This editorial refers to ‘Anthracycline-free tumorelimination in mice leads to functional and molecular cardiac recovery fromcancer-induced alterations in contrast to long-lasting doxorubicin treatmenteffects’, by Pietzsch et al.While the toxic effects of common cancer therapies on the cardiovascular system are increasingly understood mechanistically, the precise direct effects of cancers on cardiovascular diseases remain incompletely resolved , 18, 24.Advanced cancer is commonly associated with cardiac atrophy, leading to myocardial structural alterations, cardiac metabolism and myocardial remodelling. A decline in skeletal muscle mass is paralleled by a rarefication of the contractile apparatus in myocardial tissue with decreased gene expression of troponin I, associated with increased fibrosis and a reduced functional capacity, as reflected by decreased fractional shortening and cardiac output , 22. TumOf note, growing evidence adds another dimension to the diverse coherences of heart and cancer, as cardiovascular disease may also accelerate tumor growth. Preclinical findings indicate that heart failure may promote progression of cancer, as seen in a heart failure mouse model that indicated a correlation between worsening left ventricular function and tumor growth. A similar effect was recapitulated in a transverse aortic constriction mouse model, showing that cardiac hypertrophy/remodelling in the absence of systolic heart failure induced accelerated tumor growth. Several inflammatory factors secreted by the myocardium including periostin and serpinA3 were proposed to promote tumor growth, as pro-inflammatory biomarkers correlate with new-onset cancer in humans , 11.Cardiac cachexia negatively impacts morbidity and mortality of patients at risk, and effective therapies have not yet been identified . In cancIn this issue of Basic Research in Cardiology, Pietzsch and colleagues shed new light on the often neglected impact of the underlying cancer on the recovery after cancer-induced cardiomyopathy . As a noBmal1, Clock, Period1-3, and Cryptochrome 1/2. To determine the effect of this, Bmal1 was silenced by si-RNA in neonatal rat cardiomyocyte culture, which lead to a reduced mitochondrial membrane potential and increased release of cytochrome C, leading to an increased rate of apoptosis in affected cells. The authors hereby concluded that the observed changes of circadian rhythm genes exhibited significant effects on cardiomyocyte integrity and that its disruption by doxorubicin therapy can promote cardiomyocyte apoptosis, leading to a persisting disruption of cardiac integrity in contrast to the otherwise fully reversible effects of cancer on the heart.With their in vivo approach, the authors determined that cancer-related cardiomyopathy was fully reversible after therapy-free tumor elimination. Several key metabolic and functional pathways that were shown to deteriorate during advanced cancer including glucose metabolism , lipid metabolism (cardiac expression of CD36) and gene expression profiles normalized after a recovery period of 70 ± 5 days. Biochemical observations were paralleled by recovered physical strength, a physiological response to angiotensin II exposure and normalized functional parameters. Strikingly, mice that received doxorubicin treatment did not show complete recovery despite tumor elimination. Particularly, mice showed sustained changes in cardiac gene expression patterns that particularly involved circadian rhythm genes, such as Pietzsch and colleagues now propose that cancer induces substantial functional, metabolic, and inflammatory modifications, which may be reversible or serve as a potential therapeutic target. This is meticulously assessed for anthracyclines by the authors. Currently, cardiac long-term effects and their recovery from cancer itself lack a clinical demonstration and play a subordinate role in the risk assessment of patients, while therapy-related effects are extensively characterized and included in cardiac risk assessment. Arguably, a mechanistic separation of cancer- and cancer therapy-related effects cannot be easily achieved for all forms of cancer therapies. In a collective of lung cancer patients receiving ICI therapy, more frequent severe immune-related adverse events were found in patients with high tumor burden (odds ratio 8.62) , and a cBmal1 induces elevated apoptosis ex vivo, thereby proving a causative role of circadian rhythm signalling in the development of cancer therapy-related cardiotoxicity. It remains to be said that it is still not fully understood so far to what extent cancer itself influences the degree of cardiotoxicity caused by anthracyclines, since a comparison of treated mice with cancer to a control group of mice without cancer is crucial. The next developments in the field of basic science on the mechanisms of chemotherapy-associated cardiotoxicity can be eagerly awaited here.Circadian rhythm has been a largely neglected factor in both cardio-oncology and cardiovascular medicine in general , 17. TheFinally, the practical relevance for the clinical work remains, as consequences cannot be drawn based on the basis of the new data from the present study. Decreased expression of GLUT1 and GLUT4 together with lowered insulin levels corroborate the important role of glucose metabolism in maintaining cardiac integrity in cancer patients. It remains elusive whether monitoring of biomarkers, e.g., plasma insulin/c-peptide may serve as a novel risk factor . Patholo


Dear Sir,1.I read with interest Chung et al’s report of two patients who developed delayed post-operative spinal epidural haematoma after posterior spinal surgery. In both cases, magnetic resonance imaging (MRI) was utilised to accurately diagnose the haematoma compressing the spinal cord. They correctly emphasised the importance of having a high index of clinical suspicion and reported successful outcomes following surgical evacuation of haematoma2, although fluoroscopic guidance can also be utilised3. Besides epidural hematomas, CT-guided aspiration has also been advocated for decompression of epidural abscesses4.An alternative treatment to consider is imaging-guided percutaneous drainage of the intra-spinal haematoma. This can be achieved using an 18G Tuohy needle, ideally under computed tomography (CT) guidance2.The Tuohy needle is a widely-available standard needle used for epidural access by anaesthetists. This needle has a blunt rounded Huber tip that minimises the risk of damage to vital structures within the spinal canal. The curved tip also allows insertion of a plastic catheter that can be directed, hence enabling a more thorough aspiration of the intra-spinal haematoma beyond the point of the needle puncture siteAlthough open surgical drainage is the standard treatment of choice, CT-guided percutaneous drainage of acute or subacute intra-spinal haematoma may be an option where the patient is elderly and/or has high-risk comorbidities whereupon further open surgery and administrating general anaesthesia are not desirable. In the hands of a skilled proceduralist , this minimally-invasive procedure can be quickly and accurately performed with low risk of trauma to the surrounding structures.


However, raft-associatedproteins exclusively partition to the Ld and not the Lo phase in these model systems. We believe that the differencestems from the different microscopic structures of the lipid raftsat physiological temperature and the Lo phase studied atroom temperature. To probe this structural diversity across temperatures,we performed atomistic molecular dynamics simulations, differentialscanning calorimetry, and fluorescence spectroscopy on Lo phase membranes. Our results suggest that raft-associated proteinsare excluded from the Lo phase at room temperature dueto the presence of a stiff, hexagonally packed lipid structure. Thisstructure melts upon heating, which could lead to the preferentialsolvation of proteins by order-preferring lipids. This structuraltransition is manifested as a subtle crossover in membrane properties;yet, both temperature regimes still fulfill the definition of theLo phase. We postulate that in the compositionally complexplasma membrane and in vesicles derived therefrom, both molecularstructures can be present depending on the local lipid composition.These structural differences must be taken into account when usingsynthetic or plasma membrane-derived vesicles as a model for cellularmembrane heterogeneity below the physiological temperature.Coexisting liquidordered (L As the name suggests, the Lo phase displays gel-like ordering of the lipid acyl chains, whereasthe lipid rotational and translational dynamics are relatively fastakin to the Ld phase, highlighting the fluid characterof the membrane. The addition of CHOL increases the order, thickness,and stiffness of the Ld phase, yet has the opposite effectson the gel phase.2 As a result, CHOL rendersthese two phases more similar. Binary mixtures of CHOL and certainphospholipids have a threshold CHOL concentration, above which thefirst-order Ld–gel transition at Tm vanishes. For dipalmitoylphosphatidylcholine (DPPC),this happens at ∼25–30 mol % of CHOL, above which manymembrane properties show continuous temperature dependence, indicatinga uniform Lo phase. This behavior is reported by numerousexperimental approaches8 and simulations.12 Still, some studies have reported nonidealities within the Lo phase: differential scanning calorimetry (DSC) and NMR detecteda broad transition,14 which was suggested to correspondto the transition between two distinct Lo phases differingin the lipid chain tilt.15 NMR spectroscopy andX-ray scattering suggested that even at high CHOL concentrations,heating modifies the lipid structure at the glycerol level, repositionsCHOL toward lipid headgroups, and disorders the acyl chain termini.17When inserted into certain phospholipidmembranes in sufficient amounts, cholesterol (CHOL) induces the liquidordered  in biomembranes.20 Notably, this coexistence is detected in model systems only at temperaturesbelow the Tm of the high-Tm lipid. Also, giant plasma membrane-derived vesicles(GPMVs) phase-separate well below the body temperature.21 This agrees with the ability of CHOL to breakthe gel phase to an Lo one. Indeed, recent simulationshave demonstrated that the Lo phase has an internal structurecontaining small hexagonally packed and CHOL-depleted regions,24 despite CHOL’s preference for saturated lipid chains in fluidphases.25 Experiments have struggled toprovide a consistent molecular view of the Lo phase inbinary mixtures, and the situation is at least equally complicatedfor ternary mixtures: NMR26 and X-ray scattering27 resolve signals originating from the two coexistingphases; yet, their compositions are temperature-dependent. Importantly,it is unclear whether the Lo phase observed in phase-separatedvesicles differs structurally from that observed for the same mixtureat physiological T and whether the former is a faithfulmodel for plasma cell membrane heterogeneity.28 Surprisingly, raft-associated proteins partition to the Ld phase in phase-separated synthetic vesicles,29 although the same proteins can locate to the ordered phasein phase-separated GMPVs.30 Moreover, thereare even differences between the partitioning behavior of proteinsin GMPVs31 and plasma membrane spheres32 since the latter can maintain phase separationat higher temperatures due to mechanisms not present in model systems.32 Still, very few transmembrane domains are targetedto the Lo phase even in phase-separated GMPVs.33 In general, the two coexisting phases in different model systemsand in vivo have different levels of mutual similarity.37 These findings indeed suggest that the putative rafts likely differfrom the Lo phase observed in synthetic vesicles more thanonly by their size,28 and some of these factors mightalso be temperature-dependent.38Certain ternary mixtures of CHOL with low-o lipid mixtures, andprovided a molecular picture of the observed phenomena using atomisticmolecular dynamics