Kaplan–Meier survival analysis showed that eyes with an initial BCVA < 0.3  had a better survival rate after adjusting for age when failure was defined as a BCVA reduction ≥ 0.2 of logMAR. Eyes with an initial BCVA < 0.3 belonged to younger patients; more frequently had subretinal fluid as an exudative change; and less frequently had intraretinal fluid, submacular hemorrhage, and fibrovascular PED. Initiating anti-VEGF treatment before BCVA declines and advanced lesions develop would afford better visual outcomes for AMD eyes in the real-world clinic, although further analyses are required.Visual outcomes of age-related macular degeneration (AMD) have substantially improved via anti-vascular endothelial growth factor (anti-VEGF) therapy. However, the treatment effects vary among individuals. Medical charts of 104 eyes (104 patients) with AMD, treated with anti-VEGF drugs and followed up for 12–36 months, were retrospectively analyzed. Logistic regression analyses adjusted for age showed that eyes with an initial best-corrected visual acuity (BCVA) < 0.3 in the logarithm of the minimum angle of resolution (logMAR) were a positive predictor (odds ratio = 3.172; 95% confidence interval [CI] = 1.029–9.783;  Age-related macular degeneration (AMD) is a vision-threatening disease, affecting 8.4 million people worldwide . AlthougIn most phase III clinical trials, additional anti-VEGF treatments have been performed proactively and frequently following predefined protocols. In the VIEW 1 and 2 trials, 95 to 96% of patients achieved maintained or improved best-corrected visual acuity (BCVA) 2 years after the initial injection of either ranibizumab or aflibercept with a proactive treatment protocol, such as every 1 or 2 months  and treaHere, we retrospectively reviewed the visual outcomes of eyes with AMD treated with anti-VEGF drugs in a real-world setting. The current study involved all patients who received anti-VEGF treatment as the first therapy for AMD, and were followed up for at least 12 months and up to 36 months, including those who dropped out during the study period; patients who dropped out were included in Kaplan–Meier survival analysis, which may more precisely reflect real-world conditions of the daily clinical practice.Our results may help elucidate points requiring attention when examining eyes with AMD and the timing for offering treatment to this patient population in real-world settings. They may also emphasize the importance of advising individuals to visit the eye clinic when they observe even minor symptoms and clinicians to detect AMD lesions at the early stage.The procedures of this retrospective study adhered to the tenets of the Declaration of Helsinki, and the study protocol was approved by the St. Luke’s International University Ethics Committee . Informed consent was obtained from all patients involved in the study.Medical charts of patients diagnosed with neovascular AMD between January 2017 and August 2020 in the Department of Ophthalmology, St. Luke’s International Hospital , treated with anti-VEGF drugs as the first therapy for AMD, and followed up for longer than 12 months, were retrospectively analyzed. Those who were treated by other therapies than anti-VEGF drugs, such as SF6 injection for massive subretinal hemorrhage, or who had no fluorescein angiography for AMD diagnosis, were excluded. The data were collected from up to 36 months of follow-up. There were no patients with both eyes treated during this period.All patients underwent complete ophthalmologic examinations, including BCVA measurement with a refraction test, slit-lamp examinations, and indirect ophthalmoscopy after pupil dilation with 0.5% tropicamide. BCVA measured using Landolt C charts was converted into the logarithm of the minimum angle of resolution (logMAR) by calculating log (10) of the decimal score obtained by the Landolt C chart for the purposes of statistical analyses. Fluorescein and indocyanine green angiographies were recorded using a Heidelberg Spectralis HRA instrument . Optical coherence tomography (OCT) images were obtained at every follow-up visit using a Cirrus HD-OCT system  or a Heidelberg Spectralis OCT system (Heidelberg Engineering GmbH). The improvement or loss of BCVA compared with the initial BCVA was defined when the BCVA changed by ≥ 0.2 in logMAR.Patients were treated with anti-VEGF drugs: both or either intravitreal ranibizumab 0.5 mg and/or aflibercept 2 mg injections. Additional injections after the initial injection, and changes in the anti-VEGF drugs were determined by each clinician. One patient was treated with photodynamic therapy, and one received laser treatment after the initial anti-VEGF therapy according to the clinicians’ determinations.Treatment failure was defined as a BCVA reduction ≥ 0.2 of logMAR compared with the initial BCVA at each time point. Failure was also considered when patients received treatment other than anti-VEGF as described above. Survival or failure was determined every 6 months after the initial anti-VEGF treatment. p value < 0.05 was considered statistically significant.Data are expressed as the mean ± standard deviation. Analyses with the Wilcoxon rank sum test, logistic regression analyses, Kaplan–Meier survival analysis, Cox proportional hazards model, Mann–Whitney U test, and chi-square test were performed using SPSS . Non-parametric analyses were performed. A p = 0.012). Maintained or improved BCVA at the final visit ≥ 0.2 in logMAR compared with initial BCVA was observed in 93 eyes (89.4%). The mean injection number was 7.5 ± 0.5 (range 1 to 22).For the 104 eyes of 104 patients with AMD, the mean age was 73.8 ± 1.1  years, and 69 (66.3%) of the patients were men . Eighty-p = 0.045), and the presence of fibrovascular pigment epithelial detachment (PED) was a negative factor  for maintaining or achieving better BCVA at the last visit , 3.172; 95% confidence interval [CI], 1.029–9.783; st visit . Scatterst visit .p = 0.014). The survival rate at 6 months of the group with an initial BCVA < 0.3 in logMAR was 98.0% and that of the group with an initial BCVA ≥ 0.3 in logMAR was 80.4%; note that approximately half of failure cases had been observed by 6 months in the worse BCVA group.The eyes were divided into two groups according to whether they had a BCVA < 0.3 in logMAR, i.e., the median BCVA in the current study. The Kaplan–Meier survival analysis showed that of the 51 eyes that exhibited an initial BCVA < 0.3 and 53 eyes that exhibited an initial BCVA ≥ 0.3 in logMAR, 89.8%  and 58.0%  had, respectively, survived at 36 months when failure was defined as a BCVA reduction ≥ 0.2 from the initial BCVA at each time point . The eyeThe reason for failure in two eyes (40%) was due to additional treatment other than anti-VEGF and in three eyes (60%), there was decreased BCVA ≥ 0.2; one eye exhibited fibrovascular PED, one exhibited hemorrhage, and one exhibited serous PED in the group with an initial BCVA < 0.3. In the group with an initial BCVA ≥ 0.3, two eyes (12.5%) failed owing to additional treatment other than anti-VEGF and fourteen eyes (87.5%) failed owing to decreased BCVA; eight eyes exhibited fibrovascular PED, five exhibited subretinal fluid (SRF), and one exhibited intraretinal fluid (IRF) .p = 0.039) and whose BCVA > 0.5 at the last visit (p = 0.025)  . There wp = 0.041) was related to better survival probability. The baseline characteristics of the eyes related to survival or failure were analyzed using Cox proportional hazard models adjusted for age . an initp = 0.008) and less frequently had IRF (p < 0.001), SRF (p = 0.003), submacular hemorrhage > 1 disc in diameter (p = 0.030), and fibrovascular PED (p = 0.016), all at baseline (p = 0.0005).The baseline characteristics of the eyes with or without an initial BCVA < 0.3 in logMAR were further compared. Eyes with an initial BCVA < 0.3 in logMAR belonged to younger patients  letters in BCVA, measured using an ETDRS chart, the median BCVA of 0.3 in logMAR, corresponding to 0.5 in the Landolt C chart and 20/40 in the Snellen chart, was a relatively good BCVA for the eyes before receiving anti-VEGF treatment; treatment was initiated rather more actively than in the clinical trials in the current real-world study from 2017 to 2020. Overall, the mean BCVA improved in the current study, suggesting that the treatment was largely successful. Consistently, significant BCVA improvement was achieved after anti-VEGF treatments in our previous retrospective study of patients with PCV treated by a pro re nata regimen at 2 years , and anoAn initial BCVA < 0.3 in logMAR was a predictive factor for achieving maintained or improved BCVA with an OR of 3.152. This result was consistent with that reported by a previous prospective study by Minami et al. where the visual prognosis of patients with AMD whose initial BCVA was < 0.22 in logMAR, corresponding to a BCVA > 74 letters in the ETDRS chart, was analyzed, showing overall improvement in BCVA with anti-VEGF monotherapy . There wInterestingly, the eyes with an initial BCVA < 0.3 in logMAR less frequently experienced a BCVA decline of ≥ 0.2 in logMAR according to the Kaplan–Meier survival analysis. Patients with eyes with an initial BCVA < 0.3 in logMAR were younger, suggesting that these patients may have had a greater biological availability for tissue function restoration, given that older individuals are affected by age-related neuronal vulnerability . All eyeThe presence of fibrovascular PED at baseline was a risk factor for BCVA decline after anti-VEGF treatment. Fibrovascular PED was also a major reason for visual loss, and eyes with worse BCVA (≥ 0.3 in logMAR) more frequently had fibrovascular PED. This is consistent with a report that non-responding eyes, without improvement in BCVA and/or exudative changes after anti-VEGF treatment, often have fibrovascular PED ,13. FibrIRF was not a significant predictive factor for the risk of treatment failure, although the presence of initial IRF was related to worse BCVA at baseline; this may be explained by the small number of eyes with initial IRF in the current study.We analyzed the clinical data using Kaplan–Meier survival analysis. This enabled us to also include the eyes of patients who dropped out during the follow-up, potentially reflecting real-world clinical practice conditions. Patients who dropped out during the follow-up involved both those who had a good course and were satisfied, with or without reverse referral to local clinics, and those who had abandoned treatment owing to the absence of improvement or an unsatisfactory outcome. Clinicians cannot predict whether any patient will or will not drop out during the follow-up; however, according to the current study, eyes with an initial BCVA < 0.3 in logMAR could experience sustained or improved BCVA with treatment initiation. In addition, almost half of failure cases were observed within the first 6 months in eyes with an initial worse BCVA. This information could be used to encourage patients to initiate anti-VEGF treatment while their BCVA remains relatively good.The limitations of the current study included a relatively small number of patients, retrospective analysis design, involving eyes treated with either or both ranibizumab and aflibercept, and that additional treatment was determined by each clinician. However, this would reflect real-world clinical practice conditions involving variations in clinicians’ determinations over treatment, and the data would be informative to general clinicians. We adjusted only age in the logistic regression analyses considering the sample size. Because some of the patients used both drugs, we did not analyze the results according to the drug selection. All reasons for dropping out were not documented; however, the Kaplan–Meier survival analysis covered this bias.In conclusion, eyes with a relatively good initial BCVA, such as < 0.3 in logMAR, and without fibrovascular PED would achieve sustained or improved BCVA after anti-VEGF treatment within 3 years of follow-up in the real-world setting. Early treatment would be recommended for exudative AMD, although further studies are required.


