To unravel B-cell receptor (BcR) characteristics in muscle tissues and peripheral blood and gain more insight into BcR repertoire changes in peripheral blood in idiopathic inflammatory myopathies (IIMs), and study how this correlates to the clinical response to IVIG.Nineteen treatment-naive patients with newly diagnosed IIM were prospectively treated with IVIG monotherapy. RNA-based BcR repertoire sequencing was performed in muscle biopsies collected before, and in peripheral blood (PB) collected before and nine weeks after IVIG treatment. Results were correlated to patients’ clinical improvement based on the total improvement score (TIS).Prior to IVIG treatment, BcR clones found in muscle tissue could be retrieved in peripheral blood. Nine weeks after IVIG treatment, new patient-specific dominant BcR clones appeared in peripheral blood while pre-treatment dominant BcR clones disappeared. The cumulative frequency of all dominant BcR clones before treatment was significantly higher in individuals who responded to IVIG compared with those who did not respond to IVIG, and correlated with a higher CK. During follow-up, a decrease in the cumulative frequency of all dominant clones correlated with a higher TIS.In treatment-naive patients with newly diagnosed IIM, muscle tissue and peripheral blood share expanded BcR clones. In our study a higher cumulative frequency of dominant BcR clones in blood before treatment was associated with a higher CK and better treatment response, suggesting that response to IVIG may depend on the composition of the pre-treatment BcR repertoire. Rheumatology key messagesIn IIM patients (dominant) BcR clones in muscle tissues can be retrieved in peripheral blood.New patient-specific dominant clones are formed and pre-treatment dominant clones disappear nine weeks after IVIG treatment.IIM patients with a high impact of dominant clones in blood before therapy respond better to IVIG.Idiopathic inflammatory myopathies (IIM), often referred to as ‘myositis’, are a heterogeneous group of auto-immune disorders characterized by subacute, often severe progressive proximal muscle weakness. Several treatable subtypes can be distinguished: i.e. DM, antisynthetase syndrome (ASS), immune-mediated necrotizing myopathy (IMNM), non-specific/overlap myositis (NM/OM) and PM , 2. PolyIn recent years, pooled human IgG purified from healthy donors , IVIG, aAlthough B cells may play a key role in IIMs, and IVIG can influence the B-cell repertoire, little information is available on modulation by IVIG of the B-cell response at the clonal level in IIM and other auto-immune diseases, and whether differences in the effect of this modulation explain the large inter-individual variability in clinical response to IVIG . To fillAll patients signed informed consent prior to inclusion in the study. This study was conducted with approval of the local medical research ethics committee of the Academic Medical Centre, Amsterdam, and in accordance with the declaration of Helsinki.Adult, treatment-naive patients with newly diagnosed, biopsy-proven IIM were included in a 9 week phase-2 open-label study that investigated IVIG as first-line treatment in IIM patients . IVIG moRheumatology online), and results in a Total Improvement Score (TIS). TIS ≥40 was defined as response to treatment  (Rheumatology online) or myositis subtype, even in the largest group of eight DM patients, did not show significant differences (data not shown). The total number of clones retrieved from each antibody subgroup is further listed in Rheumatology online.To get a better understanding of B-cell involvement in IIMs, we started by investigating the hypothesis that in IIMs, muscle biopsies and peripheral blood harbour expanded BcR clones. We sequenced the BcR heavy chain repertoires in muscle tissue and peripheral blood obtained in all patients prior to IVIG treatment and detected multiple dominant BcR clones in all 19 muscle tissues sequenced and in 14 of the 19 peripheral blood samples sequenced . Since (P < 0.0001) (Rheumatology online). We observed that the peripheral blood repertoires were more diverse when compared with the repertoires in muscle tissues  as an indication of the maturation status of the BcR repertoire. A high mutation load indicates that the repertoire is dominated by mature BcR clones (i.e. memory and plasma blasts/cells), while a low mutation load indicates that the BcR repertoire is mainly composed of immature BcR clones (naive). When we compared the mutation load of the BcR repertoire obtained from muscle tissues to that of peripheral blood, the BcR repertoire in muscle tissues had a significantly higher mutation load compared with the pretreatment BcR repertoire obtained from peripheral blood ( 0.0001) . Finally tissues .Taken together, our analyses in this limited number of patients show that muscle tissue and peripheral blood of IIM patients harbour dominant BcR clones. In addition, the BcR repertoire of muscle tissues is mostly composed of highly mutated BcR clones when compared with peripheral blood.Rheumatology online). BcR repertoire features like CDR3 length, CDR3 charge, V and J gene usage and repertoire diversity did not differ between both time points (Rheumatology online). However, comparing dominant clones at baseline with those present 9 weeks after IVIG treatment we observed that only one patient had a shared dominant clone between both time points (Rheumatology online). In all other patients, dominant BcR clones present 9 weeks after treatment were completely different from the dominant clones present before treatment (Rheumatology online).To explore the effects of IVIG treatment on the BcR repertoire, we compared the number and cumulative frequency (impact) of dominant BcR clones in peripheral blood before and after 9 weeks of IVIG treatment. At the time points, the number of dominant BcR clones  and the reatment . Additiode novo or were in any way related to clones present prior to IVIG treatment. From each patient, the CDR3 amino acid sequences of all dominant clones retrieved at week 9 were compared with the CDR3 amino acid sequences of all clones present at baseline in a clustering analysis. Our analysis revealed that dominant BcR clones at follow-up were completely different from the BcR clones pre-treatment, as no clusters were observed between clones present prior to IVIG treatment and the newly formed dominant BcR clones after IVIG . Additionally, in comparison to the other responders, we did not see any differences in the two responders who had the highest impact of dominant clones at baseline in terms of clinical characteristics (Rheumatology online) or BcR features such as CDR3 length, CDR3 charge and V and J gene usage (data not shown). The two patients with the highest impact of all dominant clones before treatment  . Of intereatment  are two n = 19), we observed a significantly higher impact of dominant BcR clones in blood before start of therapy in responders compared with non-responders to IVIG therapy.In muscle biopsies, the impact of dominant clones did not show a correlation with response. Nine weeks after treatment, we did not observe this difference as the impact of all dominant BcR clones was comparable between responders and non-responders . In concP = 0.02, 95% CI ]. This was also reflected in a non-significant trend to association of CK with the number of dominant clones in peripheral blood (Rheumatology online). Here, the number of dominant clones but not the impact of these clones also showed a significant inverse association with baseline MMT . In muscle tissues, we did observe a non-significant  trend in correlation between baseline MMT and impact of dominant clones (Rheumatology online). There was no significant correlation between the number and impact of dominant clones in muscle tissues at baseline with MMT and CK (Rheumatology online).Next, we assessed whether BcR repertoire features correlated with various markers of disease activity or therapy response. At baseline the impact of the dominant clones in blood correlated with increased CK in blood . and non-significantly with a better TIS response . The number of dominant clones in blood did not correlate with CK, MMT or TIS (Rheumatology online). In patients who shared dominant clones between muscle tissues and blood (n = 3), no significant correlations between the number and impact of shared dominant clones (blood-muscle) and TIS, MMT or CK were demonstrated (data not shown). There was no significant correlation between the number and impact of dominant clones in muscle tissues at baseline clinical response at follow-up (data not shown).After IVIG treatment, in blood a decrease in the In conclusion, the impact of dominant BcR clones in blood correlated with higher CK levels at baseline. After IVIG, a decrease in the impact of dominant clones in blood correlated with higher total improvement score (TIS) as well as better muscle strength (MMT).In this prospective exploratory study, we identified expanded BcR clones in muscle tissues of IIM patients prior to treatment, which confirms a report on treatment-naive dermatomyositis and polymyositis patients . In addiThe analysis of the BcR repertoire in muscle tissue revealed the presence of highly mutated BcR clones when compared with BcR clones retrieved from peripheral blood, indicating the presence of matured cells of the B-cell lineage in muscle tissue. This is in line with previous literature  and expeWe also described the preferential usage of certain V-J gene rearrangements in the BcR clones present in both muscle tissues and peripheral blood. Preferential V gene usage by B-cell clones has been described in various autoimmune diseases such as RA, SLE as well as in myositis . The prede novo B-cell response that can be observed after treatment. These results are contrary to another study that investigated the effects of IVIG on the B-cell repertoire in patients undergoing desensitization therapy before transplantation and reported no major changes in the BcR repertoire after IVIG treatment [Another finding from our study was the presence of completely different dominant BcR clones before and after IVIG treatment. Similar findings have been observed in Guillain Barré syndrome patients treated with IVIG . Their rreatment . SeveralFinally, an intriguing question is whether the B-cell repertoire both before and after IVIG treatment is associated with clinical benefits in myositis patients. In our study, we found that patients who had a high impact (cumulative frequency) of dominant BcR clones before treatment responded better to IVIG treatment. Of note, the impact of dominant BcR clones in blood also correlated with higher CK levels at baseline, and a decrease in the impact of dominant clones in blood correlated with higher total improvement score (TIS). This might suggest that patients exhibiting a dominant B-cell response in the pre-treatment repertoire do respond better on IVIG. However, our data should be interpreted with care as the number of patients included in our study is limited. A study in Guillain Barré syndrome patients reported an association between IVIG-induced plasmablasts after treatment and clinical recovery . We did Our study has some limitations. Firstly, the relatively low number of patients did not allow subgroup analysis for different myositis subtypes. Therefore, our observations need additional confirmation in larger patient cohorts that allow subgroup analysis. Secondly, because we did not make use of conventional flow cytometry in our study, our analysis yields little information on the phenotype of these dominant BcR clones. Thirdly, the lack of a control group precludes us from making firm conclusions on whether the effects on the BcR repertoire seen in this study are totally due to IVIG or simply due to the passage of time. Finally, our BcR repertoire technique is not able to determine the specificity and pathogenicity of these dominant BcR clones present both before and after IVIG treatment as well as in muscle tissues. For example, if the clones are related to the formation of myositis-related antibodies or are directly involved in the disease pathogenesis. As a result, extensive approaches such as single-cell sequencing coupled with recombinant antibody expressions as well as cell stimulation assays are needed to fully unravel the specificity and pathogenicity of these dominant clones.In conclusion, we have shown that BcR clones present in muscle tissues can be retrieved in peripheral blood of IIM patients. Although not associated with treatment response, in peripheral blood, new patient-specific dominant BcR clones were formed during IVIG treatment and, pre-treatment dominant BcR clones disappeared after treatment. Finally, the high impact of dominant B-cell clones before treatment is associated with a better clinical response to IVIG, suggesting that response to IVIG might depend on the pre-treatment BcR repertoire. Future work tailored towards a better understanding of the pre-treatment BcR repertoire in myositis patients might result in the identification of biomarkers that could predict eventual response to IVIG treatment.keac602_Supplementary_DataClick here for additional data file.