simulations. We studied bilayers consisting of(1) a ternary mixture of 55 mol % DPPC, 15 mol %DOPC, and 30 mol % CHOL, and (2) a binary mixtureof 70 mol % DPPC and 30 mol % CHOL. The composition of the ternary mixture reflects the Lo phase of a phase-separated0.40/0.40/0.20 (DPPC/DOPC/CHOL) lipid bilayer at 298 K.39 On the basis of the phase diagrams, both mixtures remain in theLo phase at all studied temperatures, ranging from 293K to 333 K.40To shed light on the structure of ordered lipid phases across temperatures,we performed differential scanning calorimetry (DSC) and fluorescencemeasurements of binary and ternary LFigures S1 and S2 for more temperatures). Both in binary and ternary mixtures, DPPC chains mainly adapt an anti conformation at 293 K; yet, the amount of gauche isomers is significantly increased at 333 K. However, at 313 K thetwo mixtures differ as DPPC lipids remain substantially ordered inthe binary mixture. This indicates that DPPC undergoessome kind of a transition, yet at different temperatures for the twomixtures. The question is whether this transition is manifested inmembrane properties.Our simulations revealed distinct changes in the bilayer structuredepending on the temperature, as shown in Tcoter ≈ 308 K (ternary mixture) or Tcobin ≈ 318 K (binary mixture).The coefficients differ between the binary and ternary mixtures in both temperature regimes. The ternary mixture contains fluid DOPC, which explains theslightly larger coefficient below Tco.41As demonstrated in Methods in the Supporting Information). As shownin binary and ternary systems, and their maxima agree perfectly with the crossover temperaturesfound in our simulations , whichare associated with the melting of CHOL-poor gel and CHOL-rich Lo phases.15DSC is the tool of choiceto detect phase transitions or more subtlemolecular rearrangements. We performed such measurements on largeunilamellar vesicles for the binary and ternary mixtures .We then verified whetherlipids really exhibit LShex of chosen atoms in the acyl chain region to characterize the degreeof hexagonal arrangement of lipid molecules.24 As shown in Shex values for both the binary and ternary mixtures below Tco. However, after the crossover they convergerapidly toward values extracted for DOPC in the ternary mixture. The Shex of DPPC is slightlyhigher in the binary mixture due to the lack of packingperturbations by DOPC. The absence of any crossovers in the DOPC curveindicates that this lipid is excluded from the hexagonally packedclusters. These findings agree with our movies showing the meltingof the clusters in the ternary mixture at Tcoter, available at DOI: 10.6084/m9.figshare.13176167. Lipid exchange rates in these clusters, shown in Figure S6, also show a crossover at Tco.Next, we looked into lipid packing in the bilayers in detail.Weused the in-plane hexatic order parameter o phase,17 are present in our simulations. As shown in Tco, in line with the predicted variationin chain tilting within the Lo region.15 Clarke et al. and Reinl et al. suggested that the temperatureincrease within the Lo phase shifts CHOL toward the headgroupregion, leading to the disordering of the lipid chain terminal carbons.17 This repositioning of CHOL toward the headgroup region indeed takesplace in our simulations . Thisprocess further decreases the acyl chain ordering in the membranecore. Indeed, as shown in Tco. The glycerol region melting, suggestedto occur within the Lo phase by Clarke et al.,16 also takes place as indicated by the significantincrease in glycerol dynamics in We next evaluated whether structural changes, suggestedpreviouslyto take place within the Lulations S7. Thisulations S7. ThisMethods in the Supporting Information) distinguishes “core” chains encapsulated in the tightly-packedclusters, “edge” chains mainly at cluster edges, and“free” chains that are excluded from the clusters . The mean deuteriumorder parameter Figure S9, the “core”chains are also the least tilted, followed by the “edge”chains, and finally the “free” chains. The temperaturedependencies of both S9: The “core”,“edge”, and “free” chain populations dependon the temperature with the “core” fraction decliningrapidly after Tco, corresponding to themelting of the clusters. Moreover, while “free” chainsshow a continuous change in ordering and tilt, there is a crossoverin the values of the “core” and “edge”chains at Tco. These two factors contributeto the striking change of slope in the temperature dependencies ofthese properties in DPPC chains can be categorized based on their local structure.Our algorithm  was calculated based on theprobe emission at 420 nm and 495 nm (characteristic for Ld). Thus, GP contains informationon both lipid fluidity and hydration. High GP values associated withgel and Lo phases, and low ones with the Ld phase.For details, see the Methods in the Supporting Information.To provide further experimental evidence for the described changesin the molecular structure, we performed two complementary fluorescenceexperiments on large unilamellar vesicles. First, we utilized Patman—afluorescent polarity probe stably located at the lipid carbonyl regionof all membrane phases.binary and ternary mixtures, as well as DPPC (gel–LdTm = 314 K) and POPC , are shown in Figure S11). For POPC, GP reflects increasing lipid mobilityin the Ld phase with increasing temperature. This changeis continuous and saturates at higher temperatures. On the other hand,GP measured for DPPC displays an abrupt jump at Tm as the lipid mobility changes drastically. Please notethat below and above Tm, GP is still decreasingwith increasing temperature. The GP curves for the binary and ternary mixtures present character intermediateto that of POPC and DPPC. The changes are much smoother than forDPPC, but the fits by modified Boltzmann sigmoidal functions (seethe Supporting Information) still displayclear inflection points that correspond to the Tco extracted from our simulations and DSC .GP results of the 47 Our previous studies using time-resolved anisotropymeasurements demonstrated great sensitivity of DPH to the orderingeffect of different amounts and different species of sterols in thelipid bilayer.49The second fluorescence technique we used is based on a differentprinciple and provides complementary information about the lipid hydrocarbonchain region. Diphenylhexatriene (DPH) is a rod-like hydrophobic fluorescentprobe with simple geometry and directional emission of polarized light.It orients along the lipid hydrocarbon chains and measures their orderand dynamics—both indicative of the membrane phase.Figure S12. Similarly toGP discussed above, the average anisotropy values , DPH does not provide trustworthydata for DPPC and the binary mixture. This is likelycaused by the probe relocation and can be detected by the wavelength-dependentanisotropy data . This io phase across a range of temperatures in a binary DPPC/CHOL mixture and a ternary DPPC/DOPC/CHOLmixtures. Both mixtures are expected to be in the Lo phaseacross the studied temperature range from 293 to 333 K. Still, wediscovered two different regimes separated by a crossover at either Tcoter ≈ 308 K or Tcobin ≈ 318 K; yet, no lipid demixingwas observed.Summarizing, we have provided a molecular-level view into the structuresof the LTco, which affects many structural and dynamic membrane properties.Interestingly, the temperature dependencies of these properties weredifferent not only below and above the crossover temperature but alsobetween the binary and ternary mixtures.Still, the properties of the two mixtures converged toward each otherat low and high temperatures. The properties of the binary mixture were more different on the two sides of the crossover temperature,highlighting that the presence of DOPC is able to buffer many propertiesin the ternary mixture. Still, all studied propertieschange continuously with temperature, and no radical changes akinto a first-order phase transition were observed.The hexagonally packed clusters of DPPC chainsthat are presentat low temperatures melt upon heating at Tco obtained from simulations.Moreover, both experimental approaches indicate that this transitionis more subtle than a proper first-order phase transition. Despitethe use of probes in fluorescence experiments, the limitations ofthe simulation models, and the possible differences in the vesiclesgenerated in two laboratories, the estimated transition temperaturesdiffer by a mere few K. Moreover, all approaches systematically suggestthat the Tco values differ by ∼10K between the ternary and binary mixtures. Despite this difference, the behavior of the ternary and binary mixtures is strikingly similar.On the experimentalside, both the DSC scans and the fluorescencemeasurements suggest that a structural transition takes place at temperaturesclose to o-like regime between the Ld and gel phases. The Lo-like high values for the deuteriumorder parameters are also reproduced by our simulations at all thestudied temperatures, i.e., by structures where CHOL either is indirect contact with the chains or excluded from the hexagonally packedclusters of DPPC chains. Therefore, it seems that the two distinctmolecular structures where CHOL has two very different roles—eitherordering nearby-residing DPPC chains (above Tco) or lubricating the space between the gel-like DPPC clusters(below Tco)—lead to similar averagebehaviors that are indistinguishable by many experiments.Curiously, the two very different molecular structures at differenttemperatures—one with gel-like hexagonally packed DPPC clustersamong more fluid regions and the other consisting of a fully fluidstructure with only slightly preferred interactions among the components—areboth fluid: The characteristic time scales of lipid rotational andtranslational motions differ by only two orders of magnitude and thusall fall within the Lo/Ld coexistence in mixtureswith a low-Tm lipid and a high-Tm lipid by melting the gel phase (formed mainlyby the high-Tm lipid) that would existin the mixture in the absence of CHOL. However, this “melting”only corresponds to breaking the hexagonally packed lipids into smallerand mobile clusters. While this leads to Lo-like behavior,a large fraction of the lipid chains are still in the gel-like highlyordered yet untilted state. Only above Tco do the hexagonally packed clusters really melt, leading to properlipid mixing. Curiously, coexisting Lo and Ld phases in phase-separated DPPC/DOPC/CHOL liposomes mix above 308K (= Tcoter).27 Thus, it seems likely thatthe hexagonally packed clusters are required to sustain the Lo/Ld coexistence. Indeed, CHOL cannot induce thiscoexistence from any uniform Ld-phase mixture above Tm of the high-Tm lipid, supporting this idea.CHOLinduces the Lo phase in these two temperature regimes might play keyroles in biomembranes. Importantly, on the basis of our findings,the use of Lo/Ld coexistence observed in syntheticor giant plasma membrane vesicles at relatively low temperatures asa model for lipid rafts existing at body temperature should be questioned,as the structures of the ordered domains in these systems might bevery different. This might explain the discrepancies in protein partitioningbetween in vitro studies exploiting phase-separatedvesicles and indirect in vivo data. Synthetic andgiant plasma membrane vesicles display Lo/Ld coexistence only at room temperature or lower. In this temperaturerange, the Lo phase possibly contains clusters of verytightly packed lipid chains—a structure which is likely unableto solvate large transmembrane protein segments. Indeed, raft-associatedproteins were found in the Ld phase in synthetic lipidmixtures containing sphingomyelin29 forwhich similar tight lipid chain packing has been observed.51 The effect of temperature is manifested by anincreased tendency of peptides to partition to the ordered detergent-resistantmembranes at 310 K as compared to 277 K.38 While this finding was originally associated with hydrophobic mismatch,38 it could as well result from changes in themolecular structure of these membranes.The differences between the twomolecular-level structures of theL37 suggesting that their Lo phases might not be as rigidas those in synthetic mixtures. Since the plasma membrane is compositionallycomplex,52 it is possible that criticalfluctuations39 can assemble domains withvarying lifetimes and compositions.37 Inthis picture, domains containing very long chain sphingolipids52 could still have a Tco that is higher than the physiological temperature, suggesting thatboth of the Lo structures described in this study couldcoexist in the plasma membrane.Coexisting phases inplasma membrane-derived vesicles are compositionallyand thus also structurally more similar than in their synthetic counterparts,


