NSCLC accounts for approximately 84% of lung malignancies and the clinical application of ICIs provides a novel and promising strategy. However, approximately 80% of NSCLC patients do not benefit from ICIs due to drug resistance complicated by disciplines and diverse mechanisms. Through this review, we provide a whole map of current understanding of primary and acquired resistance mechanisms in NSCLC. In the first part, resistance mechanisms of 6 FDA-approved ICIs-related primary resistance are collected and arranged into 7 steps of the well-known cancer-immunity cycle. Acquired resistance induced by ICIs are summarized in the second part. In the third part, we discuss the future direction, including the deeper understanding of tumor microenvironment and the combinational treatment. Through this review, clinicians can get clear and direct clues to find the underlying mechanisms in patients and translational researchers can acquire several directions to overcome resistance and apply new combinational treatment.Immune checkpoint inhibitors have emerged as the treatment landscape of advanced non-small cell lung cancer (NSCLC) in recent years. However, approximately 80% of NSCLC patients do not benefit from ICIs due to primary resistance  or acquired resistance . In this review, we highlight the mechanisms of primary and secondary resistance. Furthermore, we provide a future direction of the potential predictive biomarkers and the tumor microenvironmental landscape and suggest treatment strategies to overcome these mechanisms. Non-small cell lung cancer (NSCLC) accounts for approximately 84% of lung malignancies and main subtypes include adenocarcinoma, squamous cell carcinoma, and large cell carcinoma . As a seDespite the tremendous success of ICIs in the treatment of NSCLC, approximately 80% of NSCLC patients do not benefit from ICIs due to primary resistance  or acquired resistance  . IdentifIn the well-known cancer-immunity cycle shown in , tumor cTumor mutational burden (TMB) is termed as the frequency of non-synonymous somatic mutations per DNA megabase (Mb) in the coding genome of the tumor . ExpressThe disruption of neo-antigen presentation can be caused by the downregulation of antigen-presenting machinery components or the dysfunction of DCs.Lacking antigen-presenting machinery components is a mechanism for both primary and acquired resistance, such as beta-2-microglobulin (β2M) and human leukocyte antigen (HLA). β2M is a part of HLA I complex and its loss was associated with an unfavorable prognosis in NSCLC , while l+ precursor cells into DCs [p < 0.001) [The dysfunction of DCs is another mechanism to disrupt antigen presentation. Several factors can affect the differentiation, activation of DCs . Interleinto DCs . STING sinto DCs . The gutinto DCs . In NSCL< 0.001) .IFN-α signaling pathway plays an important role in the priming of T cells by DCs and mutations in the pathway inhibits the priming and activation of effector T-cells , while tChemokines, such as C-X-C motif chemokine ligand 9 (CXCL9) and CXCL10, promote the trafficking of effector T cells while downregulation of these genes is a mechanism of primary resistance . For exaVEGF is a key regulator of angiogenesis in tumors, which inhibits the infiltration of T-cells into tumor microenvironments through downregulation of NF-κB-induced endothelial activation . In NSCLIn this step, tumor cells decrease the expression of neo-antigens to avoid T cell recognition, such as downregulation of expressed neo-antigens through promoter hypermethylation of genes expressing neo-antigens .In this step, an immune-suppressive TME characterizing by exhausted T-cells and upregulation of PD-L1 is induced through multiple mechanisms, including mutations in oncogenes and tumor suppressor genes, upregulation of alternative immune checkpoints, dysfunctions in INF-γ pathway, expression of immune-suppressive cytokines and cells, metabolism changes, and epigenetic modifications.Mutations of several pathways in NSCLC upregulate PD-L1 expression to achieve immune escape, including EGFR pathway, ALK pathway, RAS/RAF/MAPK pathway, EMT, MYC, and mTOR.No genomic aberration of EGFR mutation or ALK rearrangement is a common criterion for the clinical application of ICIs in NSCLC. Several studies showed that upregulation of PD-L1 expression should be the reason for the primary resistance against ICIs in NSCLC harboring EGFR mutation or ALK rearrangement. Activation of mutant EGFR in murine bronchial epithelial cells induced the upregulation of PD-1, PD-L1, and CTLA-4, while EGFR inhibitors inhibited the expression of PD-L1 in NSCLC cell lines.  EGFR regActivated RAS stabilized PD-L1 mRNA directly and inhibited tristetraprolin through MAPK activation to promote PD-L1 expression in lung cancer cell lines . ThroughIn erlotinib-resistant NSCLC cells, the upregulation of PD-L1 was associated with MET amplification, and the inhibition of MET significantly decreased PD-L1 in transcriptional and protein levels . ThroughInactivation of tumor suppressor genes caused by mutations induces a TME favoring immune escape through the upregulation of PD-L1. In KRAS-driven NSCLC, inactivation of tumor-suppressor gene STK11/LKB1 was associated with downregulation of PD-L1 and suppressed effector T-cells . In addiIFNγ released by effector T-cells activates Janus kinase (JAK)–signal transducer and activator of transcription (STAT) pathway to promote PD-L1 expression . In NSCLThe releasing of immune-suppressive cytokines suppresses anti-tumor immune responses, including TGF-β, tumor necrosis factor (TNF-α), and IL-6. In NSCLC patients, TGF-β signaling upregulated PD-1 and PD-L1 to promote T-cell anergy and stimulate the recruitment of Tregs to induce resistance . The expThe upregulation of alternative co-inhibitory immune checkpoints on T cells is another mechanism of ICI resistance in NSCLC, including T-cell immunoglobulin and mucin-domain containing-3 (TIM-3) and Lymphocyte Activating 3 (LAG-3) . TIM-3 iSeveral immune cells inhibit the function of effector T-cells to dampen the efficacy of ICIs through direct contact, releasing suppressive molecules (TGF-β and IL-10) and upregulation of immune checkpoints , including T regulatory cell (Treg), B regulatory cell (Breg), M2 Tumor-associated macrophages (TAMs), and Myeloid-derived-suppressor cells (MDSC) . ThroughIDO is a time-limiting enzyme catalyzing the kynurenine (kyn) pathway in tryptophan (trp) metabolism, which also works as an inhibitory immune checkpoint by promoting effector T cell apoptosis through trp shortage . In ICI Epigenetics is the study of heritable phenotype changes without changes of DNA sequence, including DNA methylation, post-translational modification, and non-coding RNA . The expSeveral mechanisms are overlapped in primary and acquired resistance. As regards the lack of neo-antigens, tumors lost 7 to 18 mutations encoding for putative tumor-specific neo-antigens through the elimination of specific sub-clones or deletion of chromosomal regions containing truncal alterations showed acquired resistance against nivolumab or nivolumab/ipilimumab . For theUpregulation of immune checkpoints and immune-suppressive cytokines are also reported in acquired resistance. In lung cancer patients with acquired resistance against anti-PD-1 therapy, the expression of PD-1 and LAG-3 were upregulated . In a prCurrently, personalized medicine approaches mainly focus on the evolution of mutated oncogenes especially driver genes to assess treatment response. With the increasing attention of immunotherapy represented by PD-1 and PD-L1, there is still a lack of effective treatment for targeting microenvironment. In fact, there is a wealth of laboratory and clinical data confirming that the immune status has an important role in indicating the final treatment outcome .As lung cancer environment status is changing with tumor evolution and response to treatment, molecular and functional new mechanism may help improve the targeting of treatment regimens to individual patient-specific conditions. In fact, there is also a large amount of laboratory and clinical data confirming that immune status is an important predictor of final treatment outcome. Recent studies have also begun to use immunological characteristics of microenvironment as a predictive biomarker for evaluating reaction for immunotherapy. At present, many studies are trying to find effective indicators for the efficacy evaluation of immunotherapy; although there are many advances in animal models and in vitro mechanism experiments, it is still an urgent scientific problem to find a reliable indicator to predict the efficacy of immunotherapy.The complex microenvironment of the lung provides superior conditions for the development of primary lung cancer and extrapulmonary tumor metastasis and provides target resources to be developed for the development of clinical treatments. Mechanistic insights into the tumor reprogramming microenvironmental landscape in lung cancer and the development of specific inhibitory drugs have ushered in a new era of cancer therapy. Some immunotherapies perform exceptionally well compared to standard chemotherapy and finding predictive biomarkers to better leverage the benefits of these therapies in the clinic remains a formidable challenge. Both PD-L1 and tumor mutational burden are used clinically as predictive biomarkers to select patients with NSCLC for immunotherapy. Since neither of them can predict the outcome of immunotherapy accurately, the characteristics of immune microenvironment and cytokine levels are being studied extensively to explore a more effective biomarker for immunotherapy. The concept of universal therapy is a thing of the past, and we have now entered the era of precision medicine for lung cancer, which is now focusing on individual molecular testing and cancer genome analysis to assist clinicians in determining appropriate treatments. To maximize the therapeutic effect, the current stage should combine genetic information with the tumor microenvironmental landscape to develop rationally designed combination therapies. More importantly, the success of targeting angiogenesis and immune cells has rekindled enthusiasm for elucidating the role of other components of the lung tumor environment for clinical assessment in lung cancer prognosis and pathophysiology.