These symbiosis genes are usually located on symbiotic plasmids or a chromosomal symbiotic island, both could be transferred interspecies. In our previous studies, Sesbania cannabina-nodulating rhizobia across the world were classified into 16 species of four genera and all the strains, especially those of Rhizobium spp., harboured extraordinarily highly conserved symbiosis genes, suggesting that horizontal transfer of symbiosis genes might have happened among them. In order to learn the genomic basis of diversification of rhizobia under the selection of host specificity, we performed this study to compare the complete genome sequences of four Rhizobium strains associated with S. cannabina, YTUBH007, YTUZZ027, YTUHZ044 and YTUHZ045. Their complete genomes were sequenced and assembled at the replicon level. Each strain represents a different species according to the average nucleotide identity (ANI) values calculated using the whole-genome sequences; furthermore, except for YTUBH007, which was classified as Rhizobium binae, the remaining three strains were identified as new candidate species. A single symbiotic plasmid sized 345–402 kb containing complete nod, nif, fix, T3SS and conjugal transfer genes was detected in each strain. The high ANI and amino acid identity (AAI) values, as well as the close phylogenetic relationships among the entire symbiotic plasmid sequences, indicate that they have the same origin and the entire plasmid has been transferred among different Rhizobium species. These results indicate that S. cannabina stringently selects a certain symbiosis gene background of the rhizobia for nodulation, which might have forced the symbiosis genes to transfer from some introduced rhizobia to the related native or local-condition-adapted bacteria. The existence of almost complete conjugal transfer related elements, but not the gene virD, indicated that the self-transfer of the symbiotic plasmid in these rhizobial strains may be realized via a virD-independent pathway or through another unidentified gene. This study provides insight for the better understanding of high-frequency symbiotic plasmid transfer, host-specific nodulation and the host shift for rhizobia.Symbiotic nitrogen fixation between legumes and rhizobia makes a great contribution to the terrestrial ecosystem. The successful symbiosis between the partners mainly depends on the  Rhizobium strains YTUBH007, YTUZZ027, YTUHZ044 and YTUHZ045 sequenced in this study were deposited in the National Center for Biotechnology Information database under the accession numbers PRJNA856439, PRJNA843512, PRJNA856444 and PRJNA856733, respectively.The genome sequences of the four Sesbania cannabina-nodulating rhizobia were classified into 16 species of four genera but with highly conserved symbiotic genes, especially for Rhizobium spp., indicating they acquired the genes through horizontal transfer. To uncover the transfer mechanism of these genes, the complete genome sequences of four Rhizobium strains were obtained and analysed. We revealed the rhizobia acquired the symbiotic plasmid through a conjugal transfer process but using a virD-independent pathway. In addition, we found the symbiotic plasmid of Agrobacterium pusense IRBG74 could not be transferred due to the absence of necessary conjugal transfer elements. This study provides insight for the better understanding of rhizobial symbiotic plasmid transfer and evolution.Rhizobia are Gram-negative bacteria known for their ability to elicit root or stem nodules on legume hosts to establish nitrogen-fixing symbiosis. This kind of symbiosis is important to the terrestrial ecosystem for contributing half of global terrestrial nitrogen compounds . The nodnod, nif and secretion-system-related genes play key roles  was constructed according to previous studies [blast software version 2.13.0. The genetic organization plots for these genes were drawn using the online program ‘gene cluster' (https://xiaochi.chifei3d.com/static/xiaochiPlot/src/gene_cluster.html). The oriT for each pSym was predicted using the online oriTfinder prediction program [The protein sequence database [including  studies . The ali program .Rhizobium strains obtained in this study were at the replicon level, with genome sizes of 6.55 to 6.75 Mb and 3–7 plasmids , which were consistent with their genome phylogenetic relationships . In addition, another 82 common genes were shared by the four S. cannabina-nodulating Rhizobium strains , followed by Sinorhizobium alkalisoli YIC4027 (158); while only one (R. binae YTUBH007 and Rhizobium sp. YTUZZ027) or two (Rhizobium sp. YTUHZ045) were detected for the Rhizobium strains. In addition, the common shared genes between each pair of the Rhizobium pSyms indicating that YTUBH007, YTUZZ027 and YTUHZ045 have closer relationships than that with YTUHZ044 .Similar to the situation for T3SS genes, no Dtr gene was found in S. cannabina-nodulating rhizobia across the world were classified as 16 species in four genera, and the symbiosis genes of all the strains formed a unique cluster [Rhizobium species presented extraordinarily highly conserved symbiosis genes [S. cannabina-nodulating rhizobia A. pusense IRBG74 and Sinorhizobium alkalisoli YIC4027 were also located in a pSym [S. cannabina-nodulating Rhizobium species. According to the phylogenetic relationships  and three new candidate species, which supported the previously reported species affiliation based upon MLSA  [In our previous study, the  cluster . Among tis genes , indicatis genes  or chromis genes . As for n a pSym . In the ionships  and the ionships , the founalysis) .nodABC and nifHDK essential for Nod factor synthesis and nitrogenase are located in the pSym, similar to the previously described pSyms [Rhizobium strains [S. cannabina-nodulating rhizobia A. pusense IRBG74 (585 kb) and Sinorhizobium alkalisoli YIC4027 (456 kb).A single symbiosis plasmid was identified in each strain and both the genes ed pSyms . The ass strains . The sizS. cannabina-nodulating rhizobia have the same origin. Due to the greatly high identities, fewer strain-specific genes and more core genes among the pSyms in the four tested Rhizobium strains , which were absent in A. pusense  and effectiveness (nitrogen fixation) were mainly determined by the symbiosis genes located on pSyms or symbiotic islands . HoweveroriT sequence region are necessary for successful conjugative transfer [oriT sequence is recognized by Dtr and then the transfer is elicited [tra genes (traACDG) [cinIR or traIR [traA encodes relaxase that interacts with oriT [traC encodes ATPase, which is involved in pilus assembly and contributes to conjugation at the cell–cell contact stage [traD encodes the coupling protein TraD, a hexameric ring ATPase that forms the cytoplasmic face of the conjugative pore [traG encodes a large transfer protein, which consists of an inner membrane domain and a large periplasmic domain involved in pilus tip assembly and mating pair stabilization [A. pusense IRBG74 without any Dtr genes, the other five tested strains harboured traA, traCDG and the regulatory genes cinI and cinR   and the or traIR . traA enith oriT ; traC enct stage ; traD enive pore ; and tralization . Except and cinR , indicattrb-like systems such as that in Sinorhizobium sp. NGR234 [virB T4SSs such as that in Rhizobium etli CFN42 and Sinorhizobium meliloti 1021 [virB T4SS is usually composed of 12 genes (virB1–11/D4): virB4 and virB11 encode ATPases that coordinate the recruitment and processing of substrates, catalyse structural changes in the T4SS channel necessary for substrate passage and also regulate pilus biogenesis [virB3, virB6 and virB8 encode integral inner membrane (IM) subunits that presumptively form an IM channel [virB1 encodes a transglycosylase that contributes to assembly of the channel across the murein layer [virB7, virB9 and virB10 encode outer membrane (OM)-associated subunits that form a structural scaffold for the portion of the channel spanning the periplasm and OM [A. pusense IRBG74 without virB1, virB3 and virB5, the other five Sesbania-nodulating strains harboured a complete set of virB genes , which was presumed to be loss of Ti plasmid and acquisition of the symbiotic plasmid from rhizobium [A. pusense IRBG74 is not self-transferrable, which is not consistent with any other species sharing the same symbiotic gene type with it [Without is genes  or couldis genes , and finhizobium . However with it . Thus, wS. cannabina-nodulating Rhizobium strains were sequenced and assembled at the replicon level and compared with another two related strains in this study. Each of the six strains harboured a pSym with size (345 554–402 479 bp) and genomic organization different from each other. The phylogenetic relationships, ANI and AAI values, and the shared genes among the pSyms indicated that they acquired the entire plasmid with a short evolutionary history. The nod, nif, T3SS and conjugal transfer related genes were located on the pSyms. All the S. cannabina-nodulating rhizobia presented very similar nod gene clusters, indicating that the legume rigorously selected the chemical structure of the Nod factor of the rhizobia; however, the T3SS might be unnecessary for the symbiosis with S. cannabina. The transferrable pSym of each strain contained oriT, cinIR, traACDG and complete virB1–11 genes but without virD, indicating that they may be transferred through a virD-independent mode or by another unidentified gene.Four Click here for additional data file.