For expanding applications of spongy graphene aerogels (GAs) cost-effectively, we report a marriage of the two-step hydrothermal reduction and atmospheric drying method to fabricate a spongy CNC-graphene aerogel (CNG) with oil/water selectivity and tunable mechanical strength by a low-cost and straightforward approach. The reduced graphene oxide (rGO) with CNC by the ice-templated method can give rise to forming the hierarchical structure of hybrid GAs within the PUS network. Meanwhile, the fractured structure of PUS with a pre-compressive step arouses more versatility and durability, involving its selective and high-volume absorbability (up to 143%). The enhanced elastic modulus and more significant swelling effect than pure sponge materials give it a high potential for durable wastewater treatment. Assembling graphene to a three-dimensional 3D) porous monolith while keeping the intrinsic advantage of the building blocks is of great promise to achieve the practical application ,2. CelluD porous Additionally, 3D graphene/cellulose monoliths utilizing APD showed excellent hydrophobicity and elasticity, emerging as promising large-scale and low-cost absorbent materials in water treatment ,12,13. XHerein, porous cellulose graphene aerogel (CNG) was prepared using a two-step reduction process without lyophilization, where the cellular walls of aerogels enclosed by macroscopic-scale sponge porous scaffold led to a primarily enhanced mechanical performance. Even when the impact load with maximum (99%) strain is applied, the CNG exhibits resilience capacity without fracture and degradation. In addition, the cooperation of GAs and sponge porous cell walls endows a water droplet “sticky” hydrophobicity, which can absorb n-heptane over 1.3 times its volume and 120 times its weight and reuse manually about 1000 times. More importantly, these graphene sponges display a noticeable swelling effect, which means that adsorbed oil extended storage in more volume space of the nanocomposite. The CNG enabled a combination of visible polymer framework and microscale graphene scaffold, which can be successfully used for efficient and cost-effective water purification. These properties also demonstrate that, if graphene sheets are assembled into polymer skeletons where graphene nanosheets are kept, novel and combined properties will be observed.http://sciencek.com/, accessed on January 2018) and its length nanoscale is approximately 100 to 200 nm size range, with the length–diameter ratio being 10–20. Graphite powder (CP), L-Ascorbic acid (AR), sulfuric acid (98% ), sodium hydroxide (AR), potassium permanganate (AR), and hydrogen peroxide (AR) were supplied by Shanghai Aladdin Bio-Chem (China) and used without further purification. Graphene oxide as a raw material was synthesized according to a modified Hummer’s method [The recycled PUS samples were obtained from Shenzhen Tenghuida Electronic auxiliary material Co., Ltd. The Cellulose Nanocrystals (CNCs) were obtained from ScienceK (s method . The radCNG was characterized with a Nicolet 6700 Fourier transform infrared spectroscopy (FT-IR). Scanning electron microscopy (SEM) images were obtained by a Hitachi SU8010 at 20 kV. The X-ray diffraction (XRD) analysis is done with an X-ray source of CuKA high efficient and energy-saving wet shaping method under atmospheric pressure was demonstrated in this work. The typical fabrication procedure was depicted in Moreover, these steps towards a more facile and green route, CNC/GA as an essential building block, are assembled into the 3D architecture of PUS. When the intermediate is frozen, GO nanosheets are expelled by the grown ice crystals, also known as ice templating, and for the formation of the micro-pore network in each sponge nest. The freezing temperature and the amount of oxygen-containing groups of GO are adjusted via reduction time . These eame time . The uniThe XRD diffraction patterns of CNC, the prepared GO and the rGO/PUS and after the CNC adding (CNG) are presented in s nature . After aarticles . These cTypical architectures of CNG sponge were prepared by the hydrothermal reduction and frozen by dry ice, as shown in Comparable results were obtained when different concentrations of the dispersed GO solution were tested. Previous research has shown the mechanical properties of the pre-treated sponge relied mainly on the skeleton contact area and being verified that the fractured sponge network shows an increase of the contact area with the compressive stress in contrast to the network without pre-compression treatment . Aside fIn contrast to what is observed in the CNG specimens, the micropores structure strongly affects the stress–strain response without a plateau stress region such as deformation over the above strain region. This phenomenon can be attributed to the high modulus of whisker-like CNCs nanoparticles and changes induced by the dual network, which combined polymer networks and graphene cellular porosity. The previous research also revealed that the compressive yield stress of porous graphene materials increases linearly with an increase in porosity . In ordeOwing to the hydrophobic porous structure and ultra-lightweight, the oil adsorption capacity  of cellulose/graphene aerogels up to 198 times their weight . PristinIn particular, the volume ratio of absorbed liquid is much higher than lightweight aerogel and other graphene-based foams as shown in In summary, spongy CNC/graphene aerogels have been successfully prepared via an ambient-drying method with a pre-compaction treatment. The corresponding hybrid structure allows CNGs to have unique compressive strength to afford compression cycling numbers and maintain a linearly mechanical property. Moreover, optimizing the freezing and drying process and controlling the internal microstructure with hierarchical pores simultaneously led to a high volumic oil-absorption capacity (up to 142%). The composite developed here also demonstrated a swelling effect with easy recyclability. Significantly, this energy saving synthesis process would be a key progress for realizing large-scale commercial production, and this graphene-based hybrid material provided access to assembling a monolith by embedding porous structures of graphene aerogel inside another porosint. The networks’ interactions changed the material’s bulk properties to find broader promising applications for graphene aerogels, including pressure sensors and petroleum contamination remediation.


Using structural equation modelling, we investigated how insomnia symptoms, sleep regularity, exercise intensity/frequency and sitting/screen-use (sedentary screen-use) interacted to predict depressive and anxiety-related symptoms before and during lockdown. We also controlled for the effects of sex and student status. Irrespective of lockdown, (a) more severe symptoms of insomnia and greater sedentary screen-use predicted greater symptoms of depression and anxiety and (b) the effects of sedentary screen-use on mental health outcomes were mediated by insomnia. The effects of physical activity on mental health outcomes, however, were only significant during lockdown. Low physical activity predicted greater insomnia symptom severity, which in turn predicted increased depressive and anxiety-related symptoms. Overall, relationships between the study variables and mental health outcomes were amplified during lockdown. The findings highlight the importance of maintaining physical activity and reducing sedentary screen-use to promote better sleep and mental health.During lockdowns associated with the COVID-19 pandemic, individuals have experienced poor sleep quality and sleep regularity, changes in lifestyle behaviours, and heightened depression and anxiety. However, the inter-relationship and relative strength of those behaviours on mental health outcomes is still unknown. We collected data between 12 May and 15 June 2020 from 1048 South African adults (age: 32.76 ± 14.43 years;  Furthermore, lifestyle behaviours such as exercise and sedentary behaviour, influence these mental health outcomes independently of sleep quality7. During the COVID-19 pandemic, many sleep-related and lifestyle behaviours changed due to ‘lockdowns’ of populations which were introduced as one of the non-pharmaceutical interventions to manage the transmission of the SARS-CoV-2 virus11. During this period, increases in depressive and anxiety-related symptoms were also widely reported13. However, the inter-relationship between sleep and lifestyle factors regarding their strength and relative contribution to mental health outcomes during lockdown, has not been sufficiently explored. The pandemic-engendered lockdowns provide a unique opportunity to draw conclusions about the relative importance of these factors, which can then be applied clinically both in ordinary times and in times of significant disruption and stress.Insomnia and an irregular sleep pattern are intimately associated with symptoms of depression and anxiety15. While there is strong, long-standing and undisputed evidence that insomnia is associated with both depression and anxiety17, more recent findings show that sleep regularity  is also a contributor to these mental health outcomes19. In a sample of older adults, aged 45–84 years with diverse ethnic origins, and after controlling for age, sex and race, those with higher sleep irregularity presented with significantly higher clinical depressive symptoms20. The association between sleep regularity and anxiety is less clear, but several papers show that shift workers with irregular sleep patterns are likely to have an increased prevalence of anxiety22.Many studies show that sleep health is critical for mental health25. However, it is unknown whether during the lockdown period (a) disturbances in sleep regularity were associated with negative mental health outcomes and (b) whether the association between sleep disturbance and mental health outcomes was more pronounced than during ordinary times.During lockdown, sleep disruption, primarily related to insomnia and poor global sleep quality, was associated with increased severity of depressive and anxiety-related symptoms28. The therapeutic benefits of exercise in managing mental health are most prominent when used in combination with standard treatment, although it can also be efficacious as a stand-alone therapy, albeit with smaller effect sizes30. During the COVID-19 lockdown period, Zhang et al.31 found that either too little or too much physical activity worsened negative emotions including depression and anxiety. They elaborated that, consistent with the U-shaped distribution of the relationship between negative emotion and physical activity, optimal levels of exercise were associated with significantly fewer negative emotions. Another study found that individuals who were active before lockdown but became inactive during lockdown, had increased depressive symptoms, feelings of loneliness and stress and decreased positive mental health32.Additionally, physical activity is important for managing symptoms of depression and anxiety33) are associated with increased symptoms of depression and anxiety35. Furthermore, increased screen-use, another sedentary behaviour, is associated with increased risk of depression5 and anxiety, although in this case the association appears to be weaker than for other