Primary cutaneous CD30-positive lymphoproliferative disorders represent the second most common subgroup of cutaneous T-cell lymphomas and include lymphomatoid papulosis, primary cutaneous anaplastic large cell lymphoma, and borderline lesions. Primary cutaneous anaplastic large cell lymphoma is characterized by the presence of solitary or localized nodules or tumors located on the extremities or the cephalic or cervical region. Large plaque parapsoriasis is a chronic inflammatory disorder that associates a high risk of progression to mycosis fungoides. We report a case of CD30+ primary cutaneous anaplastic large cell lymphoma in a patient with a long history of large plaque parapsoriasis. Peripheral T-cell lymphomas encompass 15% of non-Hodgkin lymphomas in adults . These tLymphomatoid papulosis consists of a recurrent papulonodular, hemorrhagic, or necrotic cutaneous skin eruption with spontaneous resolution over the course of a few weeks . PrimaryLarge plaque parapsoriasis is a chronic inflammatory disorder characterized by the presence of large erythematous plaques covered by fine scales, generally located on sun-protected areas. Large plaque parapsoriasis affects mostly middle-aged or older individuals, with approximately two-thirds of patients being males . Due to A 51-year-old male presented for consultation with an erythematous ulcerated placard located on the inner side of the right foot. The lesion appeared three months prior following immobilization with a plaster cast for medial malleolus fracture and was unsuccessfully treated with topical antiseptics. On clinical examination, the lesion measured 15 x 8 centimeters and was surrounded by violaceous raised borders and tendency to central clearing , without any other hematological abnormalities such as anemia, thrombocytopenia, or leukocytopenia. The bacteriological examination of the ulcerated lesion showed the presence of A lesion skin biopsy was performed, showing a diffuse, malignant, lymphoid tumoral proliferation with large cells with rounded vesicular nuclei and basophilic cytoplasm. The tumoral cells were arranged in compact islands and also in focal clusters surrounded by small lymphocytes, eosinophils, and Langerhans histiocytes. Immunohistochemical studies revealed the immunophenotype of the neoplastic lymphocytes as CD3+ and CD30+ with cytotoxic protein expression (Granzyme B). CD20, epithelial membrane antigen (EMA), and anaplastic lymphoma kinase (ALK) were negative.The patient was referred to the Hematology Department where a bone marrow biopsy was performed without identifying any pathological changes.The diagnosis of CD30+ primary cutaneous anaplastic large cell lymphoma was established, and a planned regimen treatment of 44-46 Gy in 22-23 fractions of radiation therapy was initiated.Follow-up after seven fractions of radiation therapy revealed a favorable outcome, with a significant decrease in the diameter of the ulcerated lesion Figure .Primary cutaneous anaplastic large cell lymphomas are usually solitary tumors or grouped or multifocal nodules located on the upper half of the body in middle-aged men . PrimaryPrimary cutaneous anaplastic large cell lymphoma associates favorable prognosis with a 95% survival at 10 years when extracutaneous involvement is not present and a 76%-96% survival rate at 5 years when more than one nodal basin is affected [From a clinical point of view, as seen in this case presentation, primary cutaneous anaplastic large cell lymphoma usually presents as a rapidly growing solitary tumor larger than 2 cm in diameter, which may ulcerate. Even though the rapid evolution of lesions may be alarming, patients do not associate systemic findings similar to those found in systemic lymphomas, such as weight loss, fever, or night sweats . SpontanLaboratory investigations include histopathological examination, which reveals nodular dermal infiltrates of sheets of atypical large anaplastic lymphocytes, consisting of cells with irregular horseshoe‐shaped eosinophilic nuclei, an abundant cytoplasm, and an ulcerated epidermis . ImmunohTreatment of primary cutaneous anaplastic large cell lymphoma consists of surgical excision or local radiotherapy with favorable outcome .In this case presentation, considering the erythematous plaques located on the trunk, development of the placard on the inner side of the foot also raised the suspicion of progression of large plaque parapsoriasis into cutaneous T-cell lymphomas’ tumor stage. This hypothesis was not supported by the clinical evolution of lesions, as the erythematous placards located on the latero-throacic areas completely disappeared after a short course of topical steroids. Additionally, the solitary ulcerated lesion appeared on the inner foot region, an area not characteristic for mycosis fungoides. Additionally, the solitary ulcerated lesion appeared on normal-looking skin and not on a pre-existing lesion of mycosis fungoides.Furthermore, the histopathological examination revealed anaplastic cells with irregular nuclei and basophilic cytoplasm and did not identify the characteristic cerebriform nuclei or band-like lymphocytic infiltrate, as found in cases of mycosis fungoides .Also, the favorable evolution of the ulcerated lesion after a course of seven fractions of local radiotherapy reinforced the diagnosis of primary cutaneous anaplastic large cell lymphoma.Nonetheless, the association between large plaque parapsoriasis and primary cutaneous anaplastic large cell lymphoma is rare, even though it has been cited in medical literature , and patAdditionally, another significant aspect to be considered is the occurrence of a cutaneous T-cell lymphoma after a recent trauma. Medical literature presents cases of mycosis fungoides in patients who reported trauma remotely (years before the skin lesion appeared), but no patient had recent trauma . Also, iFurthermore, the use of a cast that may contain carcinogenic materials  might beIn other words, cutaneous T-cell lymphomas can occur in other locations than large plaque parapsoriasis in patients already having it, likely due to underlying immunodeficiencies.Primary cutaneous CD30+ lymphoproliferative disorders should always be differentiated from other cutaneous or systemic lymphomas, including mycosis fungoides, as it represents a low-grade malignant lymphocytic proliferation with favorable prognosis and possible spontaneous resolution.Close follow-up of patients diagnosed with large plaque parapsoriasis is of utmost importance, as the evolution of lesions into mycosis fungoides may appear rapidly and be associated with an aggressive evolution of this affliction with a less favorable outcome.


Pial arteriovenous fistula (PAVF) occurs when intracranial arteries communicate directly with veins. PAVFs are very rare congenital vascular lesions that are commonly seen in infants and children. Arachnoid cysts are congenital cavitation often filled with cerebrospinal fluid. We present a very rare associated occurrence of bilateral pediatric PAVF and a giant arachnoid cyst presenting as torticollis in a child. So far, this is the first case.A 6-year-old male child was referred to our facility from a local hospital due to severe torticollis.An enhanced computed tomography scan revealed 2 slightly high-density masses at the anterior pontine cistern, right circumferential cistern, as well as left posterior occipital region. The same computed tomography scan revealed a giant arachnoid cyst in the left occipital as well as the temporal region with a thin cerebral cortex adjacent to the cyst.Digital subtraction angiography confirmed that the 2 high-flow lesions were PAVFs. The patient was treated with a combination of detachable coils and Onyx Liquid Embolic System (Onyx HD-500) (Covidien/ev3 Neurovascular) via the transarterial endovascular route while the giant arachnoid cyst was managed conservatively.The torticollis resolved 2 days after the procedure. He is currently well with no neurologic deficit.We advocate that in cases of PAVF with accompanying cyst, the cyst should be managed conservatively if it is not associated with intracranial hemorrhage or focal neurologic deficit. These lesions are congenital and are commonly seen in infants and children. The lesions often comprise of one or more direct supplying arteries, one draining vein and no abnormal vascular mass. In PAVF, the feeding arteries are mainly derived from the pial and cortical arteries and flow directly into a single vein to initiate high flow hemodynamic changes resulting a dilated and tortuous vein.,5Pial arteriovenous fistula (PAVF), also known as brain arteriovenous fistula, occurs when intracranial arteries communicate directly with veins. It can determine the direction of supplying artery, drainage vein, venous drainage, fistula size, as well as possible dangerous vascular anastomosis.,6 It can also measure blood flow velocity and pressure. Even in asymptomatic cases, treatment recommended because of the potentially fatal bleeding risk of the lesions. The most common treatment modalities include endovascular embolization, microsurgery, and radiotherapy.,4 The goal of treatment is to occlude the fistula site or occlusion of the feeding artery and proximal drainage vein closer to the fistula.,6Cerebral angiography is the gold-standard radiologic modality for the diagnosis of PAVF.,8 They constitute about 1% of all intracranial cystic space-occupying lesions and are normally detected incidental on radiologic imaging.,8 In children, their prevalence rate is about 2.6% and usually causes mass effect when they advance into large or giant cysts.,9 Smaller arachnoid cysts are managed conservatively unless, they cause compressive symptoms or brain damage while large cysts are often surgical resected.,10 We present a very rare concomitant occurrence of bilateral pediatric PAVF and a giant arachnoid cyst with torticollis.Arachnoid cysts are congenital cavitation often filled with cerebrospinal fluid (CSF).2A 6-year-old male child was referred to our facility from a local hospital due to severe torticollis. Prior to this, the patient had no history of head trauma or craniocerebral infection. No obvious neurologic defects were found during physical examination. Detailed cranial nerve as well as ophthalmic examination did not yield much. No murmurs were heard on auscultation, and the family denied family history of any hereditary disease. Laboratory investigations were at normal ranges. Chest X-ray and electrocardiogram were normal.An enhanced computed tomography (CT) scan revealed 2 slightly high-density masses at the anterior pontine cistern, right circumferential cistern, as well as left posterior occipital region Fig.  A, B. ThThe patient was treated with a combination of detachable coils and Onyx Liquid Embolic System (Onyx HD-500) (Covidien/ev3 Neurovascular) via the transarterial endovascular route. He was put on aspirin and clopidogrel per kilogram body daily for at least 5 days prior to the procedures. The entire procedure was done under general anesthesia with constant heparin infusion. After securing an arterial line on the right femoral artery a 5-French femoral arterial sheath was placed and coiling as well as embolization was performed via selective catheterization through the right posterior cerebral artery Fig.  C, D. CoNevertheless, the accompanying giant cyst was managed conservatively because it not presents with any associated intracranial hemorrhage or any focal neurologic deficit. Immediate postoperative angiography revealed total occlusion of both fistulas Fig. E–H. Two 3 Current investigations have shown that PAVFs have arterial feeders, nidus, as well as drainage veins and thus are not “true” AVMs. Varix formation is a unique finding in almost all patients with PAVF. Several authors have associated the formation of varix to high-pressure blood flow from arterial feeder straight into the venous drainage.,6,11Initially, PAVF was referred to as fistulous arteriovenous malformation (AVM) and classified as a type of AVM.,12 They are categorized into primary and secondary cysts. The primary type occurs as a result of separation of the arachnoid membranes in-utero leading to cystic cavitation and subsequent anomalous collection of CSFs. The secondary type occurs subsequent to surgery, trauma, infection, or intracranial hemorrhage.,13 The separation of arachnoid membranes occurs when mesoectodermal tissue detaches during the folding of the neural tube.On the contrary, arachnoid cysts are benign, extra axial, cystic disorders which occur as a result of congenital separation of the arachnoid layer. Also, congenital anomalies involving the corpus callosum, callosal agenesis, as well as Chiari malformations with neurofibromatosis type 1 have associated with arachnoid cysts.,12 This is first case of concomitant occurrence of a pediatric PAVF and a giant arachnoid cyst. The clinical presentation of PAVF differs according to patient's age as well as the existence of a varix.,4,14 Infancy often present with focal neurologic deficits and increased head circumference while children and adults present with headaches, space occupying effect, seizures, cerebral hemorrhage, as well as focal neurologic deficits.,5Congenital hereditary vascular disorders have been observed in patients with PAVFs. Small cysts are usually symptomatic while large or giant cyst causes mass effect on neurovascular structures. Huge cyst may also impede the function of adjacent brain. It may rupture resulting in intracystic hemorrhage or subdural hemorrhage resulting in abrupt life-threatening