Strongyloides stercoralis infections. This cross-sectional hospital-based study was conducted to assess the prevalence of Strongyloides stercoralis infection among hospitalized patients treated at Mahosot Hospital, the primary reference hospital of Lao People’s Democratic Republic (Lao PDR), and to validate feasible methods for diagnosing S. stercoralis infection at hospital’s laboratory.Despite the high prevalence of strongyloidiasis in the Laotian population, Laotian hospitals still lack diagnostic capacity to appropriately diagnose S. stercoralis infection by wet smear, Baermann technique, Koga Agar plate culture (KAPC), and real-time detection polymerase chain reaction (RTD-PCR) at the Infectious Diseases Ward of the Mahosot Hospital in Vientiane. The sensitivity, the specificity, the negative predictive value (NPV) of each diagnostic test, as well as their combination(s) was calculated using a composite reference standard (CRS). The correlation of the different test methods was assessed by chi-square or Fisher’s exact test. Cohen’s kappa coefficient was used to assess the diagnostic agreement of the different test methods.Between September and December 2018, stool samples of 104 inpatients were investigated for S. stercoralis infections among the study population was 33.4%. The cumulative infection prevalence statistically significantly increased from the lowest age group of 40 years and below (22.4%), to the medium (40.0%) and to the oldest age group of 61 year and above (72.7%)(P = 0.003). The cumulative infection prevalence of CRS was considerably higher in male (40.4%) compared to female patients (28.1%), but not statistically different (P = 0.184). The diagnostic sensitivity of Baermann technique, KAPC, RTD-PCR, and the combination of Baermann technique and KAPC were 60.0, 60.0, 74.3, and 77.1%, respectively. Only 13 patients (37.1%) of the total 35 S. stercoralis patients diagnosed with any technique had a simultaneously positive diagnostic test with Baermann, KAPC and RTD-PCR.The overall prevalence of S. stercoralis at a hospital setting such as Mahosot Hospital and provincial and district hospitals in Lao PDR and other low- and middle income countries in Southeast Asia.We identified Baermann technique and KAPC to be currently the most feasible and implementable standard methods for diagnosing This study was approved by the National Ethics Committee for Health Research in Lao PDR (reference no. 083/NECHR) and by the Ethics Committee Northwest and Central Switzerland (reference no. 2018–00594). Strongyloidiasis is a soil-transmitted helminth infection that affects, according to largely varying estimates, between 30 million and 370 million people worldwide , 2. The Chronic strongyloidiasis in immunocompetent individuals is mostly asymptomatic or only causes unspecific non-acute symptoms related to the gastro-intestinal tract , which hStrongyloides stercoralis infection, the irregular shedding of larvae in stool of infected individuals as well as the limited sensitivity of the available diagnostic methods remains problematic [Although various diagnostic methods have been developed to diagnose blematic , 6. ThusS. stercoralis varies considerably depending on the methodology used. In a review of available data until 2014, Schär and colleagues estimated the overall prevalence rates of S. stercoralis infection in South East Asia as follow: Cambodia: 23.6–25.6%; Indonesia: 4.2–6.3%; Lao PDR: 28.7–33.0%; Malaysia: 28.0–44.4%; Thailand: 26.0–28.2% [S. stercoralis prevalence, an S. stercoralis infection prevalence between 10 and 15% has been estimated in Southeast Asian countries [Information on the prevalence of infection with S. stercoralis prevalence in Lao PDR indicate prevalence rates from 1.4% in Khammouan and Blikhamxay Provinces [The existing study data on rovinces  to 44.2%rovinces . Of noterovinces , 11–13. rovinces , 14.S. stercoralis in stool is much lower than the egg output of other soil-transmitted helminths. Thus, microscopy-based direct methods, like simple wet smear preparation or Kato-Katz , and even conventional concentration techniques, like FECT (used to enhance the sensitivity for detecting protozoan cysts/oocysts and helminth eggs), are largely insufficient to diagnose S. stercoralis infection when only investigating a single sample. Concentration techniques specifically designed for the detection of S. stercoralis, such as Baermann or KAPC, provide more reliable results, but are cumbersome and therefore rarely used [S. stercoralis infection and hence, untreated patients, is unknown.The larval output of ely used , 15. GivS. stercoralis infection among hospitalized patients at Mahosot Hospital, as an example of a curative health service in Lao PDR, and to validate different diagnostic methods at the hospital’s laboratory.The objective of our study was to assess the prevalence of This cross-sectional hospital-based study was conducted between September and December 2018 at the Infectious Diseases Ward of the Mahosot Hospital, Vientiane, Lao PDR. The majority of patients in Mahosot hospital originate from two provinces: Vientiane Prefecture (820 000 population) and Vientiane Province (420 000 population). Only four of the total 20 districts are considered urban (about 400 000 population). Rice subsistence farming is the main activity of households in the rural districts.S. stercoralis infection prevalence in Lao PDR we anticipated a prevalence rate of 40% and calculated the sample size, with a 95% confidence interval and a 10% margin of error, to be 92 patients.Based on the available data on One hundred four consecutive patients ≥18 years of age admitted to the Infectious Diseases Ward of the Mahosot Hospital were (irrespective the cause of admission) enrolled in the study after consenting to participate.Stool samples were investigated by (1) wet smear, (2) Baermann technique, (3) KAPC, and (4) real-time detection polymerase chain reaction (RTD-PCR). One stool sample per participant was collected and material was split for the different methods accordingly. Each sample was investigated by each method once. Wet smear, Baerman, and KAPC were performed at the Mahosot hospital in Lao PDR immediately after arrival of stool samples, while RTD-PCR was performed in Basel, Switzerland.S. stercoralis larvae. This is the method routinely carried out at the laboratory of Mahosot Hospital for diagnosis of S. stercoralis.A fresh stool sample of 5 g was mixed with 3 ml of 0.9% sodium chloride. A drop of the resulting dilution was put on a glass slide, covered with a coverslip, and microscopically examined for the presence of S. stercoralis larvae.A fresh stool sample of 5 g was placed on gauze inserted into a glass funnel of 10 cm in diameter connected to a tube, and covered with tap water. The funnel was illuminated with a lamp from below and left for two hours at room temperature. The liquid in the tube containing the larvae was then transferred to a 15 ml tube and centrifuged for 5 min at ~ 344 g. The supernatant was discarded and the sediment microscopically examined for the presence of S. stercoralis larvae. To avoid confusion of Strongyloides with hookworm larvae at microscopic examination, all larvae found were assessed for morphological characteristics .Koga agar (KA) plates were prepared as described elsewhere . A freshStrongyloides spp. as previously described on a fluorescence energy transfer (FRET)-based RTD-PCR format [S. stercoralis drug efficacy trial study [Blastocystis hominis, Chilomastix mesnili, Cryptosporidium hominis/parvum, Cyclospora cayetanensis, Cystoisospora belli, Dientamoeba fragilis, Encephalitozoon hellen, Entamoeba coli, E. dispar, E. hartmanni, E. histolytica, E. moshkovskii, Giardia lamblia, Hymenolepis nana, Iodamoeba bütschlii, Schistosoma mansoni, Taenia spp., Trichostrongylus spp., and was found to be 100%.RTD-PCR testing was performed on stool samples of 100 mg conserved in 90% ethanol and stored in 1.5 ml cryo tubes at ambient temperature. For isolation of nucleic acids from stool samples the QIAamp DNA mini kit  was used according to an optimized protocol from Barda and colleagues . The RTDR format . Primer al study , 19 (datχ2) or Fisher’s exact test, as appropriate, using Stata version 15 software . Cohen’s kappa coefficient was used to assess the diagnostic agreement of the different test methods  with calculation of the 95% confidence interval (CI) and standard error (SE). For all statistical test of correlation, a P-value < 0.05 was considered significant.The sensitivity, the specificity, the negative predictive value (NPV) of each diagnostic test, as well as their combination(s) was calculated using a composite reference standard (CRS). This CRS was defined as showing a positive result in any of the tests . The correlation of the different test methods was assessed by chi-square test  provided sufficient stool sample to perform all testing and hence were retained in the analysis. The sociodemographic and medical characteristics of these patients are shown in Table S. stercoralis infection according to the testing method(s) used is depicted in Fig. S. stercoralis prevalence ranged from 2.9 to 25.5% when wet smear and RTD-PCR diagnostic test was applied as a single diagnostic test, respectively. We used the combined results of the Baermann, KAPC and RTD-PCR diagnostic test as composite reference standard (CRS). The cumulative infection prevalence for the CRS was 33.7%. In wet smear and Baermann, an infection with Opisthorchis viverrini was found in 4.8% (n = 5) and infection with hookworm was detected in 2.9% (n = 3) of the patients.The prevalence of P = 0.184). The cumulative infection prevalence statistically significantly increased (P = 0.003) from the lowest age group of 40 years and below (22.4%), to the medium (40.0%) and to the oldest age group of 61 year and above (72.7%). The mean age of S. stercoralis infected patients was 40.4 years (SE = 