found to be higher compared to the expression levels in vehicle treated mouse .Since we observed increase in pEGFR expression on e-liquid treatment in the orthotopic mouse model, we investigated the downstream signal transducers through immunofluorescence staining. The brains of both the groups were checked for tumor formation and extracted at the end time point (41 days for vehicle group and 20 days for e-liquid group). Consistent to pEGFR, it was observed that pERK expression was higher in e-liquid treated mice compared to its expression levels in vehicle treated mice   and e-liquid treated group (n = 5). MRI and H&E staining showed that e-liquid treated group showed accelerated tumor growth compared to the tumor growth rate observed in the vehicle group. Furthermore, brain tumor formation was seen within 20 days in e-liquid treated group compared to more than 1 month in the vehicle mouse group. There was also an increased expression of activated pEGFR in the e-liquid treated group. We compared the survival rates of mice by Kaplan–Meier survival curve. Higher expression of pEGFR on e-liquid treatment significantly decreased mice survival rate compared to the survival rate of the vehicle group. Thus, the in vitro cell study showed that e-liquid activates EGFR signaling and influences the growth of brain tumor cells via pERK activation while animal xenograft study showed that e-liquid promotes accelerated cancer growth which leads to poor prognosis. One point to note is that the current experiment setting is an artificial condition and the findings may not directly reflect the real human vaporizing condition. Although there is a discrepancy between the route of e-liquid administration in the experimental setting and real human vaporizing condition, either way, e-liquid phosphorylates EGFR and ERK pathways through the blood system, which we expect that our observations should reflect the consequences of the actual human condition.To further validate the findings of the Overall, the present study contributes to the existing literature by showing that e-liquid exposure can boost cell proliferation and malignancy of brain tumor via the increase in EGFR phosphorylation. Such mechanism may be induced in other types of cancers as well. Even though the study does not highlight cancer development, it provides information that can help advise cancer patients who decide to use e-cigarette regarding their potentially harmful effects on cancer progression. For further investigations, experiments using nicotine receptor antagonists are needed to verify the specific consequence of e-liquid treatment after removing nicotine from the mixture. Moreover, long time e-liquid treatments in normal cells need to be considered in order to understand the potential mechanism through which e-liquid contributes to the development of cancer. Due to limited epidemiological studies relating to the usage of e-cigarette and the incidence and survival of brain tumor, further population based studies are needed to confirm our results in humans.S1 Raw images(PDF)Click here for additional data file.S2 Raw images(XLSX)Click here for additional data file.S3 Raw images(XLSX)Click here for additional data file.


The relative increase in coronavirus disease incidence during summer 2020 in Israel was most prominent in young children. This finding contrasts with the lower increase in incidence observed in children than in adults during the school attendance period. School closure without lockdown conditions might not be independently effective at reducing spread. During July 1–August 31, 2020, the period of school vacation in Israel, coronavirus disease (COVID-19) cases surged and reached one of the highest rates in the world. We examined the nationwide involvement of children in this resurgence by comparing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections by age dynamics during the period of school vacation with that during the school attendance period.We obtained data from public national data sources . To deteTo determine positivity rate ratios (RRs) of SARS-CoV-2 tests, we calculated weekly average positivity RRs of SARS-CoV-2 PCR samples during school attendance and compared them with those of the week before school reopening , part B.>10 years of age during August 2020 to those ratios from July. We reviewed time periods related to school closure and openings and mitigation measures used in schools  to those in May–June (school weeks) for each of the age groups. Because schools were reopened gradually in May 2020, we performed a separate analysis comparing the time period when all children attended schools  to slopes during summer vacation months (July–August 2020). We analyzed differences using 2-proportion z-tests and χWe observed higher IRRs in adults than in children during school attendance (May–June); the lowest increases were in the 0–9-year group , panel AIn contrast, the 0–9 age group had the greatest increases in IRRs  and in pWe calculated slopes following linear regression of curves  Table 2.The relative increase in SARS-CoV-2 cases and in positivity of samples during summer vacation was most prominent in young children 0–9 years of age, in sharp contrast to the period of school attendance, when it was relatively flat. Parallel trends among children aged 0–9 years during August compared with July indicate that the operation of summer schools during July did not significantly influence these results.Analysis of curves of the adjusted incidence and comparisons of slopes of curves related to July–August to those for May–June revealed significantly higher rate ratios of slopes of adjusted incidence for children 0–9 years of age than any other age group. This analysis provides additional support to the finding that children in this age group are more likely to contract SARS-CoV-2 during vacation rather than during school attendance.School closure has been shown to mitigate the spread of infection in conjunction with a lockdown , as well as with different parameters (adjusted incidence and positivity rates of tests), when taken together, strengthen the reliability of the results.In conclusion, our results suggest that children, especially those <10 years of age, may contract SARS-CoV-2 infections mainly outside of school. The main implication of our findings is that that school closure without lockdown conditions might not be sufficiently effective in reducing SARS-CoV-2 spread.Additional information about coronavirus disease spread during summer vacation, Israel.