neurologic deficits.,13 Patients initially present with headaches, dizziness, nausea, vomiting, seizures, ataxia, hearing loss worsening of mood, as well as mental status changes.,12 The most cardinal clinical presentation in our case was torticollis. This is the first case of PAVFs accompanied by giant arachnoid cyst manifesting as torticollis. The torticollis may have occurred as result of compression at the foramina magnum by the cyst.The clinical presentation of arachnoid cysts differs according to their size as well as location. CT scan can also able to detect associated cerebral hemorrhage, hydrocephalus, as well as encephalatrophy.,15 Nevertheless, arachnoid cysts are seen on CT scan as extra-axial CSF dense lesions triggering local space occupying effect as well as sometimes calvarial modification.,10,13 In our case, an enhanced CT scan was very valuable because it revealed 2 slightly high-density masses at the anterior pontine cistern, right circumferential cistern, as well as left posterior occipital region which prompted us to perform a diagnostic DSA.On CT scan, PAVFs usually have homogeneous contrast enhancement with characteristic expansion of the drainage vein. In patients with PAVFs, MRI is able to identify the anatomic location, feeders, venous varix as well as regional, hemispheric, or diffuse cerebral malacia.,16 Nevertheless, MRI is unable to detect flow-empty actions produced by a nidus. On the contrary, MRI is gold-standard radiologic modality for the evaluation of arachnoid cysts. MRI is able to confirm the extra-axial site as well as typical T2-weighted signal of the cyst analogous to that of CSF. We did not further assess the patient with MRI because our facility has DSA hence DSA is the gold-standard radiologic modality for assessing PAVFs.Magnetic resonance imaging (MRI) is a very valuable radiologic modality for further evaluation of PAVFs or arachnoid cysts after CT had made the initial detection. Magnetic resonance angiography is also capable of delineating clearly the feeding arteries and veins of PAVF. Nevertheless, both magnetic resonance angiography and CTA produce static images and are incapable of recording the hemodynamic features of PAVFs. However, time-determined contrast-enhanced magnetic resonance DSA (MRDSA) can efficiently eliminate these difficulties during the evaluation of PAVFs.,17 DSA is therefore the gold-standard imaging modality for PAVFs. DSA is capable of delineating clearly the feeding arteries and veins of PAVF as well as the hemodynamic features at different time phases.,17 We utilized DSA to confirm the diagnosis of the PAVFs in our case.Computed tomography angiography (CTA) is very valuable during the evaluation of PAVFs because it is able to outline the complex angioarchitecture.,6,18 In cases where the arterial feeder is a short branch of a cortical artery and cannot be occluded, microsurgical approaches are often advocated. Nevertheless, endovascular route is still the most preferred treatment option for PAVFs. Endovascular treatment option is very simple and safe. Endovascular treatment involves the transartery as well as the transvenous routes. In cases of multiple arterial connections or high flow feeder, it often difficult to eliminate the PAVF via the transarterial approach.,6Surgery often involves resection of varix as well as ligation of both arterial feeder and drainage of the PAVF.N-butyl-2-cyanoacrylate. Nevertheless, balloons have also been used effectively to control as well as occlude the flow of feeding artery. The placement of detachable coils is very effective and efficient. Coils are not easily conveyed away by the high-speed blood flow associated with PAVFs.,14 Onyx embolization is another effective and efficient embolic agent for the treatment of high-flow PAVFs.,3 It has the capability of redirecting the flow during delivery as well as allowing for exact delivery into the fistula location. It is advocated that a combination of coils and N-butyl-2-cyanoacrylate should be used in treating selected high-velocity PAVF with complex architectures. In some complex case of PAVFs, a combination of surgery and endovascular treatment aided by intraoperative DSA in a hybrid theater is often the most effective treatment option. We successfully treated our patients with a combination of detachable coils and Onyx Liquid Embolic System via the transarterial endovascular route.The most favorably embolic agents used during endovascular therapy are detachable coils and  Conservative treatment is reserved for small and nonsymptomatic cysts. Surgical treatment often depends on the size, location, as well as the operative risk profile.The treatment of arachnoid cysts often includes conservative as well as surgery.,12 The most appropriate surgical technique for arachnoid cysts is fenestration. In fenestration, a passage is created to allow for communication between cyst and the subarachnoid space or ventricle. This technique is most suitable for arachnoid cysts in almost every location.,19 Nevertheless, ventriculocystostomy or ventriculo-cystocysternostomy is long-term treatments for cysts located in the suprasellar region. In our case, the accompanying giant cyst was managed conservatively because it does not present with associated intracranial hemorrhage or any focal neurologic deficit.Surgery is advocated for patients with focal neurologic symptoms as well as their readiness to avoid a shunt and the chance of recurrence.4Concomitant occurrence of bilateral pediatric PAVF and a giant arachnoid cyst is very rare and so far, this is the first case. The bilateral PAVFs were successfully treated with a combination of detachable coils and Onyx Liquid Embolic System via the transarterial endovascular route. Nevertheless, the accompanying giant cyst was managed conservatively because it does not present with associated intracranial hemorrhage or any focal neurologic deficit.All authors contributed toward data analysis, drafting and critically revising the paper and agree to be accountable for all aspects of the work. Seidu A. Richard and Junrao Li wrote the final paper. All authors approved the final version of this paper.Conceptualization: Junrao Li, Ting Wang, Seidu A. Richard, Changwei Zhang, Xiaodong Xie, Chaohua Wang.Data curation: Junrao Li, Ting Wang, Seidu A. Richard, Changwei Zhang, Xiaodong Xie, Chaohua Wang.Formal analysis: Junrao Li, Ting Wang, Seidu A. Richard, Changwei Zhang, Xiaodong Xie, Chaohua Wang.Methodology: Seidu A. Richard.Resources: Changwei Zhang, Xiaodong Xie, Chaohua Wang.Supervision: Changwei Zhang, Xiaodong Xie, Chaohua Wang.Writing – original draft: Seidu A. Richard.Writing – review & editing: Junrao Li, Ting Wang, Seidu A. Richard, Changwei Zhang, Xiaodong Xie, Chaohua Wang.


Hip dislocation after total hip arthroplasty (THA) or hemi-arthroplasty is a rare but serious complication. Dislocation may be prevented by appropriate positioning of the cup angle of inclination and anteversion.This report describes a 66-year-old woman who underwent revision THA using a computer tomography (CT)-based navigation system to treat an anterior dislocation after hemi-arthroplasty due to a severe posterior pelvic tilt. At initial presentation, her sagittal pelvic tilt angle, measured as anterior pelvic plane (APP) in the supine position, was 38 degrees posterior to the coronal plane. Owing to the posterior pelvic tilt, revision THA was performed using CT-based navigation, while dual mobility was utilized to reduce the risk of re-dislocation. Postoperatively, her sagittal pelvic tilt angle showed further progression over time, with an APP of 66 degrees posterior to the coronal plane in the standing position 3 years after revision THA. Simulation with the Zed Hip system showed that the risk of implant-to-implant impingement was much higher posteriorly than anteriorly. Gait analysis demonstrated hyperextension of the hip joint while walking, although hip joint function required for daily activity was maintained.Preoperative planning of implant orientation, based on posterior progression of pelvic tilt and accurate placement of components, is important to prevent dislocation in patients with severe posterior pelvic tilt. A dual mobility cup may also improve hip function in these patients. Changes in sagittal pelvic tilt affect the functional angle of implant position after total hip arthroplasty (THA). Appropriate positioning of the acetabular component can reduce the risk of hip dislocation after THA. Consideration of changes in functional cup inclination and anteversion due to sagittal pelvic tilt is critical in obtaining good clinical outcomes .This report describes a patient who underwent revision THA using a computer tomography (CT)-based navigation system to treat an anterior dislocation after hemi-arthroplasty caused by a severe posterior pelvic tilt. Use of a CT-based navigation system enabled accurate cup placement in the presence of a severe posterior pelvic tilt. Daily activities of the patient were preserved despite a progressive posterior change in pelvic tilt after revision THA.A 66-year-old woman presented at our hospital for the treatment of a dislocation 15 years after hemi-arthroplasty. She had undergone hemi-arthroplasty at another hospital using a porous coated anatomical stem  for a femoral neck fracture. The patient had poor posture due to compression fracture but was still able to walk until 4 months before presentation at our hospital. The patient had difficulty walking without experiencing trauma and was diagnosed with an anterior dislocation due to reduction of lumbar lordosis and severe posterior pelvic tilt. Because the dislocation could not be reduced at the other hospital, the patient was admitted to our hospital for treatment.2. There was no tenderness at the femoral triangle, her left leg was shortened in external rotation, she had limited range of motion  in her left hip joint, and she was unable to keep standing. An X-ray image of her hip in the supine position showed anterior dislocation of the hemi-arthroplasty with severe posterior pelvic tilt , defined as a plane through the bilateral anterior superior iliac spines to the pubic symphysis, was regarded as the anatomic plane of the pelvis in this patient. The angle between the APP and the coronal plane passing through the bilateral anterior superior iliac spines (ASIS) was defined as the sagittal pelvic tilt angle (APP tilting angle) in the supine or standing position. CT data and the Zed Hip system  showed that the APP tilting angle in this patient at admission was 38 degrees posterior in the supine position.We planned to transform hemi-arthroplasty into THA because anterior coverage with reduced cup anteversion was required for the prevention of anterior dislocation in this case. Due to the severe posterior tilting of the pelvis, cup positioning was planned preoperatively Fig. . BecauseThe operation was performed using a direct lateral approach. The stem was retained after confirmation of rigid stability during surgery. Exposure of the acetabulum revealed a bone defect in its anterior wall. A 46 mm cup was inserted at 37 degrees of inclination and − 5 degrees of anteversion relative to the APP, as determined radiographically using navigation. Because some patients experience progressive posterior changes in pelvic tilt after surgery, the dual mobility MDM X3 Mobile Bearing Hip System  was utilized to reduce the risk of re-dislocation. Intraoperative press fit on acetabular implant was adequate for initial stability.The patient started standing and walking rehabilitation the day after the operation. Three months later, she was able to walk short distances without pain and had a Harris Hip score (HHS) of 78 points. Measurement of her APP tilting angle showed progressive posterior pelvic tilting after the operation Fig. , with CTHip dislocation after THA or hemi-arthroplasty is a rare but serious complication. Dislocation may be prevented by appropriate positioning of the cup angle of inclination and anteversion , 6–8. BeOur report describes a patient who experienced anterior dislocation after hemi-arthroplasty. Previously, less than − 10 ° of APP angle was considered to increase the anterior dislocation in standing position , therefoEvaluation of global alignment using an EOS imaging system showed that the extension angle of the femur was 66 degrees relative to the APP, indicating an increased risk of bone-to-bone or implant-to-implant impingement in the standing position. This may have been due to the extension of ROM resulting from reduced cup anteversion, the surgical removal of the impinging bone, and/or the surgical improvement in contractions. ROM simulation using the Zed Hip system indicated that femoral extension of 68 degrees relative to the APP resulted in implant-to-implant impingement. Gait analysis demonstrated femoral hyperextension while walking. These results indicated that the risk of posterior impingement was high in this patient.CT-based navigation was reportedly useful tool for the accurate placement of implants during THA , 13. AppWe utilized dual mobility cup in the current case, because dual mobility cups reportedly reduce dislocation rate after THA , 14. AltThis report describes a patient who underwent THA using CT-based navigation for dislocation after hemi-arthroplasty with a posterior pelvic tilt. Implant planning in patients with preoperative posterior pelvic tilt should consider possible progressive postoperative posterior changes in pelvic tilt while standing. Dual mobility cups may be useful in patients at risk of dislocation.