Pancreatic ductal adenocarcinoma (PDAC) is an aggressive neoplasm, with surgical resection and adjuvant chemotherapy the only curative treatment. Treatment-related toxicities place a considerable burden on patients although exercise training has shown promise is helping to manage such adversities and facilitate rehabilitation. The feasibility and safety of exercise training as a supportive therapy during adjuvant chemotherapy remains unknown.Patients with PDAC were screened post-surgical resection and enrolled in a 16-week, progressive, concurrent exercise programme alongside their chemotherapy regimen. Feasibility was the primary objective detailing recruitment, retention and adherence rates throughout as well as the safety and fidelity of the intervention. Secondarily, the impact on functional fitness and patient-reported outcomes was captured at baseline, post-intervention and 3-month follow up.Eight patients consented to participate in this trial, with five proceeding to enrol in exercise training. Concurrent exercise training is feasible and safe during adjuvant chemotherapy and prevented an expected decline in functional fitness and patient-reported outcomes during this time.This case series provides preliminary evidence that concurrent exercise training during adjuvant therapy is safe, feasible and well tolerated, preventing an expected decline in functional fitness, muscular strength and health-related quality of life (HRQoL). Given the adverse effects of treatment, these findings are promising and provide further evidence for the inclusion of exercise training as a standard of care for surgical rehabilitation and managing treatment-related toxicities. Future research should explore the impact of exercise training during neoadjuvant chemotherapy, with prehabilitation now standard practice for borderline resectable disease.https://classic.clinicaltrials.gov/ct2/show/NCT04305067.ClinicalTrials.gov Identifier: NCT04305067, prospectively registered 12/03/2020, The online version contains supplementary material available at 10.1186/s13102-023-00722-3. Pancreatic cancer is an aggressive malignancy with poor survival outcomes. In 2020, 495,773 new cases of pancreatic cancer were reported globally, with 466,003 deaths . IncidenConventional exercise, particularly moderate to vigorous / high intensity aerobic and resistance training, delivered as part of rehabilitation or adjuvant therapy provokes numerous physical and psychological benefits that can alleviate several treatment-related toxicities and improve disease outcomes , 8–10. AAt present, clinical exercise trials in PDAC within the adjuvant setting are limited to a small selection of studies –23. NoneParticipants diagnosed with PDAC, post-surgical resection and scheduled for adjuvant chemotherapy were screened for eligibility by clinicians within the Northern Ireland Cancer Centre, Belfast Health and Social Care Trust. Participants had no evidence of metastatic disease and no active prior malignancies (other than PDAC) within the last 3 years. Clinicians identified suitable participants and provided participant information packs at their chemotherapy planning clinic, with a view to enrolling in the exercise intervention after completing two cycles. The rationale for introducing exercise at this point, was to ensure participants tolerated chemotherapy well, prior to commencing exercise training. Participants were screened for recent and historical comorbid conditions that might contraindicate them from the exercise intervention Table . CliniciThe exercise intervention has been described previously . BrieflyParticipants completed three outcome assessments at baseline (pre-chemotherapy cycle 3); post-intervention (chemotherapy completion) and at 3-months follow up. All assessments were performed by a clinical exercise physiologist. The trial timeline, from enrolment to completion, can be found in Fig. Feasibility was determined by the number of participants recruited, retention and adherence rates. All variables were expressed as percentages, with adherence reflecting the number of sessions prescribed versus attended. Intervention fidelity  was determined and the rate of adverse events in response to exercise or treatment, from the point of informed consent. Adverse events were graded and coded according to the Common Terminology Criteria for Adverse Events (CTCAE).2). Hip and waist circumference was measured in centimetres using a tape measure. Anthropometric assessments were captured by the same investigator throughout the trial.Height and weight was determined using a free-standing stadiometer and calibrated laboratory scales respectively. Body mass index was derived from these measurements .In our 19-month recruitment window, from 3rd August 2020 to 31st December 2021, eleven participants with PDAC were screened, deemed eligible and approached by their treating clinician. Based upon regional statistics (1993–2020), the Belfast Health and Social Care Trust average 48 pancreatic cases per year (stages I-IV), with approximately 50% of these advanced cases and considerably fewer suitable for surgical resection (~ 20%) . PositivParticipant demographics at baseline were recorded Table . The ageFive participants (63%) proceeded to the intervention and follow up at 3 months. Intervention delivery commenced on the 7th December 2020 and ceased on 29th April 2022. Participant 1 completed the trial in August 2021, attending 28 out of 32 supervised sessions during his adjuvant chemotherapy (88% adherence). Participant 2 completed the trial in September 2021 (baseline assessment and follow up outcomes only). This participant became non-contactable after baseline and despite persistent efforts to re-establish contact and seek an alternative method of delivery, participant 2 did not complete any supervised exercise sessions during adjuvant chemotherapy. Participant 2 cited a series of treatment-related toxicities for this absence, consistent with a change in chemotherapy regimen (switched from FOLFIRINOX to gemcitabine / capecitabine after cycle 2). Participant 3 completed the trial in November 2021, attending 28 / 32 supervised sessions (88% adherence). Participant 4 was the next to complete the trial in July 2022. Due to distance from the facility this participant availed of the hybrid option, predominantly completing remotely supervised exercise via Zoom (n = 17) and in person supervision (n = 5) prior to each chemotherapy cycle. Participant 4 completed 22 / 32 supervised sessions (69% adherence). The final participant completed the trial in July 2022, attending 16 / 32 supervised sessions (50% adherence). Overall, 80% (4 / 5 participants) were able to complete the exercise programme.Exercise training was interrupted 5 times during the entirety of delivering the intervention, predominantly due to treatment-related toxicities (e.g. low cell counts). In total, participants missed 34 sessions (27%) and the intended programme was modified on 49 occasions (38%) . All four participants that engaged with the intervention improved their aerobic fitness at post-intervention and at 3-month follow up. In terms of the timed sit-to-stand test, all actively engaged participants improved or at least maintained their lower extremity muscular strength at post-intervention and 3-months. Participants 1, 3 and 5 also completed 1RM testing at baseline, post-intervention and 3-months. All three tolerated this testing well and improved their upper and lower extremity muscular strength at post-intervention and again at 3-months , suggesting these measures are suitable. The outcomes vary on an individual basis immediately post-intervention and at 3-months, with some improving and some declining  provided informed consent, with three withdrawing prior to commencing exercise. Patient dropout is commonplace in clinical trials examining PDAC patients, especially those adopting exercise training. A recent systematic review estimates retention rates of 71–90% for pancreatic cancer in the neoadjuvant setting . The retWhile participants endured numerous treatment-related side effects throughout, an important finding of this case series is no intervention-related adverse events were recorded. This suggests this exercise programming is safe as an adjuvant therapy to support patients during treatment and agrees with previous findings , 20, 40.Tolerability to exercise training during adjuvant therapy is a vital consideration for PDAC patients. This trial demonstrates the fidelity of delivering aerobic and resistance exercise training, during adjuvant therapy. Obviously, throughout the course of treatment it is to be expected that patients face adversities and as a result the prescription is modified or sessions are missed, however these patients remained engaged and returned to exercise training once these subsided. It is reassuring that participants also had the capacity to escalate sessions and complete more than required on a given day, thus recovering some of the missed dose. This is a consistent finding, previously reported in localised and advanced prostate cancer , 42 and Four of the five participants in this case series improved or at least maintained their physical fitness and muscular strength. Positively these adaptations persisted at 3-month follow up, suggesting exercise training prompted a chronic adaptation and / or instilled a motivation to continue exercising beyond the cessation of the trial. Patients often experience reduced cardiorespiratory fitness and negative changes in body mass during treatment, associated with a greater risk of post-surgical morbidity and mortality , 44. TheThere is growing recognition that HRQoL measured through patient-reported outcomes (PROs) are crucial variables in oncology trials . PROs prAs body composition is associated with the risk of cachexia and thus morbidity and mortality in PDAC, it is reassuring the majority of participants involved increased or at least maintained their body mass. Similarly, resistance exercise training in the same population increased overall body weight by 3.2% . Only paFinally, all four participants regularly participating in the exercise programme subjectively reported increased levels of moderate to vigorous physical activity post-intervention. At a time when patients often face heightened treatment-related side effects, this change is favourable and potentially assisted in managing such toxicities. This is a consistent finding within the literature , 51 suggThis trial was originally planned as a UK-wide, multi-centre intervention, but due to the impact of the COVID-19 pandemic and funding limitations, only one site was successfully opened during the recruitment timeframe. Thus, the single centre limits our ability to generalise the findings UK-wide, but indeed illustrates potential trends with exercise training during treatment for PDAC and highlights a need for scaled up research. A sufficiently powered sample would permit greater analysis that could determine if any changes were statistically significant and clinically meaningful. A potential strategy to increase accessibility, would be to accommodate home-based, remotely supervised exercise as a delivery choice to determine its effectiveness on survival, recurrence and treatment-related toxicities. While this case series did facilitate this option through a hybrid model, it was in response to the COVID-19 global pandemic, which in itself created a unique limitation whereby reduced surgical capacity and reduced in person contact made recruitment more difficult. Encouragingly this trial continued to recruit, illustrating the desire of people with pancreatic cancer to participate in an exercise programme. In keeping with the methodological design of future trials, the ‘principles of training’ should form the foundation of exercise programming as well as incorporating a comparator control / usual care arm, to assess whether an exercise intervention has any meaningful impact beyond the current standard of care. A