The aim of this survey was to assess any fluctuations in anxiety levels experienced by mental health workers during the COVID-19 pandemic and the association between these changes and variables of information dissemination, risk management, and managerial support.A survey was created to assess variables of information dissemination, risk management, and managerial support. The GAD-7 was employed as measure for anxiety during and pre the pandemic The survey was conducted online via an anonymised questionnaire and disseminated by management through the heads of various disciplines within the mental health work force, using the local email portal in the Cork region. It was made available for research participation for a period of one month(JULY).Following this stage, the reported data were analysed utilizing paired samples t-test, Pearson's correlations, and a hierarchical regression. Demographic variables were controlled for during analysis.102 mental health healthcare workers participated in the survey . The mean GAD-7 total scores for Pre-COVID-19 doubled in the during COVID-19 condition. The largest effect can be seen on the GAD-7 facet of “feeling afraid as if something awful might happen” with pre-COVID-19 GAD-7 mean scores more than quadrupling during COVID-19 conditions.Managerial support had a moderate negative relationship with GAD-7 scores during the COVID-19 pandemic. Information dissemination total scores also had a moderate positive correlation with managerial support total scores and perceived risk/safety total scores. There was no correlation found between the GAD-7 total scores during COVID-19 pandemic and Information dissemination total scores nor Risk/safety total scores. Childcare was a concern for 64% of staff that it was applicable to; 45% of these staff considered altering work hours; 17% reported issues from management regarding these requests.Mental health workers have seen a dramatic increase in anxiety since the COVID-19 pandemic, particularly in the context of expecting something bad to happen. Managerial support appears to be a protective factor for increased anxiety levels in this population. Childcare has been a predominant concern and altering working hours to accommodate this has been problematic for almost 1 in 5 mental health workers. Staff satisfaction with information dissemination positively affects perceived managerial support and perceived risk management.This study is limited by the utilization of a novel self-created measure for examining variables specific to the COVID-19 pandemic and to the employment of a retrospective measure to obtain baseline anxiety scores of staff members before the pandemic.