2.7 years) and was statistically significantly higher (P = 0.004) than the age of S. stercoralis uninfected patients . The cumulative infection prevalence was 32.3% in patients from urban area and lower compared to patients from rural areas .The cumulative infection prevalence of CRS was considerably higher in male (40.4%) compared to female patients (28.1%) but not statistically different  of the total 35 PCR Fig. . Each teS. stercoralis when compared against the CRS are summarized in Table The sensitivity, the specificity, and the negative predictive value (NPV) of the different diagnostic methods to detect κ = 0.642). The diagnostic agreements between Baermann and RTD-PCR (κ = 0.589) and KAPC and RTD-PCR (κ = 0.534) were moderate.The diagnostic agreement of the different diagnostic tests according to Cohen’s kappa (κ) coefficient is shown in Table S. stercoralis infection among hospitalized patients in a semi-urban setting in Lao PDR. Previous work in a rural district of Southern Lao PDR showed a similar, though slightly higher prevalence of 41.0% [S. stercoralis infection currently remains restricted to the highly insensitive direct microscopy of wet smear preparations, the identification of infected individuals remains highly problematic and the true infection burden underestimated in Lao PDR and many low- and middle income settings in Southeast Asia.With a cumulative prevalence 33.7%, our data demonstrate a high prevalence of of 41.0% . HoweverS. stercoralis in stool samples are Baermann, KAPC, and PCR, we chose these three techniques as CRS for our study. We want to note that our study is the first one to include PCR for determining the prevalence of S. stercoralis infection in Laotian patients. Although the implementation of PCR in routine diagnostic at Mahosot Hospital and other provincial and tertiary hospitals is currently not feasible, we nevertheless included PCR in our study to ensure evaluating Baermann and KAPC against the best possible CRS and to evaluate the potential future diagnostic value of PCR in this setting.Since currently the most sensitive diagnostic methods to detect S. stercoralis infections  to 22.7% (2 samples) to 24.4% (3 samples) which was close to the mathematically modelled “true” prevalence rate of 24.8% [Since sitivity . AlthougS. stercoralis epidemiology from Southeast Asia indicate that S. stercoralis infection are predominately found in men, that the infection increases with age and that rural populations have a higher risk for infection [S. stercoralis patients follow these typical risk patterns although they have been recruited from a health services and not as the previous indicated studies from the community.Studies on nfection , 10, 14.S. stercoralis diagnosis between the diagnostic techniques could be demonstrated, a more refined picture could have been drawn with a larger sample. Furthermore, including an analysis of several stool samples per patient would have further strengthened the validity of our results. However, already in about a third of our enrolled patients the provision of a stool sample was not possible. Increasing the stool collection would have further diminished patient compliance.Our study would have benefited from a larger sample size. Although the major differences in yielding S. stercoralis in stool samples can be increased by parallel testing with different methods or by serial testing of several stool samples. The chosen strategy in daily clinical practice depends on the locally available resources and the desired certainty to detect or exclude S. stercoralis infection in an individual patient .In summary, the imperfect sensitivity of all currently available diagnostic methods for detecting S. stercoralis prevalence of 33.7% was detected among in-patients of the Infectious Diseases Ward at Mahosot Hospital, Vientiane. We identified the combination of the Baermann technique and KAPC to be currently the most feasible and implementable standard for diagnosing S. stercoralis at Mahosot Hospital, and provincial and district hospital of Lao PDR and other low- and middle-income settings in Southeast Asia. Serial testing with this combination will be considered in cases where exclusion of S. stercoralis infection is of high clinical relevance (i.e. patients at risk for hyperinfection syndrome and disseminated strongyloidiasis).A very high


Abutilon theophrasti Medik. is an annual weed, widely distributed in Asia and Europe. The complete chloroplast genome reported here is 160,446 bp in length, including two inverted repeats (IRs) of 25,064 bp, which are separated by a large single-copy (LSC) and a small single-copy (SSC) of 89,089 and 21,229 bp, respectively. The whole chloroplast genome of A. theophrasti contains 113 distinct genes, including 79 protein-coding genes, 30 transfer RNA, and four ribosome RNA. Phylogenetic analysis indicated that A. theophrasti is located in the basal position in Malveae. Abutilon theophrasti Medik. (velvetleaf) is an annual plant native to southern Asia but now a widespread agricultural weed throughout the western hemisphere. It has strong vertical stems that can grow to 3–8 feet and covered with densely stellate pubescent. Although velvetleaf is detrimental to many crops if not controlled, it can be used as a potential commercial crop . Voucher specimen was stored at the herbarium of Institute of Chinese Materia Medica (CMMI), China Academy of Chinese Medical Sciences with the specimen voucher number is 341322LY0448. Total genomic DNA was isolated using a DNeasy Plant Mini Kit . And the sequencing library was constructed and quantified following the methods introduced by Dong et al.  as the reference. The selected contigs were assembled using Sequencher version 4.10 . Gene annotation was performed with Plann  contained double introns.The complete chloroplast genome reported here is 160,446 bp in length, including two inverted repeats (IRs) of 25,064 bp, which are separated by a large single-copy (LSC) and a small single-copy (SSC) of 89,089 bp and 21,229 bp, respectively. The overall GC-content of the chloroplast genome was 36.9%. The chloroplast DNA of A. theophrasti is located in the basal position in Malveae (A. theophrasti provided a lot of genetic information for species conservation and identification of Malvaceae.We downloaded 22 published chloroplast genomes of Malvaceae and other four chloroplast genomes as outgroup taxa from Genbank to perform the phylogenetic reconstruction. All chloroplast genome sequences were aligned using MAFFT online (Katoh et al.  Malveae . The chl


This study evaluates the outcomes and toxicity of stereotactic body radiation therapy (SBRT) in ovarian cancer.This retrospective analysis considered all patients treated with SBRT from 2009 to 2018 with a primary ovarian tumor. Follow-up included PET-CT and CT scans at 2–3 month intervals. Statistical analysis primarily consisted of univariate analysis, Cox proportional hazards analysis, and the Kaplan-Meier method.p = 0.0024) and PFS (p = 0.044). Factors predictive of local failure included lower BED (p = 0.016), treatment for recurrence (p = 0.029), and higher pre-treatment SUV (p = 0.026). Kaplan-Meier analysis showed BED ≤35 Gy (p < 0.005) and treatment for recurrence (p = 0.01) to be predictive of local failure. On Cox proportional hazards analysis, treatment of lymph nodes was predictive of complete radiographic response (hazard ratio (HR) = 4.95), as was higher BED (HR = 1.03). Toxicity included 27 cases of grade < 3 toxicity, and one grade 5 late toxicity of GI bleed from a radiation therapy-induced duodenal ulcer.The study included 35 patients with 98 treatments for lymph nodes (51), local recurrence (21), and de novo solid metastases (26). Median biologically effective dose (BED), gross tumor volume, and planning target volume were 38.40 Gy, 10.41 cc, and 25.21 cc, respectively. 52 lesions showed complete radiographic response, and two-year local control was 80%. Median overall survival (OS) was 35.2 months, and two-year progression-free survival (PFS) was 12%. On univariate analysis, Eastern Cooperative Oncology Group performance status > 0 was predictive of decreased OS (SBRT provides durable local control with minimal toxicity in ovarian cancer, especially with BED > 35 Gy and treatment for lymph nodes. Ovarian cancer is a heterogeneous disease without clear screening guidelines for early detection –5. It isA variety of radiation techniques are currently being considered in the management of ovarian cancer, including intensity-modulated radiotherapy, stereotactic body radiotherapy (SBRT), and low-dose hyperfractionation combined with targeted agents , 16. PosSBRT, also known as stereotactic ablative radiotherapy (SABR), is a radiation therapy strategy that involves delivering high doses of radiation to the tumor in relatively few treatments (about 3–6) . SBRT haThe role of SBRT in metastatic gynecologic cancer has also been studied and found to be safe and efficacious, particularly when targeting lymph node recurrences , 33. TheThis retrospective analysis considered all patients at a single institution treated with SBRT for a primary ovarian tumor from April 2009–November 2018. An intention-to-treat model was undertaken, so each patient treated was included in the analysis. No exclusion criteria were specified, so patients were included regardless of the SBRT target . Treatment for recurrence was further delineated into local, regional, and distant recurrence. Local recurrence was defined as a previously treated lesion that had grown in size on imaging. Previous treatment may have included surgical resection, chemotherapy, and radiation therapy. New lesions arising within the planning target volume (PTV) of previous radiotherapy were also included as local recurrences. Regional recurrence was denoted as new disease in proximity to a previous lesion and without an anatomic barrier separating the lesions. For instance, a