Organic light-emitting diodes (OLEDs) have become the predominant technology in display applications because of their superior light weight, flexibility, power conservation, and environmental friendliness, among other reasons. The device’s performance is determined by the intrinsic properties of organic emitters. The aggregation structure of emitters, in particular, is crucial for color purity and efficiency. Intra- and intermolecular interactions, such as hydrogen bonds (H-bonds), can reduce structural vibrations and torsions, which affect the stability of emitting layer films and optoelectronic properties of emitting materials. Hence, by regulating the H-bond interaction, the desired properties could be obtained. This mini-review focuses on the influence of intra- and intermolecular H-bond interactions on the optoelectronic properties of high-performance emitters. As stated in the pioneering work of Tang and VanSlyke et al., organic light-emitting diodes (OLEDs) have attracted considerable scientific and industrial interests . ExtensiOrganic emitters are one of the indispensable parts of OLEDs; not only the properties of the monomolecular state but also those of the aggregated state can influence device performance. The aggregation structure of emitters is crucial for device color purity and electroluminescence (EL) efficiency . Intra- The intra- and intermolecular interactions in optoelectronic materials can influence their arrangement and aggregation behaviors, which could further influence, for example, carrier mobility, color purity, and efficiency. This section mainly discusses the influence of intra- and intermolecular H-bond interactions on the optoelectronic properties of RGB organic emitting materials.An efficient deep-blue emitter can lower the power consumption, increase the color gamut of full-color OLEDs, and create other visible emissions and white light through the energy transfer processes . HowevermDTC and 3DPyM-pDTC  of 62 nm and CIE of  compared with 2DPyM-mDTC  and narrow-band EL (FWHM = 66 nm), whereas the more twisted methyl-substituted compound (MetCz-ND) expressed broader band (FWHM >80 nm) sky-blue (λmax ≈ 480 nm) emission. (pDTC (pDTC shows higher color purity in deep-blue emission than the meta-substituted counterpart (3BPy-mDTC) due to the locked geometry via intramolecular H-bonding  is important for the up-conversion process from triplet to singlet excitons in devices, resulting in theoretically high internal quantum efficiencies. Qi et al. discovered that the existence of intramolecular hydrogen bonding is conducive to diminish the energy difference (ΔEst) between a singlet and a triplet, suppressing nonradiative decay and increasing the luminescence efficiency  core and three 9,9-dimethyl-9,10-dihydroacridine (Ac) donors  donors . They foIntroducing rigid and fused moieties is an effective way to enhance the red emitters’ luminescence. Still, the solubility is significantly reduced, inevitably prohibiting their applications in solution-processed OLEDs. Hence, Chen et al. proposed an intermolecular locking strategy to improve the solution processibility and photoluminescence efficiency of red emitters using a highly soluble flexible difluoroboron β-diketonate unit with exposed and easily reachable fluorines that can form H-bonds in the solid state to induce strong intermolecular locking for high luminescent efficiency . Due to One of the most promising technologies for future lighting and flat panel display applications is highly efficient OLEDs. In this mini-review, we have mainly discussed the RGB emitting materials possessing intra- and intermolecular H-bonds interactions that potentially affect optoelectronic performance. There are mainly two aspects ascribed to the interactions based on exploiting the intra- and intermolecular H-bonds interactions and analyzing the performance of different materials: 1) restricting the rotation between different donor/acceptor moieties and inhibiting the vibrational coupling of excited states, which could obtain high luminous efficiency and color purity; 2) the multiple H-bonds interactions could further enhance horizontal orientation in amorphous organic semiconductor films and significantly increase hole and electron mobilities, which is beneficial for efficiency stability with negligible roll-off. Although the H-bond interaction is weaker than a covalent interaction, it is critical in promoting the development of high-performance OLEDs. Optoelectronic materials with hydrogen bonding interactions will, predictably, attract increasing interest and attention in the future.


Dear Editor,Rv0678, a transcriptional repressor of genes encoding the MmpS5-MmpL5 efflux pump, with concomitant upregulation of the efflux pump, MmpL5, account for cross-resistance between clofazimine (CFZ) and BDQ.Rv0678 resistance-associated variants (RAVs) led to increased BDQ and CFZ minimal inhibitory concentrations (MICs) of 2- to 8-fold and 2- to 4-fold, respectively, in murine isolates, and increased BDQ MICs of 2- to 16-fold in clinical isolates.Rv0678 RAVs in clinical isolates are not associated with prior use of BDQ or CFZ, and do not result in MICs above the BDQ susceptible breakpoint (≤0.12 μg/mL).Rv0678 RAVs include single-nucleotide insertions, deletions and substitutions, large deletions, and random insertions of sequence elements.Rv0678 RAVs.Rv0678 RAVs results in treatment failure, or if treatment failure results in acquisition of Rv0678 RAVs, or if patients with Rv0678 RAVs at baseline are more likely to fail BDQ treatment.Bedaquiline (BDQ) is a diarylquinoline antimycobacterial that specifically inhibits mycobacterial ATP synthase. BDQ has been positively associated with treatment success and reduced mortality in multi-drug-resistant TB (MDR-TB),Rv0678 RAVs in Mycobacterium tuberculosis isolates prior to treatment initiation; 2) Rv0678 RAVs acquired during treatment; and 3) baseline BDQ MIC values of wild-type and Rv0678 isolates. In the 120-week TMC207-C208 Stage 2 (NCT00449644) and TMC207-C209 (NCT00910871) studies, BDQ was given for 24 weeks  with a background regimen of anti-TB drugs given for 18–24 months in TMC207-C208M. tuberculosis isolates were target-sequenced for previously described Rv0678 RAVs using the Sanger method.2In an ad-hoc analysis of two Phase 2b BDQ clinical trial data, we investigated the impact on culture conversion rates of 1) presence of Rv0678 RAVs (n = 226) had comparable conversion rates at the end of BDQ treatment (Week 24)  (n = 165) with ≥1 positive sputum culture post-baseline, patients with wild-type isolates who acquired Rv0678 RAVs post-baseline were more likely to fail treatment than those who did not acquire Rv0678 RAVs , and similarly, in the partially overlapping subset of patients with ≤3 active drugs . Similar findings were seen at endpoint .In the pooled TMC207-C208 and -C209 analysis, patients with baseline isolates without and with  = 0.52) . In anal678 RAVs . In the Rv0678 RAVs at baseline was not associated with poor treatment outcome.For patients with BDQ MICs below the breakpoint, there was no correlation with culture conversion at Week 24 . For patRv0678 RAVs.Rv0678 RAVs on treatment outcome, this is not a straightforward process to explain. We show that culture conversion can be achieved even in the presence of high BDQ MICs, provided the background regimen remains strong . This observation is made with caution because of the low incidence of baseline isolates with high MICs, which is to be expected for a drug with a new mechanism of action and limited clinical exposure at the time of conducting the Phase 2b studies. We did not evaluate any correlation between increased baseline BDQ MICs and treatment outcome in patients with wild-type vs. Rv0678 RAVs at baseline. However, there are a variety of RAVs in Rv0678 with variable effects on the BDQ MIC,Rv0678 RAVs. Consequently, based upon the limited available information, sequencing for Rv0678 RAVs is not useful to rule in BDQ susceptibility – it could only be used to exclude the likelihood of resistance due to Rv0678 RAVs. This makes development of a rapid genotypic drug susceptibility test (DST) challenging. Thus, a standardized phenotypic DST method should be considered to determine susceptibility of M. tuberculosis to BDQ, especially among pretreated MDR-TB patients.11We and others have described treatment failure on a BDQ-containing MDR-TB regimen coinciding with the emergence of Rv0678 RAVs at baseline and poor treatment outcome. However, patients with wild-type isolates who acquired Rv0678 RAVs post-baseline were more likely to fail treatment than those who did not acquire Rv0678 RAVs.In conclusion, no clear relationship was observed between the presence of isolates with


Acute myocardial injury is associated with poor prognosis in respiratory tract infections. We aimed to highlight the differences in prevalence of myocardial injury and its impact on prognosis in patients with COVID-19 compared to those with seasonal influenza.This was a single-center prospective cohort study with a historical control group. 300 age-/sex-matched SARS-CoV-2 and seasonal influenza positive patients were enrolled. Myocardial injury was assessed by electrocardiogram (ECG), transthoracic echocardiography and biomarkers including high-sensitivity troponin-I. All patients were followed-up for 30 days after enrollment for all-cause mortalitiy, admission to the intensive care unit (ICU) and mechanical ventilation.Right ventricular distress was more common in COVID-19 whereas pathological ECG findings and impaired left ventricular function were more prevalent among influenza patients. COVID-19 patients suffered from a higher percentage of hypertension and dyslipidaemia. Contrary to COVID-19, pericardial effusion at admission was associated with poor outcome in the influenza group. Severe course of disease and respiratory failure resulted in significantly higher rates of ICU treatment and mechanical ventilation in COVID-19 patients. Although distribution of myocardial injury was similar, significantly fewer cardiac catheterizations were performed in COVID-19 patients. However, number of cardiac catheterizations was low in both groups. Finally, 30-day mortality was significantly higher in COVID-19 compared to influenza patients.In adults requiring hospitalization due to COVID-19 or seasonal influenza, cardiovascular risk factors and signs of myocardial distress differ significantly. Furthermore, cardiovascular comorbidities may impair prognosis in COVID-19 patients to a higher degree than in their influenza counterparts. Both influenza virus and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are RNA viruses and infect the respiratory epithelium. Aggravation of preexisting cardiovascular and respiratory comorbidities may favor a fatal outcome in influenza and SARS-CoV-2 infections In the current study, we compare the clinical course and outcomes in patients hospitalized with COVID-19 and seasonal influenza. We focus on the incidence and possible pathomechanisms of myocardial injury and respiratory failure to provide further evidence in terms of risk factors and their implications for prognosis.This is a prospective study with a historical control cohort. Between March 2020 and January 2021, we enrolled 441 consecutive SARS-CoV-2 positive patients, that were admitted to the University Hospital of Tübingen, Germany. The historical control cohort consisted of 285 influenza patients admitted to the University Hospital of Tübingen between December 2015 and February 2019. Influenza patients were matched according to age and sex, resulting in two patient groups consisting of 150 individuals each.Cardiovascular risk was assessed by electrocardiogram (ECG), transthoracic echocardiography (TTE) and high-sensitivity cardiac troponin-I (hs-cTnI) levels. Myocardial injury was defined as elevated serum hs-cTnI level above 99th percentile according to the Fourth Universal Definition of Myocardial Infarction Seasonal influenza and SARS-CoV-2 infection were diagnosed from nasopharyngeal secretions using a real-time reverse transcriptase polymerase chain reaction. Severity of acute respiratory distress syndrome (ARDS) was further graduated according to the Berlin Definition of Acute Respiratory Distress Syndrome All patients were followed-up for 30 days after study enrollment. The primary combined endpoint consisted of all-cause mortality and/or mechanical ventilation. All-cause mortality, mechanical ventilation