Hepatocellular carcinoma (HCC) is the most prevalent cancer in the liver. The majority of ingested tryptophan is processed in the liver through the kynurenine pathway, the endpoint of which is de novo NAD+ biosynthesis. Dysregulation of tryptophan-kynurenine metabolism and NAD+ synthesis may promote mitochondrial malfunction, tumor reprogramming, and carcinogenesis. Using a publicly available gene expression dataset from liver hepatocellular carcinoma (LIHC) samples available through The Cancer Genome Atlas , we employed Principal Component Analysis (PCA), hierarchical clustering, gene-pattern expression profiling, and survival analysis to cluster patients and determine overall survival. Our analysis of genes encoding kynurenine pathway enzymes determined that patients with high QPRT expression had a poor prognosis with decreased median survival, with no effect on the maximum survival. There is a significant difference in the survival between patients with high QPRT expression relative to patients with high HAAO/AFMID expression . Patients with high QPRT expression have higher survival rates compared with low QPRT expression . To test the consequences of kynurenine-pathway inhibition in mitochondrial function and morphology we use 4-Cl-3HAA, an irreversible HAAO inhibitor, and observed a small increase in mitochondrial fragmentation in HepG2 cells after 24 hours of treatment. We conclude that kynurenine metabolism may be useful as a biomarker to predict patient prognosis among HCC patients. In ongoing work, we are testing QPRT inhibitors in cell culture as a potential adjuvant for chemotherapies.


Oncolytic adenoviruses (OAd) selectively target and lyse tumor cells and enhance anti- tumor immune responses. OAds have been used as promising cancer gene therapies for many years and there are a multitude of encouraging pre-clinical studies. However, translating OAd therapies to the clinic has had limited success, in part due to the lack of realistic pre-clinical models to rigorously test the efficacy of OAds. Solid tumors have a heterogenous and hostile microenvironment that provides many barriers to OAd treatment, including structural and immunosuppressive components that cannot be modeled in two-dimensional tissue culture. To replicate these characteristics and bridge the gap between pre-clinical and clinical success, studies must test OAd therapy in three-dimensional culture and animal models. This review focuses on current methods to test OAd efficacy in vitro and in vivo and the development of new model systems to test both oncolysis and immune stimulatory components of oncolytic adenovirotherapy. Human adenovirus (Ad) is one of the most studied viruses for cancer therapy and has shown great promise as a cancer treatment owing to its high gene transduction efficiency and genetic stability, as well as our ability to manufacture vectors to a high titer ,2. Ads aOncolysis of tumor cells after OAd infection releases pattern and damage-associated molecular patterns (PAMPs and DAMPs) and tumor-associated antigens (TAAs) that stimulate the immune response and enhance anti-tumor activity through epitope spreading or antigen cascade with limited clinical pathologies . HoweverDespite extensive research to optimize OAds as cancer immunotherapy agents, clinical responses have been modest . One roaClassical two-dimensional cell culture has been utilized since the early 1900s to study cell biology and has been adapted to many fields of research including oncology and virotherapy. This consists of a monolayer of single cells and is widely accepted due to excellent reproducibility in functional assays and ease of maintenance. Recent reviews comparing cell culture practices estimate that over 80% of current cancer research relies on conventional 2D cell culture because of its convenience, low cost, and ease of analysis . The useThe general procedure to measure OAd infection in vitro consists of cells that primarily adhere to tissue culture treated plastic plates that are in contact with neighboring cells and media with viral particles applied at particular multiplicity of infection (MOI). This practice of infection does not reflect the necessity of OAds or other therapeutic molecules to cross multiple layers of cells to reach the intended targets . Rather,ex7 and CARex8, reside on the basolateral surface and apical surface of polarized epithelia, respectively, and each mediates Ad entry from distinct epithelial surfaces [Many solid tumors are of epithelial origin and when these cells are grown in 2D culture, polarization is limited with less than 5% of the cell membrane in contact with neighboring cells . This losurfaces . HoweverNANOG and SOX2) were down regulated in 2D culture compared to 3D models [Further examination of 2D cultures suggests different patterns of gene expression emerge compared to in vivo and 3D culture experiments. In a study examining head and neck cancer cell lines, cancer stem cell (CSC) genes , and other non-cellular components . It has There are many different 3D culture systems that generally can be grouped into three categories: multicellular tumor spheroids, hydrogels, and organotypic slice-based cultures . Other 33D tumor spheroids are aggregates of cells that can be grown in suspension on minimally adherent surfaces. Tumor spheroids have been reproducibly used for decades and can be composed of tumor cells only or can contain other cell types such as fibroblasts, mesenchymal stromal cells, and endothelial cells . DependiIn a study comparing OAd infectivity of ovarian cancer cell lines in 2D monolayer vs 3D culture, Ad transgene expression as measured by luciferase signal was one to two logs higher in monolayer cultures . HoweverTesting OAd spread and replication in tumor spheroid models more closely mimics the in vivo setting compared to 2D monolayer cultures where the majority of cells are exposed to virus initially after infection . One stuSome studies have generated tumor spheroids using ultra-low attachment (ULA) plates in order to maintain the CSC population, which is reduced in 2D culture . In an AOverall, 3D spheroid cultures mimic the physical tumor microenvironment, including cell-to-cell interactions, but fail to fully recapitulate the ECM and growth factors present in solid tumors. While tumor spheroids have been generated with other cell types such as stromal and endothelial cells ,49, studHydrogel systems may more closely mimic the interactions between tumor spheroids and the ECM. Collagen, fibronectin, elastin, and laminin make up the highly heterogenous and dynamic non-cellular structure of the tumor ECM, which is not only tissue specific, but also can be continually remodeled in vivo . HydrogeTo test how OAd therapy affects tumor-endothelial interactions, Jin and colleagues established a 3D prostate cancer model utilizing Matrigel as a scaffold system . This syHydrogel systems have also been used to develop, select, and isolate more effective OAds. Kuhn and colleagues tested the cytotoxicity of ovarian-targeting OAds derived from either a hydrogel or a traditional monolayer system . Their “To date, hydrogel systems are the best model to predict how OAd will interact with both tumor cells and components of the ECM, as these models provide structure as well as essential components of the tumor microenvironment . As bothIn vitro modeling using primary resected tumors most closely resembles in vivo tumors. Here, we will call these in vitro models organotypic slices/spheroids. Organotypic slices retain the overall architecture of the tumor with ECM components, stromal cells, endothelium, and immune infiltrates . For thiOrganotypic models were first used to test OAd specificity in ovarian cancer , and sinStudies investigating the effect of Ads expressing soluble TRAIL (AdsTRAIL) on glioblastoma organotypic slices found increased caspase 3 and TUNEL expression compared to slices treated with GFP expressing virus . These rSystemic delivery of OAd therapy can cause liver damage and toxicity, especially with Ad5 serotypes, as hexon binding of blood coagulation factor X can result in liver sequestration ,63. TherStoff-Khalili and colleagues also tested the cytotoxicity of OAdΔ24 compared to replication incompetent adenovirus on healthy liver slices from both humans and mice . DespiteOrganotypic cultures are one means to test how the 3D structural microenvironment affects OAd infection in vitro. But since these samples are derived from resected tumors, these models lack tumor vascularity and complete immune responses. Organotypic cultures do retain some immune infiltrate, however, which allows investigators to measure the effect of OAd on resident immune cells . Still, As discussed above and summarized in The majority of studies show that OAds lyse cells much less effectively in 3D compared to 2D cultures, suggesting that spatial organization regulates virus spread. A recent study comparing experimental 2D vs. 3D modeling to computational modeling to determine the efficacy of OAd spread confirmed this hypothesis . ResearcAnother important factor to consider when testing different OAd vectors in 2D or 3D culture is the expression of CAR and other viral entry receptors. Both glioma and ovarian cancer models have shown that the availability of cell surface receptors in 3D models is more similar to primary tumors than in 2D models ,41. NormWhile 3D culture models more closely resemble solid tumor structures, in vitro model systems still lack vascular components. As it provides a means for delivery and immune infiltration, angiogenesis plays an important role in tumor susceptibility to OAd. Angiogenesis is difficult to replicate in vitro and requires in vivo modeling. Additionally, the lack of immune components in 3D culture systems hinders the in vitro study of anti-viral and anti-tumor immune responses as well as targeting metastases through the abscopal effect ,38. ManySimilar to all oncolytic virotherapies, the goal of OAd treatment is to specifically lyse tumor cells, modulate the tumor microenvironment, release tumor antigens and DAMPs to stimulate host immune responses to cancer cells to improve overall anti-tumor activity . As prevOne major limitation for preclinical in vivo studies of OAds is the lack of permissive non-human hosts. Therefore, human xenografts in immunocompromised mice are the gold standard in vivo model to measure the therapeutic benefit of OAds . XenograCotton rat and Syrian hamster models are semi-permissive for human OAds. Both of these in vivo models are immunocompetent and involve respective syngeneic tumor cell lines allowing for human OAds to study their lytic effects, distributions, and generated immune responses as well as toxicities ,76. ReceDue to the limited replication capacity of human OAds in other species, some groups have worked to identify murine tumor lines that are susceptible to OAd infection, such as a murine K-ras lung adenocarcinoma