new abdominal lesion in the setting of prior abdominal disease would be deemed a regional recurrence. Other disease progression not meeting these criteria was denoted as distant recurrence. Patients of all pathological subtypes were included, and the corresponding histology was recorded.18FDG, and the target of the CT scan varied, depending on the location of the SBRT target. Most frequently, CT abdomen/pelvis was used. Key dosimetric data included the dose, fractions, days between fractions, and the dose-fractionation scheme of any prior radiation. An alpha/beta ratio of 10 Gy was used for calculations of the biologically effective dose (BED), using the formula BED = total dose * . The study was exempt by the institutional review board.The number of treated lesions and the performance status were recorded for each patient, and no restrictions were made regarding the maximum lesion size for inclusion in the study. The authors decided that since no explicit exclusion criteria regarding lesion size have been developed in the setting of ovarian cancer, all patients treated with SBRT for ovarian cancer should be included. Pre- and post-chemotherapy CA125 levels were noted, as was each patient’s response to chemotherapy. Prior and subsequent treatments were also included, as were each patient’s platelet, lymphocyte, and neutrophil counts prior to and after treatments (when available). Follow-up included PET-CT and CT imaging at 2–3 month intervals, and standardized uptake values (SUV) and CA125 lab values were recorded prior to and after treatment. PET-CT generally involved total body scans using Patients were immobilized prior to planning the CT scan using a full-body vacuum bag system for position stabilization and consistency. Dose was prescribed to the PTV, which was defined as the gross tumor volume (GTV) plus 3–5 mm of margin to account for uncertainties in imaging and localization. In general, a three-dimensional conformal treatment planning approach was used with non-coplanar gantry angles to minimize dosimetric overlap of entrance and exit portals. Intensity-modulated radiotherapy and volumetric-modulated arc therapy were considered, but they were not used in this setting. Treatments were instead completed with multiple non-coplanar static gantry delivery. SBRT was delivered using a 6MV photon beam on a linear accelerator with a 2.5 mm–4 mm width multi-leaf collimator for custom shaping of portals. An on-board cone-beam CT was used prior to treatment to align the patient. It was also used several times  during treatment to correct for intra-fraction movement. A robotic couch with six degrees of freedom assisted in the alignment of the patient and localization of the target to the planning CT. Treatments were generally delivered once weekly. The median days between fractions was reported in a non-inclusive manner, such that there were 6 days between once-weekly treatments.The key endpoints of the analysis involved overall survival (OS), local control, and radiographic response. Progression-free survival (PFS) and time to salvage were secondary endpoints. Two-year local control and two-year PFS were determined using the Kaplan-Meier method. Patient follow-up was generally conducted by radiation oncology, hematology-oncology, or gynecologic-oncology. Imaging was used to classify treatment response as progressive, stable, partial, or complete. Any treatment failure was also noted on imaging, and it was distinguished as local, regional, or distant failure. Acute and chronic toxicity findings were tabulated according to the Common Terminology Criteria for Adverse Events v5.0. Ninety days was the cutoff for delineating acute from chronic toxicity.Statistical analysis was conducted for each treated lesion to analyze local control and radiographic response, and survival analysis was performed for each patient treated. Predictive factors for overall survival and local control were assessed via Cox proportional hazards regression analysis and univariate analysis, with an alpha value of 0.05. Local control and overall survival were further described using the Kaplan-Meier method, including distinctions between the overall survival and local control of different subgroups of the cohort.Thirty-five patients with ninety-eight treated lesions were included. Seventeen patients were treated for one lesion, but eighteen patients were treated for at least two distinct lesions with SBRT, including seven patients receiving at least 5 treatments. Of patients with multiple treatments, five patients had only synchronous lesions, seven had only metachronous lesions, and six suffered from both synchronous and metachronous lesions. The time of presentation for SBRT was a median 44.81 months after primary diagnosis. Only two patients presented for SBRT within 12 months of primary diagnosis. Twenty-one (60%) patients had Eastern Cooperative Oncology Group (ECOG) performance status 0 at the time of consultation for SBRT. Five patients (14%) had a diagnosed BRCA1 mutation, and 2 (6%) were positive for homologous recombination deficiency. The majority of patients (66%) had a serous papillary adenocarcinoma on pathologic review, and the other subtypes included clear cell, transitional cell, granulosa cell, endometrioid, carcinosarcoma, mucinous, and other poorly differentiated tumors . Of these, twenty-two treated lesions initially presented with nodal spread, and only ten presented with T stage less than 3. Most tumors were grade 3 on pathologic review (74%), and only one case involved a well-differentiated, grade 1 tumor. Surgical interventions were varied. They included a range of primary goals: exploration (11%), debulking (34%), lymph node resection or sampling (14%), omentectomy (31%), peritoneal stripping (11%), and bowel resection (37%). Some form of total abdominal hysterectomy with or without unilateral or bilateral oophorectomy was also undertaken in 49% of cases. Many patients (40%) still had gross residual disease after the initial debulking surgery, but 78.4% of patients were sensitive to chemotherapy. All but one chemotherapy regimen included carboplatin. The treatments included carboplatin and paclitaxel (83%), carboplatin alone (6%), carboplatin and docetaxel (9%), carboplatin and gemcitabine (3%), cisplatin and paclitaxel (3%), and carboplatin, gemcitabine, and bevacizumab (3%). Four patients used two primary chemotherapy regimens, and the median number of cycles of chemotherapy was six. CA125 was reduced after chemotherapy in the majority of cases. Six patients (17%) had received radiotherapy prior to SBRT. Five of these treatments were related to ovarian cancer, including whole pelvis radiotherapy, radiotherapy for bone metastases, and brachytherapy.p = 0.03) and PTV (p = 0.003) relative to treatments for lymph nodes.The median dose and fractionation were 24 Gy in 4 fractions, with a median 4 days between fractions. The most common dose-fractionation schemes were 20–24 Gy in 3–4 fractions (55%), 30–40 Gy in 3–5 fractions (26%), and 15–18 Gy in 3–4 fractions (14%). Median BED was 38.40 Gy, and median GTV and PTV were 10.41 and 25.21 cc, respectively. There was no limit imposed on the maximum GTV for inclusion in the study, so large tumors were also included (maximum GTV of 272.37 cc). Even so, lesions were generally smaller. Only seven treatments involved a GTV > 50 cc. Concurrent chemotherapy was involved in only six cases. Treatments were for lymph nodes (51), local recurrence (21), and de novo solid metastases (26). Treatments for local recurrence generally involved abdominal soft tissue (62%) or perigastric (19%) targets after surgical intervention and chemotherapy. In six instances, local recurrence involved re-treatment with SBRT, and in fifteen cases, radiotherapy followed treatment failure of surgery or chemotherapy. Of patients treated for de novo metastases, 77% of treatments targeted liver metastases, with the spleen, lung, and bone comprising the other treated locations  showed complete radiographic response, and partial response, lesion stability, and tumor progression were reported in 21, 12, and 1% of cases, respectively. Lesion size decreased a median 29.2% after SBRT on the first imaging follow-up. Local control was maintained in 81 cases, resulting in a two-year local control rate of 80% (Table p = 0.0024) and PFS (p = 0.044). On the other hand, factors predictive of local failure on univariate analysis included lower BED (p = 0.016), treatment for recurrence (p = 0.029), and higher pre-treatment SUV (p = 0.026). Treatment of liver metastases was also predictive of local control (p = 0.025). On Cox proportional hazards analysis, larger GTV volume was predictive of local failure (hazard ratio (HR) =1.04), but the prognostic impact of the treatment target led to wide confidence intervals (Table p < 0.005), as was treatment for recurrence (p = 0.01)  Figs. . Kaplan-p = 0.0030) and higher pre-treatment SUV (p = 0.035). Additionally, target size trended towards significance (p = 0.071). On Cox proportional hazards analysis, treatment of lymph nodes was predictive of complete radiographic response (HR = 4.95), as was higher BED (HR = 1.03) , erythema (2 cases), and diarrhea (2 cases). Acute grade 2 toxicity involved nausea and vomiting (three cases) and pain (two cases) .Local failure was one of the principal endpoints of this study, and the results were encouraging, with 83% local control at a median follow-up time of 33.67 months. This follow-up time is quite extensive, as many studies regarding SBRT for ovarian cancer include only 12–24 months of follow-up. The largest study to date of SBRT in oligometastatic ovarian cancer was written by Macchia, et al., a multi-institutional study of 15 centers considering 446 lesions treated in 261 patients, and the results were quite similar to those presented here. At a median follow-up of 22 months, the 24-month actuarial local control rate was 81.9%. Local