Nucleic acid approaches are highly adaptable and could be tremendously beneficial for personalized strategies to combat AMR pathogens.The coronavirus disease 2019 (COVID-19) pandemic is a challenge for ongoing efforts to combat antimicrobial-resistant (AMR) bacterial infections. As we learn more about COVID-19 disease and drug stewardship evolves, there is likely to be a lasting impact of increased use of antimicrobial agents and antibiotics, as well as a lack of consistent access to health care across many populations. Sexually transmitted infections have been underreported during the pandemic and are often caused by some of the most drug-resistant pathogens. In their recent article in  Antimicrobial resistance (AMR) is one of the most serious threats to public health. There are approximately 700,000 deaths/year globally due to AMR, and this number is estimated to balloon to 10 million AMR deaths/year by the year 2050 unless urgent measures are taken to combat the spread of drug-resistant organisms. Global strategies to combat AMR and prevent the emergence of new drug-resistant organisms are becoming further complicated in the era of coronavirus disease 2019 (COVID-19).Enterobacterales spp., MDR Pseudomonas aeruginosa, and Acinetobacter baumannii have been reported  protein as a preventative strategy against Neisseria gonorrhoeae infection.The COVID-19 pandemic has had an impact on diagnosis and reporting of sexually transmitted infections (STIs), with potentially serious implications for development of AMR infections. The National Coalition of STD Directors reported on the disruption of COVID-19 to intervention services for fections . Multiplfections  and supefections . In theih et al.  describeOvercoming infections with AMR bacteria has been an ongoing challenge since shortly after the introduction of antibiotics. While there are several classes of broad-spectrum antibiotics for treating infections with Gram-positive and Gram-negative bacteria, many pathogens are rapidly evolving or acquiring resistance to first-line treatments and will respond only to last-resort antibiotics. There are significant efforts to discover new antibiotic classes and develop derivatives and multidrug combinations. Recent high-throughput small molecule screens for compounds that target bacterium-specific pathways are promising , 13; howClostridium difficile toxin B (bezlotoxumab) in conjunction with the standard of care. MAbs against other bacterial pathogens in human phase trials include Staphylococcus aureus alpha hemolysin (Aridis and AstraZeneca) and Pseudomonas aeruginosa  are increasingly attractive biologics against AMR pathogens. The FDA has approved MAbs targeting inhalational anthrax (raxibacumab and obiltoxamab) and anti-learance . Howeverlearance .mBio, Parzych et al. directly injected mice with plasmid DNA encoding the immunoglobulin heavy and light chains of MAb 2C7_WT and Fc variants designed to activate complement via IgG hexamerization (2C7_E345K and 2C7_E430G) . Additionally, they show long-term protection against a difficult-to-treat pathogen. As the incidence of gonorrhea and other STIs increase, approaches such as DMAb delivery and other gene-delivered approaches could become key to reducing the emergence of AMR and preventing new infections in at-risk populations. In vivo delivery of biologics with increased potency such as 2c7_E430G DMAb as described by Parzych et al. could have an important impact on the course of AMR infection.In their recent article in 7_E430G) . The DNACollectively, the medical field is moving toward different aspects of personalized medicine to help tackle challenges like cancer and genetic diseases. Although infectious diseases are a part of daily life, their impact is often underappreciated, and AMR strategies have yet to embrace more personalized approaches . It is c


Benign multicystic peritoneal mesothelioma (BMPM) is a rare neoplasm of the abdominal mesothelium . We present the case of a 74-year-old male who presented with a right paracolic gutter fluid collection and cystic mass. The patient underwent diagnostic laparoscopy with resection of the mass. The final pathology revealed BMPM. The pathogenesis may have been related to longstanding diverticular disease, which could prove to be an underrecognized risk factor for the development of BMPM. Therefore, this case suggests a broadened differential diagnosis to include BMPM in specific cases of pre-operatively diagnosed colonic masses. The patient is disease-free 11 months post-operatively. Benign multicystic peritoneal mesothelioma (BMPM) is a loculated neoplasm arising from the mesothelial lining of the abdominal cavity . BMPM isA 74-year-old male with a past medical history of diverticulitis presented to the clinic in November 2018 for evaluation of a recurrent 13.5 cm right lower quadrant (RLQ) paracolic gutter fluid collection  Figure .Final pathology revealed benign multicystic mesothelioma with calretinin-positive immunohistochemical staining Figure . The patBMPM is 4-5 times more common in females and typically presents in premenopausal women (<30 years old) with risk factors like endometriosis, pelvic inflammatory disease, and a history of abdominal surgery . BMPM caOur case contributes to the rare instances of BMPM in men  and the While BMPM is a rare neoplasm, especially in males, it should be considered in the differential diagnosis of a colonic mass in patients with a benign recurrent abdominal fluid collection in the setting of diverticular disease and normal colonoscopy. Our case highlights the need for further identification of BMPM risk factors, which may include GI disease that extends to the colonic serosa . While our patient is currently disease-free, there is a high likelihood that BMPM may reoccur. Therefore, further investigation into the etiology of BMPM may elucidate novel post-surgical medical treatments for preventing disease recurrence.