cell line, ADS-12 . Infectiscid gamma, or NOD.scidIl2rgtm1WjlCg-Prkdc/SzJ), athymic or nude mice with human xenografts. NSG mice lack B, T, and NK lymphocytes and have defective innate cells including macrophages and dendritic cells, while athymic mice only lack T cells. These mice allow for engraftment of many human tumor cell lines, as well as some primary human-derived xenografts (PDX). With the caveat of murine stromal components that may not fully recapitulate the human TME, xenograft and PDX models enable testing of how the microenvironment impacts OAd infection [Currently, the majority of OAd in vivo testing remains in immunocompromised mice such as NSG  targeting gliomas was original tested in athymic mice and led to an impressive median survival of 131 days compared to 19 days for untreated animals . ReportsDue to the lack of immune system in many of these animal models, these studies only truly test the effect of oncolysis in vivo and not the critical ability of OV to stimulate an immune response. Thus, in order to robustly evaluate their anti-tumor activity, OAd therapy must be tested in humanized mouse models with competent and complete immune systems .Recently, humanized mouse models have evolved to investigate the interactions of cell and gene therapies with cancer and the immune system. There are multiple humanized mouse models available, which are briefly summarized in 7 PBMCs injected, human CD45+ cells make up about 50% of Hu-PBL murine peripheral blood, with the majority being T cells [−CD34+CD38− HSCs. This model allows both CD4+ and CD8+ T cells to generate Th1, Th2 and Th17 responses [The simplest humanized mouse model is the Hu-PBL model where human peripheral blood mononuclear cells (PBMC) are injected into sub lethally irradiated adult NSG mice . In this T cells . Unfortu T cells . For NSG T cells . In thes T cells . The NSG T cells . To furtesponses . There iscid/IL-2Rynull) humanized with CD34+ cord blood cells [Results from only a few studies in humanized mice have been reported to date. Kuryk and colleagues recently demonstrated that an Ad5/3 chimeric OAd armed with GMCSF (ONCOS-102) significantly reduced tumor volume when combined with pembrolizumab (anti-PD-L1) in huNOG mice (NOD/Shi-od cells . ONCOS-1od cells . As the Despite numerous encouraging pre-clinical reports of Oncolytic Adenoviruses to treat solid tumors, many of these studies have not translated to improved clinical outcomes. Here, we discuss how more accurate in vitro and in vivo models can evaluate the ability of OAds to not only induce oncolysis but also penetrate the solid tumor ECM and stimulate an immune response. Historically, 2D monolayer cultures have been used to provide a yes/no answer in determining the oncolytic effect of OAds against many tumors. We argue that these systems should continue to be used for routine screening of OAds of interest. However, monolayer culture cannot recapitulate the architecture of solid tumors, let alone provide the means to test the immune response post OAd infection. Thus, 3D culture systems provide a more realistic model in evaluating OAd virus spread, as well as infecting bystander cells with the inclusion of stromal and endothelial cells. Currently, 3D model systems are used as a secondary assay to validate traditional 2D culture, despite the fact that they more accurately model pre-clinical in vivo outcomes . Still, Human xenograft mouse models are an excellent model to test oncolysis of many OAds but cannot predict the cascading immune response that follows OAd administration. Evolution to humanized mouse models may address this limitation and further close the gap between pre-clinical and clinical successes of OAd therapies. There are not many reports yet published using reliable humanized mouse models to test the effect of OAd therapy, but as development continues, we predict this model will more accurately predict patient responses. Many patients have immunological memory to Ad infection and future studies should utilize pre-immunized humanized mice to test how the memory response affects OAd therapy. These studies will enable more accurate prediction of therapeutic doses and OAd delivery systems. Currently, there is a shift in the OAd therapy field away from OAd monotherapy and toward combining OAd with immune checkpoint blockade or other cellular therapies including CAR-T cells ,74. Inde


We herein describe a 49-year-old woman without significant cardiovascular risk factors who was transferred to our hospital with sudden onset of chest pain. The patient was diagnosed with non-ST-elevation acute myocardial infarction, and coronary angiography revealed a dissection at the proximal site of the left anterior descending artery (LAD) extending from the left main trunk (LMT) suggestive of spontaneous coronary artery dissection (SCAD). Because coronary flow was impaired after contrast injection and the patient had chest pain with ST elevation, urgent percutaneous coronary intervention was performed. The first guide wire was initially introduced from the LMT to the distal LAD, but intravascular ultrasound (IVUS) imaging revealed that the guide wire had passed through the true lumen of the left coronary artery ostium, false lumen at the ostium of the left circumflex artery, and true lumen of the distal LAD. We then reinserted another guide wire using an IVUS-guided rewiring technique from the true lumen of the LMT to the distal LAD. Finally, a drug-eluting stent was deployed to cover the dissected segment, and final coronary angiography revealed acceptable results with a patent left circumflex artery. This case report highlights that physicians should consider SCAD among the differential diagnoses in patients presenting with acute coronary syndrome, particularly in young women. In the present case, IVUS played a pivotal role in not only detecting the arterial dissection but also correctly introducing the guide wire into the true lumen. Spontaneous coronary artery dissection (SCAD) is a relatively rare but important cause of acute coronary syndrome, especially in young women without significant cardiovascular risk factors and coronary atherosclerosis , 2. In gWe herein describe a 49-year-old woman who was diagnosed with non-ST-elevation acute myocardial infarction due to SCAD involving left main bifurcation. Because the coronary blood flow of the left anterior descending artery (LAD) was impaired by an enlargement of the false lumen after contrast injection, we performed urgent PCI. The first guide wire was initially introduced from the LMT to the distal LAD, but intravascular ultrasound (IVUS) imaging revealed that the guide wire had passed through the false lumen at the ostium of the left circumflex artery (LCX). We then successfully reinserted another guide wire using an IVUS-guided rewiring technique from the true lumen of the LMT to the distal LAD. In this case, IVUS played a pivotal role in not only detecting the dissection but also introducing the guide wire into the compressed true lumen.Q-wave myocardial infarction, but laboratory testing showed elevated cardiac enzymes such as troponin T (0.855 ng/mL) as well as creatine phosphokinase (565 U/L) and its MB isozyme (66 U/L). Bedside transthoracic echocardiography revealed impaired contractility in the focal apical segment of the left ventricle, but there was no clear finding of basal hypercontractility or an apical ballooning sign suggestive of stress-induced cardiomyopathy. Overall, the estimated ejection fraction of the left ventricle was broadly preserved (60%). The patient was diagnosed with non-ST-elevation acute myocardial infarction. Because her condition was stable without chest pain on arrival, we initially administered conservative medical therapy including aspirin, prasugrel, nicorandil, perindopril, pitavastatin, and bisoprolol.A 49-year-old woman without significant cardiovascular risk factors was transferred to our hospital with a 1-hour history of sudden-onset chest pain. She had taken no medication and experienced no physical or emotional stress preceding the chest pain. On arrival, physical examination revealed stable vital signs with no abnormal findings. Electrocardiography revealed no clear findings of ischemic ST-T changes or prior Three days later, we electively performed coronary angiography via the right radial artery using a 6 Fr sheath to determine the etiology of the myocardial injury. Coronary angiography showed no significant atherosclerotic stenosis in the right coronary artery and LCX, but a dissection was found from the midportion of the LMT to the proximal site of the LAD, suggestive of type 1 SCAD , Video1 The postprocedural course was uneventful, and no major adverse cardiovascular events were observed. The peak levels of creatine phosphokinase and its MB isozyme were 1155 and 142 U/L, respectively. Follow-up coronary computed tomography (CT) angiography was performed 12 months after the procedure and showed acceptable results with no clear findings of in-stent restenosis or incomplete stent apposition Figures . The patThis case report highlights that SCAD should always be included among the differential diagnoses in patients with acute coronary syndrome, particularly in young women. Furthermore, IVUS plays a pivotal role in detecting not only the presence of a dissection but also the optimal position of the guide wire in patients with SCAD.The treatment strategy for SCAD is controversial because of the lack of randomized controlled clinical trials. Recent large-scale observational studies have suggested that conservative medical therapy is generally recommended in hemodynamically stable patients with SCAD because of the reportedly favorable short-term outcomes and high rate of spontaneous angiographic healing of the dissection –4. HowevPCI for patients with SCAD is technically challenging mainly because of difficulties in wiring into the true lumen and the risk of extending the dissection or intramural hematoma by the catheter-based procedure , 6, 8. ISeveral PCI strategies have been reported in patients with SCAD, including balloon angioplasty using a cutting balloon, placement of stents, and use of bioabsorbable scaffolds , 6, 12. In this case, because laboratory testing showed elevated cardiac enzymes on arrival and coronary angiography and IVUS imaging revealed no findings of atherosclerosis in the coronary arteries, the diagnosis of non-ST-elevation acute myocardial infarction due to SCAD was valid. However, catheter insertion and contrast injection might worsen the dissection and coronary blood flow of the LAD in such patients. Because iatrogenic catheter-induced coronary artery dissections are more common in patients with than without SCAD , we shouThis case report suggests that IVUS is useful in not only detecting the dissection but also introducing the guide wire into the true lumen in patients with SCAD, especially that involving left main bifurcation.