definitive RCT, determining the efficacy of exercise on PROs and survival, is the logical next step. On a related note, it would appear that resistance exercise may be more tolerable in this population and should receive increased attention in future investigations. As toxicities persist long into survivorship, outcome measures should be reflective of this and longitudinally followed up to determine the chronic impact of exercise training in this population as well as its impact on the risk of recurrence. Further, forthcoming studies should attempt to assess the differentials of body composition, particularly lean mass, given the risk of sarcopenia and cachexia in this population. Positively, this trial was feasible and effective for the participants involved but requires a suitably qualified and experienced exercise or health care professional to deliver and individualise the prescribed dose and oversee the immediate transition of patients into survivorship, which makes its implementation into routine NHS practice challenging. Finally, future research is also encouraged to explore the mechanisms of action of exercise training in improving disease trajectory and survival for PDAC, particularly its influence on tumour growth and anti-tumour immunity. A recent pioneering trial reported aerobic exercise restricts PDAC tumour growth in mice, mediated by IL-15 signalling (a reputed ‘myokine’) and upregulation of anti-tumour immunity, ultimately sensitising tumours to therapy . It is cThis current case series provides preliminary evidence that concurrent exercise training during adjuvant therapy for PDAC patients is safe, feasible and well tolerated and may prevent expected declines in functionality, muscular strength and HRQoL during chemotherapy. Given the effects of surgical resection and cumulative effect of adjuvant chemotherapy on outcomes, a larger definitive trial of exercise training in this model is necessary, perhaps alongside the inclusion of a home-based or hybrid alternative. Nonetheless, this trial provides an insight and good starting point in the design of future studies. Including exercise training as a standard of care for surgical rehabilitation and during adjuvant therapy could significantly reduce morbidity and mortality in PDAC and better equip patients to endure further treatment if necessary.Below is the link to the electronic supplementary material.Supplementary Material 1


The unprecedented increase in life expectancy over the past few decades has led to a rise in the global elderly population. Age-related diseases have also become an increasingly significant social, economic, and medical burden all over the world . This haHan et al. used the bioinformatics methods to find that miR-449a is downregulated in osteosarcoma and plays an important role in the mechanism of osteosarcoma by targeting CCNB1. They found that the overexpression of miR-449a could inhibit SaOS-2 cell proliferation. The research revealed that inhibition of miR-449a in osteosarcoma cells promotes cell proliferation and inhibits its apoptosis. Their results illustrated that CCNB1 was a target of miR-449a in osteosarcoma. The overexpression of CCNB1 in osteosarcoma cells could suppress osteosarcoma cell proliferation induced by the miR-449a mimic. Their findings demonstrated that targeting miR-449a/CCNB1 could have significant clinical implications for treating osteosarcoma. It may represent a potential treatment strategy using engineered exosome-based therapies for the management of osteosarcoma.Osteosarcoma is the most common primary malignant bone tumor and is characterized by a high degree of local invasiveness and a tendency to metastasize . The lonFreitas et al. indicated that the expression of the lncRNA CASC2 is downregulated during the osteogenic differentiation of human bone mesenchymal stem cells (hMSCs). The results demonstrated that matrix mineralization of hMSCs was increased with lncRNA CASC2 downregulation. They further found that lncRNA CASC2 regulated the mineralization capacity of hMSCs through target protein COMP by proteomic analysis, and the inhibition of COMP could decrease mineral deposition in hMSCs. Their study clarified that regulating CASC2 levels is a potential approach for controlling bone mineralization.With the rapid progress of the aging population in society, the prevalence of age-related diseases including osteoporosis has significantly increased and is now considered a serious public health issue . Bone reWu et al. showed that inhibition of hsa_circ_0008870 could significantly suppress chondrocyte proliferation and endochondral ossification. They further found that hsa_circ_0008870 regulates MAPK1 expression by sponge miR-185-3p in chondrocyte cells. The results indicated that the downregulated hsa_circ_0008870 decreased expression of MAPK1 by impairing the sponge action of miR-185-3p, thereby reducing chondrocyte proliferation and endochondral ossification, which results in a short stature phenotype. Their researcher revealed that hsa_circ_0008870 could be a potential therapeutic target for idiopathic short stature.In recent years, circular RNA has been found to play an important regulatory role in various diseases through multiple signal transduction pathways . The stuKnoedler et al. reviewed currently available and employed methods for free flap monitoring, including clinical examination and handheld acoustic Doppler sonography. The review also summarized modern and innovative alternatives/adjuncts in free flap monitoring, such as color duplex ultrasonography, implantable Doppler, near-infrared spectroscopy, and hyperspectral imaging. The authors further analyzed free flap monitoring methods, including thermal imaging, oxygen partial pressure, and skin paddles, and their potential in elderly patients.With the ongoing demographic changes, the number of elderly patients requiring free tissue transfer is increasing, for example, following cancer resection. Flap survival rates after transferring is always considered a vital clinical problem by the majority of researchers . Timely In summary, age-related diseases have consistently been one of the global focal points in health research. This Research Topic contains innovative therapeutic strategies for age-related diseases. Recently, due to good stability and low immunogenicity, stem cell-derived exosomes served as a promising candidate for tissue regeneration . In the


As the prevalence of pregnancies with advanced maternal age increases, the risk of fetal chromosomal abnormalities is on the rise. Therefore, prenatal genetic screening and diagnosis have become essential elements in contemporary obstetrical care. Trophoblast retrieval and isolation from the cervix (TRIC) is a non-invasive procedure that can be utilized for prenatal genetic diagnosis. The method involves the isolation of fetal cells (extravillous trophoblasts) by transcervical sampling; along with its non-invasiveness, TRIC exhibits many other advantages such as its usefulness in early pregnancy at 5 weeks of gestation, and no interference by various fetal and maternal factors. Moreover, the trophoblast yields from TRIC can provide valuable information about obstetrical complications related to abnormal placentation even before clinical symptoms arise. The standardization of this clinical tool is still under investigation, and the upcoming advancements in TRIC are expected to meet the increasing need for a safe and accurate option for prenatal diagnosis. One of the latest phenomena in current obstetrics is advancing maternal age. Recent data from the Centers for Disease Control and Prevention (CDC) emphasized the rising trend in the average age of pregnant women in the United States in which almost 19% of all pregnancies were in maternal age of 35 years and older . TherefoAt present, prenatal genetic screening and diagnostic testing are two separate categories that can be characterized by their invasiveness. Prenatal genetic screening tests are ”non-invasive” methods that include the maternal serum screening of markers related to aneuploidy with or without nuchal translucency ultrasonography, and cell-free DNA screening, known as non-invasive prenatal testing (NIPT). These tests are performed by drawing maternal peripheral blood sampling; therefore, there is no risk of procedure-related pregnancy complications. However, since these tests are only for screening purposes, when the results show a high risk of aneuploidy, confirmative diagnostic testing is mandatory. The diagnostic tests include chorionic villus sampling (CVS) and amniocentesis which are ”invasive”. Since the tests require a needle puncturing through the uterine wall to the actual placenta or amniotic fluid, the risks of complication exist with a fetal loss rate of 0.7% and 0.6% for CVS and amniocentesis, respectively [Therefore, pregnant women tend to prefer non-invasive prenatal screening to invasive diagnostic testing which has led to the rapid spread of NIPT around the world ever since its commercial introduction in 2011 . NIPT isBirth defects related to chromosomal abnormalities can impact personal and family life, both emotionally and financially. Early detection of fetal chromosomal abnormalities can inform expectant parents about congenital disabilities and provide help in making crucial decisions to control pregnancy and childbearing . In thisNIPT analyzes cell-free DNA (cfDNA) in maternal blood to determine the risk of fetal aneuploidy. The cfDNA is a mixture of predominant maternal DNA originating from the hematopoietic system  and fetaThe first report of the detection of trisomic pregnancies utilized massively parallel shotgun sequencing (MPSS) ,22. In tAnother method used for cffDNA analysis is utilizing numerous single nucleotide polymorphisms (SNP) that exist only on the chromosome of interest. A large number of SNP sequences are designed to detect variations on the chromosome of interest. The SNP-based method analyzes polymorphic loci and determines chromosomal copy numbers by looking for specific patterns in allelic distributions . This meIn many countries, NIPT is used as a secondary test for women identified as high-risk after the first trimester combined screening, and in others, it is used as a primary screening test. As compared to the prior screening methods for aneuploidy involving sequential maternal serum and/or ultrasound screening, which exhibits trisomy 21 detection rates of 81–96% with a false-positive rate fixed at 5%, NIPT demonstrates higher detection rates for trisomy 21 (99%), and also for trisomy 18 (98%) and trisomy 13 (99%) with much lower false-positive rates of 1–2% ,29,30,316–107 maternal cells) [However, NIPT exhibits quite a few limitations to consider. First of all, maternal blood contains only a small fraction of fetal cells  . For thel cells) ,35. Numel cells) . Therefol cells) . Other ml cells) ,39,40.During pregnancy, women with autoimmune disease may experience a low level of cffDNA as an inflammatory response may cause a rise in maternal cfDNA in the bloodstream. This ultimately leads to a decline in the proportion of cfDNA derived from the fetus. Systemic lupus erythematosus (SLE) patients may exhibit abnormal DNA methylation in their T cells, which, along with T cell apoptosis, can further contribute to an increase in hypomethylated cfDNA in the blood with shorter DNA fragment lengths. Consequently, NIPT analyses using next-generation sequencing may reveal a different pattern in SLE patients compared to healthy patients .Suzumori et al. showed that the concentration of cffDNA decreases in cases of trisomy 13 or 18. The smaller placental size and intrauterine fetal growth retardation observed with trisomy 13 and 18 might contribute to a lower FF . TaglaueFalse-positive test results for NIPT may arise due to confined placental mosaicism (CPM) . Since tChromosomal abnormalities are often present in malignant tumors. If a pregnant woman has a malignant tumor, the NIPT result may be a false positive or may be