control was associated with complete radiographic response and total dose > 25 Gy . Iftode 18FDG-PET/CT have also been shown to be predictive of complete response [In this analysis, factors predictive of local failure included BED ≤35 Gy, larger GTV, treatment for recurrence, and higher pre-treatment SUV. Treatment of liver metastases was also predictive of local control. Unfortunately, it is difficult to directly compare these results to literature values because the few studies concerning this topic have either not included sufficient numbers of treatments for such analyses or have focused on a different endpoint. Radiographic response has been used as a surrogate for local control, and it was the chief endpoint presented by Lazzari et al. Macchia et al. found that age ≤ 60 years, PTV ≤ 18 cc, lymph node disease, and BED > 70 Gy were associated with complete radiographic response. These factors were not found to be directly correlated with local control. In this analysis, complete response was observed in 52 cases, which is 53% of all cases included in the study but 60% of all cases with follow-up imaging. This result is quite consistent with literature values of 61.8–65.2% , 35. Herresponse . These fThe concept of higher dose delivery resulting in improved local control and even improved survival rates has been observed with SBRT in other solid malignancies , 37, 40.p = 0.0024) and PFS (p = 0.044). It is possible that the patients in this study had relatively high performance statuses compared with other ovarian cancer patients, as 60% of patients had ECOG 0 and 31% had ECOG 1. On the other hand, the majority of patients in this study (51%) were treated with SBRT for multiple lesions. This was in the context of a progression-free survival of 7.2 months and median time to salvage of 4.29 months. Lazzari et al. noted a similar treatment-free interval after SBRT of 7.4 months [Survival in this patient cohort was quite impressive, with a median overall survival of 35.2 months. This value is much higher than the poor survival generally presented in the literature . ECOG > 4 months . The dev4 months . FurtherToxicity in this study was quite low overall, with 22 cases of grade 1 toxicity, five instances of grade 2 toxicity, and one grade 5 late toxicity of GI bleed from what was believed to be a radiation therapy-induced duodenal ulcer. The most common side effects of nausea, vomiting, and fatigue were not severe. These were also relatively non-specific symptoms that may have been related to the primary disease process. There was only 1 case of grade ≥ 3 toxicity, which involved the grade 5 GI bleed. Similarly, Macchia et al. reported that only 20.7% of patients suffered from any toxicity, none of which was grade ≥ 3 . LazzarThis study suffers from some limitations regarding the inclusion of only 35 distinct patients. This could serve to depress the ability of the authors to determine prognostic factors regarding survival and could lead to high variance in the survival outcomes. Additionally, the inclusion of treatments involving local relapse may represent a significance weakness of the present analysis. It was shown that treatments for recurrence had increased rates of local failure, and they may represent a distinct clinical question from treatments for lymph nodes or de novo solid metastases. Further study is recommended to clarify this distinction, as well as the role of systemic treatment in this setting. Relatively low prescription doses were used in this study. It is possible that higher doses might have improved the complete response rate, and further study into the use of higher doses is recommended.The authors were able to analyze a large cohort of lesions treated with SBRT from primary ovarian cancer at a single institution and present the findings that the technique was associated with high rates of local control, impressive survival, and minimal toxicity. Patients with BED ≤35 Gy, larger GTV, and treatment for recurrence had increased local failure while those with treatments for lymph node disease had improved local control.


Histoplasma capsulatum peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD).Fungal peritonitis (FP) is a rare complication of peritoneal dialysis. We herein describe the second case in Asia of H. capsulatum. The peritoneal dialysis (PD) catheter was then removed, and it also grew H. capsulatum after 20 days of incubation. The patient was switched from CAPD to hemodialysis. The patient was successfully treated with intravenous amphotericin B deoxycholate (AmBD) for 2 weeks, followed by oral itraconazole for 6 months with satisfactory result. The patient remains on hemodialysis and continues to be clinically stable.An 85-year-old woman with end-stage renal disease (ESRD) who had been on CAPD for 3 years and who had a history of 3 prior episodes of peritonitis presented with intermittent abdominal pain for 2 weeks and high-grade fever for 3 days. Elevated white blood cell (WBC) count and rare small oval budding yeasts were found in her peritoneal dialysis (PD) fluid. From this fluid, a white mold colony was observed macroscopically after 7 days of incubation, and numerous large, round with rough-walled tuberculate macroconidia along with small smooth-walled microconidia were observed microscopically upon tease slide preparation, which is consistent with H. capsulatum peritonitis is an extremely rare condition that is associated with high morbidity and mortality. Demonstration of small yeasts upon staining of PD fluid, and isolation of slow growing mold in the culture of clinical specimen should provide important clues for diagnosis of H. capsulatum peritonitis. Prompt removal of the PD catheter and empirical treatment with amphotericin B or itraconazole is recommended until the culture results are known. Candida spp. was the predominant pathogen causing FP in many previous studies [Candida spp. is only rarely reported. Herein, we report a case and literature review of fungal peritonitis caused by Histoplasma capsulatum that presented with fever and subacute-onset of abdominal pain.Fungal peritonitis (FP) is a rare and serious complication of chronic peritoneal dialysis (PD), and it is associated with a high rate of hospitalization, catheter removal, permanent transfer to hemodialysis, and death . Althoug studies . FP causAn 85-year-old woman with end-stage renal disease (ESRD) presented with abdominal discomfort and high-grade fever for 2 days. She was diagnosed ESRD in 2017, and has been treated with peritoneal dialysis (PD) since then. Two weeks after catheter insertion, she had difficulty draining infused dialysate fluid due to catheter malposition, which required repositioning of Tenckhoff catheter owing to partial catheter obstruction from a fibrin clot. Since that revision, she has been on continuous ambulatory peritoneal dialysis (CAPD) without further mechanical complication. However, there were 3 episodes of CAPD-related infection that occurred within 6 months of her most recent admission.3, with 55% neutrophils, 37% lymphocytes, and 8% eosinophils. Culture-negative PD-associated peritonitis was diagnosed since blood and PD fluid cultures for aerobic bacteria reported no growth. She was successfully treated with intraperitoneal cefazolin and ceftazidime for 14 days. The second episode occurred in September 2019. Due to recurrent catheter malposition from omental wrapping, she underwent a second revision of her PD catheter. After the operation, she had a high-grade fever with non-specific organ symptoms. PD fluid analysis showed a WBC count of 103 cells/mm3, with 65% neutrophils, 21% lymphocytes, and 10% eosinophils. Blood and PD fluid culture for aerobic bacteria were no growth. Computed tomography (CT) of the whole abdomen revealed no intra-abdominal collection, and that the tip of the PD catheter was in the proper position. She then gradually improved with a reduction of WBC in PD fluid to 7 cells/mm3 after treatment with intraperitoneal cefazolin and ceftazidime for 14 days. The third episode occurred near the end of December 2019 when she presented with a high-grade fever, nausea, and vomiting, but without any remarkable physical findings. Two sets of blood culture revealed alpha-hemolytic streptococci. PD fluid analysis revealed a WBC count of 14 cells/mm3 without differential count due to a low cell count, and culture revealed a rare colony of alpha-hemolytic streptococci. Streptococcal PD-associated peritonitis and septicemia were diagnosed, and she was successfully treated with intravenous ceftriaxone for 14 days. Fungal culture of PD fluid was not sent during any of the first three episodes of culture negative peritonitis.The first episode started in August 2019 when she had cloudy PD fluid effluent without fever or abdominal complaint. Peritoneal fluid analysis showed white blood cell count (WBC) of 268 cells/mm3, with 86% neutrophils, 11% lymphocytes, and 1% eosinophils. She was then empirically treated with intraperitoneal vancomycin and ceftazidime. Gram stain of PD fluid revealed few polymorphonuclear cells with no observed bacteria; however, small oval budding yeasts were demonstrated. PD fluid culture for bacteria was sent. The culture for fungus was first sent after recurrent peritonitis that occurred within the past 5 months. Therefore, oral fluconazole 100 mg/day was given concurrently with intraperitoneal antibiotic administration. After intraperitoneal antibiotic and fluconazole treatment for one week, her fever and abdominal pain were gradually improved. Peritoneal fluid analysis showed a marked decrease in white cell count (1 cell/mm3), culture of dialysis fluid showed no evidence of bacterial growth, and fungal culture was still pending.In January 2020 or 2 weeks prior to her most recent admission, she was complaining of intermittent abdominal pain during drainage of dialysate fluid from her abdomen and a low-grade fever for 3 