sedentary behaviours such as sitting or watching television34. Indeed, Meyer et al.32 also found that individuals who spent more time on screens during lockdown were more likely to experience an increase in depressive symptoms and loneliness and an overall worsening in mental health. However, increases in sitting time during lockdown were not associated with poorer mental health outcomes. These findings suggest that from a range of sedentary behaviours, increased screen-use is likely to be associated with detrimental mental health outcomes during lockdown, although it is unknown whether this effect is attributable to the sedentary nature of screen-use or some other factor, such as light exposure (particularly at night), or the content presented on screens .High levels of sedentary behaviour  and mental health outcomes.While each of these health and lifestyle factors is directly associated with depressive and anxiety-related outcomes, there is less research on the relationship between sleep and physical activity and their subsequent cumulative effects on mental health. One study in Brazil conducted during national lockdown, on a sample of adolescents, found that physical inactivity and high screen-use (television and computer use) were associated with worse mental health outcomes defined as increased feelings of loneliness, sadness and anxietyThe lockdowns imposed during the COVID-19 pandemic allow for the investigation of multiple factors (their combinations and relative contributions) to describe some of the most important everyday determinants of mental health, under conditions of considerable stress. Our study aimed to use structural equation modelling to comprehensively examine the impact of physical activity, sedentary behaviour (including screen-use) and sleep health (including sleep regularity and insomnia severity symptoms) on symptoms of depression and anxiety before and during national lockdown in a sample of South Africans.Greater insomnia severity symptoms and irregular sleep patterns will be directly associated with greater depressive and anxiety-related symptoms and this association will be stronger during lockdown than before lockdown.Reduced physical activity and increased sedentary behaviour (including screen-use), will be directly associated with more depressive and anxiety-related symptoms and this association will be stronger during lockdown than before lockdown.Reduced physical activity and increased sedentary behaviour (including screen-use), will be indirectly associated with more depressive and anxiety-related symptoms via their influence on sleep health and this association will be stronger during lockdown than before lockdown.Based on the literature garnered from ordinary and pandemic life, we tested the following hypotheses:Descriptive data on all study variables are presented as mean ± standard deviation (SD) or median with interquartile range (IQR) in Table When assessed using the Before Lockdown dataset, goodness-of-fit indices of the hypothesised measurement model were within acceptable range : 0.025–0.042]). To achieve these fit indices, we removed item 3 of the ISI from the model and allowed several items to covary . Standardised factor loadings ranged between 0.404 and 0.983  students experienced greater symptoms of depression compared to non-students and (b) sex was not directly associated with depressive symptoms. When we re-specified the model built on the During Lockdown dataset to include the direct effects of student status on sleep and lifestyle variables, students reported poorer sleep regularity, greater sedentary screen-use and engaged in less physical activity compared to non-students.The structural model confirmed that a direct relationship exists between insomnia severity and depressive symptoms both before and during lockdown. The direction of the coefficient indicates that more severe insomnia symptoms were associated with greater depressive symptoms and that this association was somewhat stronger during, rather than before, lockdown. The relationship between sleep regularity and depressive symptoms was non-significant both before and during lockdown.Before lockdown, physical activity had no direct effect on sleep regularity, severity of insomnia symptoms, or depressive symptoms. During lockdown, however, less physical activity was directly associated with poorer sleep regularity, greater severity of insomnia, and greater depressive symptoms. Notably, during lockdown there was an indirect pathway from physical activity to depressive symptoms via insomnia severity.Greater sedentary screen-use, both before and during lockdown, was associated with less sleep regularity, and greater severity of insomnia symptoms. The direct pathway between sedentary screen-use and depressive symptoms went from being non-significant before lockdown to significant during lockdown. Both before and during lockdown, an indirect pathway existed from sedentary screen-use to depressive symptoms via insomnia symptom severity. The directionality of the coefficients for the indirect pathway indicated that greater sedentary screen-use was associated with more severe insomnia symptoms and, therefore, more depressive symptoms. This association was stronger during lockdown than before lockdown.When assessed using the Before Lockdown dataset, goodness-of-fit indices of the hypothesised measurement model were within acceptable range . We achieved these fit indices by removing item 3 of the ISI from the model and allowing several items to covary . Standardised factor loadings ranged between 0.478 and 0.881 , during lockdown than before lockdown, reported higher levels of stress, depression and anxiety.We found that, consistent with our prediction and the literatureIn our sample, the relationship between insomnia symptom severity and mental health outcomes was the strongest amongst all the mental health and sleep/lifestyle associations. However, there was no association between sleep regularity and mental health outcomes at any time point. These results suggest that for symptoms of depression and anxiety (irrespective of the context), difficulties with initiating and maintaining sleep outweigh difficulties in maintaining a regular sleep schedule.40. Amongst these, our data suggest that exercise is not a prominent coping tool under usual circumstances. However, during lockdown undertaking moderate or vigorous exercise was directly associated with a reduction in depressive symptoms, but not anxiety. Exercise may have a mood enhancing effect via its modulation of serotonergic and adrenergic activity in promoting brain-derived neurotrophic factor in the brain41. However, this exercise-related pharmacological action is not established in human or animal studies of anxiety.At odds with our prediction, modelling found no influence of time spent in moderate or vigorous physical activity on mental health outcomes before lockdown. This contrasts to previous literature and could be explained by the fact that individuals may make use of a variety of different tools to maintain a healthy mood and alleviate anxiety during ordinary life, such as socialising, entertainment and indoor and outdoor activities42 and during lockdown in diverse contexts44. Moreover, a study of adolescents in China during the current COVID-19 pandemic suggests that engaging in physical activity and reducing sitting time were important to reduce symptoms of insomnia, depression and anxiety45.Having high levels of sedentary behaviour, including screen-use, was associated with increased symptoms of depression and anxiety irrespective of the lockdown context. Similar associations have been found before lockdown, for example, in a study of Iranian children and adolescents investigating the relationship between screen time, physical activity and psychiatric distress46. Importantly, although the proportion of individuals who exercised did decrease during the lockdown period (from 68.2% to 61.0%), more than half of the sample continued to exercise at home.Most notably several indirect relationships became relevant in predicting the burden of depressive and anxiety-related symptoms during the lockdown period. For example, individuals who exercised moderately or vigorously were less likely to report symptoms of insomnia and this lack of insomnia symptoms was associated with fewer depressive and anxiety-related symptoms. This effect was not present before lockdown, where there were presumably (a) less financial, household and childcare demands on many individuals, (b) a wide availability of a variety of outlets for stress, and (c) absent psychological impacts of quarantine that would have been present during the period of lockdownA similar pattern of findings was evident for sedentary behaviour. During the lockdown period , individuals who spent more time sitting and using screens were more likely to have poor sleep quality and in turn more severe symptoms of depression and anxiety. In summary, these findings bolster the tenet that during times of restriction and social isolation it is critical to be active and concurrently minimise sitting time and screen-use to maintain healthy sleep, and in turn, psychological well-being.49 and may represent a unique resilient characteristic of females in our cohort. Other studies examining sex differences on the severity of depressive symptoms during lockdown generally follow the extant literature . However, there are specific studies which report contrasting findings. For example, a recent longitudinal study compared, amongst a number of variables, depressive symptomatology at 3-weeks and 7-weeks into a lockdown period50. The authors found that at 3-weeks females had more severe depressive symptoms than males. However, at 7-weeks their symptoms had decreased somewhat. In contrast, their male counterparts had increased depressive symptoms at 7-weeks, with no between-sex difference in this mental health outcome at this timepoint. The authors concluded that females had greater long-term resilience to lockdown quarantine than males, although it is unclear to what extent this finding is generalizable from this cohort to other contexts, given the substantial variation in sex-specific changes in work and childcare arrangements globally.Our analyses also controlled for the effects of sex and student status. We found that being female was associated with higher symptoms of anxiety, independent of lockdown, but not depression. This latter finding is in contrast to most of the literature51. This relationship remained during lockdown for depressive symptoms only. Most studies conducted during the pandemic have found that students, in contrast to non-students, experienced increased symptoms of both depression and anxiety52.Regarding student status, before lockdown being a student was associated with greater depressive and anxiety-related symptoms, consistent with prior literatureWe note several important limitations. Firstly, our sampling method was not representative of the greater South African population and it likely underrepresents individuals living in urban low-income areas and rural districts.Secondly, we note that our sample had a disproportionate number of female participants in comparison with male participants, which may have biased the results towards female participants in some analyses.Thirdly, participants responses to questions asking about their experiences before lockdown may contain recall bias.Fourthly, while our study described several relevant relationships between sleep/lifestyle variables and mental health outcomes, our findings are relatively general and cannot specify for whom these relationships are most salient. Future research should identify specific vulnerable and resilient individuals or groups by identifying how their sleep and lifestyle behaviours changed from ordinary life to the lockdown quarantine period.Many studies report on lifestyle, sleep and mental health outcomes during the COVID-19 pandemic. However, relatively few investigations have reported on the strength, directionality