Lumbar disc herniation is seen in 5–15% of patients with lumbar back pain and is the most common spine disorder demanding surgical correction. Spinal surgery is one of the most effective management for these patients. However, current surgical techniques still present complications such as chronic pain in 10–40% of all patients who underwent lumbar surgery, which has a significant impact on patients’ quality of life. Research studies have shown that transcutaneous electrical acupoint stimulation (TEAS) may reduce the cumulative dosage of intraoperative anesthetics as well as postoperative pain medications in these patients.To investigate the effect of pTEAS on pain management and clinical outcome in major spinal surgery patients.We conducted a prospective, randomized, double-blind study to verify the effect of pTEAS in improving pain management and clinical outcome after major spinal surgery. Patients (n = 90) who underwent posterior lumbar fusion surgery were randomized into two groups: pTEAS, (n = 45) and Control (n = 45). The pTEAS group received stimulation on acupoints Zusanli (ST.36), Sanyinjiao (SP.6), Taichong (LR.3), and Neiguan (PC.6). The Control group received the same electrode placement but with no electrical output. Postoperative pain scores, intraoperative outcome, perioperative hemodynamics, postoperative nausea and vomiting (PONV), and dizziness were recorded.P < 0.05); heart rate was significantly lower at the end of the operation and after tracheal extubation (P < 0.05); and there was lesser blood loss (P < 0.05). Postoperative outcomes: lower pain visual analogue scale (VAS) score during the first two days after surgery (P < 0.05); and a significantly lower rate of PONV (on postoperative Day-5) and dizziness (on postoperative Day-1 and Day-5) (P < 0.05).Intraoperative outcomes of pTEAS group compared with Control: consumption of remifentanil was significantly lower (pTEAS could manage pain effectively and improve clinical outcomes. It could be used as a complementary technique for short-term pain management, especially in patients undergoing major surgeries.http://medresman.org/uc/projectsh/projectedit.aspx?proj=183ChiCTR1800014634, retrospectively registered on 25/01/2018. The online version contains supplementary material available at 10.1186/s12871-022-01875-3 Studies have reported that 75–85% of the global population suffers from lumbar back pain at some point in life . Lumbar Nowadays, more clinicians and patients have turned to spinal surgery as a treatment option, as evidenced by a two-fold increase in spinal surgeries performed in the last fifteen years . HoweverTranscutaneous electrical acupoint stimulation (TEAS) has been shown to relieve postoperative pain, reduce the cumulative dosage of intraoperative anesthetics and minimize general anesthesia-related side effects . AccordiThis study was a prospective, randomized, double-blind RCT approved by the local Clinical Research Ethics Committee and was registered at clinicaltrials.gov . Written informed consent was obtained from each patient before enrollment in the study. Three primary outcomes were examined: (1) the VAS score for short-term pain management; (2) the consumption of remifentanil; and (3) the incidence of PONV and dizziness. The secondary outcomes were perioperative hemodynamics, intraoperative blood loss, and postoperative consumption of antiemetics.From March 2016 to February 2017, 90 patients undergoing elective major posterior lumbar spinal surgery for spinal stenosis as well as degenerating intervertebral disc under general anesthesia were assigned into two groups: patients to receive total intravenous anesthesia , and others to receive pTEAS in addition to total intravenous anesthesia .Inclusion criteria are as follows: (1) ASA I – II; (2) between 40 and 70 years of age; (3) diagnosed with lumbar spinal stenosis or lumbar intervertebral disc herniation based on imaging results; and (4) undergoing the operative procedures of posterior lumbar decompression, bone graft fusion, and internal fixation.Exclusion criteria include having a past medical history of malignant tumors or severe cardiovascular disease.Elimination criteria are as follows: (1) uncooperative patients who refuse treatment; (2) intraoperative blood loss of more than half of the total blood volume; (3) serious surgical complications such as the patient falling into a coma.The sample size was determined by previous literature. All patients (n = 90) were randomized using a computer-generated number. Numbers 1 to 45 were assigned to the pTEAS group, while numbers 46–90 were assigned to the Control group. All researchers involved in this study were blinded to these groupings. Only the stimulator was aware of the groupings; however, the stimulator was not involved in the process of data collection, processing, and the findings of this project.pTEAS was performed on the patient before induction of general anesthesia by a trained doctor. Based on the principle of traditional Chinese medicine, bilateral Zusanli (ST.36) and Sanyinjiao (SP.6) were stimulated by cutaneous electrode pads at 2/15Hz for 30 min before anesthesia induction and then at 2/100Hz throughout the operation. Additional stimulation was administered until the postoperative day (POD) 4, wherein bilateral Taichong (LR.3) and Neiguan (PC.6) were stimulated at 2/15Hz for 30 min once daily. Whereas the stimulator used in the study is Han’s acupoint stimulator , stimulated in a symmetrical bidirectional pulse with a width of 0.2 ~ 0.6 ms, the frequency of the output stimulation is an alternating dense-and disperse-mode of 2/15 or 2/100 Hz, where the 2 Hz (0.6-ms pulse width) stimulation is alternated with 100 Hz stimulation (0.2-ms pulse width) automatically. In each set (2/15 and 2/100), a 3s alternating time was given between 2 and 15 or 2 and 100 Hz, respectively. The intensity was adjusted according to individuals’ maximum tolerance, the instrument we used has two output channels, channel A and channel B. Before anesthesia induction, the anode of channel A is connected to the left Zusanli (ST.36) point, the cathode is connected to the ipsilateral Sanyinjiao (SP.6) point, the anode of channel B is connected to the right Zusanli (ST.36) point, and the cathode is connected to the ipsilateral Sanyinjiao (SP.6) point. During postoperative stimulation, the anode of channel A is connected to the left Taichong (LR.3) point, the cathode is connected to the left Neiguan (PC.6) point, the anode of channel B is connected to the right Taichong (LR.3) point and the cathode is connected to the right Neiguan (PC.6) point. Acupoints were identified in accordance with the traditional anatomic localization  system, anesthesia was induced intravenously with propofol and fentanyl. Vecuronium was administered intravenously at 0.1 mg/kg after the patient lost consciousness. Subsequently, an orotracheal intubation tube was placed. Anesthesia was maintained by propofol and remifentanil under the TCI system while the depth of anesthesia was monitored using NarcoTrend Index (NTI). Using the models put forward by Marsh and colleagues , the conPerioperative hemodynamics including systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate were recorded at five time points: induction, intubation, the start of the operation, end of the operation, and extubation. We calculated the consumption of propofol and remifentanil and recorded the intraoperative blood loss, time to extubation, operation duration, and total anesthesia duration. The patients were followed up until postoperative day (POD) 5 for the visual analogue scale (VAS) score, calculated as follows: 0 represents no pain, 1–3 denotes mild pain, 4–6 signifies moderate pain, > 7 represents severe pain and 10 shows the worst pain possible, as well as the incidence of PONV and dizziness, consumption of rescue antiemetics.t-test to compare the mean of continuous measurements between study groups. We elucidated the dichotomous variables by ‘the number of patients (percentage)’ and analyzed the data using the chi-square test, Mann–Whitney U test, or Fisher’s exact test. For all statistical tests, the level of significance was set at 0.05.After performing all statistical analyses in SPSS version 19.0, we used the two-sample Among a total of 90 patients, six were excluded: two patients suffered a massive hemorrhage of more than half of their total blood volume (each group respectively), one patient had a serious postoperative complication (Control group), whereas three patients did not have their data collected completely (Control group). Eventually, 84 patients completed the study; 40 patients in Control group  and 44 patients in pTEAS group  Fig. .P > 0.05) (Table The baseline characteristics of both groups were similar to each other (5) Table .P < 0.05, respectively]. Both groups were similar with respect to cumulative consumption of propofol , time to extubation , duration of surgery , and total anesthesia duration  , causing a delay in postoperative recovery, poor clinical outcome, or other complications such as infection or cancer. According to data gathered from the TCI system, the cumulative dosage and index of remifentanil consumption in the pTEAS group were significantly lower than that in the Control group . We also observed a lower VAS score trend in pTEAS-treated patients from POD-3 to POD-5, although this result did not show statistical significance  5. We found that the VAS score in pTEAS group was significantly lower than that in the Control group on POD-1 and POD-2 respectively . The rate of dizziness on POD-1 and POD-5 was also significantly lower in pTEAS group  Table .P < 0.05] and after tracheal extubation  respectively. However, no significant difference was observed in intraoperative blood pressure and NTI between both groups  blood pressure including SBP and DBP; (2) heart rate; and (3) NTI at the time of intubation, the start of the operation, end of the operation, and after tracheal extubation. Interestingly, the heart rate of patients in the pTEAS group was significantly lower than that of the Control group at the end of the operation   02 vs. 49vs. 1637(630) µg; Index: 0.084(0.018) vs. 0.114(0.090) µg/min/kg; P < 0.05, respectively]. Remifentanil, a selective µ-receptor agonist commonly used in anesthesia, was found to be a risk factor for increased surgical site infection in colorectal surgery . We also observed a lower VAS score trend in pTEAS-treated patients from POD-3 to POD-5, indicating that pTEAS could be used to improve the short-term management of postoperative pain.Postoperative pain usually arises from the invasive and traumatic surgical process; in addition, it imposes a healthcare burden because its management requires extensive time and resources. StatistPONV is a common side effect of surgery and anesthesia. The use of volatile agents induced moderate to severe nausea and