Subacromial-subdeltoid (SASD) bursitis is characterized by bursal distension caused by fluid collection, commonly resulting from rotator cuff tears. Aspiration of the bursal fluid associated with rotator cuff tears tends to be overlooked. The effects of combined bursal aspiration and corticosteroid injection on full-thickness tears of the rotator cuff with SASD bursitis have not been previously reported.We report the cases of 3 patients with shoulder pain caused by rotator cuff tears with marked amounts of fluid in the SASD bursa. The patients experienced intractable pain despite previous conservative management, including corticosteroid injection.Physical examination and imaging studies revealed rotator cuff tears with remarkable quantities of fluid in the SASD bursa.The patients underwent ultrasound (US)-guided aspiration of the bursal fluid and intra-articular corticosteroid injection, following which, all patients experienced reduced shoulder pain for several months.Combined aspiration of fluid in the SASD bursa and intra-articular corticosteroid injection in the rotator cuff tear is recommended, especially in cases with untreated shoulder pain unresponsive to previous conservative management. This distended bursa commonly results from rotator cuff tears.,4 Fluid within the SASD bursa, although nonspecific, is considered as an important sign of full-thickness rotator cuff tears.,5 Intra-articular corticosteroid injection is widely accepted for management of rotator cuff tears with SASD bursitis.The subacromial-subdeltoid (SASD) bursa is an extra-articular sac at the shoulder girdle. This sac is separated from the glenohumeral joint by the rotator cuff.,7 However, the potential use of aspiration in the management of rotator cuff tear-associated bursal fluid accumulation tends to be underestimated.In cases of excessive fluid accumulation in the SASD bursa, ultrasound (US)-guided diagnostic aspiration is considered the gold standard for diagnosis.To the best of our knowledge, the effect of combined aspiration of considerable amounts of fluid in the SASD bursa and intra-articular corticosteroid injection for full-thickness rotator cuff tears with SASD bursitis has not been previously reported. Therefore, this case series presents 3 patients who experienced improvement in shoulder pain after combined bursal aspiration and corticosteroid injection, although they had been unresponsive to previous conservative management.2Patient I was a 73-year-old man who experienced right shoulder pain for >2 months without any history of trauma. His pain progressively worsened with a waxing and waning course, despite use of nonsteroidal anti-inflammatory drugs and supportive physical therapy. There was no obvious improvement after injection of intra-articular corticosteroids from another hospital in the previous month. He subsequently experienced limitation of activities of daily living and night pain that worsened over time and made it impossible to sleep at night. Shoulder pain on the Visual Analogue Scale (VAS) was 5 at rest and 7 during motion. There was no history of trauma, known chronic diseases, or alcohol and drug abuse.On physical examination, the skin over the shoulder joint was normal, and gentle palpation around the shoulder joint did not elicit pain. There was no loss of passive motion of his shoulder joint. However, the empty-can, Neer, and Hawkin's tests were positive. All laboratory results were within normal limits. Plain radiographs revealed a hooked acromion in the supraspinatus outlet view. US revealed marked SASD bursal effusion with a full-thickness tear of the supraspinatus tendon Fig. A. To ens Distension of the joint cavity and SASD bursa after injection was checked to confirm that the procedure was accurate.Because the symptoms failed to resolve with conservative management, including corticosteroid injection, the authors attempted to aspirate fluid from the SASD bursa to the greatest extent possible Fig. B. Under Bursal fluid analysis revealed normal white cell counts without crystals. Acid-fast bacillus stain and gram stain were negative. Fluid culture grew no microorganisms.After aspiration and intra-articular injection, the symptoms abated. One month later, his pain score on VAS decreased from 5 to 2 at rest and from 7 to 3 during motion. Upon recheck 2 months after the combined procedure, patient I was satisfied with the pain relief; therefore, surgical management was not indicated.Patient II was a 65-year-old man who experienced right shoulder pain for >1 month with no history of trauma and known left-sided weakness after right cerebral infarction 15 years before. He complained of unbearable pain despite corticosteroid injection 3 weeks before. Subjective pain on the VAS was 7 at rest, 9 during motion. On physical examination, empty-can and Hawkin's tests were positive. US demonstrated substantial effusion of the long biceps tendon and SASD bursa with a full-thickness tear of the supraspinatus and a partial thickness tear of subscapularis tendon. He did not want MRI for economic reasons. Under US guidance, 7 mL of the clear bursal fluid was aspirated, and a triamcinolone mixture was injected in the same way. All laboratory results, including bursal fluid, were within normal limits. Compared with the scores after 1 month, his pain score on the VAS slightly decreased from 7 to 4 at rest, from 9 to 6 during motion. Although pain abated, an additional 3 mL of bursal fluid was aspirated, and triamcinolone injected again. Upon review 3 months after the repeat procedure, his pain score on the VAS decreased from 4 to 2 at rest, from 6 to 4 during motion.Patient III was a 70-year-old man who experienced right shoulder pain for >3 months with no history of trauma. There was no noticeable improvement following intra-articular corticosteroid injection 1 month before. Subjective pain on the VAS was 5 at rest and 8 during motion. On physical examination, the empty-can test was positive. US demonstrated substantial effusion of the long biceps tendon and SASD bursa with a full-thickness tear of the supraspinatus and subscapularis tendon (Fig. 3This case series is noteworthy because it describes, in detail, the clinical manifestations of the effect of combined bursal aspiration and intra-articular corticosteroid injection in rotator cuff tear patients who were unresponsive to previous conservative management.,2 It is separated from the glenohumeral joint by the rotator cuff; therefore, it does not usually communicate with the joint.,2 On normal US image, the SASD bursa contains minimal fluid, surrounded by hyperechoic layers of peribursal fat, <2 mm in thickness.,3,6,9,10The SASD bursa is an extra-articular sac at the shoulder girdle that is clinically important for the gliding movement of the rotator cuffs on the coracoacromial arch and deltoid muscle. It can result from many pathological processes, commonly resulting from rotator cuff degenerative disorders, including tendinopathies or tears.,4 Rheumatoid arthritis, gout, polymyalgia rheumatica, hydroxyapatite deposition, tuberculosis, infectious arthritis, and other pathologic conditions are less common causes.–4 Fluid within the SASD bursa is a nonspecific sign; nevertheless, it is considered to be an important sign of a full-thickness tear of the rotator cuff tendon.,5 Bursal distension can result from a subjacent tear where glenohumeral joint fluid may fill the SASD bursa through a full-thickness tear in the tendon.SASD bursitis is defined as inflammation of a bursa, characterized by bursal distension, caused by an excessive fluid accumulation in the SASD bursa with or without synovial hypertrophy. These findings support the role of anti-inflammatory treatment. Furthermore, nonsteroidal anti-inflammatory drugs and corticosteroids are widely accepted treatment of inflammation in rotator cuff disease. Corticosteroids impart both anti-inflammatory and direct analgesic effects by reducing inflammatory mediators. The onset of action of corticosteroids is 24 to 48 hours, and their duration of action is approximately 2 to 3 weeks.,13Blaine et al explained that inflammation in the SASD bursa can lead to shoulder pain with rotator cuff disease via inflammatory cytokines. Definitive diagnosis requires analysis of the fluid, and US-guided aspiration is the criterion standard.,7 Aspiration is considered if there is clinical concern for infection; however, this tends to be overlooked in cases of bursal distension associated with rotator cuff tears. Nevertheless, aspiration alone may reportedly completely alleviate impingement syndrome associated with a large quantity of fluid in the SASD bursa.In cases of substantial bursal effusion, US cannot differentiate accurately whether the fluid collection is inflammatory, infectious or hematogenous.In the cases reported here, shoulder pain was caused by rotator cuff tears with SASD bursitis based on physical examination and imaging findings. All laboratory results, including analysis, stains, and cultures of bursal fluid, were normal, ruling out other causes of fluid accumulation in the SASD bursa other than rotator cuff tear. Considering that shoulder pain failed to resolve after conservative treatment, including corticosteroid injection, the authors assumed 2 possible reasons, First, the inflammation mediators remained in the large amount of bursal fluid despite of anti-inflammatory treatment; furthermore, the previous anti-inflammatory treatment might be ineffective and inflammatory pain might persist. Second, a large amount of fluid in the SASD bursa may cause mechanical pain associated with impingement of the shoulder joint. The authors attempted to aspirate fluid in the SASD bursa to the greatest extent possible, and then injected intra-articular corticosteroid under US guidance. Furthermore, there was an increase in the distension of the joint cavity and SASD bursa to confirm that the procedure was correct. Bursa cavities that had shown distension were injected with anti-inflammatory fluid mixtures. Because the amount of inflammatory fluid diminished after aspiration, the effect of corticosteroid injection could be further enhanced. Nevertheless, the patients described in this report were only followed up for 3 months, and long-term follow-up was not achieved. This is a limitation of the present case series.To achieve an immediate effect, therapeutic aspiration of substantial fluid from the SASD bursa combined with corticosteroid injection may be more effective than corticosteroid injection alone. Aspiration removed the volume of inflammatory fluid, having an effect similar to that of bursectomy in reducing inflammation in the rotator cuff disease.This report detailed the cases of 3 patients who experienced shoulder pain caused by rotator cuff tear with SASD bursitis despite conservative treatment and their successful management with combined bursal aspiration and intra-articular corticosteroid injection. Persistent bursal distension after anti-inflammatory treatment might have caused inflammatory and mechanical shoulder pain with impingement. Our patients experienced reduced shoulder pain for several months after corticosteroid injection combined with therapeutic bursal aspiration. These cases suggest that aspiration of SASD bursal fluid with rotator cuff tear is a useful practice if shoulder pain is unresponsive to conservative management. Further studies should be performed to complete the creation of a detailed treatment protocol.Conceptualization: Jang Hyuk Cho.Investigation: Dong Gyu Lee.Resources: Dong Gyu Lee.Writing – original draft: Jang Hyuk Cho.