and relationships of multiple factors and examined these both before and during national lockdown. Our findings showed that, from a variety of sleep and lifestyle behaviours, difficulties with initiating and maintaining sleep had the most influence on symptoms of depression and anxiety, and that this relationship was exacerbated during lockdown in comparison with ordinary life. Furthermore, irrespective of the lockdown context, spending significant daily periods sitting and engaging on screens is detrimental for mental health. On the other hand, engaging in moderate to vigorous physical activity became especially relevant during lockdown with benefits to mental health. Our study shows that, in times of restriction and upheaval characteristic of lockdown, individuals can rely on physical activity as a valuable tool in managing and maintaining healthy sleep to support mental health. In the current context, where individuals are juggling multiple economic, social, educational and vocational factors, understanding which strategies are effective in reducing symptoms of depression and anxiety is an important priority.10. In this paper we focus on predicting symptoms of depression and anxiety based on two key lifestyle behaviours  and two aspects of sleep health (insomnia severity and sleep regularity). We compare the estimated relationships between all of these factors before  and during lockdown . During Alert Level 5 lockdown in South Africa individuals were only allowed to leave the home to access essential services such as groceries and medical attention. Leaving the home to exercise was not permitted and the sale of alcohol and cigarettes was prohibited. Participants completed the online survey during Alert Levels 3 and 4 between 12 May and 15 June 2020.The data presented in this analysis are from a larger observational study examining multiple lifestyle, routine and mental health outcomes reported before and during COVID-19 Alert Level 5 lockdown in a sample of South African adultsn = 767; male: n = 261; non-binary: n = 15; prefer not to say: n = 5). Of the sample, 473 were university students (age: 22.6 ± 6.39 years) and 575 were non-students . Volunteers completed an online survey in which they answered the same questions for two time points: before and during lockdown. The survey was distributed throughout South Africa using academic and social media networks together with snowball sampling techniques. We obtained ethical clearance from the Ethical Standards Committee at Rhodes University (2020-1459-3468) and the Department of Psychology’s Ethics Committee at the University of Cape Town (PSY2020-014). All methods were performed in accordance with the relevant guidelines and all participants gave informed consent prior to initiating the survey.We analysed data from 1048 South African adults  and the daytime impact of their sleep difficulties. Scores range from 0 to 28 and the cut-off scores are specified as follows: 0–7 indicates no clinically significant insomnia; 8–14 shows subthreshold insomnia; 15–21 indicates clinical insomnia (moderate severity); and 22–28 indicates clinical insomnia (severe).The Insomnia Severity Index (ISI)Participants reported their sleep regularity in terms of timing and sleep duration. Participants were asked to indicate the usual difference between their earliest and latest bedtimes and wake-up times (sleep timing regularity) and the usual difference between their longest and shortest sleep time (sleep duration regularity) in any given week before and during the lockdown period. Sleep timing regularity was calculated as the average self-reported bedtime and wake-up time regularity. Each question consisted of seven possible answers , scored from 1 (< 1 h) to 7 (> 3 h), with higher scores indicating more irregularity.54 to describe minutes per day spent doing moderate physical activity (MPA) and vigorous physical activity (VPA) as well as time spent sitting (min/day).Lifestyle factors included questions about exercise habits and screen-use duration (min/day). We used the International Physical Activity Questionnaire-short form (IPAQ)55, which consists of two items of the PHQ-2 to assess primary symptoms of depression . Summed scores range from 0 to 6, with higher scores indicating greater levels of depression. Scores of 3 or more are suggestive of a depressive disorder. We used the Generalized Anxiety Disorder 7-item (GAD-7) scale56 to assess participants’ symptoms of anxiety. This questionnaire is designed to screen for generalised anxiety disorder. Scores range from 0–28, with higher scores indicating greater levels of anxiety. Scores of ≥ 5 indicate mild symptoms, ≥ 10 show moderate symptoms, while scores ≥ 15 are suggestive of severe symptoms of anxiety.We used the Patient Health Questionnaire-2 (PHQ-2)57. Direct comparisons of before-to-during lockdown variables including self-reported insomnia symptoms, sleep regularity, physical activity, sitting time, screen-use, depressive symptoms and anxiety-related symptoms have been reported before10. Those data also examined the contribution of sex  and student status (non-student versus student) on sleep, lifestyle and mental health outcomes and found that before-to-during lockdown comparisons differed significantly by sex and student status. Hence, we controlled for sex and student status in our model testing analyses. Furthermore, we also controlled for the effects of previous diagnoses of depression and anxiety. Where these control variables did not alter the results, we excluded them from the final models.All data analyses were completed using R statistical software and packages58. All continuous variables were scaled before being entered into the model. Four separate models explored depressive and anxiety-related symptoms before and during lockdown (Before Lockdown and During Lockdown datasets). SEM models were fitted using full information maximum likelihood estimation (FIML) to reduce bias due to missing data and maximum likelihood estimation with robust standard errors to ensure multivariate normality60.We used a structural equation modelling (SEM) framework to estimate the hypothesised model using the “lavaan” package61. If the hypothesised measurement model did not have a good fit, items whose factor loadings were ≤ 0.4 were dropped62. Furthermore, modification indices regarding correlated residual variances and covariances were included in the model if they fit theoretically63.First, we tested each of the four models to establish whether the latent variables are explained by the indicators using confirmatory factor analysis (CFA). The latent variables were insomnia severity (7 items of the ISI), sleep regularity (sleep timing regularity and sleep duration regularity), physical activity (time spent in moderate and vigorous exercise), sedentary screen-use , depression (both items from the PHQ-2) and anxiety (7 items from the GAD-7). After establishing the measurement model, the structural relationships between the observed  and latent variables were estimated. Model fit was evaluated using the comparative fit index (CFI) and the root mean square error of approximation (RMSEA). An adequate fit is indicated by CFI > 0.95 and RMSEA ≤ 0.06Supplementary Information.


Chylothorax is a rare postoperative complication of congenital heart surgery. It has high morbidity with increased hospital stay and cost of treatment. Damage to the thoracic duct, disruption of accessory lymphatic vessels, and increased venous pressure exceeding that in the thoracic duct have been proposed as the possible causes of chylothorax after surgery for congenital heart disease. Prompt diagnose with early initiation of treatment will reduce the duration of drainage. Staged treatment is the general principle in managing this serious complication. Loss of chyle leads to volume, nutritional and electrolyte depletion, immunological deficiencies and hematological complications. Identifying the underlying cause and addressing it is crucial to definitive management. Chylothorax is a condition of chyle leakage from the lymphatic system into the pleural cavity . AlthougLymphatic system anatomy and physiologyThe lymphatic system is composed of lymphatic vessels, lymph nodes, and associated lymphoid organs. It plays an integral role in the regulation of tissue fluid homeostasis, immune cell trafficking, and absorption of dietary fats.Lymphatic vessels are blind-ended unidirectional absorptive vessels which transport interstitial fluid, immune cells, and macromolecules to the lymph nodes, and back to the blood circulation. The lymphatic vessels are found in almost every vascularized tissue except neural tissue and bone marrow .Lymphatic capillaries converge into the larger collecting vessels which drain via chains of lymph nodes, opening eventually into the thoracic duct and the right lymphatic trunk which open into the venous circulation Figure . There aUnderstanding digestion and absorption of dietary fat is the key in formulating management plan of disorders of this process. Small- and medium-chain fatty acids are broken down into free fatty acids by intestinal enzymes. These are then absorbed into the portal circulation. Long-chain fatty acids are treated differently. They cannot be broken down and therefore fuse with lipids  to form chylomicrons. Chylomicrons are absorbed into the lymphatic channels of small intestine to form chyle.Normal circulating volume of lymph is up to 2.5 liters per day . It compEtiology and risk factors for chylothorax after congenital heart surgerySeveral mechanisms are responsible for post-operative complication of chylothorax: damage to the thoracic duct while cannulating superior vena cava during cardio-pulmonary bypass, surgical trauma to thoracic duct and/or disruption of accessory lymphatic vessels during dissection, increased central venous pressure (exceeding lymphatic pressure) after partial or complete cavo-pulmonary anastomosis and development of central venous thrombosis (both preventing drainage of the thoracic duct) ,5. Risk High volume centers have a low incidence according to one study. The difference may be due to better pre-operative patient selection, improved post-operative care and feeding protocols, differences in surgical techniques or may be differences in reporting chylothorax . HoweverClinical featuresThe first sign of development of post-operative chylothorax is pleural fluid turning milky white in the chest tube. Sometimes chylothorax is serous, sanguineous or bloody . It can Without the chest tube, low volume chylothorax can be clinically silent. High volume collections can lead to dyspnea, cough, hypovolemic symptoms, and rarely, with rapid accumulation of fluid, may cause tension chylothorax. Since the accumulation is non-inflammatory, fever and pleuritic chest pain are not present .InvestigationsInvestigations essentially focus on confirmation of chylothorax by fluid analysis and diagnosis of the cause. A persistent chest tube drainage of >5 ml/kg/day on 4th post-operative day or a milky nature of the fluid warrants investigation and management. Chest X-Ray or ultrasound may show unilateral or bilateral pleural effusion. Examination of fluid obtained by pleurocentesis will differentiate between chylothorax, pseudo-chylothorax and pleural empyema. Chyle will have high levels of triglycerides (>110 mg/dl or higher than serum triglycerides), proteins >20 g/l), and a cholesterol content <200 mg/dl, absolute white cell count of >1,000/cumm with >80% of cells being lymphocytes 0 g/l, an,15. A trBaseline echocardiography should be done to assess ventricular function, stenosis, or surgical site thrombosis. For unclear diagnosis, cardiac catheterization, computerized tomography scans, lymphangiography, lymphoscintigraphy or dynamic contrast-enhanced magnetic resonance lymphangiography may be helpful ,10. ThesManagement of post-surgical chylothoraxTreatment of post-surgical chylothorax has two primary goals: relief of respiratory symptoms by drainage of fluid and prevent or reduce chyle collection in pleural