vomiting in 30–50% of all general anesthetized patients . A prospP < 0.05] and at the time of extubation  were significantly lower in pTEAS group in comparison to the Control group. This suggests that pTEAS may help alleviate cardiac adverse effects. A study by Fang et al. demonstrated that using TEAS apart from general anesthesia may protect against myocardial ischemia, facilitate recovery of cardiac function, and prevent apoptosis of cardiomyocytes . This data indicated that pTEAS not only has a potential protective effect on blood loss but also helps prevent complications and further injury. However, the in-depth mechanism of pTEAS warrants further research.Blood loss is an issue every surgeon and anesthetist pays a great deal of attention to during surgeries. Perioperative hemorrhage is a major surgical risk factor during both the perioperative and postoperative periods; this could potentially lead to complications, a high mortality rate, and a greater healthcare burden –39. A stNevertheless, we are aware of the limitations of our research. Firstly, this is a single-center clinical trial with a limited number of patients; a large, multicenter study is necessary to demonstrate the effectiveness of pTEAS from a broader perspective that includes other spinal surgery procedures. Secondary, the addition of a study group to receive electrical stimulation on a non-meridian and non-acupoint area would better demonstrate the effectiveness of stimulating specific acupoints.Effective pain management assumes great significance for improving patients’ quality of life (QoL), especially after major spinal surgeries. We observed that pTEAS could improve short-term pain management and clinical outcomes in these patients. Therefore, according to our recommendation, clinicians should include pTEAS as a complementary technique for effective short-term pain management, especially in patients undergoing major surgeries.Below is the link to the electronic supplementary material.Supplementary Material 1


Tripterygium Wilfordii Hook F (TwHF) preparation has been widely used in the treatments of IgA nephropathy (IgAN) in China. However, the effectiveness and safety of the new generation of TwHF preparation, KuxXian capsule, on the treatment of IgAN remains unknown.Here, we retrospectively describe our experience treating 55 consecutive IgAN patients with KunXian. We defined complete remission as proteinuria < 0.5 g/24 h and partial remission as proteinuria < 1 g/24 h, each also having > 50% reduction in proteinuria from baseline.P < 0.001) at the first follow-up. During a median follow-up of 28 weeks after KunXian administration, 25(45.5%) patients achieved complete remission, 34 (61.8%) patients achieved complete/partial remission. Of the 12 patients discontinued KunXian treatment during the follow-up, the median proteinuria was increased from 0.97 g/24 h to 2.74 g/24 h after a median of 10.9 weeks (P = 0.004). Multivariable Cox models showed that female, treatment switching from previous generation of TwHF preparation, lower initial KunXian dosage, and higher proteinuria at baseline were independently associated proteinuria remission. Of the 20 pre-menopausal females, 12 of them developed oligomenorrhea or menstrual irregularity and ten of them developed amenorrhea.At first follow-up after KunXian treatment , all but two patients (96%) showed a reduction in proteinuria. The overall median proteinuria decreased from 2.23 g/day at baseline to 0.94 g/day (KunXian is effectiveness and safety for the treatment of IgA nephropathy. Woman of childbearing age to be informed of the risk of ovarian failure after being treated with TwHF preparations. Tripterygium Wilfordii Hook F (TwHF) preparation treatment, for patients with IgAN in China. TwHF preparations were extracted from the Chinese herb TwHF , which is a vine plant belonging to the genus Tripterygium of the Celastraceae family and has been used in traditional Chinese medicine for more than five hundred years. TwHF preparations were successfully used to treat lepra reactions since 1962 and rheumatoid arthritis since1969 in China [IgA nephropathy (IgAN) is the most common cause of primary glomerulonephritis worldwide , 2. Slowin China . In the in China . Ten yeain China .The primary biologically active ingredient of TwHF, triptolide, has various promising pharmacological activities, such as immunosuppressive, anti-inflammatory, antiproliferative, antifertility, antitumor, antiosteoporosis, and neuroprotective properties . We prevTripterygium Wilfordii multiglycoside (TW), were commercially available in the early 1980s. TW was extracted and purified from TwHF using organic solvents. Wilforlide A (> 10 μg/tablet) was used as the quality control [The therapeutic and toxicity effects of TwHF preparation is different according to different extraction and purification procedures. Forty years ago, the first generation of TwHF preparation was the raw traditional Chinese herb which is the plant TwHF decocted with water  . There w control , 22. TW  control , 24. Rec control . Quantit control . HoweverSince October 2018, we started to use KX treatment for consecutive patients referred to our IgAN outpatient unit of the National Clinical Research Center of Kidney Diseases. Sixty-three biopsy-proven IgAN patients were treated with KX between October 2018 and October 2020. The standard dosage of KX is six capsules per day (150 μg /d) divided into two or three doses , 27. TheThe estimated glomerular filtration rate (eGFR) was estimated using the XiangYa equation . The proThe Kaplan – Meier method was used to plot the probability of achieving complete remission, complete/partial. Survival time was determined from the beginning of the first KX treatment until the event of interest. Patients not achieving remission were considered as censored at the time of the last visit. In the complete/partial remission composite endpoint the survival time for participants was time to event until complete/partial remission. In a multivariable context, the Cox regression model was carried out to test predictors of achieving complete remission and complete/partial remission composite endpoint. Due to its skewed distribution, proteinuria was square root-transformed before statistical analyses.2 test or Fisher’s exact test. All statistical analyses were carried out using R (version 4.0.5). Two-tailed P < 0.05 findings were considered statistically significant.The data of baseline and follow-up characteristics were presented as numbers and percentages, means and SDs, or medians and IQRs, as appropriate. Paired t-test, Wilcoxon signed-rank test (paired samples Wilcoxon test), or paired Kruskal-Wallis test was used to compare the differences between baseline and follow-up. Categorical variables were compared using the Pearson χBy October 2020, 63 consecutive patients with IgAN were treated with KX in the Outpatient Clinic of the IgA Nephrology Unit Table . Eight pP = 0.57) or eGFR  between patients switched from TW therapy and those who did not. There were 24 women and 31 men in this study. Females had a lower urine protein at baseline than males , while eGFR was similar . There were 34 patients who received the standard dose of KX (six capsules per day), 12 received four capsules per day, and nine received three capsules per day.There were 20 patients stopped TW and switched to KX therapy after enrollment. There were no differences in the levels of baseline urine protein  at the first follow-up. The overall percentage in reduction of proteinuria from baseline was 50.4% (IQR 37.8–66.7%). A total of 23 patients (41.8%) achieved complete/partial remission and 10 patients (18.2%) achieved complete remission. The characteristics of patients with complete/partial or no remission at first follow-up were shown in Table Figure There were 50 patients available for analysis at the second follow-up after treatment . At the second follow-up, the median proteinuria of the 50 patients was further decreased to 0.87 g/day  weeks, 25 (45.5%) patients achieved complete remission, 34 (61.8%) patients achieved complete/partial remission, and 41 patients (74.5%) achieved > 50% reduction in proteinuria from baseline values after KX administration. Partial/complete remission was achieved over a median of 8.4 weeks , and complete remission was achieved over a median of 14.7 weeks .As shown in Fig. P = 0.004).As described previously, six patients discontinued KX treatment before the second follow-up Fig. B. An addP = 0.001) and complete remission  than males. Twenty patients were being treated with TW before starting KX therapy. After enrollment in this study, they were switched to KX therapy. Of the 20 patients, five (25%) achieved complete remission and nine (45%) achieved complete/partial remission during the treatment. Of the 35 patients not switching from TW therapy, 20 patients (57.1%) had complete remission, and 29 (71.4%) had complete/partial remission. The multivariable Cox models showed that patients switching from TW had a significantly lower rate of complete/partial remission  and complete remission  than those switching from other therapies. In this study, patients with higher proteinuria at baseline were more likely to receive a higher dosage of KX treatment. The initial dosage of KX was not associated with proteinuria remission in the univariate Cox models. However, after adjusting for sex, age, treatment switching type, eGFR, mean artery pressure at baseline and proteinuria at baseline, the initial KX dosage was significantly associated with complete remission  and marginally associated with complete/partial remission . The eGFR at baseline was not associated with protein remission, suggesting the effectiveness of KX is not affected by kidney function. The cumulative complete and complete/partial remission according to sex and treatment switching type were shown in Fig. Multivariable Cox models were used to analyze factors associated with proteinuria remission after KX treatment Table . FemalesP = 0.08), initial KX dosage , and treatment switching type .A multivariable linear regression model showed that after adjusting for age, follow-up time, proteinuria, mean artery pressure, and eGFR at baseline, the percentage reduction of proteinuria from baseline to the first follow-up was associated with sex , increased LDL cholesterol, increased HDL cholesterol, slightly increased ALT and slightly increased AST from baseline to the first follow-up. The serum albumin levels were increased to 37.7 ± 0.42 g/dl at the second follow-up .One patient occurred liver injury at the first follow-up. Another two cases of liver injury were observed during follow-up. As shown in Table TwHF preparation to treat proteinuric kidney disease have been used for over 40 years in China . In thisOvarian failure is the most important adverse effect among premenopausal women taking TwHF preparation therapy . TwHF prLiver injury with significant elevation of serum transaminases could be observed during TwHF preparation treatment. The mechanism of triptolide-induced hepatotoxicity remains unknown. Mice or rats treated with a high dose of TwHF preparations expressed a slight increase in serum transaminases with insignificant liver damage. Thus, direct liver damage by these drugs may not be the only reason for their hepatotoxicity , 36. TheAnother question that needs to be addressed is whether KX should be used in patients with impaired kidney function. In this study, the eGFR was stable after KX administration. Thus, KX is safe for patients with impaired kidney function. As shown in Table Our study showed that KX had a dose-response effect in the reduction proteinuria in patients with IgAN. As high incidence rate of amenorrhea were observed within 6 months of KX treatment, woman of childbearing age should to be informed of the risk of ovarian failure after being treated with TwHF preparations. The long-term safety and efficacy of KX in the treatment of IgA nephropathy should be further explored.