days. Her PD fluid effluent had also become cloudy. She was febrile with a temperature of 38.2 ͦ C, but reported no abdominal tenderness on physical examination. PD fluid analysis revealed a WBC count of 380 cells/mmDespite treatment with intraperitoneal antibiotic and oral fluconazole 100 mg daily for 2 weeks, she developed recurrent abdominal discomfort, loss of appetite, cloudy PD effluent for 3 days, and high-grade fever for 1 day prior to admission. She was then admitted on 24 January 2020. On examination, her body temperature was 38.4 °C, and generalized abdominal tenderness was found. All other examination findings, including investigation for PD catheter exit site infection, were unremarkable.3, with 92% neutrophils, 8% lymphocytes, and rare red blood cells (RBC). Gram stain of the dialysate effluent still demonstrated rare small oval budding yeasts  revealed a WBC count of 11,340/μL, with 83.5% neutrophils, 9.5% lymphocytes, and 0.2% eosinophils; a hemoglobin level of 9.9 g/dL; and, a platelet count of 295,000 /μL. Blood chemistry showed a high level of creatinine, which was consistent with her renal disease. Analysis of her PD fluid effluent showed an elevated WBC count of 278 cells/mmH. capsulatum  0.7 mg/kg/day. The Tenckhoff catheter was removed on the day after admission due to suspected fungal peritonitis. Intraoperative finding revealed turbid dialysate fluid and fibrotic scar at the exit site of the peritoneal dialysis catheter. Renal replacement therapy was switched to intermittent hemodialysis via a newly inserted temporary double-lumen catheter at the right internal jugular vein. Bacterial culture reported no growth thereafter. After two weeks of hemodialysis, a white colony of mold was observed macroscopically from a fungal culture taken two weeks prior to admission Fig. . Microsctum Fig. . AnotherH. capsulatum peritonitis. Intravenous AmBD at a dose of 0.7 mg/kg/day was continued for a total of 2 weeks, followed by oral itraconazole capsule 600 mg daily for 3 days, and 200 mg twice daily thereafter. Our patient’s abdominal pain and fever were gradually improved. She was discharged and subsequently given a course of oral itraconazole 200 mg twice daily for a total duration of 6 months. The patient was continued on hemodialysis and is currently stable. No adverse event of itraconazole was observed during follow-up.The final diagnosis was CAPD-associated H. capsulatum peritonitis is an extremely rare infectious complication in chronic PD patients. Approximately 3–6% of all peritonitis episodes in patients undergoing PD were caused by fungus, and Candida spp. is the most often reported group of fungal pathogens [CAPD-associated athogens . ReporteH. capsulatum peritonitis have been published. We identified only 7 case reports of H. capsulatum peritonitis in CAPD patients published over the past three decades  in 2016, the administration of antifungal agents and immediate catheter removal are recommended when fungi are identified in PD effluent [itonitis . Most pritonitis –10. Our H. capsulatum peritonitis is an extremely rare condition that is associated with high morbidity and mortality. Demonstration of small yeasts upon staining of PD fluid, and isolation of slow growing mold in the culture of clinical specimen should provide important clues for diagnosis of H. capsulatum peritonitis. Prompt removal of the PD catheter and empirical treatment with amphotericin B or itraconazole is recommended until the culture results are known.In conclusion,


Clostridioides difficile is the leading cause of nosocomial infections and a worldwide urgent public health threat. Without doubt, there is an urgent need for new effective anticlostridial agents due to the increasing incidence and severity of C. difficile infection (CDI). The aim of the present study is to investigate the in vivo efficacy of auranofin (rheumatoid arthritis FDA-approved drug) in a CDI mouse model and establish an adequate dosage for treatment. The effects of increased C. difficile inoculum, and pre-exposure to simulated gastric intestinal fluid (SGF) and simulated intestinal fluid (SIF), on the antibacterial activity of auranofin were investigated. Auranofin’s in vitro antibacterial activity was stable in the presence of high bacterial inoculum size compared to vancomycin and fidaxomicin. Moreover, it maintained its anti-C. difficile activity after being exposed to SGF and SIF. Upon testing in a CDI mouse model, auranofin at low clinically achievable doses (0.125 mg/kg and 0.25 mg/kg) significantly protected mice against CDI with 100% and 80% survival, respectively. Most importantly, auranofin (0.125 mg/kg and 0.25 mg/kg) significantly prevented CDI recurrence when compared with vancomycin. Collectively, these results indicate that auranofin could potentially provide an effective, safe and quick supplement to the current approaches for treating CDI. Clostridioides difficile is the worldwide leading cause of nosocomial infections and antibiotic-associated diarrhea1. A recent report released by the Centers for Disease Control and Prevention (CDC) stated that about 223,900 patients were hospitalized with C. difficile infections (CDI) in the United States in 2017, which was associated with around 12,800 mortality cases and in excess of $1 billion healthcare cost2.3. Disease manifestations are attributed to the toxin-mediated damage elicited by the two major toxins TcdA and TcdB. These toxins catalyze inactivation of host GTPases  and perturbation of actin cytoskeleton, ultimately causing intense inflammation, loss of tight junctions of the intestinal mucosal layer, enormous fluid secretion, cell rounding and finally necrosis and apoptosis of the colonic mucosal cells5. The incidence and severity of CDI has increased dramatically due to the overuse of antibiotics and the emergence of hypervirulent epidemic strains such as, but not limited to, pulsed-field gel type North American pulsotype 1 (NAP1) or PCR ribotype 027, which were responsible for several outbreaks globally7. Moreover, the clinical management of CDI is hindered by the ability of C. difficile to produce spores which are highly resistant to environmental conditions, antibiotics and disinfection processes. Spores can persist on unsuitable environments for long periods and spread in the environment8. Once ingested by susceptible hosts, these spores germinate, in response to bile acids in the gut, into vegetative cells that colonize in the intestine, produce toxins and establish infection9. Consequently, C. difficile spores serve as the major cause CDI dissemination and recurrence.CDI symptoms range from mild to severe watery diarrhea to more severe life threatening complications such as pseudomembranous colitis, toxic megacolon, colon perforation, sepsis, systemic inflammatory response syndrome and shock10. Vancomycin or metronidazole treatments are limited by the high treatment failure , and the high recurrence rate (25–30%)11. Furthermore, fidaxomicin has lower recurrence rate due to its less disturbance effect on gut microbiota; yet, its high cost restricts its use14. Further compounding the CDI problem is the emerging resistance or reduced susceptibility to these antibiotics15. Thus, the critical and the unmet need for developing new anti-CDI therapeutics cannot be overemphasized.Even though the overuse of antibiotics is responsible for CDI, the management of CDI requires antibiotic administration. Currently, only two drugs are approved for treatment of both non-severe and severe CDI; vancomycin and fidaxomicin. While metronidazole is not FDA-approved for treatment of CDI, it was previously recommended as a first-line therapeutic option for CDI in adults. It use is now restricted to non-severe CDI cases when patients are unable to obtain or be treated with vancomycin or fidaxomicin17. Recently, auranofin has gained interest in repurposing for treatment of bacterial and parasitic infections23. Furthermore, it is undergoing Phase II clinical trials for the treatment of amoebic dysentery, giardiasis (NCT02736968) and tuberculosis (NCT02968927). Auranofin possesses strong antibacterial and antifungal activities25. We previously demonstrated that auranofin has a potent anticlostridial activity with strong inhibition of both toxins and spores production in vitro24. We hypothesized that auranofin’s potent antibacterial and antivirulence activity against C. difficile would be beneficial in treating mice infected with C. difficile in an in vivo CDI mouse model. The main objective of the present study was to investigate the in vivo efficacy of auranofin treatment in a CDI mouse model and to study the ability of auranofin to prevent CDI recurrence. In addition, this study established the doses needed to achieve 100% protection in CDI mouse model and prevent recurrence. The impact of increasing C. difficile inoculum, and its pre-exposure to simulated gastric fluid and simulated intestinal fluid, on the antibacterial activity of auranofin were also investigated.Auranofin is an FDA-approved anti- rheumatoid arthritis drug, with a well-studied safety profile for human useC. difficile is known to colonize the intestinal tract in large populations. Additionally, a higher inoculum (~106 CFU/mL) is often used to infect animals in in vivo CDI models. It was reported that the bacterial burden recovered from cecal and fecal contents of infected mice had averages of ~106 to 107 CFU/g28. The dependence of the antibacterial activity of anticlostridial drugs on the inoculum effect is an important consideration, especially for a weakly absorbed drug like auranofin (85% of the administered dose is not absorbed and recovered in feces)29. After being administered orally, auranofin will be localized in the gut, and target the colonizing C. difficile populations. However, the standard antibacterial susceptibility assays typically evaluate test agents at a lower inoculum size (~105 CFU/mL). Thus, we