Although rare, external compression of the left main coronary artery (LMCA) by a pulmonary arterial aneurysm (PAA) as a consequence of pulmonary arterial hypertension causing stable angina pectoris is well described. However, acute myocardial infarction is extremely rare, particularly with a full array of electrocardiographic, biochemical, and echocardiographic features, as in this scenario.  In this case, a 62-year-old man with a past history of severe fibrotic lung disease was hospitalised with chest pain. The patient had dynamic anterolateral ischaemic changes on electrocardiography and serially elevated high-sensitivity troponin I. Transthoracic echocardiography revealed impaired left ventricular ejection fraction with anterolateral hypokinesis. Coronary angiography with intracoronary imaging revealed external compression of the LMCA. Computer tomography (CT) scans confirmed new PAA, compared to previous scans. The patient was successfully treated by percutaneous coronary stent implantation.  Progressive dilatation of the pulmonary artery due to pulmonary arterial hypertension can result in acute MI secondary to external compression of the LMCA. Clinicians should be mindful of acute coronary syndromes in patients with long-standing pulmonary hypertension presenting with chest pain. Pulmonary arterial hypertension (PAH) is associated with aneurysm of the main pulmonary artery (PA). In normal anatomy, the PA lies adjacent to the left coronary sinus of the aorta. As the left main coronary artery (LMCA) arises from the left coronary sinus, it may be compressed by a PA aneurysm (PAA). Although rare, a small number of case reports have described this phenomenon in the presence , 2 and aMyocardial infarction (MI) as a result of external compression of a coronary artery has been previously documented in patients with anomalous coronary origin or course  and normA 62-year-old man with a past history of severe fibrotic lung disease requiring long-term oxygen therapy was hospitalised with typical angina pain with no resolution despite sublingual glyceryl trinitrate use. ECG demonstrated dynamic anterolateral ST depression with T wave inversion in anterior and lateral leads . High-seThe patient was not felt to be a suitable candidate for surgery and underwent IVUS-guided percutaneous coronary intervention with a 5 × 20 mm everolimus drug-eluting stent deployed directly without any predilatation. Postdeployment, IVUS confirmed a well-apposed stent video  with resMI due to external compression of the left main stem can occur by 2 main mechanisms. In normal coronary anatomy, severe PAA can develop following longstanding PAH, resulting in acute compression of the LMCA. In patients with anomalous coronary origin or course interruption of coronary flow, it occurs due to compression of the LMCA between the PA and the high-pressured aorta and can occur without PAA.In PAH patients who experience LMCA compression by the PA, stable angina pectoris has been the dominant syndrome reported by numerous case reports, but this case demonstrates that acute MI can also occur, and is supported by electrocardiographic, biochemical, and echocardiographic parameters. The LMCA is the vessel most at risk of compression, and due to the significant myocardial territory supplied, occlusion can result in significant or even life-threatening myocardial injury.Even if the acute MI event is survivable, major infarction of the LMCA territory in PAH patients could significantly impair long-term prognosis. Such patients are likely to have coexisting right ventricular pressure or volume overload, and acute left ventricular infarction may result in biventricular failure. This has the potential to decompensate pulmonary function due to the combination of pre- and postcapillary pulmonary hypertension. Clinicians should therefore be mindful of acute coronary syndromes occurring in PAH patients presenting with chest pain. As demonstrated in this case, such patients can be easily assessed by CT and intracoronary imaging and successfully treated with prompt percutaneous implantation of an intracoronary stent. It is therefore suggested that extrinsic compression by an aneurysmally dilated PA should be considered in the differential diagnosis of chest pain in patients with severe PAH. Coronary angiography alone can misdiagnose extrinsic LMCA compression, but IVUS can more accurately determine the extent of LMCA stenosis and is associated with lower rates of major clinical events .It is worth noting that because of the slit-like nature of the narrowing, 45° left anterior oblique (LAO) or 30° LAO cranial angulation coronary angiographic planes cross-sectioning the narrow axis of the compressed LMCA best visualise this pathology, whereas other planes crossing the wide axis of the narrowing frequently miss the compression . Shorter


They were also at an increased risk of 30-day mortality , intensive care unit transfer  and endotracheal intubation . The afebrile state was also an independent risk factor associated with 30-day mortality in cirrhotic patients with bacteremia. Clinicians should perform a prudent evaluation in cirrhotic patients and carefully monitor for possible signs of serious infection even in the absence of fever.Cirrhotic patients with bacteremia are at an increased risk of organ failure and mortality. In addition, they can develop serious infection without fever because of their impaired immune response. Our study aimed to investigate the clinical characteristics and outcomes in afebrile bacteremic patients with liver cirrhosis. A single-center, retrospective cohort study was performed on adult patients who visited the emergency department from January 2015 to December 2018. All patients with bacteremia and diagnosis of liver cirrhosis were enrolled and classified as either afebrile or febrile. In total, 104 bacteremic patients with liver cirrhosis  were included in the study. Compared with the febrile group, patients in the afebrile group showed a significantly higher rate of inappropriate antibiotics administration (43.6% vs. 20.4%,  Among these, bacteremia is a serious and systemic infectious disease requiring aggressive treatment and investigation2. Compared to non-cirrhotic patients, bacteremia in cirrhotic patients shows significantly higher mortality and morbidity risk and prolonged hospitalization5.Patients with liver cirrhosis are prone to develop infection because of their cirrhosis-associated immune dysfunction, increased intestinal mucosa permeability and decreased hepatic bacteria filtration6. Clinicians frequently rely on the presence of fever to initiate infection workup7; however, fever is a complex and non-specific host defense response against infection, and might be absent in bacteremic syndrome8. Afebrile bacteremic patients often have atypical clinical manifestations, such as lethargy or confusion9, leading to decreased survival and poorer prognosis10.Patients with fever accompanied by altered mental status and hypotension, may help clinicians to diagnose bacteremia12; which makes the traditional Systemic Inflammatory Response Syndrome (SIRS) criteria inaccurate in the identification of patients with infection13. It has been proposed that scoring systems focused on organ dysfunction, such as quick Sequential Organ Failure Assessment (qSOFA) score or Chronic Liver Failure Sequential Organ Failure Assessment (CLIF-SOFA) score have better prediction ability in sepsis and prognosis stratification in patients with cirrhosis13. Despite this, previous studies regarding bacteremia in cirrhotic patients mainly focused on the severity of cirrhosis, bacteriology, source of infection, and presence of drug-resistant organisms; none of them addressed the issue of body temperature, which could influence the decision of treatment initiation16. Our study aimed to investigate the prevalence, clinical characteristics, and prognosis in afebrile bacteremic patients with liver cirrhosis.It is well known that patients with cirrhosis and bacterial infection frequently present with atypical manifestation, such as normothermiain vitro susceptibility were determined after 5–7 days of incubation. True bacteremia was defined as blood culture of ≥2 sets collected from separate sites yielding the same bacteria, or 1 set of blood culture yielding pathogen corresponding to the patient’s clinical manifestations. The study was carried out in accordance with the principles of the Declaration of Helsinki, and the protocol was approved by the local Institutional Review Board of E-DA hospital (EMRP-108–003). The requirement of informed consent was waived due to the retrospective observational nature of the study.A retrospective cohort study was conducted at a tertiary referral medical center with approximately 60,000 emergency department (ED) visits per year. We enrolled all adult patients (age ≥18 years) who visited the ED from January 1, 2015 to December 31, 2018 and fulfilled both criteria for further analysis: ED diagnostic code for liver cirrhosis ; and positive blood culture results in ED. Patients with fungemia, contaminated blood samples, transferred from other medical facilities (including prior antibiotics use), and immunosuppressant use were excluded. During the ED course, physicians would collect blood samples from the patients for microbial culture and commence antimicrobial therapy accordingly if any of these criteria fulfilled: 1. Patients presented with a clinical manifestation of SIRS ; 2. Patients had evidence of infection by diagnostic test  regardless of SIRS score; 3. Patients developed symptoms of acute on chronic liver failure (ACLF), such as jaundice, coagulopathy, hepatic encephalopathy, etc. Usually within 2–3 days after blood sample collection, the laboratory would notify attending physicians by telephone or message if they detected bacterial growth in incubated blood culture bottles; the species identification and the 9/L or >1.2 × 109/ L or bandemia ≥10%) scores for infection severity stratification in the bacteremic patients17. We stratified cirrhotic patients according to the etiology of cirrhosis  and severity 18, as well as the calculated parameters of organ dysfunction in patients with cirrhosis19. The source of bacteremia was classified as respiratory tract infection , urinary tract infection , spontaneous bacterial peritonitis (diagnostic paracentesis with polymorphonuclear leukocyte count of ≥ 250 cells/µL), skin or soft tissue infection, biliary tract infection, and primary bacteremia (source of unknown origin). The methods of source control  were recorded according to the medical records.We collected data on demographic characteristics, initial ED vital signs, pre-existing co-morbidities, laboratory results, microbiological data, source of bacteremia, and initial use of antimicrobial agents from the manual chart review and electronic medical records of all eligible patients. We used the quick Sepsis Related Organ Failure Assessment (qSOFA)  and the Systemic Inflammatory Response Syndrome (SIRS) . The initial antimicrobial therapy was considered “appropriate” if both of the following criteria were met: the antimicrobial regimen was administered within 24 hours after blood sample collection21, and the pathogen was susceptible to the antimicrobial agent based on the result of an in vitro susceptibility test. If these criteria were unfulfilled, the therapy was considered “inappropriate”. The primary outcome in this study was the 30-day mortality rate, while the secondary outcomes included rate of intensive care unit (ICU) transfer, endotracheal intubation (i.e. respiratory failure), shock (defined as need of vasopressors to maintain hemodynamic stability despite adequate fluid administration during ED stay), and renal replacement therapy administrated within hospital stay .All eligible patients of this study were divided into febrile and afebrile groups for primary and secondary outcomes measurement. The afebrile state was defined as temperature <38 °C in the tympanic membrane during the patient’s ED course (without any antipyretic agent use); otherwise any episode of tympanic membrane >38 °C measured during the patient’s ED course was defined as the febrile state. The patients were empirically treated with antibiotics in accordance with the recommendations of the European Association for the Study of Liver (EASL)t-test and Chi-square tests were used to compare the continuous and categorical variables, respectively. The Mann-Whitney test was used for continuous variables if data were not normally distributed. The 30-day survival curves of the study groups were created using the Kaplan-Meier survival analysis, and the means were compared using the log-rank test. Cox proportional hazards regression model was used to analyze the independent variables associated with 30-day survival. We incorporated all variables with p-value < 0.1 