Retained placenta (RP), a quite common disorder in dairy cows, shows a high negative impact on their health status and milk production.To investigate the difference in the serum proteome between the cows with RP and the physiologic puerperium (PP).Analysis of serum samples from nine cows with RP and six with PP using high-resolution liquid chromatography-tandem mass spectrometry approach. The proteins differing in the relative abundance between the PP and RP groups were classified using the Protein Analysis Through Evolutionary Relationship tool. For the pathway enrichment analysis, the REACTOME tool, with the human genome as the background, was employed. The criterion for significance was the false discovery rate corrected P-value less than 0.05.In total 651 proteins were identified with altered relative abundance of ten proteins. Among them, seven had higher, and three showed lower relative abundance in RP than in the PP group. The differently abundant proteins participated in 15 pathways: six related to hemostasis, three involved in lipoprotein metabolism, and the remaining ones associated with for instance redox homeostasis, post-translational modification, and scavenging. Finally, the validation of the proteomic results showed that haptoglobin and lipopolysaccharide-binding protein levels reliably differentiated between the RP and PP groups.The pattern of serum proteome alterations in the cows with RP mirrored several interplaying mechanisms underlying the systematic response to the presence of RP, therefore representing a source to mine for predictive or prognostic biomarkers.  It reprThe preceding eight decades of research established an extensive list of RP pathological features and risk factors, which is still far from complete Peter . The mosIn the previous proteomic studies of RP, the researchers have focused on the tissue proteome. Using the gel-based proteomic approach they showed differences in the tissue proteome composition between the retained and normally expelled placentas  regarding the abundance of the proteins identified using high-throughput tandem mass tag-based liquid chromatography-tandem mass spectrometry approach. In addition, the objective was to assess the relationship between the alterations in the proteome composition and the intensity of the acute phase reaction (APR), glycemia, calcemia, and lipolysis indicators.2.2.1.i.m.) alongside the first dose of oxytetracycline. All cows recovered successfully.The study included 15 cows, nine with RP and six with PP, from private farms in the Zagreb County, Croatia. The cows were kept in separate barns. They were all of the Simmental breed, except one, being crossbreed with Holstein Friesian breed. The cows were multiparous, with the age ranging between three and five years. All cows had spontaneous calving. Non-specific clinical signs, such as agitation, inappetence, tachycardia, and tachypnoea, appeared in cows with RP soon after the delivery. Every cow underwent a gynecological examination 12 − 24 h after the calving, and RP was diagnosed if the fetal membranes were seen hanging from the vulva or remained inside the uterus .2.2.The protocol as published by Horvatić et al.  was follm × 5 mm; 12 min; flow rate of 15 μL/min), peptides were separated on the analytical column  by combining two mobile phases: the mobile phase A, 0.1% formic acid in water, and the mobile phase B, 0.1% formic acid in 80% ACN. The separation protocol started with a linear gradient of 5–55% mobile phase B over 120 min, then continued with 55% to 95% for 1 min, held at 95% for 2 min, and returned at 5% B during 20 min at the flow rate of 300 nL/min. When separated, the peptides were ionized with a nanospray Flex ion source  containing a 10 μm-inner diameter SilicaTip emitter  and analyzed on Q Exactive Plus mass spectrometer . The parameters for the mass spectrometry-based analysis were as follows: the positive ion mode using data-dependent analysis Top8 method; full scan MS spectra covering the m/z range from 350.0 to 1800.0 with a resolution of 70,000; injection time: 120 ms; AGC target: 1 × 106; isolation window: ± 2.0 Da; dynamic exclusion: 30 s; HCD fragmentation at step collision energy (29% and 35% NCE) with a resolution of 17,500; AGC target: 2 × 105; criteria for the precursor ions exclusion from fragmentation: the unassigned charge state, or charge states of +1 and more than +7. To perform qualitative and quantitative analysis from the obtained spectra, we applied the SEQUEST algorithm in the Proteome Discoverer software  and searched for the data against the UniProt Bos taurus FASTA files  according to the following parameters: two trypsin missed cleavage sites; precursor tolerance 10 ppm; fragment mass compliance ± 0.02 Da; carbamidomethyl (C) fixed peptide modification, oxidation (M), and TMT sixplex  dynamic modifications. The false discovery rate (FDR) for peptide identification was computed according to the Percolator algorithm in the Proteome Discoverer workflow based on the search results against a decoy database and was set at 1% FDR. The criteria for protein identification were: the presence of at least two unique peptides and the 5% FDR. For the proteins’ quantification, the first step was to correlate the relative intensities of the extracted reporter ions and the fragmented peptides. After that, we calculated the proteins’ relative abundances as the ratio between the relative intensities in the individual sample and the internal standard of the corresponding TMT sixplex™.For the high-resolution LC-MS/MS analysis of TMT-labelled peptides, the protocol from previous studies , fibrinogen alpha chain (FGA), and tetranectin (TNCT) was measured with the bovine-specific commercially available enzyme-linked immunosorbent assays (ELISA) kits according to the Manufacturerʼs instructions . For the LBP kit (Bovine Lipopolysaccharide-binding protein (LBP) ELISA kit; Catalogue CodeBOEB0664), the Manufacturer declared sensitivity 0.281 ng/mL, intra-assay coefficient of variation (CV) 6.2%, inter-assay CV 8.5%, and spike recovery 97%. The specifications for the FGA kit  ELISA kit; Catalogue CodeBOEB0567) were: sensitivity 3.0 ng/mL, intra-assay CV 6.2%, inter-assay CV 9.1%, and spike recovery 113%. The TNCT kit (Bovine Tetranectin (CLEC3B) ELISA kit; Catalogue CodeBOEB0666) had the following characteristics: sensitivity 0.31 ng/mL, intra-assay CV 6.5%, inter-assay CV less 9.1%, and spike recovery 106%. Haptoglobin (HP) concentration was measured with the previously validated 2.4.Commercially available kits  run on the automated analyzer Abbott Architect c4000  were used to measure glucose, urea, creatinine, total protein, albumin (ALB), total bilirubin (T-BIL), cholesterol (CHOL), triglycerides (TRIG), non-esterified fatty acids (NEFA), β-hydroxybutyrate (BHB), aspartate aminotransferase (AST), gamma-glutamyl transferase, lactate dehydrogenase (LDH), and glutamate dehydrogenase. The concentration of serum amyloid A (SAA) was analyzed using the commercially available ELISA kit  and indicated the intensity of APR.2.5.http://www.r-project.org/.) (Accessed July 10 2021).), following the detailed instructions by Kuleš et al. (via the UniProtKB ID mapping tool (https://www.uniprot.org/uploadlists/), which allowed the Gene Ontology (GO) classification, using the Protein Analysis Through Evolutionary Relationship (PANTHER) tool (http://www.pantherdb.org/) with the subset of GO terms (GO Slim database) , using the human genome as the background. The criterion to denote a pathway as significant was the FDR corrected P-value less than 0.05 , among which 114 were master proteins. The volcano plot in The analysis of the MS/MS spectra identified 651 proteins in total , protein-binding activity modulators , intercellular signal molecule , metabolite interconversion enzyme  and transfer/carrier proteins . Finally, the results from the REACTOME tool  indicate3.2.3.3.The median SAA level was twenty times higher in the RP than in the PP group, indicating that a strong APR accompanied RP; glycemia and total bilirubin concentration were higher, and gamma-glutamyl transferase level lower in cows with RP . Several3.4.partial=0.845, p < 0.001). The first step in assessing the extent of the proteomic alterations was to calculate the relative abundance median in all samples for each protein identified as having a different abundance between the study groups. We counted afterward how many proteins in every sample actually had the altered relative abundance, meaning higher than the median for the proteins with the RP-associated increase or lower for the proteins whose relative abundance decreased in RP. The alterations were found in only two cows with PP, each having one protein altered. In the RP group, the alterations occurred in the samples from all cows. The number of proteins having the altered abundance was between 7 and 10. 