To present the second case of photopigment bleaching phenomenon in fluorescein angiography (FA) and the first case of this phenomenon due to impending central retinal vein occlusion (CRVO).A 32-year-old healthy female noticed blurred vision in her right eye one day before presentation. Despite the 20/20 visual acuity at presentation, mild increased retinal vascular tortuosity and unilateral photopigment bleaching phenomenon in FA was observed in the right eye. Three weeks later, she developed a complete CRVO with visual acuity reduction to 20/40 that responded well to the intravitreal injection of aflibercept. Impending CRVO can cause unilateral photopigment bleaching phenomenon in FA that may be due to retinal ischemia. After continued exposure to short- wavelength light, photo-isomerization and saturation of the visual pigments can cause decrease in their absorptive capabilities and progressive increase in background auto-fluorescence. This phenomenon is called photopigment bleaching.,4 However, Breazzano et al recently reported the first case of this phenomenon in a scanning laser ophthalmoscopy (SLO)-based FA image. Here, we report the second case of photopigment bleaching in FA and the first case of the occurrence of this phenomenon in a case of impending central retinal vein occlusion (CRVO).This phenomenon was previously described in FAF.A 32-year-old healthy female was referred with a complaint of blurred vision in her right eye since one day before presentation. The best-corrected visual acuity (BCVA) was 20/20 in both eyes. There was a suspicious relative afferent pupil defect (RAPD) in her right eye. Results of anterior segment examination was unremarkable. The family history and her past medical history were negative. In funduscopy of the right eye, there were an increased vascular tortuosity and retinal dot and blot and flame shape hemorrhages [Figure 1]. Systemic work up was performed for hypertension, cardiac anomalies, diabetes, and hypercoagulability state that were all negative. FA was performed with confocal scanning laser ophthalmoscope system using the Heidelberg retina angiograph . Photopigment bleaching phenomenon was seen in the late-phase FA [Figure 2d]. We reinvestigated the frame numbers taken from each eye and their time provided at the top of the print outs to rule out significant difference in number of frames taken or time of blue-light exposure in eyes. Three weeks later, she came back with visual acuity reduction to 20/40 in her right eye. Vascular tortuosity and retinal hemorrhages significantly increased in the right eye funduscopy [Figure 1d]. OCTA  showed subretinal fluid and intraretinal cystic spaces and spongy edema in the foveal region [Figure 1e]. After an intravitreal injection of 2 mg /0.05 ml aflibercept , dramatic improvement in visual acuity was observed.,3,4 However, the term “photopigment bleaching phenomenon” should be used when there is not any atrophic photoreceptor layer and the increased autofluorescence is due to saturation of photopigments in the presence of structurally normal photoreceptors. In this case we did not observe any structural abnormality in macular OCT. However, mild ischemia and stasis in vascular system due to impending CRVO can cause earlier saturation of visual pigments and result in decrease of their absorptive capabilities. Unilaterality of the phenomenon in this case can be a reason for the possible effect of ischemia in this phenomenon.In FA, earlier phases images are sometimes acquired with 30- or 55-degree lenses and later images are captured with 102-degree lenses. In this situation, when exposure to short wavelength is continued or decreased tolerance of photopigments is present , the “photopigment bleaching phenomenon” may be observed. Due to photo-isomerization and saturation of visual pigments in previously illuminated 55-degree area, we have hyper-fluorescence in central 55 degree (in round or rectangular shape which is dependent on the lens type) that is surrounded with an unbleached hypo-fluorescent area in 102-degree images [Figure 2d]. Similar increased background auto-fluorescence can be seen in patients with atrophic photoreceptors and retinal disorders that involve the outer retina.Nil.There are no conflicts of interest.