or admission to intensive care unit (ICU) served as secondary endpoints. Follow-up was conducted via hospital discharge letters and telephone interviews.U test, respectively. Hence, values are either presented as mean ± standard deviation or median with 25th/75th percentile. Categorial variables were compared with cross tabulations and consecutive chi-squared tests. Correlations of non-normally distributed data were assessed using the Spearman’s rank correlation coefficient (rho). Kaplan–Meier curves including log rank tests were applied to compare intergroup survival. Where indicated, Cox-regression analyses were used to determine independent associations.SPSS version 26.0  was applied for all statistical analyses. Normally and non-normally distributed data were compared with Student’s t-test and Mann–Whitney Baseline characteristics and incidence rates per 100 person years, both stratified according to COVID-19 and influenza, are shown in Table Patients suffering from influenza presented with lower left ventricular function (LVEF%) at study inclusion when compared to COVID-19. On the other hand, right ventricular (RV)-function was significantly worse in SARS-CoV-2 positive patients. Fittingly, systolic pulmonary arterial pressure (PAPsys) was higher and significant pulmonary as well as tricuspid valve regurgitation were more common in these individuals. Pericardial effusion (PE) was significantly associated with occurrence of the combined endpoint in influenza patients (p < 0.001), although prevalence of PE was low compared to substantially higher rates of PE in COVID-19 patients  in the overall cohort had an indication for cardiac catheterization based on significantly elevated hs-cTnI levels. Rate of cardiac catheterization was low in both groups, however, significantly more cardiac catheterizations were performed in influenza patients compared to COVID-19 .Rate of moderate to severe ARDS was significantly elevated in the COVID-19 group  Cardiovascular risk factors were more prevalent in hospitalized COVID-19 patients compared to influenza. (2) COVID-19 was associated with RV-distress while influenza patients presented with higher rates of impaired LV-function and ECG abnormalities. (3) A low number of patients with significantly elevated hs-cTnI levels received cardiac catherization, abandoning recommendations of the current guidelines on treatment of AMI. (4) In the current age- and sex-matched cohort, mechanical ventilation and ICU treatment were 6-times higher in the COVID-19 group and (5) SARS-CoV-2 patients had a threefold increased mortality risk when compared to individuals suffering from influenza.Erden et alOur findings confirm current evidence showing higher mortality and morbidity in SARS-CoV-2 compared to seasonal influenza Numerous potential mechanisms leading to myocardial injury in seasonal influenza and SARS-CoV-2 infection are discussed to date. In addition to direct viral invasion, platelet hyperactivity, endothelial activation, oxygen supply and demand mismatch as well as enhanced atherosclerotic plaque vulnerability may be enhanced In the current study, cardiac catheterization was performed less frequently in COVID-19 patients compared to those suffering from influenza, which may have had an impact on increased mortality in COVID-19 patients. Thus, abandoning guideline-established treatment strategies highlights an important problem in infectious diseases.Our study is limited by the single center retrospective assessment of hospitalized patients with seasonal influenza. However, a low burden of influenza infections during the COVID-19 pandemic impedes a prospective approach with large numbers of cases. One of the limitations of the study is a moderate study population size. Furthermore, validation cohorts are needed to confirm the distinct associations of COVID-19 and influenza on prognosis. Therefore, we are currently cooperating with university hospitals in Germany to exchange our data on COVID-19 and influenza. A major objective of this collaboration is to establish validation cohorts for the discovered single-centre findings. Finally, vaccination status was also not recorded in the influenza group, so a vaccination-related bias for a milder course of disease would be conceivable.In summary, clinical course, cardiac involvement and prognosis among hospitalized patients with seasonal influenza and COVID-19 differ considerably. In our opinion, acute and pre-existing cardiovascular disease affects COVID-19 patients in a far more drastic manner than their influenza counterparts, rendering stringent cardiovascular assessment and treatment by a COVID-19 heart team indispensable.


Astronauts undergo significant microgravity-induced bone loss during space missions, which has become one of the three major medical problems hindering human's long-term space flight. A risk-free and antiresorptive drug is urgently needed to prevent bone loss during space missions. D-mannose is a natural C-2 epimer of D-glucose and is abundant in cranberries. This study aimed to investigate the protective effects and potential mechanisms of D-mannose against bone loss under weightlessness.The hind legs of tail-suspended (TS) rats were used to mimic weightlessness on Earth. Rats were administered D-mannose intragastrically. The osteoclastogenic and osteogenic capacity of D-mannose in vitro and in vivo was analyzed by micro-computed tomography, biomechanical assessment, bone histology, serum markers of bone metabolism, cell proliferation assay, quantitative polymerase chain reaction, and western blotting. RNA-seq transcriptomic analysis was performed to detect the underlying mechanisms of D-mannose in bone protection.The TS rats showed lower bone mineral density (BMD) and poorer bone morphological indices. D-mannose could improve BMD in TS rats. D-mannose inhibited osteoclast proliferation and fusion in vitro, without apparent effects on osteoblasts. RNA-seq transcriptomic analysis showed that D-mannose administration significantly inhibited the cell fusion molecule dendritic cell-specific transmembrane protein (DC-STAMP) and two indispensable transcription factors for osteoclast fusion (c-Fos and nuclear factor of activated T cells 1 [NFATc1]). Finally, TS rats tended to experience dysuria-related urinary tract infections (UTIs), which were suppressed by treatment with D-mannose.D-mannose protected against bone loss and UTIs in rats under weightlessness. The bone protective effects of D-mannose were mediated by inhibiting osteoclast cell fusion. Our findings provide a potential strategy to protect against bone loss and UTIs during space missions.The online version contains supplementary material available at 10.1186/s12967-022-03870-1. Serious weightlessness-induced bone loss occurs in astronauts during space flight, which leads to a significant increase in the risk of fractures and nephrolith and causes irreversible damage to the skeletal system –3, makinNormally, osteoblasts form new bone while osteoclasts absorb bone, thus bone mass usually remains balanced. Mechanical stimulation is crucial for the development and maintenance of bone structure. Mechanical loading expedites bone formation, conversely, the absence of mechanical stimulation reduces bone mass . NumerouSpace travel also leads to reduced immune competence and a potential increase in the risk of infections –11. BecaMultiple interventions have been explored to prevent bone loss in space, including physical exercise and related medical interventions. However, the tested compounds had side effects such as digestive and renal disturbance, and hepatic dysfunction –17. TherAn extensive literature search indicated that various natural fruit juices including cranberry , 19, bluEscherichia coli, preventing bacterial attachment to the urothelium in UTIs  and c-Fos). The cell–cell fusion of TRAP-positive mononuclear osteoclast precursors is essential for the formation of functionally mature osteoclasts that secrete protons to resorb bone . DC-STAMUTIs are fairly common among adult women; half of all women will have ≥ 1 UTI during their lifetime and 20–40% will experience recurrent UTIs . HoweverSeveral limitations of our study should be further addressed. Whether different concentrations of D-mannose exhibited different effects on osteoclasts should be further explored, although D-mannose may act as a beneficial health product over a wide range of concentrations. The concrete mechanisms of D-mannose in osteoclast cell fusion should also be thoroughly investigated if D-mannose is to be used in astronauts to combat weightlessness-induced bone loss and UTIs during space missions in the future.The present findings demonstrate that TS rats in a simulated microgravity environment experienced severe bone loss because of disrupted bone homeostasis as well as UTIs because of dysuria. Cranberries could protect against bone loss and UTIs in TS rats, and the D-mannose present in cranberries had important osteoprotective and anti-inflammatory effects. Both in vivo and in vitro experiments showed that D-mannose blocked osteoclastogenesis via DC-STAMP-mediated osteoclast cell fusion. Our results may be useful in designing a safe strategy for protection against bone loss and UTIs in astronauts during space missions.Additional file 1: Figure S1. a) A rat tail suspension device. b) The rats were suspended from the tail. c) Juice from three kinds of fruit: cranberry, blueberry, and raspberry. d) Implementation of animal experiments. e) Curve graph of body weight of rats over time. Figure S2. Anthocyanins in three fruits were determined by HPLC. HPLC: high performance liquid chromatography. Figure S3. Suspension does not cause bone loss in rat jaw. a) Representative micro-CT images of mandibular bone. b) Bone mineral density was analyzed at the root bifurcation of the first mandibular molar (red arrow) and mandibular angle (red circle). c) Bone mineral density of alveolar and mandibular angle. Figure S4. D-mannose alleviated urinary tract infections in rats exposed to simulated microgravity. a) H&E staining of kidney and urethra slice and blue arrows indicate hemorrhagic foci. b) Count of leukocytes in urine and neutrophils in blood of rats. Figure S5. D-mannose supplement exhibited no obvious toxic and side effects on the body of rats. H&E staining of slice of liver, spleen, and kidney. Figure S6. Fluorescein isothiocyanate staining of RAW 264.7 cells. Figure S7. Fluorescein isothiocyanate staining of rat bone marrow-derived macrophages (rBMDMs).


Immune cells are dysfunctional during long-term ethanol consumption and may contribute to the progression from healthy to problem drinking. Lymphocytes from mice with chronic ethanol exposure characterized by impaired functional activity, manifested in the combination of increased spontaneous proliferation against the background of low sensitivity to T- cell mitogens.We first demonstrated that original compound meta-chloro-benzhydryl-urea (m-ch-BHU) in vitro restored long-term alcoholized mice lymphocytes activity through GABA(A) receptors. We also revealed the possibility of animal’s behavioral regulation by the transplantation of immune cells with definite functional characteristics, also modulated by psychoactive drugs. Based on the previous results we investigated effects of m-ch-BHU modulated lymphocytes transplantation in recipients with experimental alcoholism.Male (CBAxC57Bl/6)F1 mice with 6-month 10% ethanol exposure were undergoing the transplantation of syngeneic long-term alcoholized mice lymphocytes, pretreated in vitro with m-ch-BHU. Recipient’s ethanol consumption, nervous and immune systems functional activities were estimated.It was shown that transplantation of lymphocytes with in vitro m-ch-BHU modulated functional activity caused in syngeneic recipients with chronic alcohol exposure essential ethanol consumption decrease and stimulation of motor and exploratory activities in the “open field” against the background of cytokines modulation in brain. The significant stimulation of humoral immune response, estimated by the relative number of antibody-forming spleen cells, and stimulation of DTH reaction were also detected in recipients after lymphocytes transplantation.Results demonstrated that transplantation of m-ch-BHU modulated lymphocytes caused positive psychoneuroimmunomodulating effect in animals with chronic alcohol exposure, so, it may be considered as a promising method in the treatment of alcoholismNo significant relationships.