4.Our study brought the first data about the comprehensive changes in the serum proteome associated with the presence of RP in dairy cows. Using high-throughput TMT-based LC-MS/MS methodology, we identified a set of ten proteins with altered relative abundance in serum differing between the cows with RP and PP. The functions of these ten proteins, together with the direct relationship between the extent of the proteome changes and the intensity of APR, pointed out that a complex systemic response to RP designated the pattern of the proteome changes in serum.Four of the ten proteins with the RP-associated abundance changes represented the archetypic positive acute phase proteins (APP) in ruminants: HP, LBP, ITIH 4, and fibrinogen. Accordingly, the observed serum proteome alterations, to a large extent, reflected the activation of the innate immune mechanisms , has a well-established role as a risk factor for RP , also known as heparin cofactor II, aggravated the abovementioned deleterious effects by causing a procoagulant hemostatic disbalance in cows with RP. Apart from anticoagulant function, studies on animal models revealed that SERPIND1 also showed vascular protective effects (Grover and Mackman It is necessary to highlight that the RP-associated alterations of serum proteome involved the increased abundance of proteins with the protective biological role. Among them were HP and HPX, the traditional "allies against heme toxicity" (Smith and McCulloh Higher GPX altered relative abundance in the RP group might be an additional protective mechanism, endeavouring to decrease oxidative stress associated with RP. However, the lack of difference in activity between the RP and PP groups questioned the protective efficiency. Opposing our findings, Li et al.  detectedvice versa situation could be intriguing. A potential explanation could be that the changes in the tissue proteome indicated in situ mechanisms involved in RP pathogenesis and, as such, did not reach a significant amount in systemic circulation. Nevertheless, caution is necessary due to the methodology-related bias, as Wawrzykowski et al. (The results of the studies addressing the tissue proteome differences between the retained and physiologically expelled bovine placenta (Fu et al. i et al.  used geli et al. , which wOur study, analogously with previous reports (Dervishi et al. Traditionally, the pathogenesis of RP relied on two features: inflammatory and metabolic, attributable to the disequilibria in glucose, lipid, and calcium metabolism. These features interact; nevertheless, understanding the hierarchy between them has been a matter of challenge LeBlanc . In our Serum concentrations of LBP, HP, and SAA differentiated between the RP and PP groups with acceptable sensitivity and specificity, thus marking these three APPs potential candidates for future studies on RP biomarkers. While thinking about their application in patients, several features appeared as challenging. The measurement for diagnostic purposes would not be rational due to the straightforwardness of the clinical findings in RP Peter . Their pThe small number of the cows studied marks our results as pilot. Also, all cows were multiparous and, therefore, less susceptible to the harmful effects of the periparturient inflammation (Pohl et al. 5.The pattern of retained placenta-associated changes in the serum proteome of dairy cows, profiled using the high-throughput technique, consisted of alterations in the relative abundance of ten proteins. In the pathobiological context, the pattern recouped pathways regulating the innate immunity mechanisms with strengthening or ameliorating effects. The current findings offered a few candidates for prognostic biomarkers in cows with retained placenta, thus raising the necessity for further clinical validation studies.Click here for additional data file.


Over the past 20 years, numerous tyrosine kinase inhibitors (TKIs) have been introduced for targeted therapy of various types of malignancies. Due to frequent and increasing use, leading to eventual excretion with body fluids, their residues have been found in hospital and household wastewaters as well as surface water. However, the effects of TKI residues in the environment on aquatic organisms are poorly described. In the present study, we investigated the cytotoxic and genotoxic effects of five selected TKIs, namely erlotinib (ERL), dasatinib (DAS), nilotinib (NIL), regorafenib (REG), and sorafenib (SOR), using the in vitro zebrafish liver cell (ZFL) model. Cytotoxicity was determined using the MTS assay and propidium iodide (PI) live/dead staining by flow cytometry. DAS, SOR, and REG decreased ZFL cell viability dose- and time-dependently, with DAS being the most cytotoxic TKI studied. ERL and NIL did not affect viability at concentrations up to their maximum solubility; however, NIL was the only TKI that significantly decreased the proportion of PI negative cells as determined by the flow cytometry. Cell cycle progression analyses showed that DAS, ERL, REG, and SOR caused the cell cycle arrest of ZFL cells in the G0/G1 phase, with a concomitant decrease of cells in the S-phase fraction. No data could be obtained for NIL due to severe DNA fragmentation. The genotoxic activity of the investigated TKIs was evaluated using comet and cytokinesis block micronucleus (CBMN) assays. The dose-dependent induction of DNA single strand breaks was induced by NIL (≥2 μM), DAS (≥0.006 μM), and REG (≥0.8 μM), with DAS being the most potent. None of the TKIs studied induced micronuclei formation. These results suggest that normal non-target fish liver cells are sensitive to the TKIs studied in a concentration range similar to those previously reported for human cancer cell lines. Although the TKI concentrations that induced adverse effects in exposed ZFL cells are several orders of magnitude higher than those currently expected in the aquatic environment, the observed DNA damage and cell cycle effects suggest that residues of TKIs in the environment may pose a hazard to non-intentionally exposed organisms living in environments contaminated with TKIs. Scientific and public concern about the presence of pharmaceutical residues in the environment has increased as they are repeatedly detected worldwide, especially in aquatic environments. Of particular concern are cytotoxic anticancer drugs, as their therapeutic principle is based on damage to genetic material, which is associated with severe side effects in patients. Recently, residues of certain cytotoxic anticancer drugs have been reported to cause genotoxic effects in certain sensitive aquatic species, even at environmentally relevant concentrations .Tyrosine kinase inhibitors (TKIs) are a group of drugs that have been increasingly used in the last 20 years for targeted therapies of various types of malignancies. Their main mechanism of action is binding to the active site of tyrosine kinases, thereby disabling the phosphorylation of tyrosine kinase secondary signal transducers involved in cell proliferation, growth, and angiogenesis, among others . MoreoveThe first drug in this class, imatinib mesylate (IM), was developed for the treatment of BCR-ABL associated leukemia and entered the market in 2001 . It is sDanio rerio) embryos showed that the TKIs studied caused predominantly sublethal effects such as oedema, lack of blood circulation, and the formation of blood aggregates. The authors suggested that the observed sublethal effects are due to the antiangiogenic activity of the TKIs pyrene (50 μM), an indirect-acting genotoxic agent which requires metabolic activation for its genotoxic effects, and etoposide (0.17 μM), a direct-acting genotoxic agent, were selected as positive controls. After 72 h, floating and adherent cells were collected, resuspended in ice-cold 1x PBS, and immediately analyzed. Propidium iodide (PI) at a final concentration of 1 μg/mL was added to the cells 5 min before the start of measurements using the MACSQuant Analyzer 10 flow cytometer . MASCQuantifiy software  was used to quantify PI negative and positive cells. The experiments were repeated three times independently. Statistical significance between the treated groups and control was determined by one-way ANOVA with post hoc multiple comparison Dunett’s test using GraphPad Prism V6 . * p < 0.05, ** (p < 0.01), *** (p < 0.001) were considered statistically significant.ZFL cells were seeded onto T25 culture plates at a density of 450,000 cells for 24 h. Cells were then exposed to erlotinib , sorafenib , regorafenib , dasatinib , and nilotinib . The positive control was etoposide (0.17 μM), which is known to arrest cells in the G2/M phase of the cell cycle. After 72 h, cells were trypsinized (0.25% trypsin-EDTA) and washed with 1x PBS before fixation in 4% paraformaldehyde (PFA). For flow cytometric analysis, fixed cells were washed in cold 1x PBS and stained with Hoechst 33258 dye (diluted in 0.1% Triton X-100 1:500) as described by Stampar et al. . Flow cyp < 0.05 was considered statistically significant.The induction of DNA strand breaks after TKI exposure was assessed by the comet assay according to Møller et al. , with mi2 culture plates  and left for 24 h to attach. Cells were then treated for 72 h with TKIs at the following concentrations: dasatinib (0.03 μM), erlotinib (40 μM), nilotinib (20 μM), regorafenib (3 μM), and sorafenib (4 μM). ZFL cells were subsequently exposed to medium containing cytochalasin B (2 μg/mL) and incubated for an additional 48 h. The floating and adherent cells were then collected by trypsinization, centrifuged, washed with 1× PBS, and incubated in cold hypotonic solution (75 mM KCl) for 5 min. Fixed cells were transferred to a microscope slide, air dried, randomized, and coded. The slides were stained with AO (20 μg/mL) and analyzed at 400× magnification under a fluorescence microscope . A total of 500 binucleated (BNC) cells (1000 BNC per replicate) with preserved cytoplasm were manually scored per experimental point. The number of micronuclei  cells), nuclear buds (NBUDs) and nucleoplasmic bridges (NPBs) was determined according to standard criteria [p < 0.05 was considered statistically significant.The CBMN cytome assay was performed according to Fenech  with mincriteria . The nucectively . Experimp < 0.05 and *** p < 0.0001 were considered statistically significant.ZFL cells were seeded onto 24-well culture plates (Nunclon) at a density of 35,000 cells per well for 24 h. Cells were then treated with erlotinib , sorafenib , regorafenib , dasatinib , and nilotinib . Etoposide (0.17 μM and 0.68 μM) was used as a positive control. After 72 h, cells were placed on ice for 20 min, and subsequently a 0.05 mg/mL EMA solution was added to each well. The cells were placed on ice for 30 min and exposed to light for photoactivation of the EMA fluorochrome. Afterwards, cells were washed and resuspended in lysis solution  containing 0.2 μM SYTOX Green and 0.25 mg/mL RNAse A, and incubated for 1 h in the dark at 37 °C. After incubation, lysis solution (85.6 mg/mL sucrose and 15 mg/mL citric acid) containing 0.2 μM SYTOX Green was added to the wells of the plate and incubated for a further 30 min at room temperature in the dark. Cells were analyzed on the same day using MACSQuant Analyzer 10 flow cytometer. MASCQuantify Software 2.11. was used to analyze each sample, and the percentage of micronuclei was determined after the acquisition of a total of 20,000 gated nuclei events, excluding EMA-positive events. One-way ANOVA with post hoc multiple comparison Dunett’s test using GraphPad Prism V6  was carried out. * In conclusion, the present study showed the cytotoxic effects of the investigated TKIs, as decreased ZFL cell viability and the arrest of ZFL cells in the G0/G1 phase of the cell cycle were confirmed. Nilotinib, dasatinib, and regorafenib induced the formation of DNA strand breaks, which were transiently present and most likely formed as intermediates in the DNA repair processes. However, none of the TKIs studied induced genomic instability of the ZFL cells. The results suggest that apoptosis may be involved in the mechanism of action of dasatinib. These results provide new insights into the potential adverse effects of TKIs on non-intentionally aquatic non-target organisms, as residues of TKIs in the environment may pose a risk to organisms living in these environments. Although the adverse effects have been observed at high concentrations of TKIs that are not currently expected to occur in the environment, a potential risk to unintentionally exposed environmental organisms cannot be completely excluded, particularly because of the increasing consumption of TKIs worldwide and the emergence of new TKIs in clinical practice, whose residues will eventually enter the environment.