in the univariate analysis into the regression model. A two-tailed p-value < 0.05 was considered statistically significant. All the statistical analyses were performed using the Statistical Package for the Social Sciences version 22.0 software .The characteristics of the afebrile and febrile bacteremic patients with liver cirrhosis were recorded and compared. Data were presented as mean with standard deviation or medians with interquartile range for continuous variables, and numbers (%) for categorical variables. Two-sample This observational study was approved by the Institutional Review Board of EDa hospital (EMRP-108-003), the informed consent was waived due to the retrospective observational nature of the study.From January 1, 2015 to December 31, 2018, we identified 2362 adult ED cirrhotic patients, of which 1823 had hospital admission. The most common reason for admission was an infectious disease (52.6%), followed by gastrointestinal bleeding (27.3%). Blood cultures were drawn from 937 cirrhotic patients, of which 169 had positive blood culture results. After excluding patients with contaminated blood samples (N = 15), insufficient laboratory data (N = 18), inter-facility transfer (N = 23), and immunosuppressant use (N = 9), 104 bacteremic patients with liver cirrhosis  were finally enrolled for further analysis.p = 0.01). The afebrile and febrile groups did not differ in proportion with respect to etiology or severity of cirrhosis, although more than half of the patients in both groups belonged to Child’s C classification , indicating poor liver function performance. The distribution of ACLF grades was also similar in both groups. In the sepsis scoring system, a significantly lower proportion of the afebrile group fulfilled the SIRS criteria , while both groups showed non-significantly different distribution in the qSOFA scoring system . Eight patients, all of whom belonged to the febrile group, received delayed (more than 24 hours) antibiotic administration. Regarding the effectiveness of the antimicrobial agents, the following empirical drugs were ineffective in 31 patients : third-generation cephalosporin (21/31), amoxicillin/clavulanic acid (6/31), and fluoroquinolones (2/31). Taken together, the rate of inappropriate antibiotic therapy was significantly higher in the afebrile group than in the febrile group  (Table p = 0.02). The afebrile bacteremic patient group also had a higher rate of ICU transfer  and endotracheal intubation  (Table p = 0.02). Moreover, multivariate Cox proportional hazard regression analysis revealed that CLIF-SOFA score and afebrile state were independently associated with increased probabilities of 30-day mortality 24. Interestingly, cirrhosis itself has been recognized as a potential risk factor of afebrile bacteremia, further strengthening the distinct disease entity and treatment complexity10.Previous studies considered afebrile bacteremia as a unique phenomenon in the elderly25. Although the prognosis and survival of patients between alcoholic and non-alcoholic cirrhosis were similar in previous studies27, alcoholic cirrhotic patients tended to have bacterial infections, less incidence of hepatocellular carcinoma formation, and more mortality events attributed to infectious disease27. Previous systemic reviews demonstrated that in hospitalized patients with decompensated cirrhosis related acute illness, median survival is <6 months with Child-Pugh score ≥10 or MELD score ≥18, which was seen in the majority of our cirrhotic patients28. These reports could explain why our sicker patient cohort was more susceptible to acute illness, especially infection events, resulting in worse outcome compared with other comorbidities24.Our patients with cirrhosis were younger and predominantly male, and half of them had cirrhosis attributed to alcoholism, which was different from a recent epidemiological research on liver cirrhosis13. Cirrhotic patients may have hypersplenism, use beta-blockers, and present leukopenia and bradycardia, thus showing a lack of the SIRS parameters29. Furthermore, reduced production of acute- phase proteins, such as C-reactive protein (CRP), in patients with decompensated liver cirrhosis, made them had a weaker severity prediction and stratification ability in response to infection30. In concurrence with these issues, more than half of our afebrile bacteremic patients presented absence of tachycardia or leukocytosis, neither with marked CRP elevation, which further lowered the warning level for clinicians, thereby dismissing infectious diseases10. Also, other scoring systems (such as Pitt bacteremia score) which rely on inflammatory parameters including the presentation of fever, revealed limited ability in bacteremia severity stratification in patients with cirrhosis1.It is not surprising that the proportion of patients fulfilled the SIRS criteria in the afebrile group was far less than that of the febrile group because they were divided by body temperature, a determinant included in SIRS criteria. Nevertheless, SIRS criteria exhibited poor accuracy in diagnosing cirrhotic patients with a bacterial infection, including in-hospital mortality discrimination and septic shock development, ICU transfer or acute on chronic liver failure prediction19. The CLIF-SOFA score, which incorporated six variables of organ dysfunction , has been validated as a useful tool for short-term mortality prediction in cirrhotic patients with acute decompensation19. Acute-on-chronic liver failure (ACLF), which is characterized by acute deterioration of liver function with or without extra-hepatic organ failure, carries a significantly higher risk of mortality especially when accompanied by organ failure12. The bacterial infection is the common identifiable factor triggering ACLF, and both of them could result in liver function deterioration with multiple organ failure, and mortality in patients with cirrhosis31. In concert with this concept, the bacteremia events precipitated our fragile cirrhotic patients to both sepsis and ACLF progression, leading to mortality and other adverse outcomes. The independent 30-day mortality prediction ability of the CLIF-SOFA score in our regression model also strengthens the idea that the extent of organ dysfunction correlated better with the prognostic significance in patients with cirrhosis19.It had been proposed that markers of organ dysfunction rather than inflammatory variables have better prognosis impact and mortality prediction performance in cirrhotic patients with sepsis16. The distribution of bacteremic isolates in our study cohort was similar to previous studies, predominantly presenting gram-negative pathogens including Escherichia coli and Klebsiella pneumoniae predominantly, suggesting that the gastrointestinal tract is the most common source of bacterial infection in cirrhotic patients32.Unlike other diseases that were more likely to have bacteremia with respiratory or urinary tract origin, cirrhotic patients tend to have spontaneous bacterial peritonitis as their primary infection source, which is consistent with our results33 as delayed antibiotics administration in patients with bacteremia has been recognized as an independent risk factor of mortality32. Interestingly, in contrast with the newest Surviving Sepsis Campaign guidelines that recommended the broad-spectrum antibiotics to be administrated within 1 hour for patients with sepsis and septic shock33, there were no unambiguous definitions regarding the “appropriate timing” of antibiotics administration in previous bacteremia studies, although most of them used 24 hours as the cut point21. The significantly higher rate of ineffective antibiotic administration in our patients  was unexpected, although the agents were prescribed in accordance with the international recommendations regarding the treatment of bacterial infection in patients with cirrhosis12. This was possibly because some of (13/31) the cases were classified as primary bacteremia that lack the typical signs of infection. Meanwhile, the high yield of multi-drug-resistant pathogens in our study is also consistent with the finding that the prevalence of multi-drug-resistant bacteria in cirrhotic patients has increased worldwide12. It was more prominent in the afebrile group who had blunted inflammatory response and showed absence of conventional inflammatory parameters, further complicating the identification of the infection source and choice of antimicrobial regimen24.The timing and selection of antibiotics treatment differed significantly between our afebrile and febrile groups, with much higher rate of inappropriate use noted in the afebrile one. Prompt and appropriate antibiotics management is a crucial element in treating patients with sepsis10. This could be attributed to their higher proportion of inappropriate antibiotics treatment, since timely and adequate antimicrobial therapy was still considered as an important prognostic factor in cirrhotic bacteremic patients, regardless of their comorbidities or infection severity34. In this study we demonstrated that body temperature is not a reliable marker for clinicians to differentiate infectious events in patients with cirrhosis, and could overlook the disease severity of the afebrile patients, thus delaying initiation of sepsis bundle, including antibiotics treatment, resulting in higher mortality risk. Another explanation for grave prognosis in the afebrile group is the consequence of their highly impaired systemic immune response to infection, predisposing serious complications and mortality, although this had not been validated by immunological assays35.The 30-day mortality in our afebrile bacteremic group was substantially higher (40%), and was similar to a previous afebrile bacteremia studyThe lack of significant differences in the rate of septic shock between the two groups was unexpected, and probably because we only identified those patients needing vasoactive agents to maintain hemodynamic stability during the ED course as the shock condition, not taking account of the following ICU or ordinary ward course. Therefore, we may have missed a portion of patients who developed shock later. Also, we found no significant differences in the proportion of renal replacement therapy between the two groups, which could be because the majority of the patients  had no kidney failure defined in CLIF-SOFA scoring system , hence only 6 of them received renal replacement therapy making the comparison less meaningful. Nevertheless, the analysis of cumulative survival probabilities and other organ failure parameters, including the rate of ICU transfer and respiratory failure, all indicated a far worse prognosis in afebrile patients.33. Second, the different epidemiological data of our study cohort may limit the extrapolation ability of these results. Third, all data obtained from the manual chart reviews and electronic medical records made recall and selection bias inevitable. Fourth, our study failed to recognize patients who did not undergo blood culture tests in the ED, but developed bacteremia subsequently. Finally, some patients may have taken antipyretic agents before the ED visit, which may have influenced our stratification based on body temperature. Nonetheless, we defined the afebrile state as the absence of fever during the entire ED course, thus minimizing the effect of anti-pyretic use before the ED treatment.There were several limitations in our study, including its monocentric and retrospective design. First, we did not calculate the detailed amount of fluid administration in bacteremic patients; although the source control was recorded and compared between the two groups, we didn’t take account of the actual timing of these interventions which could also influence the prognosis of patients with sepsis and septic shockIn summary, afebrile bacteremic patients with liver cirrhosis conform a unique, but not a minority group. They have multifactorial immune system impairment and, lack of typical manifestations of infectious disease, which results in delayed diagnosis and inappropriate antimicrobial agent use. They carry an overwhelmingly higher rate of respiratory failure and, ICU transfer, further associated with a worse prognosis. Clinicians should pay more attention while treating cirrhotic patients, and rely not only on their body temperature or laboratory results; while the parameters of organ dysfunction such as the CLIF-SOFA score, have been validated as a more reliable prognostic factor in cirrhotic patients with bacteremia. They should always keep in mind the possibility of occult severe infection when unusual clinical manifestations are presented, such as lethargy, confusion, unexplained hypotension, or other symptoms of organ dysfunction. Only early recognition and prompt treatment can avoid deterioration of the patients and improve their outcomes.