Radon is a naturally occurring radioactive gas and considered as a serious carcinogen to humans. Continuous radioactive decay of this gas emits high-energy alpha particles. Long-term radon exposure induces oxidative stress and inflammatory response, which results in chronic lung diseases. However, biological effects after radon exposure in other organs have been rarely reported. As the outermost organ of the human body, the skin suffers from environmental damage to agents such as air pollution. Epidemiological studies indicated that areas with high level of radon had a high incidence of skin cancer. However, whether radon exposure induces skin damage has not been reported yet. In this study, we established a radon-exposed mouse model and found that radon exposure affected the structure of skin tissues, which was manifested by inflammatory cell infiltration and skin atrophy. Using proteomic approach, we found 45 preferentially expressed proteins in 60 Working Level Months (WLM) group and 314 preferentially expressed proteins in 120 WLM group from radon-exposed skin tissues. Through microRNA (miRNA) sequencing profiling analysis, 57 dysregulated miRNAs were screened between the control and radon-treated mouse skin. By integrating the dysregulated proteins and miRNAs, radon-induced fatty acid synthase (FASN) was investigated in greater detail. Results showed that FASN was regulated by miR-206-3p and miR-378a-3p and involved in the pathogenesis of radon-induced skin damage. Overexpression of FASN inhibited the proliferation, and induced in WS1 cells. Our present findings illustrate the molecular change during radon-induced skin damage and the potential role of FASN during this process. Radon is a ubiquitous radioactive gas that is responsible for approximately half of the human annual background radiation exposure globally and is the decay product of uranium , 2. Cont3 is estimated to be 25 mSv  and 28 [49.12%] down-regulated) in radon exposure skin tissues . Long-term radon exposure can cause oxidative stress, inflammatory response and result in chronic lung diseases including pulmonary fibrosis and lung cancer. Since inhalation is the primary route of radon exposure, much of the current studies for radon focuses on lung cancer as the main health outcome. Additionally, cumulative radon exposure was associated with higher risk of ER negative breast cancer. The P38 MAPK signaling and phosphocholine synthesis gene sets were significantly enriched in ER negative breast tumor and ER negative normal-adjacent samples with higher cumulative radon exposure , 11. HowAs showed in proteomic analysis, there are 72 common dysregulated proteins (26 up-regulated and 46 down-regulated) were identified in both 60 and 120 WLM groups. The up-regulated and down-regulated proteins are likely responsible for the effect of radon-induced skin damage. The down-regulated proteins included Mup17, S100a9 and Mup1, etc. Whereas THRSP, ACACA, FASN, ACLY were up-regulated. These up-regulated genes are related to FA synthesis. FAs are essential constituents of all biological membrane lipids, and are important substrates for energy metabolism. There are two sources of FAs for animal metabolism, exogenously-derived (dietary) FAs and endogenously-synthesized FAs. The biosynthesis of the latter is catalyzed by FASN. It comprises six separate enzymatic grooves that work together to produce a 16-carbon chain saturated FA, palmitate, from acetyl-coenzyme A (CoA) and malonyl-CoA in the presence of nicotinamide adenine dinucleotide phosphate hydrogen (NADPH) . The promiRNAs have been identified as promising biomarkers in cancer and other diseases. Past research has documented that mechanism underlying lung cancer induced by radon may involve alterations in the expression of miRNA-34a gene and consequent disturbances in apoptosis . In thismiRNAs exert their functions through mRNA decay or translation inhibition. In the latter mechanism, the mRNA level of a protein-coding gene usually remains unchanged, whereas protein level is affected. Here we analyzed the relationships between the miRNA and the protein profiles and identified that FASN is positively regulated by miR-378a-3p and miR-206-3p, which has not been reported previously. Based on our results, we postulate that miR-206-3p and miR-378a-3p may regulate FASN in indirect mechanisms, this needs to be further explored. FASN is responsible for the de novo synthesis of FAs, which is involved in the preservation of biological membrane structure, energy storage and assembly of factors involved in signal transduction . In normThis study provides evidence that radon exposure destroys skin integrity, which is accompanied by dysregulated proteins and miRNAs expression. Specifically, FASN was positively regulated by miR-206-3p and miR-378a-3p, and involved in the pathogenesis of radon-induced skin damage. Our present findings illustrate the molecular changes during radon-induced skin injury and the potential role of FASN in inducing this damage.The authors state no conflict of interest.Supplementary_Table_rrac037Click here for additional data file.


Odors trigger various emotional responses such as fear of predator odors, aversion to disease or cancer odors, attraction to male/female odors, and appetitive behavior to delicious food odors. Odor information processing for fine odor discrimination, however, has remained difficult to address. The olfaction and color vision share common features that G protein-coupled receptors are the remote sensors. As different orange colors can be discriminated by distinct intensity ratios of elemental colors, such as yellow and red, odors are likely perceived as multiple elemental odors hierarchically that the intensities of elemental odors are in order of dominance. For example, in a mixture of rose and fox-unique predator odors, robust rose odor alleviates the fear of mice to predator odors. Moreover, although occult blood odor is stronger than bladder cancer-characteristic odor in urine samples, sniffer mice can discriminate bladder cancer odor in occult blood-positive urine samples. In forced-choice odor discrimination tasks for pairs of enantiomers or pairs of body odors vs. cancer-induced body odor disorders, sniffer mice discriminated against learned olfactory cues in a wide range of concentrations, where correct choice rates decreased in the Fechner's law, as perceptual ambiguity increased. In this mini-review, we summarize the current knowledge of how the olfactory system encodes and hierarchically decodes multiple elemental odors to control odor-driven behaviors. The sense of smell functions as an extremely wide-ranging environmental sensor that informs us about approaches to odor sources of delicious or decayed foods, predators or others, healthy or diseased individuals, roses, other flowers, cedar trees, or camphor trees, etc. In addition, odors trigger various emotional responses such as fear to predator odors, aversion to disease or cancer odors, attraction to male/female odors, appetitive behavior to delicious food odors  a set of G protein-coupled receptors (GPCRs) remotely discriminates and detects various color/odor stimuli, (2) sensory cells encode them into cellular signals with signal amplification via cyclic nucleotide second messenger systems and cyclic nucleotide-gated cation channels, and (3) elemental information in colors and odors would be extracted in the third neurons in the visual/olfactory pathway by addition and/or subtraction of signals between multiple receptors via inhibitory signals -carvone from its (+)-form rapidly within seconds. As different relative strengths of Y and R elemental colors for different orange colors, odors of the carvone enantiomers differ in relative intensities of overlapped elemental odors of sweet, fresh, and herbous (R(–)-carvone is fresher than S(+)-carvone, whereas S(+)-carvone is sweeter than R(–)-carvone. In addition, the most prominent elemental odors of R(–)- and S(+)-carvones are uniquely spearmint-like and caraway-like odors, respectively. In a hierarchical elemental odor coding, differences in the principal elemental odors and/or relative elemental odor profiles allow easy discrimination between similar but spearmint-like and caraway-like odors. Similar to color vision, some evidence indicates that elemental odors are extracted by addition and subtraction of signals between cognate receptors and non-cognate receptors in the 3rd neurons via inhibitory signals -caA schematic diagram of the main olfactory pathway from the first neurons to the third neurons is illustrated in There are seven olfactory cortical areas, which directly receive output signals from the OB tufted/mitral cells, the anterior olfactory nucleus (AON), the anterior piriform cortex (aPC), the posterior piriform cortex (pPC), the amygdala (AMY), the amygdalo-piriform transition area (Amy-PirTA), the entorhinal cortex (EC), and the olfactory tubercle (OT) . Among tWe have found direct evidence for the feedforward inhibition-driven hierarchical enhancement of a given elemental odor in an odor mixture. It is well-known that a fox-unique compound, 2,5-dihydro-2,4,5-trimethylthiazoline (TMT), induces fear stress responses in mice as an olfactory cue of the predator, increasing in plasma adrenocorticotrophic hormone (ACTH). Signals from ORs for TMT are sent to the bed nucleus of stria terminalis (BST) via the Amy-PirTA for releasing plasma ACTH -carvone and selectively reduced sensitivity to S(+)-carvone with a 104-fold higher detection threshold (red star). More surprisingly, ΔD mice displayed an extremely reduced discrimination sensitivity for R(–)- vs. S(+)-carvone odors with a 1010-fold higher discrimination threshold (red bar) compared to those of WT mice (R(–)-carvone indicates the existence of highly sensitive ventral ORs, which are yet identified as well as the most sensitive dorsal ORs to S(+)-carvone. Nevertheless, this impaired odor discrimination for R(–)- vs. S(+)-carvone could not be explained by the combinatorial receptor coding scheme - and S(+)-carvones definitely differ each other even after deletion of all dorsal ORs (marked by the cross) -carvone-unique elemental odors via initially activated feedforward inhibitory signals. If this is the case, the deletion of the key OR, the dorsal helix-8-2nd-Glu car-5*, likely leads to impair to represent a prominent or robust auxiliary R(–)-carvone-unique spearmint-like odor in the aPC pyramidal cells and results in prominent R(–)-/S(+)-carvone-common sweet and herbous odors via signals from car-266 OR (enclosed in the orange rectangle) and its cognate ventral ORs. Ventral ORs would be less sensitive to S(+)-carvone than the most sensitive dorsal ORs. Thus, the remaining less sensitive ventral ORs are unlikely to represent robust signals of S(+)-carvone-unique caraway-like odor via feedforward inhibitory signals. Moreover, ΔD mice also retain a similar sensitivity to TMT as WT mice but cannot recognize the TMT odor as a predator-characteristic odor, resulting in no fear response  mice displayed an exquisite “supersensitive detection” (black star) and similar “supersensitive discrimination” (black bar) to enantiomeric odor pairs of wine lactones and carvones in an odor plume-guided Y-maze behavioral assays  Sato et. Surpris WT mice   for bladder cancer odor by 5 × 105-fold .Interestingly, the genetic ablation of all dorsal ORs elevated odor discrimination thresholds  resulted in odor choice at the chance level and the learned odor pair made the sniffer mice possible to discriminate them again at a high correct rate, although the urinary biomarkers were at similar concentrations of ppq between pre‡- and post†-RP P:Um. These