space . Managem1. Conservative treatmentThe goals of conservative management are to reduce chyle production by nutritional measures and relieve symptoms by image-guided chest tube drainage. This helps in re-expansion of lung, optimizes lung function and also guides treatment strategies. Sometimes drainage approximates lung and pleural surfaces, thereby sealing the leak.Nutritional management should be aggressive with advice from a nutrition expert. Chylothorax diet aims at providing low long-chain triglycerides (because they undergo second esterification and enter lymphatic duct in the form of chylomicrons), and high medium-chain triglycerides  either as oral or nasogastric tube feeding. A 10-day treatment with long-chain fatty acid-free MCT diet was found to be effective in 71% of patients in one study . In caseDrugs may be added as indicated, like diuretics, sildenafil, angiotensin-converting enzyme (ACE) inhibitors, or heparin for thrombosis. Cardiac catheterization may be needed to document increased venous pressures and address stenosis with balloon dilatation or placement of stents .Figure Success of any conservative regimen is when the drainage output becomes <2 ml/kg/day. Throughout the treatment, chylothorax nutritional management should be continued. Even after reduction in chyle output, dietary management with MCT diet should be continued for 6-8 weeks and with low-fat diet for another six weeks .Majority of patients, up to 80%-85%, respond to conservative treatment ,20. Trea2. Interventional treatmentPatients who fail to respond to conservative treatment have the option of surgical or interventional treatment. Surgical treatment reduces mortality from 50% to 10%. Indication for surgical treatment include chyle production exceeding 100 ml/kg/day or 100 ml/year of age for five days, persistent chyle drainage of >100 ml/day for >2 weeks despite conservative management, unchanged drainage output for one to two weeks ,15, or cEarly reoperation for chylothorax may put anastomosis at risk and conservative treatment for two to four2-4 weeks is therefore recommended. However early surgical treatment is recommended in small children with high volume losses due to their delicate fluid and electrolyte balance.a: Surgical TreatmentDirect surgical ligation of thoracic duct is done from above the diaphragm between T8 and T12. After ligation, the lymph drains via lymphatic collaterals and lympho-venous anastomoses. The challenge is identification of the thoracic duct or the leakage site which can be made prominent by giving cream intra-operatively by nasogastric tube. Thoracoscopic ligation of the thoracic duct has also been done. If leakage site is not identified, then mass ligation of the thoracic duct and tissue around it, aorta, azygous vein and esophagus is done or ligation of cisterna chyli may also be helpful . ThoraciPleurodesis, a procedure involving chemical obliteration of pleural space using talc, tetracyclin, bleomycin or povidone-iodine, may be successful in patients who continue to produce chyle in large amounts after surgery . Pleuro-b: Interventional Radiological TreatmentExpertise in this field is very limited and therefore it is recommended in refractory cases of chylothorax. Lymphangiography  outlines the thoracic duct and the leakage site. Embolization is done through micro-catheters using ethiodized oil (lipiodol), endovascular coils and n-butyl cyanoacrylate glue, alone or in combination ,21. AfteMorbidity from post-surgical chylothorax The impact of chylothorax is considerable because it increases morbidity and puts patients twice at risk of dying as compared to patients who do not develop chylothorax . DelayedThere is a reported increased risk of sepsis due to the bacteriostatic properties of lecithin and fatty acids in the chyle as well as decrease in cellular and humoral immunity (hypogammaglobulinemia). There is an increased loss of anti-thrombin and fibrinogen, the former causing increased risk of thrombosis and the latter bleeding diathesis . ElectroLarge effusions compromise lung function, which is relevant in patients with single ventricle physiology. In patients with Fontan surgery, plastic bronchitis is a frequent comorbidity associated with chylothorax, both related to abnormal pulmonary lymphatic perfusion . Long-teChylothorax is a rare complication of congenital heart surgery. It significantly increases morbidity and mortality, cost of treatment and length of hospital stay. Early diagnosis and prompt initiation of treatment may lead to early resolution. There is no overall consensus on best management protocol or therapeutic strategies. Different algorithms reported reflect Institutions or physicians experience and preference. Mainstay of treatment is conservative with MCT diet and dietary supplements. Other treatment modalities if needed also have a high success rate. Prevention may be important by careful patient selection in single ventricular physiology, creating fenestration in Fontan circulation and foramen ovale in anticipated post-operative right atrial hypertension and aggressive medical management of restrictive right ventricular physiology in tetralogy of Fallot.


Professional society guidelines are emerging for cardiovascular care in cancer patients. However, it is not yet clear how effectively the cancer survivor population is screened and treated for cardiomyopathy in contemporary clinical practice. As electronic health records (EHRs) are now widely used in clinical practice, we tested the hypothesis that an EHR-based cardio-oncology registry can address these questions.The aim of this study was to develop an EHR-based pragmatic cardio-oncology registry and, as proof of principle, to investigate care gaps in the cardiovascular care of cancer patients.We generated a programmatically deidentified, real-time EHR-based cardio-oncology registry from all patients in our institutional Cancer Population Registry . We investigated: (1) left ventricular ejection fraction (LVEF) assessment before and after treatment with potentially cardiotoxic agents; and (2) guideline-directed medical therapy (GDMT) for left ventricular dysfunction (LVD), defined as LVEF<50%, and symptomatic heart failure with reduced LVEF (HFrEF), defined as LVEF<50% and Problem List documentation of systolic congestive heart failure or dilated cardiomyopathy.Rapid development of an EHR-based cardio-oncology registry was feasible. Identification of tests and outcomes was similar using the EHR-based cardio-oncology registry and manual chart abstraction (100% sensitivity and 83% specificity for LVD). LVEF was documented prior to initiation of cancer therapy in 19.8% of patients. Prevalence of postchemotherapy LVD and HFrEF was relatively low . Among patients with postchemotherapy LVD or HFrEF, those referred to cardiology had a significantly higher prescription rate of a GDMT.EHR data can efficiently populate a real-time, pragmatic cardio-oncology registry as a byproduct of clinical care for health care delivery investigations. The success of cancer therapies has led to a growing population of cancer survivors, over 17 million in the United States in 2020. Surviving cancer no longer marks the final treatment goal but rather the beginning of “cancer survivorship.” An important facet of this care is the recognition and management of the cardiotoxic effects of cancer therapies, which include traditional metabolic diseases such as hypertension, dyslipidemia, and insulin resistance, as well as overt cardiovascular diseases, including coronary artery disease, left ventricular dysfunction (LVD), and heart failure with reduced left ventricular ejection fraction (HFrEF) .Electronic health records (EHRs) used for day-to-day patient care activities provide a unique repository of aggregate data about this at-risk population . HierarcIn this study, we aimed to test the hypothesis of the feasibility to rapidly construct a cardio-oncology registry from existing EHR data and to employ such a registry, as proof of concept for (a) care gap identification for optimizing individual patient care, (b) analysis of one’s local population or local oncology management patterns, and (c) comparison of the use of guideline-directed medical therapy (GDMT) among patients who were referred to cardiology vs those who were not.Documentation of clinical care delivered to all patients at University of Texas Southwestern Health System is recorded within our enterprise-wide EHR, Epic (Epic Systems). Our overall EHR-based cancer population registry included all patients with a cancer diagnosis listed on their Problem List, using the intentionally broad SNOMED CT concept hierarchy-based value set definition:  AND NOT . A patient with any diagnosis on their Problem List that fit the above rule was included in the broad Cancer Population Registry .After filtering for patients with documentation in the EHR oncology module, the Cardio-oncology Registry members comprised 8275 patients who had received cancer treatment from January 1, 2011 until June 30, 2017. Patients meeting the criteria for LVD or HFrEF (see definitions below) that predated cancer treatment were excluded (n=372), leaving a final population of 7903 patients . More spFor all cancer patients in the registry, if an LVEF measure was available prior to the chemotherapy initial exposure date, the patient was counted as having a prechemotherapy ejection fraction assessment. If any LVEF measure was available following their chemotherapy initial exposure date, they were counted as having a postchemotherapy LVEF assessment. For the purposes of this analysis, postchemotherapy LVD was defined as LVEF<50%  and postchemotherapy systolic HFrEF was defined as presence of systolic heart failure and/or dilated cardiomyopathy on the Problem List. Patients meeting the criteria for LVD or HFrEF prior to the chemotherapy initial exposure date were excluded (n=372). Manual chart review was performed by two authors (AC and VZ) to verify the diagnostic accuracy of the above-described methodology for data extraction. For LVD  as detected by the EHR registry, manual review was performed on 100 randomly selected charts, including 50 charts of patients identified as having LVD measures and 50 charts of patients identified as not having LVD measures. Similarly, for HFrEF as detected by the EHR registry, manual review was performed on 200 randomly selected charts, including 100 charts of patients identified as having HFrEF measures and 100 charts identified for patients as not having HFrEF measures. Interrater agreements between the two authors were 86% for HFrEF and 94% for LVD. A third author (SD) adjudicated the cases in which AC and VZ disagreed and made the final decision.Once posttreatment cardiac dysfunction has developed, neuro-hormonal medical therapy  for cardiomyopathy with reduced ejection fraction is recommended according to American College of Cardiology (ACC)/American Heart Association (AHA) guidelines . Registr2 test. Sensitivity of EHR-based outcomes detection was calculated by dividing the number of true positive outcomes confirmed by manual chart review over the sum of true positives and false negatives. Specificity was calculated by dividing the number of true negatives over the sum of true negatives and false positives. Two-sided P values <.05 were considered significant. Statistical analysis was carried out using Microsoft Excel 365.Categorical variables are shown as numbers and percentages. Continuous variables are shown as median (IQR). Comparisons between two dichotomous categorical variables were performed using the χ2. The most common treatment was anthracyclines, followed by HER2 antibodies and other tyrosine kinase inhibitors.Among the 8275 patients included in our EHR cardio-oncology registry , the majP=.43). After the chemotherapy initial treatment date, a significantly higher percentage of all patients had a documented ejection fraction assessment compared to assessment prior to chemotherapy initiation . Patients treated with anthracyclines or HER2 antibodies had a significantly