Stroke can lead to varying degrees of oropharyngeal dysphagia, respiratory muscle dysfunction and even increase medical complications such as aspiration, malnutrition and death. Recent studies suggest that inspiratory and expiratory respiratory muscle training (IEMT) can improve swallowing efficacy and may reduce aspiration events. The main purpose of this study is to examine whether an 8-week IEMT programme can improve respiratory muscle strength and swallow dysfunction severity in subacute stroke patients with dysphagia.Retornus-2 is a two-arm, prospectively registered, randomized controlled study with blinded assessors and the participation of fifty individuals who have suffered a stroke. The intervention group undergoes IEMT training consisting of 5 sets of 10 repetitions, three times a day for 8 weeks. Training loads increase weekly. The control group undergoes a sham-IEMT protocol. The primary outcome examines the efficacy of the IEMT protocol to increase respiratory muscle strength and reduce dysphagia severity. The secondary outcome assesses the longitudinal impact of dysphagia on body composition and nutritional assessment over a 6-month follow-up.IEMT induces an improvement in respiratory muscle strength and might be associated with relevant benefits in dysphagia patterns, as well as a reduction in the number of aspiration events confirmed by videofluoroscopy or fiberoptic endoscopic evaluation of swallowing. The description of the impact of swallowing impairment on nutritional status will help develop new strategies to face this known side-effect.https://clinicaltrials.gov/ct2/results?cond=retornus+2&term=&cntry=ES&state=&city=&dist=Clinicaltrials.gov NCT03021252. Registered on 10 January 2017. WHO trial Registration data set: Due to heavy traffic generated by the COVID-19 outbreak, the ICTRP Search Portal does not respond. The portal recommends other registries such as clinicaltrials.gov. Protocol version: RETORNUS 2_ PROTOCOL_2.The online version contains supplementary material available at 10.1186/s13063-021-05353-y. Stroke is one of the major causes of disability in adults, being an important public health concern . Stroke-Breathing, eating and cough function play an important role in the prevention of aspirations and consequent respiratory complications. Regulator mechanisms are located on the brainstem , 4 and cThe prevalence of respiratory muscle weakness in subacute stroke is very high . After aOver the last decade, a novel non-pharmacological approach to respiratory complications has been developed and tested in several neurological diseases. Positive results have been observed using inspiratory and expiratory muscle training (IEMT) to improve cough effectiveness and airway protection in neurological patients –14. To dFocusing on stroke patients, some authors tested a dual training programme for inspiratory and expiratory muscle training (IEMT) and concluded that IEMT induces significant improvement in inspiratory and expiratory muscle strength. This could potentially offer an additional therapeutic tool aimed at reducing respiratory complications at 6 months in stroke patients  while prIEMT is also a therapeutic strategy to be considered in patients with dysphagia mainly because of the effect of expiratory muscle training (EMT) on suprahyoid muscles and constrictors. EMT reduces the pharyngeal residue in Parkinson disease  by improUnder the hypothesis that IEMT could improve respiratory and swallow function in subacute stroke, a randomized clinical trial is designed to assess the effectiveness of an 8-week IEMT programme to improve respiratory muscle strength and swallowing function in subacute stroke patients with dysphagia.The Retornus-2 study has been designed as a parallel-group double-blind randomized controlled trial with allocation ratio 1:1 in a superiority framework of the intervention and intention-to-treat analyses. The study will follow the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines .The study is carried out in the Neurorehabilitation Unit, Physical Medicine and Rehabilitation Department, of a tertiary hospital in Barcelona .The population of interest in this study is comprised of stroke outpatients with oropharyngeal dysphagia. The inclusion criteria for the study are (1) oropharyngeal dysphagia diagnosed by a videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic swallow study (FEES) secondary to first ischemic stroke, (2) stroke onset >3 weeks and (3) preserved cognitive function (MMSE >24). Exclusion criteria include (1) motor or sensitive aphasia which could impair complete understanding of exploratory items; (2) serious cardiovascular events , neuromuscular diseases (neurodegenerative diseases) or metabolic myopathies conditions that could interfere with the results and/or measurements; and (3) medicines with potential effect on muscle structure and function .2O. Training load was