This study examines changes in utilization and costs trends associated with migraine medications.Migraine attacks are a burden to many patients. There are many pharmacotherapy options available with newer migraine drug classes entering the market in the past decade. Little is known about the use, associated costs, and the impact of the newer agents.This retrospective, cross-sectional study examined 2017–2020 administrative claims from a large national pharmacy benefits manager. Patients aged ≥ 18 years enrolled in commercial, Medicare, Medicaid, or health insurance exchange insurance plans who filled ≥ 2 prescription claims for triptans, ergotamines, isometheptenes, gepants, ditans, and CGRP mABs were included. A two-sample t-test was conducted to estimate whether differences in mean utilization and costs between 2017 and 2020 were statistically significant for migraine drug classes, except for CGRP mABs, which were estimated between 2018 and 2020.n = 203,110; 2020) of patients were women. The number of 30-day adjusted prescription fills for prophylaxis remained stable over the four-year period, except for CGRP mABs, which increased from 0.5%  to 5.3% . Antiepileptics, antidepressants and beta blockers were the most common prophylaxes, while triptans, non-steroidal anti-inflammatory drugs/non-narcotic analgesics and opioids were the most common treatments utilized. CGRP mABs were the most expensive, while utilization of triptans were the highest. CGRP mABs had the largest increase in utilization (177.5%) and costs (166.3%) PPPM in 2020 ($291.17) compared to 2018 ($109.35), the year they were first available (p < 0.001). Between 2018 and 2020, costs increased overall and for commercial and Medicare enrollees, but remained unchanged for Medicaid and HIX members.The sample ranged from 161,369 (2017) to 240,330 (2020) patients. 84.5% (Our study demonstrates a shift in migraine medication utilization from 2017–2020, where increased use of CGRP mABs had a significant contribution to increased costs. These increased pharmacy costs must be weighed against the improved tolerability of these agents likely resulting in other healthcare and indirect cost savings.The online version contains supplementary material available at 10.1186/s10194-022-01476-y. Migraine is one of the most common neurological diseases, affecting at least one in six Americans  and 14% Patients with migraine attacks report worse disability or quality-of-life and those with higher headache frequency reported worse health status than those who do not report headaches , 8, 9. F1Freceptor) [Multiple pharmacotherapy options exist to prevent and treat migraine attacks. Pharmacotherapy of migraine focuses on acute treatment  and prophylactic treatments . Acute treatment of migraine attacks are either non-specific pain pharmacotherapies, such as non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, or migraine specific, such as triptans and ergot derivatives, and more recently, the gepants  , and diteceptor) –24. Propeceptor) .Costs related to migraine can be both direct  and indirect . In 2016, it was estimated that the total direct and indirect economic burden of migraine in the United States (US) was 36 billion dollars. Patients with migraine attacks reported, on average, $6575 higher healthcare costs than patients without migraine attacks . PatientThis was a retrospective, cross-sectional study using deidentified member-level enrollment and administrative claims from a large national pharmacy benefits manager (PBM) from January 1, 2017-December 31, 2020. Inclusion was limited to adults aged ≥ 18 years enrolled in commercial, Medicare, Medicaid, or health insurance exchange (HIX) insurance plans whose pharmacy benefits were managed by the PBM. Prescription drugs used specifically for the treatment of migraine were used as a proxy for selecting patients with migraine. Patients who filled two or more 30-day adjusted prescription claims for either triptan, ergotamine, isometheptene, CGRPmABs, gepant or ditan drug classes at any time during this four-year period were included. Members who switched insurance types  within the year were excluded.The prescription drug classes examined in this study were broadly divided into two categories: migraine prophylaxis (or preventive) drug classes and migraine treatment drug classes. Specific drugs within all medication classes examined in this study were identified using the proprietary generic product identifier associated with prescription drugs and are listed in Appendix Table The number and percentage of patients per medication was calculated. Utilization was defined as the total number of 30-day adjusted prescription fills PPPM and calculated by dividing the days’ supply by 30 to standardize as 30-days’ supply; summing up all prescription fills and dividing by the number of months of eligibility for all patients for each of the four years. Annual costs for all migraine acute and prophylactic classes were defined as gross costs net of  rebates PPPM, in 2020 US dollars, by adjusting for inflation using the Consumer Price Index (13). Gross costs comprised of ingredient costs, taxes, dispensing fees, administrative fees, and member out-of-pocket costs for each year, and represent costs after all manufacturer concessions are accounted for (including rebates and discounts) for each of the four years. Gross costs were summed up for all patients, for each medication class and total overall, and divided by the number of months of eligibility for all patients in each year. Independent variables included age, gender, and insurance type .p < 0.05 for the overall sample and among insurance types. A separate two-sample t-test was conducted to determine whether differences between 2018 and 2020 were statistically significant at p < 0.05 for CGRP mABs since they were approved and marketed in 2018. All analyses were conducted using SAS statistical software v9.4 .Differences in mean utilization and costs PPPM for each medication class were examined from 2017–2020. A two-sample t-test was used to determine whether differences between 2017 and 2020 were statistically significant at n = 135,869, 84%) in the study were women across all years. A higher proportion of migraine patients belonged to the 45–64 age group. The study population reflected a mostly commercially insured population . Over the course of the four-year period, the relative percentage of younger patients (aged 18–64) increased each year while the relative percentage of older patients (aged 65 and older) decreased each year in the overall sample population and in the commercial and Medicaid subgroups; however, in the Medicare subgroup, the relative breakdown by age remained consistent  of all migraine utilization, which increased to 5.3% (n = 0.075) in 2020. The percentage was highest for commercial enrollees  and lowest for Medicaid enrollees . The most common migraine acute class overall was triptans ranging from 35.4% of all utilization in 2017 (n = 0.516) to 34.5% in 2020 (n = 0.486), followed by NSAIDs and non-narcotic analgesics  and non-acute opioids use . When examining the percentage contribution to gross cost net of rebates PPPM by all drug classes, CGRP mABs had the largest increase over the study period. In 2017, CGRP mABs comprised 3.0% of all migraine drug costs ($3.12), which increased to 30.0% in 2020 ($33.55), the highest across all migraine drug classes examined in this study  compared to 2017 . This was due to a 4.2% decline in utilization of acute migraine medication classes that offset a 3.8% increase in utilization of migraine prophylactic medication classes over the same period (p < 0.001). While antidepressants (3.5%), beta blockers (3.4%) and ACEI/ARB (4.8%) all had positive four-year trends, the uptick in utilization for CGRP inhibitors also had a significant contribution to the overall utilization increase for migraine prophylactic medication classes. CGRP inhibitor PPPM utilization relatively increased by 177.5% in 2020 (0.652) compared to 2018 (0.235), the year in which they were first available (p < 0.001), while utilization of triptans , NSAIDs and non-narcotic analgesics  and barbiturates  declined, chronic opioid  and ergotamine use  remained relatively unchanged. In the commercially insured sample, non-acute opioid use increased by 4.6% (p < 0.001), while utilization for these drugs declined among Medicare  and Medicaid enrollees , and remained unchanged from HIX enrollees . Notably, there were declines in utilization across all migraine acute and prophylactic medication classes among Medicaid enrollees, many of which were statistically significant at p < 0.001. Among those aged 65 or older, overall utilization remained unchanged (p = 0.997), while use of opioids  and ergotamine  increased, although overall use of these agents was low in all time periods.Overall, there was a 3.0% decline in the number of 30-day adjusted migraine medication prescription fills PPPM on average in 2020 (p < 0.001), from $128.41 in 2017 to $112.01 in 2020 (Table p < 0.001) in average costs. When examining the change from 2018 to 2020, there was an increase of 7.3% (p < 0.001) in average costs, primarily driven by a 166.3% increase in PPM costs for CGRP mABs (p < 0.001) In addition, gepants and ditans were first marketed in 2020, which also contributed to an increase in average cost for migraine therapies for that year.Examining the differences in migraine medication costs net of rebates between 2017 and 2020, we found that average costs PPPM declined by 12.8% (p < 0.001) and were not significantly different for HIX enrollees (p = 0.398). For patients aged 18–64 years, overall costs declined by 13.1% between 2017 and 2020, but increased by 7.3% between 2018 and 2020 (p < 0.001). Triptan costs declined by 53.5% from 2017 to 2018, while CGRP costs increased by 167.8% between 2018 and 2020 (p < 0.001). For patients 65 