evaluated the impact of the high C. difficile inoculum , compared with the standard inoculum , on the antibacterial activity of auranofin. Upon testing against SI, auranofin exhibited a potent in vitro activity against the C. difficile strains tested with MIC values ranging from 0.25–1 µg/mL . Additionally, its MIC90 with the HI was the same as that of the SI. Conversely, vancomycin’s activity was negatively impacted by the increased inoculum size , in accordance with a previous report30. Additionally, its MIC90 with the HI was one-fold higher than that of the SI.noculum ~06 CFU/mLnoculum ~06 CFU/mL31. Drugs stability in presence of the GIT fluids can be investigated by incubating the drug in simulated gastric fluid (for 1-2 hours) and simulated intestinal fluids (for 3-4 hours) to mimic the in vivo drug exposure to these fluids32. To investigate the effect of SGF and SIF on the antibacterial activity of auranofin against C. difficile, auranofin, and vancomycin and fidaxomicin (control antibiotic) were incubated with SGF and SIF for 2, 4 and 24 hours and their MICs against 2 clinical C. difficile strains were determined. As depicted in Table C. difficile ATCC BAA 1870, even after 24 hours exposure, and increased by one-fold only against C. difficile ATCC 43255 after 24 hours exposure. This result suggests that auranofin was stable after exposure to the gastric pH and was not affected by the enzymes of gastric fluids. Similarly, vancomycin and fidaxomicin MICs (after exposure to SGF) were similar to or one-fold higher than their corresponding MICs in absence of SGF. Furthermore, auranofin MICs, after incubation with SIF up to 24 hours, were equal to or one-fold higher than its MIC without incubation with SIF . The stability of a drug in gastric and intestinal fluids provides evidence whether it is prone to degradation process by the effect of GIT fluids prior to absorptionIF Table , suggestIF Table . This reC. difficile24 in addition to its stability in SGF and SIF prompted us to investigate its efficacy in a CDI mouse model and its potential to protect mice from CDI recurrence. In our study, CDI was established first before treatment. Three groups of mice were treated with  of auranofin. Two additional groups were used, positive control (vancomycin) and negative control (vehicle) groups. Mice were treated with the corresponding drugs for 5 days and monitored for disease symptoms. As shown in Fig. 33. In addition, auranofin, at low clinically achievable concentration (0.125 mg/kg), was able to protect 100% of the mice against C. difficile during the 5-days treatment period. Interestingly, the higher doses (0.25 mg/kg and 0.5 mg/kg) protected only 80% and 40% of mice, respectively. There was no significant difference in survival between vancomycin-treated, and auranofin (0.25 mg/kg)- treated groups. This effect (lower dose more effective) could be due to the potent anticommensal activity of auranofin against the human gut intestinal microbiota34, which could increase by increasing the administered dose leading to establishment of C. difficile colonization in the intestine and higher mortality. This activity was also, reported for niclosamide against C. difficile where the lower dose (2 mg/kg) protected mice from CDI more effectively than higher doses (10 mg/kg and 50 mg/kg)35. The effectiveness of lower dose of auranofin could also be explained by their potent anti-inflammatory activity. It was reported that the anti-inflammatory drug, indomethacin, increased the severity of C. difficile infection in mice36. Additionally, in previous study investigating the efficacy of auranofin against vancomycin-resistant enterococci peritonitis, lower doses of auranofin provided the best protection (100%)37. Moreover, Fig. The potent antibacterial and antivirulent activities of auranofin against 42. In addition to subsequent prolongation of C. difficile shedding and transmission, 1 out of every 5 patients experienced C. difficile recurrence episode died within 30 days of diagnosis43. Then, we sought to investigate this promising activity of auranofin in preventing C. difficile recurrence. Mice were infected and treated for 5 days and mice were monitored for survival and possible C. difficile recurrence until the 20th day. Vancomycin-treated mice, in accordance with a previous study33, were susceptible to C. difficile recurrence where 60% of mice died after stopping vancomycin treatment. In contrast, auranofin (0.125 mg/kg and 0.25 mg/kg), significantly protected mice from CDI recurrence with 100% and 80% survival, respectively after 20 days  started to increase till they reached the normal weight. In contrast, auranofin-treated (0.125 mg/kg and 0.25 mg/kg) groups maintained a stable body weight along the duration of the experiment.Symptomatic recurrence of CDI occurs in approximately 20% of patients and is challenging to treat45. Consequently, the most effective dose in this study, (0.125 mg/kg), is within range of doses administered clinically to humans. In addition, the therapeutic benefits and toxicity profile of auranofin have been monitored in clinical trials in more than 5,000 rheumatoid arthritis patients taking the drug and some of whom were monitored for more than 7 years. Auranofin did not show any evidence of cumulative toxicity and it was approved by the FDA for long-term treatment of rheumatoid arthritis in 198546. Furthermore, auranofin is approved for long-term treatment of rheumatoid arthritis, a much greater course than would be expected for anticlostridial therapeutics.A point worth noting, auranofin doses used in this study are achievable clinically. The recommended long term dosing regimen of auranofin in adult patients is 6-9 mg daily, and 0.1–0.25 mg/kg/day for children, in a single dose or divided dosesin vitro antibacterial activity was stable in the presence of high bacterial inoculum size compared to vancomycin and fidaxomicin. Moreover, it maintained its anti-C. difficile activity after being exposed to SGF and SIF. Interestingly, it significantly protected mice against CDI at low doses (0.125 mg/kg and 0.25 mg/kg). Most importantly, auranofin (0.125 mg/kg and 0.25 mg/kg) significantly prevented CDI recurrence. These results indicate that auranofin warrants further investigation as a new CDI treatment option.In conclusion, this study investigated the effectiveness of auranofin, at clinically achievable doses, as a CDI therapeutic. Auranofin’s C. difficile strains (Table 2PO4) , vancomycin hydrochloride, gentamicin sulfate, kanamycin monosulfate, taurocholic acid , metronidazole , and colistin sulfate, fidaxomicin  were purchased commercially.All experiments were performed following the relevant guidelines and regulations of the Purdue University Institutional Biosafety Committee. ns Table  were obtC. difficile inoculum size on the minimum inhibitory concentrations (MICs) of auranofin and control antibiotics, as described previously48. Briefly, standard inoculum (SI: ~5 × 105 CFU/mL) and high inoculum (HI: ~5 × 107 CFU/mL) of each C. difficile strain were prepared in brain heart infusion supplemented broth (BHIS) and tested against auranofin and control antibiotics. Plates were then, incubated anaerobically at 37 °C for 48 hours. MICs reported are the lowest drug concentration that completely suppressed the growth of bacteria, as observed visually.The broth microdilution assay was used to determine the impact of 49. Briefly, SGF (pH = 1.2) was prepared by dissolving NaCl (2 g) and pepsin (3.2 g) in 7 mL of concentrated HCl and deionized water was subsequently added to make up a final volume of 1 L. Then, the pH was adjusted to 1.2. To prepare SIF (pH = 6.8), 6.8 g of KH2PO4 was dissolved in 250 mL of water, and 77 mL of 0.2 N NaOH and 500 mL of deionized water were added. Afterwards, 10 g of pancreatin was added, and the pH of the resulting solution was adjusted to 6.8.Simulated gastric fluid (SGF) and simulated intestinal fluid (SIF) were prepared as described earlier48 was used to determine the MICs of auranofin and control antibiotics in presence of SGF and SIF. Briefly, auranofin and control drugs were incubated with each of SGF and SIF for 2, 4 and 24 hours. After the corresponding times, broth microdilution assay was performed to determine the MICs of the tested drugs.The broth microdilution assayC. difficile spores were prepared as described earlier50. Briefly, C. difficile ATCC 43255 was inoculated onto BHIS agar and incubated anaerobically for 5 days. Spores were collected anaerobically using PBS containing 10% bovine serum albumin, heated at 70 °C for 20 minutes to get rid of vegetative cells and counted by dilution and plating onto BHIS supplemented with 0.1% taurocholic acid. Spores were then, stored at 4°C overnight before infecting mice.33 with modifications. Since disruption of microbiota depends on mice drinking naturally, we performed three modifications: (1) increasing the concentrations of antibiotics to ensure microbiota disruption, (2) adding 7.5% sucrose to the drinking water containing antibiotics to overcome the very bitter taste of the antibiotics in drinking water, as mice are expected to decrease their rate of water consumption due to its bitter taste, and (3) extending the duration of administering antibiotic cocktail in drinking water to 5 days to ensure microbiota disruption. Eight-week-old female pathogen-free C57BL/6 mice  were pre-treated with an antibiotic cocktail in sterile drinking water to disrupt the mice normal intestinal microflora, reducing the colonization resistance and facilitating infection with the toxigenic strain of C. difficile. The cocktail contained kanamycin (1.2 mg/mL), gentamicin (0.105 mg/mL), colistin (2550 U/mL), metronidazole (0.645 mg/mL), vancomycin (0.135 mg/mL) and sucrose (75 mg/mL) for 5 days. Afterwards, mice were switched to regular autoclaved water for 2 days and they received a single dose of clindamycin (10 mg/kg) intraperitoneally 