set to the inspiratory and expiratory pressures allowing patients to perform 10 maximal repetitions (RM), and adjusted weekly by 10 cmH2O if tolerated. Patients performed five sets of 10 inspirations and expirations, three times a day, 7 days per week, for 8 weeks. The control group received the same training schedule using a sham valve. Patients of both groups received standard therapy consisting of swallowing manoeuvres, oral exercises and compensatory techniques aimed at improving self-management of dysphagia and protect the airway. The training session was supervised by a Speech and Language Therapist (SLT) twice a week, and the other sessions were self-assisted at home.The intervention consists of an IEMT protocol using the Orygen Dual Valve . This device allows patients to train inspiratory and expiratory muscles simultaneously, and loads can be adjusted independently at regular intervals of 10 cmHThere are no special criteria for discontinuing or modifying allocated interventions. Patients requiring discontinuing or modifying the interventions were withdrawn from the study. Strategies to improve adherence to respiratory training included providing a record sheet to register the home training sessions. Concomitant SLP therapy or respiratory therapies  were not permitted during the trial.outcomes are contemplated: strength of the inspiratory and expiratory muscles after an 8-week IEMT protocol, estimated with maximal inspiratory and expiratory pressures  expressed in cmH2O, and dysphagia severity assessed by VFSS. Secondary outcomes are voluntary peak cough flow (measured using a PEFR meter) and tongue strength (measured with the IOPI® system). All data was collected at baseline, end-treatment and 6-month follow-up.Two primary Respiratory complications were also registered during the follow-up by asking the participants and were checked in the personal health history if whether they had been admitted to a hospital  for respiratory causes (e.g. pneumonia or lung infections).The principal investigator screened the eligibility of potential participants during hospital admission as of April 2017. These patients received detailed information about the study procedures and were invited to participate. Demographic and clinical characteristics of the participants were collected at baseline (T0). Primary and secondary outcomes were assessed at baseline (T0), after 8 week-exercise intervention (T1) and 6-month follow-up (T2), as shown in Fig. 2O in PImax, anticipating potential losses of 15% . These assumptions have been based on data of de Menezes et al. . Changes during follow-up are assessed by analysis of variance using mixed repeated measures and a one-factor design for the analysis of values over time.All statistical tests are two-tailed and statistical significance has been set at 0.05. IBM SPSS 22.0 software is used for statistical analysis. The final report will follow CONSORT 2010 guidelines.When estimating the study’s sample size, the possibility of loss to follow-up was considered and factored into the calculation. Moreover, other missing data was accounted for by handling drop-outs as non-finishing intervention, in accordance with the intention-to-treat principle.Given the non-pharmacological nature of this study, a data monitoring committee is not required. Any adverse effect related to the exercise intervention or any unintended effect was registered. There are no anticipated problems that could be detrimental to the participant. Interim analyses are not contemplated, but if required, only the main investigators will be involved.No steering committee was constituted. The principal investigators supervised correct development of the trial. A monthly meeting was held to detect any eventual difficulties or errors. Both investigators were responsible for the design of the trial but did not participate in data recruitment or intervention. They met with the intervention group every 6 months, to detect and correct any eventual difficulties during the recruitment and follow-up processes, data management and monitoring and statistical analysis of outcomes. They were responsible for assessing the rate of progress to ensure that the trial was conducted in accordance with the study plan.No intermediate audits were contemplated. But should any unexpected adverse effects appear, audit process will be carried out in order to detect and correct the side-effects.