higher frequency of postchemotherapy LVEF assessment than patients not exposed to these known cardiotoxic therapies .LVEF was documented prior to initiation of chemotherapy in 1636 (19.77%) of all 8275 patients , with 97To validate the performance of an EHR-based cardio-oncology registry to identify clinically relevant outcomes, a random selection of patient charts  were reviewed for diagnostic accuracy. For detection of postchemotherapy LVD (LVEF<50%), only the patients undergoing postexposure screening (n=3196) were considered to be at risk. Compared with manual review of all cardiovascular imaging study reports, the SQL query–based method of LVEF extraction had 100% sensitivity and 83% specificity for detection of LVD . For detOverall, the prevalence of LVD (LVEF<50%) among the subpopulation with postchemotherapy LVEF assessment was 9.4% . This prP<.001) compared with that of all other patients (In contrast to LVD (which was captured by SQL queries of cardiovascular procedures), HFrEF is a clinical entity that can be captured by Problem List documentation. The overall prevalence of documented postchemotherapy HFrEF was 2.5%. Patients exposed to HER2 antibodies had a significantly higher prevalence (patients .P<.001), ACE inhibitors/ARBs , and MRA .Of the patients who developed postchemotherapy LVD or HFrEF, 237 (63.9%) were referred to cardiology. Compared with patients who were not referred to cardiology, those who were referred to cardiology had a significantly higher frequency of prescriptions for beta-blockers  baseline LVEF prior to initiation of cancer therapy was documented in only 20% of patients treated for cancer; (2) the prevalence of LVD and HFrEF related to cancer therapeutics was relatively low ; and (3) among patients who developed postchemotherapy LVD or HFrEF, those who were referred to cardiology had significantly more prescriptions for a GDMT.Clinical guidelines in this field are relatively new ,3, creatAn EHR-based cardio-oncology registry can also provide descriptive statistics on the local oncology population as a byproduct of routine clinical care. Overall, incidences of LVD and HFrEF postcancer treatment were low . Of note, patients receiving anthracyclines and HER2 antibodies had a lower incidence of LVD when compared with that of patients receiving other types of chemotherapy. This difference likely reflects selection bias and relative underscreening of the population exposed to chemotherapy classes not traditionally viewed as cardiotoxic. In contrast to LVD (which was captured by SQL queries of cardiovascular procedures), HFrEF is a clinical entity that can be captured by Problem List documentation. Patients exposed to HER2 antibodies had a significantly higher prevalence of HFrEF documentation. This is perhaps attributable to increased provider awareness of this medication’s cardiotoxic effects and a tendency to code volume overload states in these patients as heart failure. These prevalence estimates varied based on chemotherapy exposure but are also likely influenced by cancer type, heterogeneity of echocardiographic screening, as well as referral bias. Nevertheless, the observational data derived from routine clinical care provide an opportunity for narrowing the focus of pre and postexposure screening efforts. We are currently investigating use of this EHR registry to develop a predictive tool to estimate the risk of cancer therapeutics–related cardiac dysfunction at the time of cancer diagnosis.Once posttreatment cardiac dysfunction has developed, neurohormonal GDMT for cardiomyopathy with a reduced ejection fraction is recommended according to ACC/AHA guidelines . PerhapsOur study further supports the premise that pragmatic clinical research employing EHR data can be feasible and fruitful -14. EHR-Developing an institution-wide cardio-oncology registry, as we have done here, enables local care gap closure initiatives and can foster future clinical research projects. Moreover, combining experiences across multiple institutions offers the promise of advancing the field faster, and with broader applicability and patient benefit. As above, adopting standard terminologies  greatly facilitates combining data from multiple sites. Additionally, the use of standard Health Level Seven International Fast Healthcare Interoperability Resources (FHIR) now enables communication of data between EHRs and a common registry database. For instance, we have successfully employed FHIR to integrate data from our produced Epic EHR to a REDCap study database . Thus, oFor this initial report, we used a single cancer treatment start date, corresponding to the patient’s first treatment episode on our EHR’s oncology module. Some patients can have more than one cancer, or a late recurrence of an original cancer, and thus have more than one cancer treatment episode. More sophisticated analyses would require performing some evaluations at the episode level rather than the patient level and including start/stop dates of treatments. Chemotherapy dosing is not accounted for in this analysis; thus, more sophisticated dose-effect or epidemiologic studies would also be needed to account for this variable. For all of the above, the additional data elements needed are collected in the EHR as a byproduct of clinical care, and such additionally requested information types can be added iteratively to the Cancer Population Registry, expanding relevance and utility for multiple purposes.We used each patient’s Problem List as the source of their oncology diagnoses as well as their comorbid conditions. Although Problem List completeness remains an area of concern for pragmatic clinical trials and registries , ProblemCardiac complications of both established and newer chemotherapy agents have given rise to the emerging subspecialty field of cardio-oncology and generated guidelines for optimizing care. EHR-derived population health tools for detecting and resolving care gaps are needed. From this EHR-based cardio-oncology registry, we found (a) an apparent care gap in adherence to guidelines for baseline ejection fraction assessment; (b) documented postchemotherapy cardiac dysfunction to be a relatively rare event; and (c) a second care gap in prescribing guideline-directed medications for patients with posttreatment cardiomyopathy, with improved rates among patients seen by a cardiologist. As a byproduct of clinical care, EHR data can efficiently populate a real-time pragmatic registry of cardio-oncology patients with data enabling pragmatic comparative effectiveness research.


Spindle cell lesions of the breast comprise a heterogeneous group of lesions, ranging from reactive and benign processes to aggressive malignant tumours. Despite their rarity, they attract the attention of breast pathologists due to their overlapping morphological features and diagnostic challenges, particularly on core needle biopsy (CNB) specimens. Pathologists should recognise the wide range of differential diagnoses and be familiar with the diverse morphological appearances of these lesions to make an accurate diagnosis and to suggest proper management of the patients. Clinical history, immunohistochemistry, and molecular assays are helpful in making a correct diagnosis in morphologically challenging cases. In this review, we present our approach for the diagnosis of breast spindle cell lesions, highlighting the main features of each entity and the potential pitfalls, particularly on CNB. Breast spindle cell lesions are generally classified into two main categories: bland-appearing and malignant-appearing lesions. Each category includes a distinct list of differential diagnoses and a panel of immunohistochemical markers. In bland-appearing lesions, it is important to distinguish fibromatosis-like spindle cell metaplastic breast carcinoma from other benign entities and to distinguish fibromatosis from scar tissue. The malignant-appearing category includes spindle cell metaplastic carcinoma, stroma rich malignant phyllodes tumour, other primary and metastatic malignant spindle cell tumours of the breast, including angiosarcoma and melanoma, and benign mimics such as florid granulation tissue and nodular fasciitis. The origin of spindle cell lesions of the breast (BSCLs) is highly variable and represents multiple lineages. The proliferation of myoepithelial cells [The component cells of the breast show a high degree of phenotypic plasticity with multiple lines of differentiation resulting in the diverse morphology that is observed in normal, hyperplastic and neoplastic breast tissue –5. The oal cells  and the al cells , 8. Breaal cells , 10. MalBSCLs encompass a broad range of pathological entities that may be benign, locally aggressive, or malignant. Accurate diagnosis is of crucial importance to ensure appropriate management. The morphological overlap between some of these lesions can lead to misinterpretation or misdiagnosis of benign and malignant entities, particularly in the limited material present in a core needle biopsy (CNB). Ancillary techniques including IHC and molecular assays are often helpful in such cases. Pathologists need to be familiar with the diverse morphological appearances of the different entities, the range of differential diagnoses, and the optimal IHC panels in the various scenarios Table . In thisThe most important challenge in the diagnosis of bland-appearing BSCLs is the exclusion of fibromatosis-like MBC –14 Tabl. This raAlthough fibromatosis is a locally aggressive lesion that was traditionally excised after CNB diagnosis, the current trend is to adopt a more conservative observational approach , 15. SurAlthough fibromatosis-like MBC is associated with an excellent prognosis as compared with other MBCs, , 17 locaThe remaining bland-appearing BSCLs can be classified according to the nature or histogenesis of the proliferating cells as follows:These include fibromatosis , nodularFibromatosis of the breast is a rare locally aggressive or benign mesenchymal transformation of connective tissue origin, usually originating from the fascia of pectoral muscles or Cooper’s ligaments [igaments , 29–32. igaments .Fig. 2FiNodular fasciitis is a rapidly growing reactive/benign self-limiting mass-forming breast lesion that may be tender or painful. It is composed of a clonal proliferation of bland-appearing stellate fibroblasts arranged in a loose fascicular to a storiform pattern (tissue culture-like or feathery growth pattern)  Fig. . The celScar is one of the most common bland-appearing BSCLs of the breast and accurate identification is facilitated by a history of trauma or previous surgery and recognition of additional accompanying features including fat necrosis, haemosiderin deposition, foamy macrophages, and foreign body giant cells. A reactive spindle cell nodule is likely to represent an exuberant reparative process (i.e. young scar)  Fig. . It may Myofibroblastoma of the breast, a tumour showing myofibroblastic differentiation without epithelial features, may simulate spindle cell MBC and other BSCLs of the breast [e breast . It has e breast .Fig. 5MySolitary fibrous tumour (SFT) is a rare BSCL of uncertain origin that tends to retain its typical morphology. It is variably cellular and is composed of round to spindle-shaped cells with little cytoplasm, often arranged in a short storiform pattern (patternless distribution), traversed by eosinophilic bands of collagen, and thin-walled branching blood vessels  may present a bland cytological appearance and is included in the differential diagnosis of bland-appearing BSCLs. Recognition of epithelial clefts may facilitate diagnosis. It is our experience that stroma-rich PT with a bland SCL appearance is typical CD34 positive. CD34-negative stroma is usually seen in high-grade PT.24. They usually maintain characteristic morphology and IHC evidence of smooth muscle differentiation, strongly positive for smooth muscle markers and negative for CD34, p63, and CKs. Leiomyoma usually involves the nipple region but is occasionally seen within the breast parenchyma.Leiomyoma