Secretagogin (SCGN) which acts as a calcium signaling sensor, has previously been shown to be expressed by a substantial population of cortical GABAergic neurons at mid-gestation in humans but not in mice. The present study traced SCGN expression in cortical GABAergic neurons in human fetal forebrain from earlier stages than previously studied. Multiple potential origins of SCGN-expressing neurons were identified in the caudal ganglionic eminence (CGE) lateral ganglionic eminence (LGE) septum and preoptic area; these cells largely co-expressed SP8 but not the medial ganglionic eminence marker LHX6. They followed various migration routes to reach their target regions in the neocortex, insular and olfactory cortex (OC) and olfactory bulbs. A robust increase in the number of SCGN-expressing GABAergic cortical neurons was observed in the midgestational period; 58% of DLX2+ neurons expressed SCGN in the cortical wall at 19 post-conceptional weeks (PCW), a higher proportion than expressed calretinin, a marker for GABAergic neurons of LGE/CGE origin. Furthermore, although most SCGN+ neurons co-expressed calretinin in the cortical plate (CP) and deeper layers, in the marginal zone (MZ) SCGN+ and calretinin+ cells formed separate populations. In the adult mouse, it has previously been shown that in the rostral migratory stream (RMS), SCGN, annexin V (ANXA5), and matrix metalloprotease 2 (MMP2) are co-expressed forming a functioning complex that exocytoses MMP2 in response to calcium. In the present study, ANXA5 showed widespread expression throughout the cortical wall, although MMP2 expression was very largely limited to the CP. We found co-expression of these proteins in some SCGN+ neurons in the subventricular zones (SVZ) suggesting a limited role for these cells in remodeling the extracellular matrix, perhaps during cell migration. Furthermore, restructuring of the extracellular matrix by MMP2 promotes neuroblast migration  of human thalamic projection neuron development  and intermediate zone/cortical plate (IZ/CP) delineated by the nuclear staining (DAPI).via MGE toward the LGE and dorsal telencephalon. SCGN+ cells were also observed in the post-mitotic layer of the sub-pallial septum  or the septum  and the olfactory bulb (via RMS). After 8 PCW, large streams of SCGN+ cells also started migrating into the neocortex.In this study, we have confirmed that a substantial proportion of cortical GABAergic neurons express SCGN by mid-gestation in the developing human forebrain and shown that a higher proportion of cortical GABAergic neurons express SCGN than express CalR. Reporting on expression at younger stages for the first time, we observed that SCGN expression by GABAergic neuron precursors occurs at all stages of development, and we observed four major origins for SCGN+ GABAergic neurons, the CGE, LGE, subpallial septum, and preoptic area. SCGN+ cells predominantly co-expressed SP8 but not markers for cells of MGE origin. The earliest born SCGN+ cells appeared to mainly target the basolateral complex  and Reelin, Neuropeptide Y and some CalR expressing neurons typical of CGE-derived neurons  starts forming from cells observed to spread from the olfactory region to the nearby anterior/ventral cortex  co-express SCGN by mid-gestation in human, compared to only 45% that express CalR (this study) and up to 50% that is estimated to derive from the human CGE  abnormally expressed on the exofacial part of cell surface membrane in a CaBy mid-gestation intense expression was observed in a small subset only of cells resembling migrating neurons in the CP but was more extensively expressed in cells in the upper subplate (SP) at the boundary with the CP. The SP is known to contain a rich ECM, and by mid-gestation can be divided into layers containing cells of different phenotypes  that SCGN+ neurons express both these proteins and may behave like cells of the adult RMS, remodeling the local ECM in response to CAThe expression of SCGN by a considerable proportion of human cortical GABArgic neuron precursors of potentially diverse mature phenotypes is a striking but enigmatic observation. Raju et al.’s  demonstrhttps://www.ebi.ac.uk/arrayexpress/; www.ebi.ac.uk/arrayexpress/experiments/E-MTAB-4840.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: The studies involving human participants were reviewed and approved by the Newcastle and North Tyneside NHS Health Authority Joint Ethics Committee. The patients/participants provided their written informed consent to participate in this study.GC contributed to study design, data analysis and manuscript preparation. AA contributed to study design, data collection, data analysis and manuscript preparation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Abnormal uterine function affects conception rate and embryo development, thereby leading to poor fertility and reproduction failure. Exosomes are a nanosized subclass of extracellular vesicles (EV) that have important functions as intercellular communicators. They contain and carry transferable bioactive substances including micro RNA (miRNA) for target cells. Elements of the cargo can provide epigenetic modifications of the recipient cells and may have crucial roles in mechanisms of reproduction. The dairy industry accounts for a substantial portion of the economy of many agricultural countries. Exosomes can enhance the expression of inflammatory mediators in the endometrium, which contribute to various inflammatory diseases in transition dairy cows. This results in reduced fertility which leads to reduced milk production and increased cow maintenance costs. Thus, gaining a clear knowledge of exosomal epigenetic modifiers is critical to improving the breeding success and profitability of dairy farms. This review provides a brief overview of how exosomal miRNA contributes to inflammatory diseases and hence to poor fertility, particularly in dairy cows.  Poor reproductive efficiency is directly linked with metabolic disorders, a decline in longevity, reduced milk production, greater involuntary culling rate, and higher cow maintenance rates . Dairy cFertility affects the biomolecules transferred within the body engulfed in exosomes ,10. A grThe early lactation period has been identified as a time of great metabolic stress for the animal and susceptibility to all forms of the disease occurs during this time . InflammExtracellular vesicles were first detected in plasma as procoagulant platelet-derived particles in 1946  and in lThe bilipid layer of an exosome is rigid  and the The generation of exosomes begins as an inward budding of late endosomes from the multivesicular body (MVB) membrane in which the endosomes later form into an intraluminal vesicle (ILV)  and thenThere are two suggested mechanisms for the sorting of exosomal cargo into MVBs. One is through an endosomal sorting complex required for transportation (ESCRT) protein machinery which involves four separate proteins ESCRTs (ESCRT-0 to ESCRT-3) . This meAlternatively, there has been suggested another exosomal cargo sorting pathway which is ESCRT-independent . It invoIt has been reported that tetraspanin proteins are also involved in exosome biogenesis in protein loading mechanisms. Ubiquitous specialized membrane platform known as Tetraspanin-enriched microdomain (TEM) involves sorting receptors and signaling proteins into compartments in the plasma membrane  and thatNormally gap junctions, cell surface protein/protein interactions, soluble secreted factors like hormones or cytokines are used as cell communicators for signal transduction purposes . AdditioAfter exosomes enter the target cell, fusion with endosomes enables the horizontal genetic transfer of exosomal cargo to the cytoplasm of the target cell . BioactiThe functional activity of exosomes differs depending on the originating/parental cell type and the cell’s current fate , therefore, exosomal cargo also differs . This caExosomes also have key regulatory functions in the immune system including antigen presentation , immune As mentioned earlier, exosomal cargo is a reflection of the physiological status of the secreting tissue. Therefore, the differential expression of exosomal cargo between high- and low-fertility dairy cows is now gaining great attention in the research field . This maExosomes carry complex functional molecules ranging from proteins , lipids In the following sections, we will focus on the epigenetic molecules that can be carried within exosomes.Milk exosomal mRNAs are involved in metabolic, degradation and signaling pathways ,71. BoviAlmost 80% of the transcribed genes of the mammalian genome are non-coding ,74. Non-A very small number of studies cover research on exosomal lncRNA related to fertility. But a recent study on bovine milk exosome-derived lncRNA has been reported a profile of lncRNAs involve in immunity, development and reproduction . NonetheExosomal miRNA plays a vital role in inter-cellular and inter-organism level signal transduction. MiRNAs are theorized to act as an epigenetic regulators acting on approximately 60% of all mammalian genomes. ,79,80. TBovine milk contains high amounts of exosomes and the exosomal cargo contents include biologically active molecules ,86. The Exosomal miRNAs show a higher resistance to adverse external conditions . This su2 (PGE2) following treatment with exosomes loaded with miRNA-143 (which is a known inhibitor of cyclooxygenase-2 (COX-2), an enzyme required for the production of PGE2) [It has been reported that the miRNAs present within exosomes were different from the miRNA content of the cell which infers that certain miRNAs are packaged into the exosomes in a unique selective way . A circuof PGE2) . This efof PGE2) . The assof PGE2) . In a coof PGE2) . These s2 (PGE2) and prostaglandin F2 alpha (PGF2α) in cells with low fertility exosomes [Biological factors such as mRNA/protein abundance and turnover can influence the differential expression of inflammatory mediator genes ,100. Cytexosomes . Increasexosomes ,102.The relationships between miRNA and fertility have been revealed recently exposing the severity of the epigenetic behavior of miRNA in exosomal cargo . Higher DNA modifications in the exosomal cargo and the consequent epigenetic modification are responsible for tumor progression ,110,111.Vasa Homology (Bvh) gene has been reported to be higher in dairy bulls with poor sperm motility [Bos taurus sperm populations [Apart from exosomal cargo, modifications to the structure of the DNA and histone proteins regulate fertility ,116. Genmotility . It has motility . The cytulations . DNA metulations . Identifulations .Bioinformatic analysis has shown histone acetylation gene overlap between exosomal mRNA and proteins in transgenerational epigenetic inheritance . An oligNon-exosomal epigenetic modification  in histone affects embryo implantation and spermatogenesis ,127. It Inflammation in the reproduction tract alters the natural reproductive cycle and ultimately diminishes the potential fertility and pregnancy success of a dairy cow. Additionally, dairy cows suffer from common postpartum uterine inflammatory diseases, e.g., mastitis, metritis and endometritis. These diseases affect dairy cow management by requiring additional labor and financial resources to maintain, treat or cull animals. Exosomes offer a potential method for the evaluation and diagnosis of inflammatory, reproductive and fertility disorders through exosomal content characterization and comparison. Moreover, the ability of exosomes to transport biological molecules including miRNA  could be manipulated as a method for the delivery of therapeutic agents to alter cellular pathways for the benefit of a dairy cow’s reproductive health. So far, successful isolation techniques of miRNA from exosomes are being explored. However, the diagnostic and therapeutic potential of exosomal miRNA to improve bovine fertility is yet to be explored fully.