or older, despite not having statistically significant overall migraine cost changes between 2017 to 2020, had a 34.4% decrease trend in triptan costs from 2017 to 2020 and a 148.4% increase in CGRP costs between 2018 and 2020 (p < 0.001).Regarding costs differences amongst insurance types, the trends were similar for commercial and Medicare enrollees, while they declined for Medicaid enrollees  increased during the study period, they still represented only 17.8% of migraine prescriptions in 2020. However, because of their significantly greater cost, they accounted for 39.7% of overall costs in 2020. Due to their recent entry into the market, data are limited on comparative effectiveness of the CGRP mABs and older preventative therapies, but some conclude that CGRP mABs have similar effectiveness for migraine prophylaxis . The PCOEven with a slight decline in utilization over time, triptans were the most popular migraine treatment, reflecting their wide availability of products and formulations and proven track record for effectiveness. This likely reflects favorable insurance formulary practices, as most oral triptans have a generic equivalent with average wholesale prices from $9-$600 for a 30-day supply, and an average cost of $31.92 for our population in 2020 . In addiOther trends merit some discussion. Opioids are not recommended for treatment of migraine, although they are commonly used for this indication . BecauseOur analysis expands upon previous research that has been conducted on migraine related costs in US based health systems, which have found the newer pharmacotherapy options are more cost-effective for a subset of patients , especially when adding in indirect costs . Prior tThe study has caveats and limitations inherent with analyzing claims data. The study population mainly included commercially insured patients versus those with Medicaid and Medicare, which limits generalizability as it does not reflect national breakdowns of health insurance coverage in the US . BecauseOur study adds to the current literature as it captures the shift of utilization and cost of when CGRP mABs entered the market. These changes in utilization and cost trends allow payers and patients to have a better understanding of treatment costs, especially as clinical guidelines and practices are updated to address this expensive burden and public health problem. Future studies are needed to evaluate the impact of newer migraine medications relative to older medications on healthcare utilization, improved quality-of-life, and work outcomes for patients with migraine.Additional file 1: Appendix Table 1. Migraine Preventive and Acute Rescue Prescription Medication Classes.


Care for People with Multiple Sclerosis (PwMS) is increasingly complex, requiring innovations in care. Canada has high rates of MS; it is challenging for general neurologists to optimally care for PwMS with busy office practices. The aim of this study was to evaluate the effects of add-on Nurse Practitioner (NP)-led care for PwMS on depression and anxiety , compared to usual care .PwMS followed by community neurologists were randomized to add-on NP-led or Usual care for 6 months. Primary outcome was the change in HADS at 3 months. Secondary outcomes were HADS (6 months), EQ5D, MSIF, CAREQOL-MS, at 3 and 6 months, and Consultant Satisfaction Survey (6 months).n = 120, Usual care arm n = 108). There were no significant baseline differences between groups. Study subjects were highly educated (71.05%), working full-time (41.23%), living independently (68.86%), with mean age of 47.32 (11.09), mean EDSS 2.53 (SD 2.06), mean duration since MS diagnosis 12.18 years (SD 8.82) and 85% had relapsing remitting MS. Mean change in HADS depression (3 months) was: -0.41 (SD 2.81) NP-led care group vs 1.11 (2.98) Usual care group p = 0.001, sustained at 6 months; for anxiety, − 0.32 (2.73) NP-led care group vs 0.42 (2.82) Usual care group, p = 0.059. Other secondary outcomes were not significantly different. There was no difference in satisfaction of care in the NP-led care arm (63.83 (5.63)) vs Usual care (62.82 (5.45)), p = 0.194).We recruited 248 participants; 228 completed the trial .Retrospectively registered on The online version contains supplementary material available at 10.1186/s12883-022-02809-9. Multiple Sclerosis (MS) is the leading cause of non-traumatic disability in young adults . It is mn = 324 responders) reported that 70% experienced challenges in obtaining appointments with their neurologists  as appropriate. The primary outcome of difference in change of HADS-D and HADS-A from baseline to 3 months was analyzed using independent T-test. An independent T-test was also used to assess the difference in change between HADS-D and HADS-A between baseline and 6 months as well as the other questionnaires - EQ5D and MFIS. The CSQ Likert scales were analyzed as continuous variables, with the overall satisfaction score being calculated as a sum of the scales of each question and analyzed using an independent t-test to determine a difference between the intervention and control groups.Data analysis was performed using R 3.4.0 computer software .Data were analyzed according to the intention-to-treat principles. Trial and Data Management was completed by EPICORE Centre  for the NP-led group vs 1.11 (2.98) Usual care group, p = 0.003  for the NP-led group vs 0.57 (SD 3.11) Usual care group, 003 Fig. ; and forp = 0.54. The mean change for the EQ5D score at 3 months was 1.58 (14.5) for the NP group vs − 0.02 (14.99) for UC group, p = 0.54. The mean change at 6 months for the MFIS and EQ5D showed a similar trend but was also not statistically significant.The difference in mean change for MFIS and EQ5D were not statistically significant Table . The meap value of 0.194. No statistical differences were noted on any of the sub-scales between the two groups  and for the Usual care group was 62.82 (5.45), with a To our knowledge, this is the first study to examine the impact of an “add-on” specialized MS NP-led care to PwMS in comparison to usual care through community neurologist and family physicians’ practices. We found that NP-led care was associated with improved depression levels for PwMS at 3 months, sustained at 6 months, compared to usual physician care. At 6 months, an improvement in anxiety was observed. This study suggests that NPs could address many of the unmet needs identified by PwMS , 23: impWe looked at depression and anxiety levels for PwMS as primary and secondary outcome measures over the short-term intervention of 3 and 6 months. We felt depression and anxiety levels might be the most responsive factors over the short-term in relation to participants’ quality of life (QoL). Depression has been reported to influence PwMS’ QoL in multiple studies –58. OverIt has been suggested that NPs might be easier to access and less costly to see than physician health providers for PwMS , 74–76. There was no difference in level of satisfaction by PwMS in being cared for by a specialized NP compared to usual care received from community neurologists. This is in line with what has reported in the literature where the MS nurse was identified as the preferred medical contact , 83, 84.This study provides an alternate and possibly cost-saving management strategy to complex management of symptoms and QoL measures for PwMS. These findings corroborate other studies identifying the benefits of NP patient care , 75, 85,Trials, the NP provided an independent and holistic approach to study participants, including independent referrals to community resources, independent ordering of investigations and prescription of symptomatic medications [The patients involved in this study self-reported their data which could be susceptible to subjective bias. Participants presumably participated in the study if they were open to being treated by an NP in addition to their CN, likely viewing NP positively, which could impact the finding of similar consultant satisfaction between arms. However, despite the potential bias, the findings of our study are consistent with what has been reported in the literature. Even though we opened the study to PwMS followed by general community neurologists or family physicians, all of the study participants were followed by a general neurologist. This is likely due to the methods of recruitment, primarily based within community neurologists’ office. Future studies could examine the value of an MS specialized NP in specialist and primary care settings. The control arm for our study included limited support to community neurologists by registered nurses who also work within a tertiary MS clinic setting. Due to the limited resources and time that the registered nurses could provide to the community neurologists, the registered nursing support consisted only of rooming patients, updating medication lists, and aiding in disease-modifying therapy access and renewals. Therefore, the registered nurses did not provide interventions provided by the nurse practitioner in the active arm of symptomatic strategies, lifestyle strategies etc. It is likely that a trained registered nurse could perform some of the duties performed by the NP in our study. However, as outlined in the study protocol paper in ications . Time waOur study is generalizable to other healthcare settings, where generalists such as family doctors and general neurologists care for PwMS outside of a tertiary MS-subspecialty clinic. We did not examine the add-on aspects to NP-led care in the MS subspecialty clinic settings. We carried out our study with PwMS in a public healthcare system in Canada. However, there are similar challenges in meeting care needs of other chronic diseases in any healthcare system.Our study did not select for participants, considering their sex and gender. Consecutive prospective participants visiting their community neurologists’ offices were approached to participate in the study. Prospective participants consented and were randomized after consent to participate in either arm. However, 82% of the participants were of female sex; this reflects the female preponderance to getting MS in comparison to males, and is consistent with other studies examining MS within populations. Gender was not collected in our study, and is a limitation of our study. Going forward, future clinical trials examining NP involvement in care for PwMS should examine if there are differences in consultant satisfaction by gender in receiving care from an NP.Our study demonstrated that adding a specialized NP to the care of PwMS improved depression over three and 6 months. There were no differences seen in satisfaction of care received by an NP as participants’ usual care. Examining the effect of a NP in a CN setting, delivering care to PwMS through multi-disciplinary means, such as through a patient advocacy management model , holds pAdditional file 1.