non-reportable. The risk of confirmed malignancy is significantly higher especially when multiple chromosomal abnormalities are detected by NIPT ,57. CathA vanishing twin (VT) is a spontaneous reduction of an embryo and/or gestational sac following documented fetal cardiac activity in both fetuses of a twin gestation during the first trimester . Since cTherefore, to overcome the limitations of NIPT, a different method to non-invasively retrieve fetal cells has been constantly investigated. One of the approaches that has drawn attention was obtaining trophoblast cells in the cervix which naturally migrate from the placenta into the reproductive tract ,63. HistThe main mechanism of trophoblast cells traveling down to the cervix had been developed from the fact that upon implantation in early gestation, as the placenta develops by anchoring its villi to the uterine decidua, extravillous trophoblast (EVT) cells are differentiated and they invade into the glands and blood vessels of the uterus . These EPlacenta starts developing once a blastocyst implants in the uterine decidua. During the placentation period of 5 to 12 weeks in pregnancy, trophoblasts at the base of the anchoring villi differentiate into EVT cells, and this allows for embedment in the uterus . The migThere are two different secretion and migration paths of EVTs through the endometrial tract. Interstitial EVT cells penetrate the uterine epithelium at the margin of the placenta and replace the uterine epithelial lining from the basal side, exposing themselves to the uterine cavity . AnotherTherefore, it is speculated that EVT cells migrate to the cervix only during the limited period of placenta growth. Previous studies were able to successfully obtain EVT cells by cervical brushing as early as from 5 weeks of gestation and only up to 20 weeks of gestation ,76,77. Ap < 0.001). This pilot study presents evidence that trophoblast cells can reliably be obtained and identified among cervical cells in the first trimester by immunohistochemical staining for HLA-G and suggests for the first time that abnormal pregnancies may be predictable based on the abundance of trophoblast cells in the cervical canal [TRIC was developed as a solution to the technical challenge of analyzing placental cells in real time. The unique expression of HLA-G was found on the surface of EVT cells and by using the antibody to this antigen, adult tissues could easily be excluded from the samples obtained via the reproductive tract, thereby leaving the cell population of our interest . Imudia al canal .A limiting feature of using trophoblast cells obtained from the cervix for non-invasive prenatal testing is the excessive presence of maternal cells which makes fetal cell isolation difficult. TRIC protocol using HLA-G for immunomagnetic isolation has been developed to obtain trophoblast cells from the cervix with a high degree of purity in ongoing pregnancies . Jain etBecause cell isolation methods based on visual recognition and micromanipulation are time-consuming, and the specificity is operator-dependent, Bourlard et al. tested partially automated methods for EVT cell retrieval. HLA-G positive cells diluted in HLA-G negative cells were isolated by flow cytometry (FACS Aria III) or magnetic cell sorting (DynaMag™-2 Magnet) but no HLA-G positive cells could be recovered from exocervical samples. This result suggested that trophoblasts are too rarely and inconstantly present in non-invasive exocervical samples to be reliably retrieved by standard immunoisolation techniques . EndocerEver since the first discovery of trophoblasts in the cervix, various studies have proposed methodologies for obtaining the trophoblasts and technical ways for isolating trophoblasts for analysis. This comprehensive method named TRIC  can be outlined in four steps, as depicted below .Historically, sampling of maternal cervical mucus has been attempted via several different methods. The techniques include endocervical lavage, cervical mucus aspiration, or cytobrushing which all succeeded in obtaining trophoblasts with various success rates ,86. As og for 5 min at 4 °C. After washing the cells three times in 20 mL of PBS, the sample is fixed with a formaldehyde 3.7% solution at 4 °C for 10 min. Then, the fixed cells are centrifuged at 900× g for 5 min, washed with cold PBS three times, and counted for analysis.After the endocervical sampling, the brush needs to be immediately immersed in phosphate-buffered saline (PBS) solution in a test tube. Then, the sample should be acidified with 3% acetic acid (300 μL/10 mL) at room temperature for 5 min to dissolve mucus products and centrifuged at 900× Once a successful sampling of the endocervical cells is achieved, another key step is the sorting of fetal cells (EVTs) from maternal cells. In the beginning era of TRIC studies, a micromanipulation isolation technique was used which sorted out cell clumps with the villous morphology of trophoblast cells ,88. ReceAfter the isolation, confirming the purity of EVTs in the final specimen is imperative. Expression levels of b-hcg can be measured as a trophoblast marker by immunocytochemical labeling . SeveralFISH can also be useful especially when X and Y chromosome probes are used for analyzing the isolate. Since FISH directly labels specific genes with fluorescent dyes, it enables the visualization of the number of copies of genes or chromosomes of each cell. Therefore, numerous studies have demonstrated XY signals in specimens from male fetuses that validate the existence of fetal-origin cells ,89,91. MA recent experiment has accomplished the DNA profiling of EVTs obtained by TRIC by the next-generation sequencing of SNPs and STRs. The study collected samples at 5 to 19 weeks of gestation and fetal DNA fractions were 85 to 99%, with 100% concordance between the allelic profiles of fetal DNA and reference placental DNA. It also showed 100% correct fetal gender identification in all samples . AlthougDespite copious preceding studies, the reproducibility of TRIC remains controversial due to its varying success rates (75–100%) reported in confirming fetal cells . Since tp = 0.003) [One of the most important steps in TRIC is fixation. Previously, our institution used an alcohol-based Thinprep solution composed of water (40–70%) and methanol (30–60%) for the sample fixation ,85; this= 0.003) . This stAnother key technique in TRIC is the immunomagnetic isolation of the trophoblasts. To maximize the purity of captured fetal origin cells (EVTs), the antibody that binds to the antigen specifically expressed only in EVTs should be chosen. As mentioned earlier, HLA-G expression is one of the characteristic features in EVTs which distinguishes them from maternal-origin cells. Different types of HLA-G antibodies such as G233 and 4H84 are known to bind to them . A recenp < 0.001) [HLA-G structurally consists of heavy-chained alpha domains  and β2-microglobulin in extracellular regions which results in seven isoforms (HLA-G1 to G7) based on different combinations of the domains . Each HL< 0.001) .Nonetheless, the immunofluorescence results of these filtered HLA-G immunoisolated trophoblasts showed interference with maternal mononuclear cells that are retrieved during sample collection. Previous immunophenotyping studies have proved CD56 expressions on the surface of maternal mononuclear cells ,99, and Previous large population-based studies analyzing the effectiveness of primary screening through cfNIPT have shown that cfNIPT had a miss-detection rate of 17–25% of atypical fetal chromosomal aberrations ,102,103.A recent follow-up study on TRIC by another institution reported that 44% of samples had an adequately high fetal DNA fraction for genetic testing , and in 23% of cases, a single nucleotide variant (SNV) carried by the unborn fetus was correctly identified by Sanger sequencing . Nonethep < 0.001); in other words, early pregnancy failures such as ectopic pregnancy and blighted ovum can be distinguished from normal pregnancies with a 97% positive predictive value, 87% negative predictive value, 93% sensitivity, and 95% specificity [Pregnancy-associated complications that are related to placentation can affect the number of cells obtained by TRIC. This can be expected intuitively since TRIC targets the retrieval of EVTs which are shed from the placental margin as the placental bed grows in size with embedding vascularization. Studies have demonstrated that the rate of HLA-G positive cells obtained by TRIC was significantly lower (by about 4-folds) in abnormal pregnancies, such as ectopic pregnancy and blighted ovum, compared to normal intrauterine pregnancies (cificity . This stp = 0.052)) [Moreover, further serious obstetrical complications related to placentation in advanced gestation are intrauterine growth restriction (IUGR) and preeclampsia. The failure of EVT cells to invade uterine spiral arteries and to remodel the maternal vascular system is a key contributing factor leading to poor placentation . Therefo 0.052)) .Furthermore, another study was designed to evaluate the expression of particular proteins known to be related to abnormal placentation in EVT cells retrieved by TRIC. This was to determine whether the expression levels in cases who later develop IUGR or preeclampsia are different from those in normal pregnancies. The transcervical samples were collected between 6 and 20 weeks of gestation and the purity rate of isolated fetal cells was found to be 97.7% in the control groups and 96.6% in the adverse outcome group without statistical significance. The results showed that in cases of IUGR and preeclampsia, the expression of pregnancy-associated plasma protein-A (PAPPA), soluble fms-like tyrosine kinase-1 (sFLT1), soluble endoglin (sENG), alpha-fetoprotein (AFP), placental growth factor (PGF), and galectin 14 (LGALS14) were already altered in EVT cells obtained before 20 weeks of pregnancy with statistical significance. Specifically, sFLT1 and sENG (anti-angiogenic factors) were increased and PGF (a pro-angiogenic factor) was decreased in the adverse outcome group . These rOverall, these studies imply the infinite potential of TRIC which can provide valuable information about uteroplacental insufficiency even before clinical symptoms develop. Compared to the currently used clinical tools, TRIC will have a greater advantage in its usefulness in early pregnancy. Continuous investigations about trophoblasts obtained in the cervix by TRIC are required to develop a novel non-invasive technique that can accurately predict placenta-related pregnancy complications.Providing professional prenatal genetic counseling to pregnant women with options for various prenatal genetic testing is crucial in obstetrics. Currently, NIPT  is most widely used as a prenatal genetic screening analysis, but it has its limitations as it requires confirmation via other invasive tests. On the other hand, TRIC is a promising non-invasive diagnostic tool that directly obtains intact fetal cells from the maternal cervix. In addition to its non-invasiveness, TRIC exhibits many other advantages such as possible early detection at 5 weeks of gestation, and consistent results independent from maternal obesity. Moreover, the trophoblast yields from TRIC can provide valuable information about obstetrical complications related to abnormal placentation even before clinical symptoms arise.Numerous studies to date have built a strong foundation for the future validation of TRIC. Over the next few years, additional studies are expected to establish a thorough method that can be applied in the actual clinical setting as a diagnostic tool for prenatal testing. Future study targets may be suggested to investigate negative selection methods to remove maternal cells from transcervical samples for a maximum purity rate and to elaborate on DNA extraction or analysis techniques for precise diagnosis. Hopefully, these advancements could meet the globally enlarged need for safe, new prenatal diagnosis options.