post assays confirmed that the sniffer mice basically choose one of the Y-maze branches by olfactory cues but not by visual cues. In addition, the prostate cancer-characteristic odor would be perceived as relatively stronger elemental odors compared to urine-common elemental odors  and 1.6–3.8-fold, respectively, suggesting a reduced tumor volume.An olfactory cue of prostate cancer odor resulted in an extremely low odor discrimination threshold of 9.2 × 10al odors   identical between humans and mice in class-I  and class-II  ORs, and TAARs  , which would differ in specific interaction with Golfα or Giα leading to different rapidity and robustness of cellular responses in OSNs. In addition, quite similar or different odorants-activated OR signals are processed separately and/or interactively in seven distinct olfactory cortical areas. In this odor information processing, one of the key processes is a constantly rapid and specific interaction between ORs and Golfα, because variable binding kinetics of OR–Golfα interaction could cause changes in an order of signal inputs from ORs to the brain between higher and lower affinities to a given odorant resulting in unlikely sniffing-by-sniffing variation in odor representations. Type-specific stable interaction sites in the C-terminal region of G protein have been proposed  , Grantin-Aids for Scientific Research (C) , Nihon University Research Grant (#kyo09-010 to MM), the Human Frontier Science Program grant n-RG19/96 to TI, grants from Aino University to YM, and research budget from Sumitomo Chemical Co., Ltd for SPME-GC-MSmeasurements. The authors declare that this study received funding from Japan Tobacco INC.The authors declare that this study received research budget from Sumitomo Chemical Co., Ltd, which was used for SPME-GC-MS measurements. This study received funding from Japan Tobacco INC. The funder had the following involvement in the study: Shared features of odor coding between humans and mice.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


As an important component of the tumor immune microenvironment (TIME), tumor-associated macrophages (TAMs) occupy a significant niche in tumor margin aggregation and respond to changes in the TIME. Thus, targeting TAMs is important for tumor monitoring, surgical guidance and efficacy evaluation. Continuously developing nanoprobes and imaging agents paves the way toward targeting TAMs for precise imaging and diagnosis. This review summarizes the commonly used nanomaterials for TAM targeting imaging probes, including metal-based nanoprobes , fluorine-19-based nanoprobes, radiolabeled agents, near-infrared fluorescence dyes and ultrasonic nanobubbles. Additionally, the prospects and challenges of designing nanomaterials for imaging and diagnosis  are described in this review. Notwithstanding, TAM-targeting nanoplatforms provide great potential for imaging, diagnosis and therapy with a greater possibility of clinical transformation. Cancer ranks as one of the leading causes of death in modern society around the world and is also a major obstacle to the improvement of the human lifespan. In 2020, 19 million new cancer cases were reported worldwide  and almost 10 million cancer deaths  ,4,5. (2)Undoubtedly, most treatment failure and cancer recurrence are associated with the complicated tumor microenvironment . It is aTAMs-targeted imaging probes combine the existing imaging technology and TAM-targeted modification to target tumor-associated macrophages through the modification of mannose, polypeptide and polysaccharide against the receptors, such as CD206 (human mannose receptor), TREM2 (triggering receptor expressed on myeloid cells 2), legumain and scavenger receptor-A overexpressed by TAMs . This reImaging of TAMs using MRI usually takes metal elements as the core coating with the targeting moiety and responsive chemical bonds or enzymes . As freqTo track the imaging of glioblastoma (GBM) tumor-associated macrophages (TAMs), Runze Yang  et al. r3) was much smaller than that of the SPIO + AMF group (1319.50 mm3). Moreover, by remodeling the tumor immune microenvironment by replenishing cytokines and related immune cells, SPIO also exhibited depletion and repolarization of M2 macrophages; thus, the entire nanoprobe was described as a multi-stratal diagnosis and treatment system (−1s−1) that was comparable to that of Resovist (143 mM−1s−1), a commercial contrast agent composed of very small (5.8 ± 2.5 nm) superparamagnetic iron oxide (USPIO) with a carboxydextran coating.The surface modification of the iron oxide nanoplatform effectively improves the targeting ability for TAMs. Li et al.  designedt system a. Assesst system c. The inIn recent years, superparamagnetic iron oxide nanoparticles have also been used in magnetic particle imaging (MPI) positioning according to the signal generated by SPIO in a free magnetic field. In contrast to MRI, MPI provides quantitative information on in vivo iron labeling of macrophages in a 4T1 mouse model, indicating that MPI may serve as an adjunct to other imaging techniques. MPI technology can supplement the quantitative information of local iron . CombineRegarding diagnosis and treatment integration, the diversity of Fe-based imaging probe preparation methods endows iron-related nanoparticles with potential as drug carriers for loading tumor-killing drugs or microenvironment-regulating cytokines. Additionally, the discoveries of the iron oxide magnetocaloric effect and ferroptosis signaling pathway strengthened the antitumor function of Fe-based nanoparticles . The MRIAdditionally, sulfated dextran-coated iron oxide nanoparticles (SDIO) can target macrophage scavenger receptor A  and obtain better retention and imaging efficacy . Likewis2+ complexes exhibited short blood circulation times and brain assembly toxicity. To avoid the abovementioned detrimental effects, Luo et al. created a bioactivated in vivo assembly (BIVA) magnetic resonance (MR) probe called TSP (mannose-Lys-Lys-Lys-Lys-Arg-Arg-Lys-Ppa[Mn]). Mannose-modified nanoparticles-targeted TAMs and mediated molecular internalization  iodo-DPA-713, a macrophage-specific imaging agent. By fusing MRI and PET images, specific uptake of the radiotracer was observed within and proximal to the primary tumor at early stages and metastases in the lungs at later stages . C. C3+ coucitation b. Due to19F and nanobubbles, some novel materials, such as single wall carbon nanotubes, gold nanoparticles and manganese imaging agents also take part in this examination of TAM-targeting probes.TAMs, which generally accumulate at the edge of tumors, play an important role in cancer progression and the tumor immune microenvironment. As a consequential scope to unveil tumor status and limit the boundaries of tumors, TAM-targeting nanoprobes have received increasing attention and focus. This review mainly introduces some materials applied to target TAMs and focuses on the literature on TAM-targeting efficiency, pharmacokinetics and surgical guidance. In addition to exploring the application of archetypal imaging molecules such as iron oxide, Some tendencies have appeared in the process of designing TAM-targeting nanoprobes at the current stage, including: 1. Combining diagnosis with therapeutic treatment. 2. Noteworthy interest in multimode and multilevel imaging probes. 3. Requiring high-precision target ability. 4. Refining the pharmacokinetics of probes to achieve a low background signal and distinct tumor site imaging. Additionally, pharmacokinetic improvement will prolong the imaging window of TAM-targeting probes in a serviceable way and provide long-term noninvasive tumor monitoring platforms. Simultaneously, TAM-targeting imaging technology profoundly interacts with other technologies as well. According to the PyRadiomics workflow, Starosolski et al.  analyzedHowever, there are still some obstacles hindering TAM-targeting imaging strategies. Initially, TAM-targeting tumor imaging was not a direct way to characterize cancer cell appearance. Regardless of the great imaging effect coming from phagocytosis and the critical niche of TAMs in the TIME, there still exists an information feedback chain from macrophages to tumor cells. In the mode of estimating the preparation therapy effect and guiding operation, the information feedback chain may be swayed by fluctuations in the immune environment and inflammation-related factors (e.g., pseudo progression of tumors created by the transformation of the local inflammatory environment during the radiotherapy/chemotherapy cycle  and chan


We have studied an unvaccinated heart transplant 64-year-old patient admitted for low-grade fever, dry cough, general malaise, and bilateral interstitial infiltrates, after two months of a diagnosis of coronavirus disease 2019 (COVID-19) bilateral pneumonia. A bronchoalveolar lavage and transbronchial biopsy were performed. Bacterial, mycotic and viral infections were ruled out including repeated reverse transcription polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).+ and CD8+ T cells with positive immunolabelling for granzyme B were observed, indicating a continuing cytotoxic process that might have induced proliferation and fibrosis.Diffuse thickening of alveolar septa with fibrosis and infiltration of lymphocytes and macrophages into the alveolar septa with aggregates of CD4An intense ongoing immunopathological cellular reaction, potentially triggered by SARS-CoV-2 overcoming the anti-inflammatory and immunomodulatory effects of the immunosuppressive drugs is suggested by these findings, opening to debate the usual approach of minimizing immunosuppression after COVID-19 in transplant patients when presence of SARS-CoV-2 has been ruled out. The classic patterns of the pulmonary involvement induced by the coronavirus disease 2019 (COVID-19) in immunocompetent patients are bilateral pneumonia, diffuse alveolar damage and an eventual progression toward a fibroproliferative stage [Most histopathological documentation has originated from autopsy reports , and recThe mortality of heart transplant patients with COVID-19 has been reported to be between 15-33%, with in-hospital mortality reaching 41% , which iNevertheless, until now, there has been limited information concerning the management of heart transplant patients with COVID-19 and no available in-vivo lung histopathological data.We recently studied a non-vaccinated 64-year-old male patient who had received a heart transplant in 2008 and was admitted in late December 2020 with a diagnosis of COVID-19 bilateral pneumonia without systemic involvement. Chest radiography on admission showed bilateral infiltrates. At that point, maintenance anti-rejection immunosuppression was achieved through tacrolimus 2 mg bi-daily plus mycophenolic acid 1080 mg bi-daily. Supplemental oxygen (6 L/min) was required to achieve a 94% oxygen saturation (SaO2). According to the RECOVERY trial findings [Fifty-eight days after his initial admission, the patient was transferred to our centre. At admission, he presented with low-grade fever, dry cough and general malaise. On physical examination, the patient was thirsty, with a dry mouth, a temperature of 37.8 °C, a heart rate of 72 beats per minute and blood pressure of 125/70 mmHg. A body mass index of 21 kg/m2 was calculated, and the patient showed 93% SaO2 without supplemental oxygen (SaFiO2 of 443). Diffuse and bilateral Velcro-type crackles were detected by auscultation. No abdominal pathological findings or evidence of heart failure were observed. Bilateral pulmonary infiltrates were evident on chest radiography and computed tomography (CT) Figure -1C.Because of the uncertain aetiology of pulmonary infiltrates and the possibility of opportunistic infections in a transplant patient, bronchoalveolar lavage and transbronchial biopsy were performed. Negative bacterial, mycotic and viral results (including repeated reverse-transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in both nasopharyngeal swabs and bronchoalveolar lavage samples) were obtained.Pathologically, as shown in Figure The patient showed progressive improvement of his clinical status being discharged after 10 days with a SaFiO2 of 452.4 breathing room air with the administration of mycophenolic acid 1080 mg/day and prednisone 8 mg/day Figure .The pulmonary inflammatory, organising and fibroproliferative consequences of COVID-19 in immunocompetent patients have been described mainly from autopsy studies with only a few in-vivo published data ,11. EvenPatients undergoing transplantation require immunosuppression to avoid donor organ rejection. Immunosuppressants affect viral replication, as well as inflammatory and fibro-proliferative tissue responses. Thus, decision-making regarding the adjustment of immunosuppression in transplant patients with COVID-19 remains open to debate .The most frequently described clinical patterns in immunocompetent deceased patients with COVID-19 have been bilateral pneumonia, diffuse alveolar damage and a late fibroproliferative stage . A subgrIn our case, post-COVID-19 pulmonary fibrosis was diagnosed according to the criteria suggested by Huang et al.  .It has been shown that in COVID-19 pneumonia, an initial acute viral response phase is activated, giving rise to diffuse alveolar damage, followed by disease progression modulated by the host inflammatory response . A late Histologically, COVID-19 pulmonary involvement has been divided into three principal patterns: a) predominantly epithelial, showing epithelial cell death with secondary hyperplasic changes and diffuse alveolar damage; b) predominantly vascular, showing microvascular damage, micro-thrombi and acute fibrinous and organising pneumonia; and c) predominantly fibrotic, with evidence of interstitial fibrosis and alveolar obliteration. The pathogenesis of the fibrotic changes involves repetitive damage to the alveolar epithelium leading to an ineffective repair process with epithelial dysfunction . FibrotiData from a recently published review show that approximately 20% of COVID-19 patients progress to fibrotic sequelae that persist until the one-year follow-up [Heart transplant patients represent a unique population of immunosuppressed subjects in which SARS-CoV-2 may cause an unpredictable clinical course of infection. Histopathological data are still lacking for vulnerable patients .In this late in-vivo transbronchial biopsy obtained from a COVID-19 pneumonia immunosuppressed heart transplant patient, we were able to demonstrate extensive proliferative and fibrotic changes in the absence of evidence of viral presence two months after the initial viral infection.Even after viral clearance, our findings show persistent cellular immune response and ongoing pro-organising and pro-fibrotic processes, which might have been triggered by the virus and not halted by patient-adjusted immunosuppression. The cellular inflammatory reaction seems particularly noteworthy based on the abundance of CD8+ T cells with evident granzyme B immunohistochemical staining. This finding is particularly interesting considering its development despite the patient receiving immunosuppressive drugs  that interfere with T- and B-lymphocyte activity and possess antiproliferative actions.It is not easy to describe major histopathological or imaging differences between the fibroproliferative phases of COVID-19 pneumonia and the late stages of idiopathic interstitial pneumonias which should always bring up the issue of its nosologic characterization and eventually the use of a common therapeutical approach like steroids or anti-fibrotic agents .In transplant patients, reduction of immunosuppressive medication during the initial stages of the disease appears to be a reasonable approach to control acute viral replication and could influence its clinical expression. On the other hand, since much of the lung damage observed in later stages could result from immune hyperactivation driven by T cells, a sharp decrease in immunosuppression when no active viral replication is demonstrable might contribute to an increased organising and/or fibroproliferative delayed response .The decisions pertaining to the continuation, modification or discontinuation of immunosuppressants in transplant patients with COVID-19 remain controversial and still lack sound scientific evidence. Our study highlights a persistent cellular inflammatory response based on the abundance of CD4+ and CD8+ T cells with evident granzyme B immunohistochemical staining in a late COVID-19 pneumonia heart transplant patient.These findings suggest that the ongoing immunopathological cellular and humoral reactions triggered by SARS-CoV-2 are resistant to the anti-inflammatory and immunomodulatory effects of immunosuppressive drugs and could contribute to an increase in lung proliferative and fibrotic changes in the absence of evidence of viral presence.


As the Coronavirus Disease-2019 (COVID-19) pandemic continues, healthcare providers struggle to manage both COVID-19 and non-COVID patients while still providing high-quality care. We conducted a systematic review/meta-analysis to describe the effects of the COVID-19 pandemic on patients with non-COVID illness and on healthcare systems compared to non-pandemic epochs.We searched Ovid MEDLINE/EMBASE/Cochrane Database of Systematic Reviews/CENTRAL/CINAHL . All study types with COVID-pandemic time period  with comparative non-pandemic time periods . Data regarding study characteristics/case-mix/interventions/comparators/ outcomes . Twenty-eight studies (17%) reported significant changes in morbidity (where 93% reported increases), while 30 studies (18%) reported no significant change (very low certainty). Thirty-nine studies (23%) reported significant changes in hospitalizations (97% reporting decreases), while 111 studies (66%) reported no significant change (very low certainty). Sixty-two studies (37%) reported significant disruptions in standards-to-care (73% reporting increases), while 62 studies (37%) reported no significant change (very low certainty).There was a significant increase in mortality during the COVID pandemic compared to pre-pandemic times for non-COVID illnesses. When significant changes were reported, there was increased morbidity, decreased hospitalizations and increased disruptions in standards-of-care.CRD42020201256 .PROSPERO  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease-19 (COVID-19), has spread globally to over 180 countries on 6 continents with over 500 million confirmed cases of COVID-19 worldwide, and over 6 million deaths  to creatThis shift in prioritization of the health system may have unintentional and underappreciated effects on patients without COVID, including altered access to health services and/or altered models of care. The pandemic may be contributing to substantial negative consequences for patients , 6 alongAccordingly, to focus attention on this issue, we conducted a systematic review (SR) and meta-analysis (MA) to describe the effects of the COVID-19 pandemic on non-COVID outcomes with respect to patient mortality, morbidity, acute care hospitalizations and disruptions to standards-of-care . Our SR serves to inform health care leaders, professionals and health policy makers, who have generated and implemented policy to prioritize resources throughout the COVID-19 pandemic, of the potential widespread impact of COVID-19 on capacity to sustainably provide standards-of-care and optimize outcomes for patients presenting with illnesses unrelated to COVID-19.This SR was conducted and reported in accordance with the PRISMA guidelines , and wasWe systematically searched Ovid MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register (CENTRAL), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception 1948 to December 31, 2020. Last search was completed on Dec 31, 2020. Searches were performed by a research librarian (DKL), and were adjudicated by a second health information specialist (MS) using Peer Review Electronic Search Strategy (PRESS) criteria  12]..12].mortality; morbidity; pandemic; non-pandemic time periods; outcomes; healthcare disruption; healthcare system delivery; public health policy/measures; societal/public behaviour; acute care hospitalizations; occupancy rates; economics. We also screened reference lists of identified relevant individual studies and reviews.We used a combination of subject headings and keywords: Exposure and study and control time periods were defined as during the COVID-19 pandemic  compared to non-COVID-19 pandemic time periods .Mortality was evaluated at the longest time interval provided for each study, and classified as increased or decreased relative to pre-pandemic epochs.Morbidity was defined as the state of being symptomatic or unhealthy for a disease or condition , and as A “disruption to standards-of-care” was defined as any change to a delivered health service  which had a statistically significant change during the COVID-19 pandemic period as compared to a non-COVID pandemic historical control period  , 14.Articles were considered eligible if they met the following criteria: (1) adult patients (≥18 years old); (2) randomized control trials (RCTs), observational studies and case series with control groups at any level . We excluded all animal and pediatric studies. Conference abstracts and non-peer reviewed websites were excluded. We excluded case reports and case series without control groups. No language restrictions were applied.Paired reviewers  independently screened the titles and abstracts of identified articles. Articles deemed potentially eligible by either or both reviewers advanced to the full-text review stage, and were screened for inclusion by paired reviewers (including pilot testing against eligibility criteria). Disagreements at this stage were resolved through discussion and consultation with a third reviewer, if necessary. We used Covidence  to manage search results, screening, and selection of studies . Our data priori data abstraction tool was piloted for all reviewers and was subsequently used to collect the following data from eligible articles: study characteristics , patient group demographic/clinical data, interventions and comparators, clinical outcome data , and jurisdiction(s) in which the study was performed.An We assessed risk of bias in observational cohort and case-control studies using the Newcastle-Ottawa Scale (NOS), examining the following domains: selection, comparability and exposure for cohort and case-control studies. Each of the criteria for the NOS scales for cohort/case-control studies are found in the footnotes . QualityWe used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the following domains for each clinical outcome: individual study risk of bias, indirectness, imprecision, inconsistency and publication bias. Certainty in evidence from observational studies started as low, with RCTs starting as high. Final certainty was rated as high, moderate, low or very low –19.Continuous data was presented as means and standard deviations (SD), or medians and inter-quartile ranges (IQR), and were compared (where appropriate) using a t-test or Wilcoxon rank sum test. Categorical variables and proportions were compared using the Pearson’s Chi-Square or Fischer’s exact tests as appropriate. We summarized the eligible studies in terms of point estimates or