(European Parliament and Council Regulation EU 2016/619). Detailed, understandable oral and written information was provided to patients and family members, and an informed consent to participate will be signed by all participants   and the European Union Prior to any intervention, each patient was informed about the risk and the goals of the current study. Patients were allowed to withdraw from the study at any time for any reason. Patients received the required treatment regardless of participation in the study.Participants, the research team and trial registries were notified of any eventual modifications of the study protocol.Confidentiality included in data managementDeclaration of interest/Competing interests (included in the Declarations section)Access to data/Availability of data and materials (included in the Declarations section)Ancillary and post/trial care (included in the Declarations section)The findings of this research project will be disseminated nationally and internationally in scientific meetings, and we will seek publication in peer-reviewed journals.This study is an attempt to evaluate the effect of IEMT on respiratory muscle function and dysphagia severity. Adherence to the 8-week protocol was ensured by using an external device for training. Retornus-2 is the natural follow-up of the first study of our group, the Retornus I study, in which we reported that inspiratory and expiratory muscle training (IEMT) induces significant improvement in inspiratory and expiratory muscle strength and could potentially offer an additional therapeutic tool aimed at reducing respiratory complications at 6 months in stroke patients . SecondlIn conclusion, the results of the trial may result in important advances in neurological dysphagia rehabilitation. First, the magnitude of effect on dysphagia may be higher than previous trials, where the focus is placed on improving respiratory strength. Second, the trial tests the capacity of patients for training at home, facilitating rehabilitation intervention. Finally, if the results lead to a reduction in hospital admissions, respiratory muscle training could help reduce direct and indirect costs associated with stroke.Samples from rehabilitation units usually have an initial bias because patients tend to be preselected for their potential to follow a rehabilitation programme. This is an initial bias due to the fact that not all the stroke patients are admitted to follow an intensive rehabilitation programme and some of them are transferred to other facilities (e.g. nursing home). Patients in our study were recruited during their stay in the neurorehabilitation ward (intensive rehabilitation). Once functional status was enough to return home, our Health System provided transport facilities to continue the rehabilitation programme.The decision to only evaluate patients in a subacute stroke phase may provide limited results and make extrapolation to other populations difficult. The homogeneity of participants due to selected-dysphagic post-stroke events impacts on the applicability of our findings to the general stroke population but not for a population similar to the sample described in this study.Protocol version number: Retornus-2_2Begin recruitment: 05/07/2017End recruitment: 03/31/2020End data collection: 09/31/2020Trial status: Enrolment is completedStatement about trial status: Because of the COVID-19 pandemic, enrolment was closed in March 2020 with 48 patients . The follow-up ended in September 2020.Additional file 1. A: Informed consent. B: Informed consent.Additional file 2. Ethical Approval DocumentAdditional file 3. SPIRIT checklist.Additional file 4. Funding Documentation.


Bariatric surgery has been proposed to improve glycemic control in morbidly obese patients by stabilising the gut barrier and alleviating endotoxemia-induced insulin resistance. Here, recent studies are highlighted which reveal site-specific and at times opposing effects of bariatric surgery on the gut barrier. Further understanding the underlying mechanisms may not only inform the development of novel gut-based drugs for the initial treatment of type 2 diabetes, but possibly also assist in the management of its eventual relapse. The gut lumen harbors trillions of microbiota which normally reside symbiotically in the host. Under certain conditions however, such as in inflammatory bowel disease (IBD), this healthy balance is lost, and there is an expansion of pro-pathogenic gut microbiota which disrupt the otherwise protective gut barrier. The resulting translocation of microbial products such as lipopolysaccaride (LPS) from the cell wall of gram-negative bacteria through ’leaky’ gut epithelial cells into the general circulation is referred to as endotoxemia. This is characterized by both a localised and systemic low-grade inflammatory response via the activation of toll-like receptor 4 (TLR4) expressed in innate and adaptive immune cells. In 2008, it was proposed based on experiments on mice that obesity-associated insulin resistance can be traced to microbiota-mediated disruption of the gut barrier and the ensuing endotoxemia . This idBariatric surgeries such as vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) are indicated for individuals with morbid obesity when conservative treatments fail. These gastrointestinal anatomy-modifying interventions not only cause unmatched weight loss, but