The aim of this meta-analysis was to compare clinical outcomes between those who underwent coronary artery bypass grafting (CABG) alone and CABG with mitral valve repair (MVR) in patients with moderate ischemic mitral regurgitation. The present study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two authors performed a comprehensive search of international databases, including PubMed, EMBASE, and the Cochrane Library, for relevant studies published from inception to March 1, 2023. The search was performed again before the submission of the manuscript on March 20, 2023. Primary outcomes assessed in the present meta-analysis included early mortality and long-term mortality. Secondary outcomes assessed in the present meta-analysis included change in New York Heart Association (NYHA) score from baseline, change in ejection fraction (EF) from baseline (%), and major cardiovascular events (MACE). A total of 13 studies were included in the present meta-analysis. Out of 13 included studies, four were randomized control trials (RCTs) and nine were retrospective cohort studies.The pooled analysis showed that early mortality was significantly lower in patients in the CABG group compared to the CABG+MVR group . Long-term mortality was also lower in patients who underwent CABG compared to patients in the CABG+MVR group. However, the difference was statistically insignificant . No significant differences were reported in the EF score between patients who underwent CABG and patients who underwent CABG plus MVR . NYHA score was significantly lower in patients in the CABG+repair group compared to the CABG alone group .In conclusion, our meta-analysis suggests that concomitant MVR during CABG may not improve clinical outcomes in patients with moderate ischemic mitral regurgitation. Further clinical trials are needed to investigate this intervention in more detail. Ischemic mitral regurgitation of moderate severity occurs in nearly 10% of patients after myocardial infarction . IschemiCurrently, there is general agreement regarding the treatment of severe ischemic mitral regurgitation. However, the most efficient approach for the treatment of moderate ischemic mitral regurgitation remains controversial . Some exIt remains uncertain whether the reduced occurrence of mitral regurgitation after the combined procedure confers any clinical advantages. Several studies have indicated that simultaneous mitral valve surgery results in functional improvements , 10, whiMethodologyThe present study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Search Strategy and Study SelectionTwo authors performed a comprehensive search of international databases, including PubMed, EMBASE, and the Cochrane Library, for relevant studies published from inception to March 1, 2023. The search was performed again before the submission of the manuscript on March 20, 2023. The search strategy used Medical Subject Headings (MeSH) terms and Boolean algebra operators to achieve maximum sensitivity. The keywords used for the search were “ischemic mitral regurgitation,” “coronary artery bypass,” and “mitral valve surgery.” The reference lists of all included articles were also reviewed to prevent any article from being missed in the meta-analysis.The study selection process was conducted independently by two authors. In the first level, titles and abstracts were reviewed, and the full text of eligible studies was obtained for a detailed assessment of inclusion and exclusion criteria. Any disagreement between the two authors in the process of study selection was resolved through discussion.Eligibility CriteriaThe present meta-analysis included all studies that involved adult patients with clinically significant coronary artery disease and associated ischemic mitral regurgitation. Only those studies that directly compared outcomes between patients who underwent CABG only and those who underwent CABG with MVR were included in the analysis. Case reports, case series, and review articles were excluded from the study. Additionally, studies that did not report the outcomes assessed in the present meta-analysis were also excluded. No limitations were imposed on the sample sizes and patient characteristics.Data Extraction, Outcomes Measures and Quality AssessmentThe data extraction of each included study was carried out using an Excel-based sheet. Data extraction was performed by two authors independently. Any disagreement between two authors was resolved by consensus or discussion with the third author. The data extracted from individual studies included author name, year of publication, study groups, sample size, follow-up duration and patients’ characteristics.Primary outcomes assessed in the present meta-analysis included early mortality  and long-term mortality. Secondary outcomes assessed in the present meta-analysis included change in NYHA (New York Heart Association) score from baseline, change in ejection fraction (EF) from baseline (%) and major cardiovascular events (MACE). The quality of the studies was independently assessed by two authors independently using the Cochrane quality assessment tool for randomized controlled trials (RCTs) and the New Castle-Ottawa Scale (NCOS) for observational studies.Statistical AnalysisAnalysis was performed using Review Manager (RevMan) Version 5.4.1. . Outcomes were assessed using standard techniques of meta-analysis. The mean difference (MD) was calculated for continuous outcomes with 95% confidence interval (CI) and risk ratio (RR) was reported for categorical outcomes with their 95% CI. Summary statistics were calculated using fixed-effect or random-effect models based on I-square statisics calculation. Pooled RR and mean differences were calculated using fixed effect model if I-square statistics were <50%. Otherwise random-effect model was used to calculate pooled estimates. A p-value less than 0.05 were considered significant. I-square value of less than 25% represented mild heterogeneity, 25%-50% represented moderate heterogeneity and higher than 50% represented high heterogeneity. Meta-analysis results are displayed in forest plots. Subgroup analysis was performed based on study design including observational studies and RCTs.ResultsOur systematic search yields 869 articles. After removing duplicates, 846 studies were gone through title and abstract screening. After the screening process, 818 studies were excluded and full text of remaining 28 studies was retrieved for detailed assessment of inclusion and exclusion criteria. Finally, 13 studies were included in the present meta-analysis. Figure Meta-analysis of outcomesEarly Mortality and Long-Term MortalityA pooled analysis of nine studies, including 1,676 patients, showed that early mortality was significantly lower in patients in the CABG group compared to the CABG+MVR group , as shown in Figure Six studies comprising 1093 patients were included in our analysis. No significant differences were reported in the EF score between patients underwent CABG and patients underwent CABG plus MVR  as shown in Figure Six studies comprising 379 patients were included in the pooled analysis. Overall, NYHA score was significantly lower in patients in CABG+repair group compared to the CABG along group  as shown in Figure Three studies involving 1094 patients were included in our pooled analysis. No significant difference was found between two groups in the risk of MACE events . No significant heterogeneity was reported among the study results .Subgroup AnalysisTable DiscussionIn this meta-analysis, we evaluated the effectiveness of concomitant mitral valve (MV) repair during CABG in improving clinical outcomes in patients with moderate ischemic mitral regurgitation. Our findings showed that while there were no significant differences in long-term mortality between the two groups, short-term mortality was significantly higher in patients who received concomitant MV repair during CABG surgery. We conducted subgroup analyses based on study design, and the pooled analysis of RCTs did not report any significant differences between the two study groups in terms of early or long-term mortality. However, the pooled analysis of observational studies showed higher early mortality and long-term mortality in patients who underwent CABG with MVR, primarily due to the high weightage of three studies ,17,18. CCompared with CABG alone, CABG plus MVR improved heart failure symptoms, including changes in the NYHA class baseline, but no significant differences were reported between the two groups in terms of change in EF. The meta-analysis conducted by Kopjar et al. did not report any significant differences between the two groups in NYHA class . HoweverThe RCT conducted by Fattouch et al. , which cThe decision to operate on the mitral valve for IMR depends on the severity of the regurgitation and whether or not CABG is necessary. For patients with moderate IMR who require CABG, some surgeons recommend MV surgery to improve symptom relief. However, there is limited evidence to support this approach. The rationale is that CABG alone may not effectively reduce regurgitation, and persistent or worsening MR may lead to poor outcomes. On the other hand, proponents of isolated CABG argue that treating the underlying cause can result in reverse remodeling of the left ventricle, which can reduce MR. The effectiveness of this method largely depends on whether viable myocardium is present. Penicka and colleagues showed that patients with moderate IMR who underwent isolated CABG and had viable myocardium and no papillary muscle dyssynchrony had limited improvement in regurgitation .Castleberry et al. conducted the most extensive research to date on the management of ischemic mitral regurgitation . Their sStudy limitationsIn our meta-analysis, some reports utilized outdated surgical techniques, and there have been significant improvements in the techniques for MVR and types of annuloplasty prostheses over time. Although some observational studies included in the analysis reported outcomes of patients who underwent surgery over 20 years ago, a separate analysis of only RCT data strengthened our results. These trials included patients from a recent period who followed current principles of MV repair. Furthermore, the present meta-analysis revealed higher rates of early and long-term mortality among patients receiving CABG alone, largely due to the significant weighting of particular studies. As these studies were of an observational nature, caution should be exercised in interpreting the results. Moreover, definitions of some clinical endpoints differed slightly across studies, which may have reduced the accuracy of our findings. Moreover, significant heterogeneity was reported for EF and NYHA outcomes. This heterogeneity might be attributed to significant variation in the follow-up duration and differences in the evaluation of these scores. To account for heterogeneity among studies, we used a random-effect model. However, since only four RCTs were conducted on this topic, more multicenter RCTs need to be conducted with a large sample size in the future to obtain more accurate findings that can help healthcare professionals develop recommendations regarding when and how to carry out MVR while performing CABG.In conclusion, our meta-analysis suggests that concomitant MVR during CABG may not improve clinical outcomes in patients with moderate ischemic mitral regurgitation. Our findings demonstrate that early mortality was significantly lower in patients who underwent CABG alone compared to those who received CABG with MVR. Although long-term mortality was also lower in the CABG alone group, the difference was statistically insignificant. The analysis of ejection fraction showed no significant difference between the two groups. However, the analysis of the New York Heart Association Functional Classification showed that patients in the CABG plus repair group had a significantly lower score than those in the CABG alone group. The subgroup analysis based on study design showed that the pooled analysis of randomized controlled trials did not report any significant differences between the two groups in terms of early or long-term mortality, while the pooled analysis of observational studies showed higher early and long-term mortality in patients who underwent CABG with MVR. Overall, the results suggest that careful consideration should be taken when deciding whether to perform concomitant MVR during CABG surgery. Further studies are needed to investigate this issue in more detail.