proportions, with p-values or 95% confidence intervals [CIs], if available. Significance was set at 0.05.2 statistic, the χ2 test for homogeneity . We considered an I2 value greater than 50% indicative of substantial heterogeneity. We investigated further with subgroup analyses to assess clinical and methodological sources of heterogeneity. We assessed for publication bias using Begg’s funnel plots if there are 10 or more studies per outcome [We performed a meta-analysis of observational studies in this SR, with RevMan  version 5.4 software for the outcome of mortality. We will use the method of DerSimonian and Laird to pool effect sizes for each outcome under a random-effects model for all outcomes of interest . We asse outcome –23.Given the heterogeneity, variation and disparate reporting for morbidity, hospitalizations/occupancy, disruptions in standards-of-care, we could not conduct a meta-analysis for these outcomes.Potential and expected clinical sources of heterogeneity were explored for selected outcomes . When a sufficient number of trials were available (e.g. >10 studies), we conducted the following pre-specified subgroup pooled analyses (hypothesized direction of effect in parentheses):High vs. low risk of bias studies .High (HIC) vs. low-middle income (LMIC) countries, as defined by World Health Organization  Medical vs. surgical vs. medical/surgical case-mixes If subgroups effects were credible, we presented the outcomes separately for each subgroup.If we encountered missing data, we attempted to contact the study authors for additional information or clarity. If we could not obtain additional data, we analyzed the available data and reported the potential impact of missing data in the discussion.Of 11,581 records identified through our search, we reviewed 336 full-texts, and included 167 studies which fulfilled eligibility criteria . SummaryOf the 167 studies, there were 164 (98%) observational cohort studies and 2 (1%) case-control studies, and 1 (1%) case-series with control groups. The predominant setting for these studies was acute care hospitals . These studies were largely conducted in a single country  with 35 individual countries contributing (highest was the United States with 31 studies) .The top five primary illness categories were as follows: cardiovascular ; mixed multi-illness ; neurological ; trauma ; and, respiratory or gastrointestinal , each .The risks of bias (RoB) assessments using the Newcastle-Ottawa Scale tools for observational studies are shown in For cohort studies , NOS tooFor case-control studies , NOS tooStudy outcomes are presented in 2 = 97%). This observation was consistent for grouped systems including: cardiovascular ; respiratory ; and trauma/musculoskeletal .For overall mortality , our metFifty studies (29.8%) reported a statistically significant change in mortality, while 47 studies (28.0%) reported no significant change, and 71 studies (42%) did not report on mortality. Of those 50 studies which reported a significant change in mortality, 49 studies (98.0%) reported an increase in mortality, while one study (2%) reported a decrease in mortality during the COVID-19 pandemic compared with non-COVID-19 pre-pandemic historical controls. Ninety-seven observational studies reporting mortality  were downgraded for RoB (“very serious” RoB due to high proportion of poor NOS scores), and inconsistency (high heterogeneity). This led to a “very low” level of certainty in the quality of evidence.Twenty-eight studies (17%) reported a statistically significant change in morbidity, while 30 studies (18%) reported no significant change, and 110 studies (66%) did not report on morbidity. Of those 28 studies which reported significant changes in morbidity, 26 studies (93%) reported an increase in morbidity, while two studies (7%) reported a decrease in morbidity during the COVID-19 pandemic compared with non-COVID-19 pre-pandemic historical controls. Morbidity was reported in 58 observational studies, where we similarly downgraded for RoB (“very serious” RoB due to high proportion of poor NOS scores), inconsistency (high heterogeneity), and imprecision . This led to a “very low” level of certainty in the quality of evidence.Thirty-nine studies (23%) reported a statistically significant change in acute care hospitalizations/occupancy, while 111 studies (66%) reported no significant change, and 18 studies (10%) did not report on hospitalizations/occupancy. Of those 39 studies which reported statistically significant change in hospitalizations/occupancy, one study (3%) reported an increase in hospitalizations/occupancy, while 38 studies (97%) reported a decrease in hospitalizations/occupancy during the COVID-19 pandemic compared with non-COVID-19 pre-pandemic historical controls. Hospitalizations and occupancy were reported in 150 observational studies, which were downgraded for RoB (“very serious” RoB due to high proportion of poor NOS scores), inconsistency (high heterogeneity), and imprecision . This led to a “very low” level of certainty in the quality of evidence.Sixty-two studies (37%) reported a statistically significant change in disruptions to care, while 62 studies (37%) reported no significant change, and 43 studies (26%) did not report on disruptions to care. Of those 62 studies which reported on disruptions to care, 47 studies (76%) reported an increase in disruptions to care, while 15 studies (24%) reported a decrease in disruptions to care  during the COVID-19 pandemic compared with non-COVID-19 pre-pandemic historical controls. Disruptions in standards-of-care were reported in 124 observational studies, where we downgraded for RoB (“very serious” RoB due to high proportion of poor NOS scores), inconsistency (high heterogeneity), and imprecision . This led to a “very low” level of certainty in the quality of evidence.Pre-specified subgroup analyses for mortality are shown For RoB , there wFor HIC vs. LMIC countries , there wFor level of healthcare intervention , there wFor case-mix , there wThere was no significant change between inverse variance pooling and Mantel-Haenszel Random-Effects Forest Plot . Mantel-Visual inspection of Begg’s funnel plots did not reveal publication bias for the outcome of mortality .In this systematic review of non-COVID illness occurring during the COVID-19 pandemic, patient outcomes were variably affected by the pandemic compared to historical non-pandemic epochs. However, our meta-analysis revealed a significant increase in mortality during the COVID pandemic for non-COVID illness as compared to pre-pandemic time periods (very low certainty evidence), which was consistent across most subgroups evaluated. A substantial proportion of studies reported changes in morbidity; health services and disruptions associated with the pandemic, although this was not universal. The following directional trends were observed: increased morbidity; decreased hospitalizations and lower occupancy; and increased disruptions in care in multiple jurisdictions from low certainty evidence .While this would preclude strong inferences or definitive recommendations on the nature of the public health interventions and health systems responses to the COVID-19 pandemic crisis, this analysis provides insight into the potential substantial trade-offs that have occurred for both patients with non-COVID illness and health systems capacity to meet standards-of-care. In multiple jurisdictions, excess all-cause mortality  has been reported over and above recorded COVID-19 deaths alone . ThereinOur systematic review adds new knowledge on the potential scope and magnitude of the effects of the COVID-19 pandemic on all non-COVID illness. There is emerging literature that excess mortality is not only driven by COVID-19 deaths , but theThere are fundamental trade-offs that occur when employing public health measures and policies during pandemics. Potential negative effects of the pandemic include affecting social determinants of health  alongside healthcare disruption that may have contributed to the overall excess mortality, morbidity, and disruptions in standards-of-care in the non-COVID population. As a society, do we continually tradeoff and prioritize COVID patients at the expense of non-COVID patients, especially those who continue to flaunt public health measures, refuse vaccines and spread misinformation? Are we willing to accept prolonged, sustained disruptions to healthcare systems and society, while continually delay care of non-COVID patients? This is all interwoven and extremely complex pieces of the puzzle within public health policy all need to be weighed such that both COVID and non-COVID patients are not harmed.Anticipating ongoing global disruptions to healthcare is a key to weathering unanticipated short and long-term COVID-19 pandemic effects to non-COVID patients, which includes: (1) evidence-based, expedited vaccination where available, with mandates quickly implemented; (2) surge capacity planning aimed at: i) creating capacity as needed; ii) preserving acute health system capacity for non-pandemic illnesses; iii) attending to non-acute healthcare systems needs that were lower priority . This systematic review highlights the potential unintended and collateral effects on health services access, care quality and outcomes for patients with non-COVID-related illness , and shoa priori protocol, with due consideration to study quality, risk of bias and overall certainty of the evidence using GRADE alongside our meta-analysis methodology.The strengths of our SR include a comprehensive search strategy and a rigorous process for study selection and data abstraction based on an This SR also has several limitations, most of which relate to limitations of the primary studies analyzed. As mentioned, given the heterogeneity and variable reporting, we could not conduct a meta-analysis for all outcomes. GRADE certainty of evidence was very low for all outcomes, driven primarily by many studies with high risk of bias  and inconsistency . Delayed or lack of presentation to acute care hospitals may have resulted in increased death out of hospital with death upon arrival or no transfer to acute care facility, which may have biased findings due to under-reporting. Moreover, there is both likelihood of underreporting in the literature and temporal delays in further publications describing health systems effects of the COVID pandemic on non-COVID illnesses . FurtherThe COVID-19 pandemic had variable associations with non-COVID illness patient outcomes  in multiple jurisdictions (very low certainty). Where significant changes were described, there was evidence of increased mortality, increased morbidity, decreased acute care hospitalizations/occupancy and increased disruptions in care across variations in case-mix and multiple jurisdictions (very low certainty). Informing healthcare policy and decision-makers of the potential pandemic effects is crucial to mitigate the impact of the COVID-19 pandemic on both COVID and non-COVID patients.S1 Appendix(DOCX)Click here for additional data file.S1 Table(DOC)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S4 Fig(TIF)Click here for additional data file.S5 Fig(TIF)Click here for additional data file.S6 Fig(TIF)Click here for additional data file.S7 Fig(TIF)Click here for additional data file.S8 Fig(TIF)Click here for additional data file.


Blood Cancer Journal 10.1038/s41408-022-00756-9, published online 29 November 2022Correction to: In this article, corresponding sections of the treatment algorithm Figures should have been noted in parentheses  preceding the relevant text to facilitate reference between the content areas.The original article has been corrected.