also a host of other metabolic benefits such as the remission of type 2 diabetes in most cases. Endotoxemia is also alleviated in patients after VSG and RYGB , althouget al. [ex vivo functional and gene expression analyses of jejunal and colonic tissue samples. They found that jejunal samples from the VSG-treated mice had reduced paracellular and transcellular permeability as determined by sulfonic acid and horse radish peroxidase (HRP) fluxes, respectively. Interestingly, this was not found in jejunal samples from mice pair-fed to VSG-treated mice arguing for a surgery-specific effect. In line with the functional findings, jejunal mRNA expression of several gut barrier-associated proteins including junctional adhesion molecule-A and occludin were selectively upregulated in VSG-treated mice. The authors then strikingly found the opposite pattern in the colon. That is, VSG-treated mice had increased transcellular and paracellular colonic permeability although this was not associated with any changes in colonic gene expression. Perhaps unexpectedly, but in line with the greater bacterial load present in the large compared with the small intestine, systemic endotoxemia was increased specifically in VSG-treated mice. While these findings are at odds with the outcome of VSG on endotoxemia in patients described above [In the first study by Blanchard et al. , mildly ed above , they pred above .et al. [in vivo functional experiments. It was found that protein expression of occludin was clearly increased in the jejunum of RYGB-treated mice, while protein expression of the gut barrier-associated protein zona occludin-1 was clearly increased in the colon. Nevertheless, jejunal and colonic permeability were similarly decreased in RYGB-treated mice as determined by localised fluorescein isothiocyanatedextran injections. Correspondingly, endotoxemia was alleviated in these mice as it is in humans after RYGB thus providing confidence that this feature of the clinical procedure can effectively be modeled in the preclinical setting. Next, the authors investigated the potential site-specific effects of RYGB on gut inflammation. They found that mRNA expression of the proinflammatory cytokine interleukin 1 beta (IL-1β) decreased in the jejunum of RYGB-treated mice, while mRNA expression of pro-inflammatory IL-6 decreased in the colon. This was also reflected in the circulating levels of both cytokines, confirming that RYGB mitigates the state of chronic low-grade systemic inflammation associated with obesity. In order to identify the underlying, site-specific mechanisms for the alleviation of endotoxemia associated with RYGB, a different approach was taken from previous studies and gene expression analysis was performed on factors involved in host defense in jejunal and colonic samples. It was found that mRNA expression of the Paneth cell-derived antimicrobial factor regenerating islet-derived protein 3 beta (REG3β) increased in the jejunum, while mRNA expression of both REG3β and REG3γ increased in the colon of RYGB-treated mice. In contrast, mRNA expression of the enzyme intestinal alkaline phosphatase (which dephosphorylates LPS) increased in both the jejunum and colon of these mice. While these insightful findings are only associational in nature, they uniquely suggest that RYGB creates a gut environment that is hostile to pathogenic bacteria and effectively neutralizes LPS alongside reducing gut permeability. They are also in line with the findings of Blanchard et al [In the second study by Jin et al. , severelet al. [Given the above discoveries, one might ask what accounts for the site-specific effects of bariatric surgery on the gut barrier? This is unlikely to be a circulating factor acting on the basolateral side of enterocytes. Instead, it is more likely that luminal factors acting on the apical side of enterocytes are responsible considering how reconfiguration of gastrointestinal anatomy imposes site-specific compositional changes in the gut lumen due to redirection of digestive secretions and shifts in the gut microbiota. To directly test this idea, Hankir et al.  applied et al. [et al. [et al. [In a subsequent study by Hankir et al. , content [et al.  and Jin  [et al. , ileal c [et al. . The for [et al.  in Caco- [et al. . It woulInitially considered as simply mechanical interventions, bariatric surgeries are now recognized as having complex molecular, cellular and systems effects. This is reflected nicely in the context of a leaky gut, where physically cutting and then merging the gastrointestinal tract leads to widespread and site-specific changes in the molecular building blocks of the gut barrier that overall alleviate endotoxemia-induced insuin resistance. Future studies can reveal whether designing drugs that target the gut barrier in the same way as bariatric sugeries do can effectively treat type 2 diabetes in a safe and non-invasive manner.