1 day prior to C. difficile challenge.The study was reviewed, approved and performed following the guidelines of the Purdue University Animal Care and Use Committee (PACUC) and according to the recommendations in the Guide for the Care and Use of Laboratory Animals of the National Institutes of Health. Mice were housed in individually ventilated autoclaved cages and received sterile food and water ad libitum throughout the duration of the experiment. CDI mouse model was performed as described previously6 spores of C. difficile ATCC 43255 via oral gavage using a ball tipped metal feeder. Number of spores used were re-counted after infection to confirm the infected dose.For infection, mice were restrained and infected intragastrically with 1.3 ×10Following infection, mice were randomly allocated into groups (n = 5) for treatment. Two hours post-infection, three groups were treated orally with auranofin , one group was treated with vancomycin (10 mg/kg) via oral gavage, and one group was treated orally with the vehicle (10% DMSO in PBS). Treatments were continued once daily for five days and mice were checked (6 times daily) for disease signs .C. difficile recurrence, mice were infected, as described above and two groups were treated orally with auranofin (0.125 mg/kg and 0.25 mg/kg), one group was treated with vancomycin (10 mg/kg) via oral gavage, and one group was treated orally with the vehicle (10% DMSO in PBS) for 5 days. Treatments were stopped after 5 days and mice were monitored (6 times daily) for disease signs and recurrence of infection till the 20th day. Then, mice were humanely euthanized at 21st day post-infection using CO2 asphyxiation.In order to investigate the activity of auranofin in preventing The survival data were analyzed by Log-rank (Mantel-Cox) test utilizing GraphPad Prism version 6.00 for Windows .All animal housing and experiments were reviewed, approved and performed under the guidelines of the Purdue University Animal Care and Use Committee and carried out in strict accordance with the recommendations in the Guide for the Care and Use of Laboratory Animals of the National Institutes of Health.


Results of multivariable logistic regression analysis revealed that OPG  and CRP  levels were independent predictors of PAD in patients on PD. OPG can also be used to predict PAD development with the area under the receiver operating characteristic curve of 0.823  in patients on PD. Therefore, serum OPG and CRP levels can be considered as risk factors for PAD development in patients on PD.Osteoprotegerin (OPG) is a potential biomarker of cardiovascular disease complications and severity. Peripheral arterial disease (PAD) is associated with an increased risk of death in patients on peritoneal dialysis (PD). Therefore, this study aimed to evaluate the relationship between serum OPG levels and PAD by measuring the ankle-brachial index (ABI) of patients on PD. A commercial enzyme-linked immunosorbent assay kit was used to measure OPG values. Left or right ABI values of <0.9 were categorized as the low ABI group. Among 70 patients on PD, 13 (18.6%) were categorized in the low ABI group. Patients in the low ABI group had higher prevalence of diabetes mellitus ( Peripheral artery disease (PAD), which affects approximately 202 million people worldwide, is a condition affecting the atherosclerosis process involving arteries other than the coronary or intracranial arteries . StudiesOsteoprotegerin (OPG), which is produced by various organs such as the lungs, intestines, kidneys, bones, heart, and vessels, is a member of the tumor necrosis factor receptor superfamily . ThroughA total of 70 patients who underwent PD for at least 3 months at Hualien and Dalin Tzu Chi Hospitals from June 2015 to October 2016 were recruited. Blood pressures (BPs) of all patients were measured by trained staff in the morning using standard mercury sphygmomanometers with appropriate cuff sizes after allowing the patient to sit and rest for at least 10 min. Systolic BP (SBP) and diastolic BP (DBP) values obtained 3 times at 5-min intervals were averaged. This study was approved by the Protection of Human Subjects Institutional Review Board of Tzu Chi University and Hospital and was conducted under the tenets of the Helsinki Declaration. Signed informed consents were obtained from all patients before participating in the study. Patients with acute infection, malignancy, acute myocardial infarction, pulmonary edema, heart failure, or taking cilostazol or pentoxifylline during the blood sampling period or those who refused to sign the informed consent were excluded. Among the included patients, 51 received continuous ambulatory PD , with 3–5 dialysate exchanges per day, and the remaining 19 patients received 4–5 dialysate exchanges each night using an automated device . Weekly fractional clearance index values for urea (weekly Kt/V), peritoneal Kt/V, total creatinine clearance, and peritoneal creatinine clearance were obtained from medical records.2).All anthropometric variables were measured in the morning with patients fasting overnight and without dialysate in the abdominal cavity. Body weights and heights were measured by trained staff with patients in light clothing and without shoes and recorded to the nearest 0.5 kg and 0.5 cm, respectively. Body mass index was calculated as weight (kg) divided by height-squared  was used to measure serum total calcium, phosphorus, fasting glucose, albumin, blood urea nitrogen, creatinine, total cholesterol, triglyceride (TG), and C-reactive protein (CRP) levels. A commercially available enzyme immunoassay or enzyme-linked immunosorbent assays were used to measure serum intact parathyroid hormone (iPTH)  and OPG  levels, respectively [Biochemical tests were performed on morning samples obtained after an overnight 8–10 h fasting before the dialysis exchange. Approximately 5 mL of fasting blood samples were obtained and immediately centrifuged at 3000 × ectively .ABI values obtained using an oscillometric method were used to measure BP in both arms and ankles  ,14. ABI 2 test between patients. Variables significantly associated with PAD in patients on PD were tested for independence using the multivariable logistic regression analysis. The receiver operating curve (ROC) was used to calculate the area under the curve (AUC) to identify the most accurate cutoff value of OPG to predict PAD in patients on PD. All statistical analyses were performed using the SPSS software for Windows . A p value of <.05 was considered statistically significant.The Kolmogorov–Smirnov test was used to measure data normality. Normally distributed data were expressed as mean ± standard deviation, and two-tailed Student’s independent t-tests were used for between-patient comparisons. Non-normally distributed data were expressed as medians with interquartile ranges and compared using the Mann–Whitney U test  between patients. Categorical data were expressed as number with percentage and compared using the χp = .044). Serum CRP (p < .001) and OPG (p < .001) levels were higher but serum creatinine (p = .013) and peritoneal Kt/V (p = .048) levels were lower in patients on PD in the low ABI group than those in the normal ABI group. No statistically significant difference was observed in gender, coexisting HTN, smoking, or use of CAPD model between the 2 groups.The characteristics of 70 patients on PD are shown in p = .002) and log-CRP levels  were significantly associated with and identified as independent predictors of PAD in patients on PD (p < .001) , the multivariable logistic regression analysis showed that the serum OPG  .The results in this study showed that patients on PD with low ABI had significantly higher OPG and CRP levels as well as lower creatinine and peritoneal Kt/V. In addition, serum OPG and CRP levels were identified as significant predictors for PAD development in patients on PD.2 had a 2.5-fold higher risk for developing PAD than those with >60 mL/min/1.72 m2, independent of traditional factors [Evidences showed that the number of patients diagnosed with PAD had significantly increased in the past 2 decades, with 28.7% and 13.1% global increase in the number of low–middle and high income countries and with expected 40% increase of prevalence in China . In the  factors . With th factors . Moreove factors . Besides factors ,20. The  factors ,20. ConsOPG, a secretory glycoprotein belonging to the tumor necrosis factor receptor family, produced from the CV system, lung, kidney, and bone, was well known to modulate osteoclastogenesis and vascular calcification ,6,21. StConventional PD fluid used glucose as the osmotic agent with the possible results of formation of glucose degradation products to induce peritoneal inflammation and oxidative stress ,27. MoreIn DM patients, insulin was found to regulate the OPG production and vascular calcification in human aortic smooth muscle cells , and 24-One limitation of this study was that this was a cross-sectional study in a single center with limited number of patients on PD without enough power. The second limitation was the absence of case-matched control group; thus, the mechanism between OPG and ABI in patients on PD could not be concluded in this study. Thirdly, by using ABI lower than 0.9 as having PAD in this study might lead to some misdiagnosis in dialysis patients with vascular calcification (non-compressible arteries) and resulted in false negative diagnosis. Therefore, the definite relationship between serum OPG and PAD in patients on PD should be confirmed by further longitudinal studies before confirming the cause-effect relationship.In conclusion, the serum OPG level together with CRP was considered as significant predictors of PAD in patients on PD in this study. These findings indicated that OPG, a bone-modulating protein, might have a role in the PAD development of PD patients, but the mechanism remained to be further elucidated.