This study on pyogenic spinal infections with intraspinal epidural involvement (PSI +) compared the outcome of patients with spinal cord injury (SCI) to those without (noSCI) taking diagnostic algorithm, therapy, and complications into account.Patients were enrolled in an ambispective study (2012–2017). Diagnostic and therapeutic algorithms, complications, and neurological outcome were analyzed descriptively. Survival was analyzed applying Kaplan–Meier method and Cox regression.n = 55) and noSCI (n = 79). A higher percentage of endocarditis  was detected in the noSCI group. The majority (81%) received combinatorial therapy including spinal surgery and antibiotic treatment. The surgery complication rate was 16%. At discharge, improvement in neurologic function was present in 27% of the SCI patients. Length of stay, duration of ventilation and the burden of disease-associated complications were significantly higher in the SCI group . Lethality risk factors were age , and empyema/abscess extension , dominating over additional effects of Charlson comorbidity index, SCI, and type of treatment. The overall lethality rate was 11%.In total, 134 patients with a median (IQR) age of 72 (61–79) years were analyzed. Baseline characteristics were similar between the SCI  or without myelopathy (noSCI). If SCI develops, the rate of disease complications is higher and early specialized SCI care might be substantial to reduce complication rates. Pyogenic spinal infections with intraspinal epidural involvement (PSI +) represent a subgroup whose diagnosis, treatment, and outcome have been rarely studied  and CCI  but were not different in sex and BMI. In patients receiving conservative therapy, antibiotic treatment lasted for a total of six weeks in eight (32%) cases, three months in 14 (56%) patients, and for longer than three months in three (12%) patients.Combinational therapy including spinal surgery in conjunction with local/spinal irrigation was performed in 46 (84%) in the SCI group versus 63 patients (80%) in the noSCI group. The surgical approach was dorsal in 90 cases (83%), ventral in two cases, and combined dorsoventral in 17 cases (15%). Revision surgery was required in 17 cases (16%) due to mal-positioning (4%), persistent spine infection (5%), wound secretion (4%) or hematoma (4%). Antibiotic therapy was administered three months in 104 patients (95%), and longer than 3 months in 5 patients (5%).Disease-associated complications, such as urinary tract infection, pressure ulcers and circulatory dysregulation, were significantly higher in the SCI group Table , whereasOverall, a lethal outcome during of PSI + occurred in 15 patients 11.2%). The Kaplan–Meier analysis of cumulative survival during initial treatment, revealed no difference between noSCI and SCI groups , age per 1-year increase (HR (95% CI), 1.10 (1.03–1.18), CCI (HR (95% CI), 1.19 (1.01–1.40), p = 0.033) and the type of treatment (conservative) (HR (95% CI), 3.39 (1.12–10.06), p = 0.028) as risk factors for lethality. In the multivariable (covariate-adjusted) Cox-regression model, the number of ≥ 3 segments involved (HR (95% CI), 4.72 (1.57–14.20), p = 0.006), and age per 1-year increase were reaching statistical significance as risk factors for lethality (HR (95% CI), 1.09 (1.02–1.16), p = 0.014), whereas the effects of CCI and type of treatment were becoming smaller (Table The bivariate (unadjusted) Cox regression model identified a number of ≥ 3 segments involved (HR 95% CI), 3.45 (1.22–9.72), % CI, 3.4The SCI group comprised more motor incomplete SCI  than motor complete SCI  cases at admission. The neurological level was prevailingly lumbosacral . Improvement of the neurological status until discharge was observed in 13 of 48 patients (27%)  compared with the literature 14–37%), probably due to a relatively short “red-flag” to admission time 4–37%, pr.Staphylococcus aureus is detected in 30–80% of cases of spondylodiscitis [Overall, a pathogen was detected in 67% in this study versus 81% of cases in other studies , 18. Fordiscitis , 19.Antibiotic therapy periods are reported to range between 3 and 12 weeks, with duration of intravenous application of 4–6 weeks , 20–22. Surgical treatment is usually recommended in case of deformity, persistent or increasing infection, presence of SCI, and intraspinal process , 25–27. In our study, surgery was done in 81% of all cases. Due to patients’ refusal for operation or Inability to operate due to general condition, 19% were treated conservatively. In 82% of the cases undergoing surgery, a dorsal approach with laminectomy and, if necessary, with stabilization was performed. The dorsal-only approach with fusion without ventral debridement did not result in reinfection in a study with 48 patients at a mean follow-up of 64 months . In contSome disease-associated complications were significantly increased in the SCI group. The high proportion of urinary tract infections could be related to inadequate bladder management and targeted antibiotic therapy for spinal infections, which does not cover the pathogen spectrum of urinary tract infections. The higher rate of pressure ulcers in the SCI group was due to inadequate mobility. Notably, there was no significant difference between the regarding pneumonia and thromboembolism. In particular, the significantly longer ventilation time in the SCI group did not result in a higher rate of pneumonia, this finding is probably attributable to prophylaxis of SCI-associated pneumonia by early mobilization and physiotherapy.In the SCI group, improvement in neurological function was demonstrated in 27% of the cases. Compared to the literature, persistent impairment with sensory deficits up to 90% and bladder dysfunction up to 50% have been described , 36.The mortality rate in this study was 11.2% with no difference between the groups with and without SCI. The literature data on mortality of patients with ISA and ISE vary; mortality rates of 10–20% have been described , 37, 38.Based on the subgroup PSI + described in this study and the high rate of patients with neurological deficits (44%), we consider the relatively low lethality rate of 11.2% is possibly indicating the effectiveness of our extended diagnostic algorithm and multimodal treatment concept.Length of stay and ventilation time were clearly higher in the SCI group. According to the health economic calculations, this is associated with approximately 2.5-fold higher treatment costs in the SCI group. This health economic aspect should be considered in future health services research on improved strategies for the management of PSI + .Limitations of this study relate to the ambispective and single-center design. However, as the patients were consecutively enrolled, the risk for selection bias is reduced. Potentially, also additional risk factors not included in this study could be relevant. Nevertheless, given the understudied topic and lack of information on PSI + induced myelopathy/SCI are, we feel that this study provides relevant widely missing data to better understand baselines as a basic requirement for interventional studies.PSI + with or without myelopathy/SCI are subgroups to be evaluated on their own and represent a serious urgent, and life-threatening clinical condition. In our study, comprehensive diagnostics and a multimodal therapeutic algorithm including SCI-specific treatments were necessary. Even though when compared to the literature with mortality rates of up to 20%, the mortality rate in this study was lower (11.2%) but still substantial. Spinal infections represent a major mortality risk , 4. WhilA higher in-hospital mortality was observed in older patients and when multiple spinal segments were affected. In PSI + with SCI, improvement of neurologic symptoms occurred in 27% of the cases. In case emerging PSI + -associated myelopathy/SCI, access to early specialized SCI care is a plausible strategy to reduce complication rates, length of stay and treatment costs.