and low-grade leiomyosarcoma may arise from the smooth muscle of the breastNeurofibroma and schwannoma may rarely occur in the breast and are diagnosed on morphology with IHC if required.Some rare examples of hamartoma show prominent myoid differentiation that may result in spindle cell morphology. Spindle cell and atypical lipomas that can occur in the breast may rarely simulate other spindle cell tumours. Cellular variants of angiolipoma of the breast may simulate spindle cell MBC and even angiosarcoma , 39.Although low-grade angiosarcoma, dermatofibrosarcoma protuberans (DFSP) and low-grade fibromyxoid sarcoma, and myofibroblastic sarcoma typically show bland cytological features, these tumours show distinct architectural features sufficient for their identification.IHC is a useful ancillary tool in the diagnosis of bland-appearing BSCLs as outlined above. It is best to use a panel of antibodies, to maintain a broad differential diagnosis and to interpret the findings in the light of morphology and clinical context. No IHC marker is completely sensitive or specific and pathologist should not attach undue significance to any individual marker. When spindle cell MBC is in the differential diagnosis, it is important to use a panel of antibodies against epithelial markers, including both low and high molecular weight CKs as no individual antibody stains all MBCs , 40. MosCTNNB1) have been reported in fibromatosis of the breast [CTNNB1 were not identified in PTs or MBCs [CTNNB1 and APC (adenomatous polyposis coli) gene mutations are mutually exclusive. APC mutations are detected in approximately 11% of breast fibromatosis [Mutations at exon 3 of the β-catenin gene , BCOR gene (67%), and KMT2D gene (50%) in contrast to primary breast angiosarcomas .Molecular studies of PT, including gene sequencing analysis, showed ectively –92. Othe and NF1 –94. Regi tumours . RARA mud in PTs . In a red in PTs , five ofA thorough approach to the assessment of BSCLs incorporates consideration of the clinical presentation and any relevant clinical history, knowledge of the radiological findings, careful appraisal of morphology (current and previous if relevant), and judicious use of IHC and molecular testing while maintaining a broad differential diagnosis. For example, a history of a rapidly growing nodule in superficial breast tissue together with tissue culture like appearances and extravasation of red blood cells (RBCs) should lead to consideration of a diagnosis of nodular fasciitis. IHC may be used to confirm the diagnosis and to exclude MBC. Nuclear β-catenin positivity in lesional BSCL cells should not be considered pathognomonic of fibromatosis unless fibromatosis-like MBC has been excluded by confirming lack of expression of CKs and p63. In malignant-appearing BSCL, a history of conventional-type IBC treated with radiotherapy raises the possibility of post-irradiation primary breast sarcoma. However, if the prior BC in the affected or contralateral breast was a spindle cell MBC or included a spindle cell component, the lesion is likely to represent a recurrence. In difficult cases, IHC will usually clarify the diagnosis. Osseous or chondrosarcomatous differentiation is more likely to be a component of malignant PT or MBC with heterologous elements rather than a primary osteosarcoma or a chondrosarcoma of the breast . A previBenign-appearing SCLs with clear evidence of CK and p63 expression should be considered malignant (fibromatosis-like MBC) and a B5b diagnosis should be rendered, which necessitates complete excision with sentinel node biopsy. The UK NHSBSP and RCPath guidelines recommend categorising benign-appearing BSCLs that lack defining features on morphology or IHC on CNB as B3 . ThAt the malignant end of the spectrum, spindle cell MBC is the most common diagnosis. A malignant diagnosis (B5b ) can be In conclusion, BSCLs constitute a broad spectrum of morphologically overlapping entities, ranging from benign/reactive processes to aggressive malignant tumours with different management strategies. BSCLs can generally be classified as bland-appearing and malignant-appearing lesions. In addition to the morphology, clinical history and IHC are most helpful in their diagnosis. Molecular assays may help in the diagnosis of some lesions, but they are not available in most laboratories. It is important to consider a wide differential diagnosis and to have a structured approach with focussed IHC panels. It is essential to distinguish low-grade spindle cell MBC from other “benign” entities in view of the prognostic and management implications. Many BSCLs are diagnosed as B3 on CNB and require careful multidisciplinary review.


Interstitial interface keratitis (IIK) in lamellar keratoplasty is a term used to describe infectious keratitis that primarily involves the graft-host interface. It poses specific challenges due to impaired access for microbiological testing and poor penetration of antimicrobial drugs, as well as ease of deeper extension of the microorganism. A 33-year-old male with a medical history of left eye deep anterior lamellar keratoplasty (DALK) with keratoconus, subsequently complicated with steroid-induced glaucoma controlled with Xen tube insertion, presented with acute left eye pain and redness for two days due to one broken corneal graft suture at 5 o’clock position with infiltrate at the graft-host junction. He was treated for suture-related bacterial keratitis (culture-negative) with intensive single broad-spectrum topical antibiotic after suture removal. However, the condition worsened, with dense stromal infiltrate extending into the graft-host interface junction which further progressed to an endothelial plaque. Systemic and topical antifungal treatments were started with adjunctive intracameral and subconjunctival voriconazole before improvement was observed. The condition was resolved with localized scarring without the need for repeat keratoplasty. The best-corrected vision was maintained at 6/36 due to residual sutured-related astigmatism with no signs of corneal graft rejection. Lamellar keratoplasty poses an increased risk of fungal IIK even after several years if there is a predisposing factor e.g., steroid usage and broken suture. Timely diagnosis and intervention are the keys to ensure an optimal outcome. Infective keratitis is one of the most severe complications which may occur post-corneal transplant, especially after penetrating keratoplasty. Long-term topical corticosteroid usage in keratoplasty and exposed or broken corneal sutures in corneal graft increase the risk of infection. Steroids also may mask the signs of infection for a long period of time and delay the diagnosis due to the slow growth of microorganisms .In recent years, lamellar keratoplasty is getting more popular and is replacing penetrating keratoplasty. Deep anterior lamellar keratoplasty (DALK) is a relatively new surgical technique that selectively replaces the anterior portion of cornea down to the Descemet's membrane, preserving the Descemet's membrane and endothelial layer . DALK haIn lamellar keratoplasty, e.g., DALK, there is a formation of an interface between the donor graft and recipient bed known as the graft-host interface. Infection that arises from this space in the deep stromal layer is known as interstitial interface keratitis (IIK) and poses a treatment challenge due to impaired access for microbiological testing and penetration of antimicrobial drugs ,4. SharmA 33-year-old gentleman with no known medical illness underwent uncomplicated DALK in his left eye for keratoconus three years ago without complication. He was treated with tapering dosage of topical dexamethasone 0.1% for about one year which was then maintained at once daily frequency. However, the patient developed steroid-induced glaucoma and underwent minimally invasive glaucoma surgery with Xen tube insertion in the second year of DALK. Subsequently, no topical antiglaucoma was needed in later years.He presented to the emergency eye clinic three years after the DALK with acute onset painful left red-eye for two days. Slit-lamp biomicroscopic examination revealed a broken corneal graft suture at 5 o’clock position with white to cream-colored deposit (infiltrate) at suture area over the superficial graft-host junction with clear graft Figure . IntraocHe was treated for suture-related bacterial keratitis with suture removal and then followed by monotherapy broad-spectrum topical antibiotic (gutt. moxifloxacin 0.5%) two hourly with two topical antiglaucoma medications and continued on low dose topical steroid (gutt. loteprednol 0.5%) once daily on the left eye Figure . HoweverDespite this intensive antibacterial treatment, and the initial corneal tissue culture and sensitivity showing no growth, the clinical findings worsened with denser stromal infiltrate and formation of endothelial plaque Figure . The corAfter a few days of antifungal therapy, cyclosporine topical immunosuppressant ointment 0.1% was added as slow improvement was observed. Meanwhile, the topical antifungal and antibiotics were tapered slowly. After about six weeks of treatment, the infiltrates and endothelial plaque contracted and scarred, with minimal graft thinning and vascularization Figure . The antInterstitial interface keratitis (IIK) between the donor and host cornea following lamellar keratoplasty is a rare complication. Sharma et al. found that microbial keratitis developed in post-keratoplasty in 15 cases out of 135, but only three involved the interface area . The mosThe time from surgery to presentation varies. Interface keratitis can present even from day one and up to several months post-uncomplicated keratoplasty. Late-onset IIK following lamellar keratoplasty is unlikely caused by Candida species unless there is a history of trauma or intervention . The risMicrobiological and histopathological examinations are the mainstay of investigation for diagnosis of IIK followed by anterior segment-optical coherence tomography (AS-OCT) and confocal microscopy to help for the confirmation and to monitor the disease progress . Sharma Treatment options for IIK can be divided into medical and surgical therapies. At initial presentation, empirical broad-spectrum antimicrobial therapy must be started for sterilization phase. In cases of suspected fungal keratitis, both systemic and topical antifungals such as natamycin, fluconazole, amphotericin B, and voriconazole can be considered during initial presentation itself. The medical therapy could be changed according to clinical response and microbiological findings on its growth and sensitivity. Steroid therapy has always been controversial in infectious keratitis and generally contraindicated in fungal infection ,16. OtheHowever, the deep location of infiltrates in the interface challenges the penetration of eye drops. Medical therapy alone is typically not very effective, due to the deeper location of the infection. Gao et al. reported that 63% of IIK failed medical therapy and required surgical therapy . Thus, sIn our case, the multi-route combination of topical, subconjunctival, and intracameral antifungals, together with the initial topical prophylactic antibacterial, successfully treated the infection without the need for penetrating keratoplasty. Timely initiation of immunomodulator further protected the graft from rejection.Eyes with a history of lamellar keratoplasty have the risk of fungal IIK even after years of surgery if there is presence of predisposing factor. Timely diagnosis and intervention are the keys to ensure optimal outcomes in IIK without the need for repeating keratoplasty. AS-OCT is a rapid non-invasive test that can provide high-resolution images of graft-host interface junction at all times. The early initiation of antifungal therapy is beneficial and highly recommended even though the culture is not suggestive. It plays a major role in the outcome of the surgery. In the future, it is beneficial to send the suture to involve for microbiological analysis in suture-related keratitis patients.