Tumor resection could increase treatment efficacy of epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKI) in patients with advanced EGFR-mutant non-small cell lung cancer (NSCLC). This study aimed to retrospectively analyze patients with advanced EGFR-mutant NSCLC from a Taiwanese tertiary center and receiving EGFR-TKI treatment with or without tumor resection. A total of 349 patients were enrolled. After propensity score matching, 53 EGFR-TKI treated patients and 53 EGFR-TKI treated patients with tumor resection were analyzed. The tumor resection group showed improved progression-free survival (PFS)  and overall survival (OS)  compared to the monotherapy group. In the subgroup analysis of patients with newly-diagnosed NSCLC, the tumor resection group showed longer PFS  and OS  than the monotherapy group. In conclusion. the combination of EGFR-TKI and tumor resection provided better PFS and OS than EGFR-TKI alone, and patients who underwent tumor resection within six months had fewer co-existing genomic alterations and better PFS. Several phase III studies have demonstrated that the use of first- or second-generation EGFR-tyrosine kinase inhibitors (TKI) could increase progression-free survival (PFS) compared to platinum-based chemotherapy in advanced NSCLC patients with EGFR mutations9, which makes EGFR-TKI the mainstay treatment strategy for this condition. Studies focused on head-to-head comparison revealed that second-generation EGFR-TKI, afatinib and dacomitinib, show significant PFS improvement compared with first-generation EGFR-TKI11. Moreover, the phase III FLAURA study further demonstrated better PFS and overall survival (OS) than first-generation EGFR-TKIs. Although the FLAURA study showed promising results, the use of osimertinib, a third generation EGFR-TKI, as the first-line treatment remains controversial14. First, the GioTag study revealed that the sequential use of afatinib and osimertinib has a median OS of approximately four years in patients with acquired T790M resistance15. Moreover, there are no head-to-head comparisons between first-line osimertinib and sequential use of second-generation EGFR-TKI followed by osimertinib as second-line treatment. Second, the incremental cost-effectiveness ratio for osimertinib was higher than first and second-generation TKI in many studies18. Thus, sequential treatment could be an alternative, and the extension of PFS by the first-line treatment becomes an essential point of consideration.The epidermal growth factor receptor (EGFR) mutation is the most common oncogenic gene among patients with advanced-stage non-small cell lung cancer (NSCLC)19, the combination of erlotinib and bevacizumab, an anti-VEGF monoclonal antibody, increased PFS and objective response rate (ORR) compared with erlotinib alone. Another phase III RELAY study20 also demonstrated the significant prolongation of PFS when combining erlotinib with ramucirumab, a VEGF receptor 2 monoclonal antibody. However, both these trials failed to demonstrate the benefit in OS. The second strategy was combining chemotherapy with EGFR-TKI. Both the phase III NEJ009 study in Japan21 and the phase III TATA study in India22 revealed that the combination of gefitinib and platinum-based chemotherapy increased PFS and OS compared with gefitinib alone. However, more than half of the patients in these two trials developed grade 3 toxicities, mainly hematological, which limited its application in clinical practice. Therefore, the surveillance of novel combination strategies is warranted.The combination of EGFR-TKI and other treatments has been widely studied. A first promising treatment strategy is the combination of EGFR-TKI and vascular endothelial growth factor (VEGF) pathway inhibitors. In the phase III study NEJ02624. Similar results were also found in patients with EGFR-mutant NSCLC. The application of consolidative local ablative treatment could significantly improve the PFS and OS among patients with EGFR-mutant NSCLC25. Another cohort study also demonstrated that local treatment to the site of progressive disease could prolong PFS and OS in EGFR-mutant advanced NSCLC patients with acquired resistance to first-line EGFR-TKI26. As a kind of local treatment, surgery was also studied to increase the efficacy of systemic treatment. A study analyzing the Surveillance, Epidemiology, and End Results (SEER)-registered database demonstrated that thoracic surgery could improve the prognosis in patients who received chemotherapy27. However, studies focused on the role of surgery among patients with EGFR-mutant NSCLC who received EGFR-TKI provided inconsistent results due to the heterogeneous patient population30. Recently, a retrospective cohort revealed that patients who underwent a resection of the primary tumor had a significantly better outcome than those who did not; however, most patients in the study had recurrence after curative surgery31.. In addition, whether surgery also has benefits among patients with newly diagnosed NSCLC remains unknown.Many studies have revealed that local ablative treatment can improve the treatment outcome in patients with advanced NSCLC who received chemotherapy32. In the current study, we performed a retrospective study with propensity score matching (PSM) analysis to overcome selection bias, increase the evidence level, and investigate the implementation of tumor resection in routine clinical practice for patients with EGFR mutations and advanced NSCLC treated with EGFR TKI.Our previous study documented that salvage pulmonary resection after TKI was safe and feasibleFrom July 1st, 2013, to December 31st, 2020, all patients with newly diagnosed or recurrent EGFR-mutant advanced NSCLC who visited a hospital in southern Taiwan were enrolled in the study. All patients received complete staging examination including chest computed tomography (CT) scan, bone scan, and brain imaging [CT or magnetic resonance imaging (MRI)] based on the tumor, node, metastasis (TNM) system proposed by the American Joint Committee on Cancer, 7th edition. Patients who had stage I–IIIA or did not receive EGFR-TKI treatment were excluded. This study was approved by the Review Board and Ethics Committee of National Cheng Kung University Hospital (NCKUH B-ER-108-324). The baseline characteristics of these patients, including age, sex, mutation subtype, performance status, initial brain metastasis, and TNM staging, were recorded. The surgical resection of the primary tumor was performed at the discretion of the treating providers.33.Given that all the patients who underwent primary tumor resection had a good performance status (ECOG 0–1), other patients with lower performance status (ECOG ≥ 2) were excluded. All data were anonymized, and, given the study’s retrospective nature, the need for written informed consent was waived by the Review Board and Ethics Committee of National Cheng Kung University Hospital (NCKUH B-ER-108-324). This research was carried out following approved guidelines and the Declaration of Helsinki. The residual tumor specimens of all patients who underwent surgery were evaluated by genomic testing. Adequate samples were tested for targeted sequencing of 409 cancer-related mutations by ACT Genomics  with their next-generation sequencing platform ACTOnco panel34 or death, with censoring at the date of the last follow‐up if the patient had not progressed. The duration of OS was defined as the period from EGFR-TKI treatment initiation until death. Both the PFS and OS were followed up until December 2020.All the patients underwent computed tomography of the chest every 12 weeks after the initiation of EGFR-TKI treatment to evaluate their tumor responses. Brain imaging and bone scans were performed if related symptoms were present. The primary endpoint was progression-free survival (PFS), and the secondary endpoint was overall survival (OS). PFS was calculated from the date of EGFR-TKI initiation until the date of radiological progression according to the Response Evaluation Criteria in Solid Tumors (RECIST) v1.136. Age, sex, tumor size, nodal stage, EGFR mutation subtypes, and tumor resection were chosen as the predictors and prognostic factors. Subgroup analyses of PFS and OS were also performed by age, sex , disease stage (newly diagnosed versus recurrence), brain metastases at baseline (presence versus absence), EGFR mutation type (exon 19 deletion versus Leu858Arg substitution). Statistical Analysis System® software version 9.4  was used to perform the analyses. All the reported p values are two-sided.The frequencies and descriptive statistics of the demographic and clinical variables were calculated. Categorical variables were compared using the Chi-square test or Fisher’s exact test, whereas continuous variables were compared using Student’s t-test or the Wilcoxon rank-sum test. The PFS and OS were estimated by the Kaplan–Meier method and compared using the log-rank test. We also performed Cox proportional hazards regression for the predictors of PFS and OS. The selection of possible predictors and determinants was based on prior studies37. To account for the matched design, we also performed paired t-tests.We matched one patient who received EGFR-TKI and tumor resection with one patient who received EGFR-TKI alone (without replacement) by propensity score matching using the nearest-neighbor method based on the estimated propensity scores. Propensity scores were computed using logistic regression. Selected covariates included age (≥ 70 years vs. < 70 years to ≥ 60 years vs. < 60 years), sex , stage (recurrence vs. newly diagnosed), mutation subtype (Exon 19 deletion vs. Exon 21 L858R substitution), and presence of brain metastasis (presence vs. absence). The balance between patients who received surgery and propensity score-matched patients receiving EGFR-TKI alone was measured using standardized differences, expressed as percentages. An absolute value of < 10 suggests that the two groups are well balancedA total of 349 newly diagnosed or recurrent EGFR mutation-positive advanced NSCLC patients who visited the hospital from July 1st, 2013, to December 31st, 2020, were enrolled , followed by left lower lung n = 14), right lower lung (n = 14), right upper lung (n = 6), right middle lung n = 2), and multiple lobes (n = 1). Only two patients in the surgery group had tumor invasion to the mediastinum or chest wall. The remaining patients with T3 or T4 disease had separate tumor nodules in the ipsilateral lung. Before propensity score matching, patients with distant organ involvement, including brain, liver, bone, and adrenal gland, mostly received EGFR-TKI monotherapy , while 19 patients received surgery after six months of EGFR-TKI treatment (late surgery group). The median PFS was not reached [interquartile range 39.3-NR months] among patients in the early surgery group, which was longer than patients in the late surgery group . A previous study had demonstrated a significant correlation between the expression level of EGFR and PD-L1 from the analysis of the data from the Cancer Genome Atlas Program52. The expression of PD-L1 in EGFR-mutant NSCLC may result from the activation of the cell-intrinsic EGFR pathway instead of cell-extrinsic stimulation from the tumor immune microenvironment53.Previous studies had demonstrated that adjuvant chemotherapy could provide better disease-free survival among patients with early-stage NSCLC after surgery58. However, the acquired resistance mechanism to adjuvant therapy also has an important role. In the final analysis of the ADJUVANT trial, only 36.8% of patients received subsequent targeted therapy in the gefitinib group, which is lower than those in the chemotherapy group60. This data implied that the EGFR-TKI-resistant tumor would occur after adjuvant-targeted therapy. The resistance mechanism to osimertinib is more complex, including on-target C797 mutation, activation of bypass pathway, and histological transformation61. Currently, there is no optimal subsequent therapy after acquired resistance to osimertinib. Furthermore, the use of osimertinib should also consider cardiotoxicity62, which is seldomly reported in first- or second-generation EGFR-TKIs. In the present study, we maintained systemic therapy using the same EGFR-TKI instead of switching patients to osimertinib, which may result in lower cardiac toxicity and a higher chance of allowing for subsequent targeted therapy. Our study had some limitations that need to be mentioned. First, this was a retrospective, single-institution study, and the number of patients in our cohort was limited. However, using the propensity score matching, we adjusted for patients’ demographic biases that are inevitable in real-world studies. Second, for correct matching, all the patients in the current study had a good performance status; whether the same result could be noted in patients with poor performance status remains unknown. Third, the late surgery group patients had shorter PFS and a higher proportion of co-existing genomic alterations, which implies early tumor resection may have more benefit. However, we did not perform NGS testing before the initiation of EGFR-TKI due to insufficient tissue samples. Whether early surgery could reduce the incidence of co-existing genomic alterations still warrants prospective study. Fourth, only two patients had tumor invasion to the mediastinum or chest wall in the surgery group. Although both patients had very good tumor response after EGFR-TKI therapy and post-operative N0 disease, the limited number of patients with tumor invasion to mediastinum or chest wall precludes a definitive conclusion. Whether residual tumor resection could provide clinical benefit in patients with tumor invasion to the mediastinum or chest wall needs further investigation. Fifth, although there is no significant difference in distant metastatic burden between patients with and without residual tumor resection, a marginally higher proportion of patients in the surgery group had bone metastasis. This result implies that the benefit of residual tumor resection may be limited to patients with a relatively low metastatic burden. A future prospective study is warranted to validate the result.After ADAURA study, the adjuvant osimertinib became the only FDA-approved therapy that could prolong disease-free survival in patients with stage IB to IIIA EGFR mutation-positive NSCLC31, we provided more evidence in patients with newly-diagnosed EGFR-mutant NSCLC. Moreover, we also found that the patients who underwent tumor resection within 6 months after the initiation of EGFR-TKI treatment had better PFS and a lower proportion of co-existing genomic alterations, which might imply the potential benefit of early surgical intervention. However, the use of tumor resection might be limited in patients with mediastinal invasion or a high metastatic burden because of limited patient number and unbalanced subgroup. A randomized phase III study comparing EGFR-TKI and surgery with EGFR-TKI alone is needed to verify whether the early tumor resection may increase survival.In conclusion, our study revealed that the combination of EGFR-TKI and tumor resection provided better PFS and OS than EGFR-TKI alone. Compared with a previous retrospective studySupplementary Tables.