Systematic andindependent control over surface reactivity and electric field strengthwould accelerate the discovery of highly active electrocatalysts forthese reactions by providing a means of reducing the transition stateenergy through field stabilization. Herein, we demonstrate that intermetallicalloying enables independent and systematic control over d-band energeticsand work function through the variation of alloy composition and oxophilicconstituent identity, respectively. We identify several intermetallicphases exhibiting properties that should collectively yield higherintrinsic activity for CO reduction compared to conventional Cu-basedelectrocatalysts. However, we also highlight the propensity of thesealloys to segregate in air as a significant roadblock to investigatingtheir electrocatalytic activity.Many electrosynthesis reactions, such as CO This rate-determining stepis hypothesized to be the dimerization of two adjacently adsorbedCO* intermediates to form a highly dipolar and polarizable OCCO* intermediate.34 Enhancing the stability of the OCCO* intermediate relative to theCO* reactants would yield superior intrinsic electrocatalytic activityand energy efficiency. However, a linear scaling relationship existsbetween OCCO* and CO* because both species bind to the electrode surfacethrough carbon atoms. Methods for breaking this scaling relationshipmust be identified so that electrocatalysts with superior intrinsicactivity can be developed.Electrocatalysis enables chemicaltransformations to be directly driven by renewable electricity, providinga green alternative to conventional chemical synthesis methodologies.2 reduction is significantly influencedby the identity ofthe electrolyte cation.39 In fact, the ethene partial current density increasesby roughly an order of magnitude at a fixed applied potential as theidentity of the electrolyte cation moves down the alkali metal group.This cation sensitivity is hypothesized to be the result of the dependenceof the local electric field strength on cation identity.39 Larger alkali cations exhibit lower solvationenergies, which enables them to more easily shed their solvationshell and closely approach the negatively charged cathode surface,elevating the local electric field strength. An elevated electricfield enhances multicarbon product formation because OCCO* exhibitsgreater electric field sensitivity than CO*.39 Thus,local electric fields enable the scaling relationship that existsbetween OCCO* and CO* to be broken. The extent of cation promotionalso depends on the surface atomic structure of the electrocatalystitself, with more densely packed surfaces exhibiting greater cationsensitivity.39 The surface structure dependenceof cation promotion has been explained in terms of the potential ofzero charge of the electrocatalyst, which systematically shifts tomore anodic potentials as the work function of the surface increases.40 While cation identity and the potential of zerocharge collectively determine the local electric field strength, theimpact of the potential of zero charge is much more significant.39 Thus, electrocatalysts with a similar CO* bindingenergy as Cu but a higher work function should exhibit significantlysuperior intrinsic kinetics for CO reduction to multicarbon products.The identification of such materials would be accelerated by a materialplatform enabling independent and systematic tuning of the surfacereactivity and work function. If identified, this material platformcould be applied to a wide array of organic electrosynthesis reactionsinvolving the formation of a dipolar and polarizable transition stateduring the rate-determining step, facilitating the development ofsustainable electrocatalytic technologies for commodity and fine chemicalsynthesis.The rate of multicarbon product formationobserved during CO49 Thus, intermetallics can be thought to consist of a catalyticallyactive late transition metal and an electronic modifier, which canbe either an early or post-transition metal. The electronic modificationsexhibited by the late transition metal are characterized by a systematicshift of the d-band away from the Fermi level toward higher bindingenergies.48 The extent of theseelectronic modifications is a function of both the strength  and the number  of intermetallicbonds the late transition metal participates in. Transition metalsurface reactivity is largely determined by d-band energetics.51 Thus, the ability to systematically modify the energetics of thed-band provides a direct method for systematically tuning the surfacereactivity to the optimum value for a given catalytic application.As a result, it should not be surprising that intermetallic alloysexhibit desirable activity and selectivity for a variety of thermallycatalyzed reactions. In fact, several Ni-, Pd-, and Pt-based intermetallicalloys exhibit Cu-like reactivity for methanol steam reforming,57 a reaction that involves similar reaction intermediates as electrochemicalCO2 reduction. This Cu-like catalytic activity has beenattributed to the electronic modifications arising from intermetallicbonding, which yield surfaces with Cu-like d-band energetics.57An intermetallic is an alloy that exhibits an orderedsolid-statestructure. This ordered structure arises due to the electronic dissimilarityof the constituent metals, which results in the formation of a strongheteronuclear bond between them. This strong heteronuclear bond significantlymodifies the electronic properties of the constituent metals througha ligand effect.58 As a result, the d-band energetics of these alloys are expectedto be similar at commensurate compositions. However, the various possibleearly and post-transition metal constituents exhibit work functionsspanning a range of roughly 2 eV.60 Thus, theidentity of the post-transition metal constituent is expected to playa significant role in determining the work function of the resultingintermetallic surface. Therefore, intermetallic alloys are a promisingmaterial platform that could enable the independent and systematictuning of surface reactivity (d-band energetics) and electric fieldstrength (work function). If validated, this capability could be leveragedto develop superior electrocatalysts for CO reduction through theselective field stabilization of OCCO* relative to CO*. To this end,an ideal candidate electrocatalyst should exhibit d-band energeticssimilar to those of Cu but an elevated work function.While the d-band energetics of intermetallics depend on thestrengthof the intermetallic bond and alloy composition, the work functionof the intermetallic surface is expected to be a linear combinationof the work functions of the constituent metals. Many intermetallicsystems exhibit similar formation energies.23 If this criterion is not met, then an intermetallic bond will notexist between the constituent metals until more cathodic potentialsare applied, negating the possibility of discovering an electrocatalystsuperior to Cu. Second, the intermetallic alloy formation energy shouldbe more exergonic than the adsorption energy of CO to Cu. The uniqueability of Cu to catalyze electrochemical CO reduction is hypothesizedto be due in part to its uniquely moderate CO adsorption energy.61 Thus, intermetallic phases exhibiting similar CO adsorption energiesas Cu have the best chance of catalyzing CO reduction. However, ifthe cohesive energy of the candidate intermetallic phase is not greaterthan this CO adsorption energy, then the intermetallic alloy willspontaneously segregate upon CO adsorption. Finally, the intermetallicsurface should exhibit a work function greater than that of Cu, assumingthat the work function is equivalent to a linear combination of thework functions of the constituent metals. The higher the work function,the stronger the local electric fields will be at a fixed appliedpotential, the more stable OCCO* will be relative to CO*, and thehigher the intrinsic CO reduction activity is expected to be. Roughly300 bimetallic intermetallic systems consisting of a group 8, 9, 10,or 11 element and a group 3, 4, 5, 6, 12, 13, 14, or 15 element wereevaluated using these selection criteria (Supporting Information (SI), section SI-1). Roughly 50% of these intermetallicsystems were removed from the candidate list because many early transitionmetals will not be in a metallic state until potentials more negativethan −1.2 V vs SHE are applied. Roughly 90% of the remainingcandidates were eliminated because many form intermetallic bonds ofinsufficient strength to prevent alloy segregation upon CO adsorption.Only 20 Rh-, Ir-, Pd-, and Pt-based intermetallic systems satisfyall of these requirements. Of these, Pd-based intermetallic alloyswith Ge, Sn, and In were selected for further investigation becausethe strength of their intermetallic bonds vary by only 30 mV whilethe work functions of the post-transition metal constituents spana range of 1 eV.Hundredsof different bimetallic intermetallic alloys exist, eachwith multiple stable phases. Experimentally exploring this entirephase space is a daunting task. However, promising intermetallic systemscan be quickly identified by using a series of selection criteria.First, both constituent metals must be in a metallic state beforethe onset potential of electrochemical CO reduction over Cu, whichis roughly −1.2 V vs SHE in 0.1 M KOH.section SI-2). Theirbulk compositions were measuredusing energy dispersive spectroscopy , and their crystal structures were measured using grazingincidence X-ray diffraction . These measurements confirmed the phase purity of all of the intermetallicphases investigated herein . Scherrer and Williamson–Hall analyses of the diffractiondata indicated that the average crystallite size decreased and thatthe maximum lattice strain increased as the Pd content of the thinfilms increased . However,these systematic variations were relatively small, corresponding toaverage size and maximum stress variations of only 15 nm and 0.2%,respectively, across the entire composition range investigated. Theintermetallic thin films were then transferred into an ultrahigh vacuumsystem where electronic structure characterization was performed.Surface cleaning was performed before electronic structure characterizationusing a rastered Ar ion beam. Subsequent X-ray photoelectron spectroscopymeasurements confirmed that the near-surface compositions of thesefilms were equivalent to the bulk after this cleaning step . Furthermore, low energy He ionscattering indicated that the surface composition of these thin filmsis approximately equivalent to that of the bulk after this cleaningstep . The influenceof intermetallic alloy composition on the d-band energetics of Pdwas measured for the PdxSnx1– system because it exhibits the greatest number ofstable intermetallic phases. The d-band energetics were found to systematicallyshift away from the Fermi level and narrow as the Sn content of theintermetallic alloy increased, as shown in 2 provide the best match. The systematic tuning of the Pd d-band shouldyield systematic changes in the CO adsorption energy of Pd. To validatethis notion, CO temperature-programmed desorption was performed, asshown in 2  were significantly lower than thoseobserved over pure Pd (350 K) and in close agreement with pure Cu(160 K). Thus, the electronic modifications induced by intermetallicbonding significantly reduce the surface reactivity of Pd, makingit nearly identical to Cu.Intermetallic thin films were synthesized bycosputtering  are all stable. However, phases of the form PdMwere selected for further investigation because they are expectedto exhibit the desired d-band energetics. This is exactly what isobserved, as shown in 104s24p1 vs 3d104s24p2). Conversely, the work function of these intermetallicsis significantly influenced by the identity of the post-transitionmetal, as shown in section SI-9). Several ofthese Pd-based intermetallic alloys exhibit Cu-like d-band energeticsbut significantly higher work functions, such as PdGe (+0.26 eV)and PdSn (+0.12 eV). However, PdGe is the most promising phase becauseit exhibits a d-band center only 0.1 eV closer to the Fermi levelthan Cu and a work function 0.26 eV higher. These properties willyield a CO* adsorption energy similar to Cu but an elevated electricfield strength under cathodic polarization. Intermetallic alloyingcan also influence surface reactivity by changing the adsorption sitenuclearity. CO adsorbs to monometallic Pd at the bridge sites. However,CO adsorbs to PdZn surface alloys at Pd atop sites, despite the factthat such alloys still expose an abundance of Pd–Pd bridgesites.62 These observations suggest thatthe electronic modifications arising from intermetallic bonding playa larger role in modulating the CO adsorption energy in comparisonto the modifications to adsorption site nuclearity. However, the adsorptionsite nuclearity will play a critical role in determining the reactionselectivity. Promising intermetallic electrocatalysts must exposeneighboring CO adsorption sites in order to catalyze CO dimerization.Luckily, a surface termination of the bulk PdGe structure is expectedto expose alternating rows of each constituent metal,64 providing an abundance of neighboring CO adsorption sites for efficientC–C coupling.As previously mentioned, Pd forms intermetallicbonds of similarstrength to Ge, Sn, and In. Thus, the Pd d-band energetics of theseintermetallics are expected to be independent of the identity of thepost-transition metal for commensurate compositions. Pd-based intermetallicphases of the form Pd54 Catalyst pretreatment plays a significant role in modulating theactivity and selectivity of these materials due to their susceptibilityto segregation upon air exposure. Surface segregation in air occursdue to the oxophilicity differences of the constituent metals, whichare greater than the strength of the intermetallic bond for all intermetallicsystems. This means that all intermetallic alloys are susceptibleto segregation in air, as shown in 2 overlayerthat completely buries the electronically modified Pd centers beneaththe surface, as shown in section SI-10). Thus,it should be no surprise that these intermetallics do not exhibitCO reduction activity after air exposure .Intermetallic materials have received significantinterest forthermal catalytic applications in recent years. These studies havedemonstrated that the activity and selectivity of these materialsis significantly influenced by the catalyst pretreatment methodology.section SI-12). Cyclingof PdGe beyond the oxidation potential of Ge results in the near-instantaneousdissolution of all of the Ge in the sample. Thermal pretreatmentswithout subsequent air exposure are difficult and are rarely performedon electrocatalysts. In fact, such pretreatments have not been performedin any peer-reviewed investigation of intermetallic electrocatalyststo date. Therefore, the surface structures of the intermetallic electrocatalystsin the few studies that have been performed are ill-defined and likelydo not exhibit the unique electronic properties that make these materialspromising for electrocatalytic applications. There is a significantneed to develop experimental methods that enable the electrocatalyticactivity of these materials to be easily and accurately assessed,so that the utility of their unique electronic properties for electrocatalyticapplications can be confirmed and rigorously investigated.High temperature catalyst pretreatmentin a reducing environmentis typically performed to reduce conformal surface oxides and providethe atomic mobility required to restore the intermetallic surface.While thermal pretreatment is ubiquitous in thermal catalysis, thesame is not true for electrocatalysis. In fact, electrocatalyst pretreatmentoften only entails cycling the applied potential until a stable voltammogramis obtained. While this electrochemical pretreatment will certainlyreduce these surface oxides, it will not provide the thermal energyrequired to restore the intermetallic surface and can also resultin significant leeching of the more oxophillic constituent metal intothe electrolyte  and electric field strength (work function) through variationof the alloy composition and oxophilic constituent identity, respectively.This capability can be leveraged to develop superior electrocatalystsfor reactions involving the formation of dipolar transition statesduring the rate-determining step, such as the reduction of CO


Conspicuous facial features, such as blushing in primates, can communicate social/emotional/physiological states in animals. However, the role of bare facial features is less well studied in birds than in humans or primates. We investigate the Java sparrow, which is characterised by conspicuous rings of swollen and blushed bare skin around the eye. Eye rings show no clear sex difference, although the swelling is associated with breeding. Java sparrows are socially monogamous, with mutual courtships and long-term pair-bonding. Therefore, it is plausible that eye rings function in within-pair communication. Specifically, do eye rings reflect psychophysiological conditions after pair formation? We assessed variations in ring thickness in pair-bonded birds and compared them with single birds and pairs of non-bonded individuals. Over the 12-week experimental period, pair-bonded males and females had an increased ring thickness, unlike the controls. We suggest eye rings convey breeding motivations or serve as fertility signals. This would be of great importance for ensuring reproductive synchrony in tropical birds like the Java sparrow. Our results contribute to understanding the evolution of facial ornamentation in birds, which was often overlooked in the past studies. Macaca mulatta) males with redder faces are more attractive to females [Mandrillus sphinx), a red face is an indicator of social dominance in males [Bare skin colouration in terrestrial endothermic animals potentially plays an important role in conveying physical and emotional states of individuals through flushing or changes in pigment depositions , 2 , comb redness is thought to be haemoglobin-based and predicts sperm viability in males [Caracara cheriway) receiving aggression had a flushed cere but aggressors did not [Aegypius tracheliotos) with flushed heads were more likely to win an aggressive interaction [Ara ararauna) showed increased blushing of bare cheek skin when they had positive social interactions with caretakers [Birds also exhibit colourful bare areas which may be used as signals, including legs, beaks, irises, pupils, and facial skin (including combs and wattles) , 12. Thein males , 21, butin males . A limit did not . Converseraction . In captretakers .The eyes or eye areas in birds may exhibit stunning conspicuousness with signalling functions , 26. ForLonchura oryzivora), as the species has intriguing features. Both males and females have bright pink bare skin around the eye  from a laboratory population. Changes in eye ring size were observed over a 12-week experimental period. Individuals investigated include: pair-bonded (n = 24), single (n = 18), or birds with a non-preferred partner (n = 10). Eight birds were used in both the pair-bonded and non-preferred partner conditions. First, the Java sparrows were allowed to form mating pairs by placing them in two unisex cages which were side by side. We observed the social interactions exchanged between birds in both cages. Male and female pairs displaying courtship behaviours (such as singing and dancing directed toward the other sex) were isolated in separate cages and further observed over a few days . Paihip see: . Those bAll experiments were performed in a controlled environment suitable for Java sparrow breeding . Birds were provided a finch seed mixture ad libitum, consisting of foxtail millet (coated with egg yolk), rice, water, shell grit, and green vegetables.In all experiments, photographs of both sides of each bird’s face were taken every week during the 12-week experimental period. During the first week, photographs included a ruler in the frame to determine the length and height of the eye. Every subsequent photograph did not include a ruler as the calculated eye length from the initial images provided the scale due to eye length being a consistent morphological feature. ImageJ  was usedTo investigate weekly alterations in bird eye ring size  we used two linear mixed-effect (LME) models. We predicted the eye ring of pair-bonded birds may continue to increase in size or reach a peak during the observation period, and so considered the models with and without a quadratic term of week as an explanatory variable. We compared model fitting, relying on AIC. These models also incorporated sex as a fixed effect and bird identity as a random effect to address data dependence on information from the same individual. Similarly, we investigated the weekly body mass data.This study was conducted with approval from the Institutional Animal Care and Use Committee of the National University Corporation at Hokkaido University (No. 16–0020) in accordance with the Hokkaido University Regulations of Animal Experimentation. During the study, stress was minimised, and all birds were cared for and treated appropriately in accordance with the Guidelines for Ethological Studies from the Japan Ethological Society.Eye rings in pair-bonded Java sparrows significantly increased in thickness over the duration of the experiment in both sexes . The modBody mass varied differently from the eye ring results. Birds caged in pairs (in both conditions) gained weight during the 12-week observation period . Conversely, individually caged birds tended to lose weight (p < 0.086) Click here for additional data file.S1 Data(XLSX)Click here for additional data file.


Cystoid macular edema is a known complication of omidenepag isopropyl usage. Omidenepag isopropyl is a selective prostanoid EP2 receptor agonist, and its association with macular edema has mainly been identified in pseudophakic eyes. Herein, we report a case of cystoid macular edema caused by omidenepag isopropyl use in a phakic eye with an implantable collamer lens.A 38-year-old woman was diagnosed with left eye glaucoma and prescribed omidenepag isopropyl. She had undergone bilateral implantation of implantable collamer lenses approximately 12 years prior to the glaucoma diagnosis. After 9 months of using omidenepag isopropyl, she presented with blurred vision in the left eye; swept source optical coherence tomography revealed cystoid macular edema in this eye. Omidenepag isopropyl usage was discontinued, and bromfenac sodium hydrate was administered twice daily instead. After 2 months, the patient’s visual discomfort was completely ameliorated. Additionally, an optical coherence tomography examination confirmed that the macula had normalized.We report a case of cystoid macular edema development after omidenepag isopropyl use in a patient with glaucoma who had undergone bilateral implantable collamer lens implantation. This case shows that the possibility of cystoid macular edema occurrence should be considered when omidenepag isopropyl is used, even in phakic eyes, after the insertion of implantable collamer lenses. Omidenepag isopropyl (OMDI), a selective non-prostaglandin prostanoid EP2 receptor agonist, has been recently used for the treatment of glaucoma. OMDI induces a reduction in the intraocular pressure by acting on both the conventional and unconventional aqueous humor outflow pathways . The advOn April 30, 2009, a 38-year-old woman underwent ICL implantation in both eyes for correction of a refractive error. Twelve years later, slit lamp examination and gonioscopy confirmed the presence of an open-angle structure in the left eye, with no other abnormalities in the anterior eye segment . Furthermore, glaucomatous changes in the optic disc and retinal nerve fiber layer as well as visual field defects were observed. Thus, she was diagnosed with open-angle glaucoma of the left eye. The patient had no history of any other ophthalmic diseases, systemic diseases (such as systemic hypertension or diabetes mellitus), and treatments . At the time of glaucoma diagnosis, the best corrected visual acuity (BCVA) was 20/20, and the intraocular pressure in both eyes (determined using a Goldmann applanation tonometer) was 15 mmHg. Furthermore, swept source optical coherence tomography (SS-OCT) revealed a normal macula in the left eye , lattice degeneration with a history of retinal photocoagulation (n = 1), and a history of trabeculectomy (n = 1). Similarly, a case of CME development after OMDI use has been reported in a 59-year-old patient with primary angle closure glaucoma and a history of laser iridotomy [Considering that the condition of the patient in this case remained stable after ICL implantation, we believe that their OMDI use was most likely associated with CME occurrence. As with conventional topical prostaglandin analogs , 7, 12, Therefore, although rare, CME can occur in phakic eyes following OMDI use. The case reported herein is significant because unlike previously reported cases, it involved CME that developed after topical administration of OMDI to the phakic eye of a relatively young patient who had undergone ICL implantation. In addition, the patient had no history of using conventional prostaglandin analogs prior to OMDI use; she further had no history of other ophthalmic diseases as well. The laser iridotomy required for ICL implantation  or the i