A prospective cohort study was performed to evaluate whether the Optical Quality Analysis System (OQAS) can serve as a valuable additional indicator for appropriate posterior capsulotomy referral.One hundred and five eyes from 96 patients undergoing capsulotomy were divided into precapsulotomy logMAR CDVA ≤0.1 group and logMAR CDVA > 0.1 group. CDVA, and the Visual Function 14 index (VF-14) score were estimated before and 1 month after capsulotomy. The objective scattering index (OSI) value was measured by using the OQAS. Posterior capsule opacification (PCO) severity was assessed with Evaluation of PCO 2000 (EPCO 2000) software.r = 0.451), EPCO score (r = 0.789), and VF-14 score (r = 0.852). LogMAR CDVA has weak correlation with VF-14 score (r = − 0.384) and EPCO score (r = 0.566). VF-14 score was correlated with EPCO score (r = − 0.669). In the logMAR CDVA ≤0.1 group, there was no significant difference in logMAR CDVA between precapsulotomy and postcapsulotomy (P > 0.05). In the two groups, all the other optical quality parameters were significantly improved after capsulotomy (P < 0.05). In logMAR CDVA > 0.1 group, the area under the curve of the ROC of the OSI was 0.996 (P = 0.000). In logMAR CDVA ≤0.1 group, the area under the curve of the ROC of the OSI was 0.943 (P = 0.000).In logMAR CDVA > 0.1 group, the correlations of OSI, logMAR CDVA, EPCO score and VF-14 score were very strong preoperatively. In logMAR CDVA ≤0.1 group, preoperatively, OSI was correlated with logMAR CDVA .The study protocol was registered at the Chinese Clinical Trial Registry. Register:  Cataract surgery is the most common surgical procedure performed by ophthalmologists . PosteriNeodymium: yttrium-aluminum-garnet (Nd:YAG) laser posterior capsulotomy is accepted as a standard treatment for PCO . AlthougThe decision to perform laser capsulotomy was based on the percentage of the opacification area and VA , but theThe Optical Quality Analysis System  is based on the double-pass technique and developed to evaluate vision quality objectively . The OQAwww.chictr.org.cn (no. ChiCTR1800018842).This study was approved by the Ethical Committee of the Fourth Affiliated Hospital of China Medical University. Written informed consent was obtained from each participant. The study was registered at Ninety-six patients (105 eyes) were enrolled in this study, collected from the Fourth Affiliated Hospital of China Medical University, diagnosed as PCO and had been undergone Nd: YAG laser posterior capsulotomy. The laser procedure was performed by the same experienced doctor(Lu B.). The diameter of capsulotomy was 4 mm. All of the patients had previous uneventful small incision phacoemulsification surgery with aspherical monofocal IOL implantation. All of the patients had varying degrees of visual disturbances, such as visual loss, photophobia or slightly blurred vision. Exclusion criteria were severe dry eyes, corneal diseases, glaucoma, retinal or macular pathologies, diabetes mellitus, the post-capsulotomy CDVA > 0.3 (logMAR acuity) and nature pupil diameter less than 4 mm. The patients were classified according to the precapsulotomy corrected distance visual acuity (CDVA) as the group of logMAR CDVA ≤0.1 and the group of logMAR CDVA > 0.1.In the study population, the parameters were obtained twice: before and 1 month after capsulotomy. The parameters included detailed slit lamp examination, intraocular pressure, optical coherence tomography, CDVA and the Chinese version of Visual Function 14(VF-14)index. The retinal image, degree of haze inside the eye, and condition of visual function were analyzed in terms of objective scattering index (OSI), modulation transfer function (MTF) cut-off value, Strehl ratio (SR), predicted visual acuity (PVA) 100%, PVA20%, and PVA9% measured with the OQAS II by using the double-pass technique .The CDVA was measured with a rear-lighted Early Treatment Diabetic Retinopathy Study (ETDRS) chart on a logMAR scale, according to the modified Early Treatment Diabetic Retinopathy Study protocol .For PCO severity assessment, retroillumination images of PCO were analyzed with Evaluation of PCO 2000 (EPCO 2000) software . In thisUnder the condition of the natural pupil, visual quality was examined by a clinical double-pass instrument  by the same operator according to the standard operating protocol. All measurements were carried out under the 4 mm artificial pupil setting by the instrument to ensure consistency. In order to ensure that the natural pupil of the subjects was greater than 4 mm  during tThe double-pass (DP) method is an objective technique based on recording images of a point-source object after reflection on the retina and a double passage through the ocular media . The MTFOur research used the Chinese version of the VF-14 index to evaluate patient’s subjective visual function and quality of life. The VF-14 is a measure of perceived visual function based on 14 everyday activities that may be affected by cataracts. No questionnaire specifically assessing visual disabilities for PCO has been published, but the VF-14 has been validated in patients with other ocular diseases , 26. EacP-value was smaller than 0.05.All analyses were performed using IBM SPSS Statistics 25.0. All data were expressed as the mean ± standard deviation. Wilcoxon signed-rank test was applied to the preoperative and postoperative comparisons. Bivariate correlation models and Spearman correlation coefficients were used to analyze the relationship between variables. Receiver operating characteristic (ROC) curve analysis was used to evaluate the OSI cut-off value. Significant differences were recorded when the Ninety-six patients (105 eyes) were enrolled in this study, ranging in age from 51 to 83 years, with an average age of 64.2 ± 11.08 years. PCO occurred 0.5–3.5 years after phacoemulsification combined with intraocular lens implantation, with an average of 1.57 ± 1.03 years.r = 0.824, P = 0.000)            , and objective indexes OSI, MTF-cut off, SR, PVA100%, PVA20%, PVA9% were also significantly improved, compared with precapsulotomy .In this study, 64 eyes had logMAR CDVA > 0.1 before the operation. As shown in Table P > 0.05), VF-14 scores were significantly improved compared with precapsulotomy (P = 0.000). The objective indexes of OSI, MTF-cut off, SR, PVA100%, PVA20%, PVA9% were significantly improved compared with precapsulotomy .In this study, the precapsulotomy logMAR CDVA of 41 eyes were less than or equal to 0.1, and the average logMAR visual acuity was 0.06 ± 0.03. All these patients complained visual disturbance symptoms of varying degrees. The precapsulotomy average VF-14 score of these patients was 73.68 ± 5.21. After mydriasis, detailed fundus examination and OCT examination were performed to exclude retinal diseases, and then laser posterior capsulotomy was performed. As shown in Table P = 0.000). In precapsulotomy logMAR CDVA ≤0.1 group, the AUC of the OSI was 0.943 (P = 0.000), suggesting that the OSI had high sensitivity and accuracy in the both groups.According to the ROC curve analysis Fig. , in precAt present, the clinical evaluation of laser capsulotomy indications is still mainly based on slit lamp examination and the degree of visual impairment . NowadayThis study found that in patients with good baseline vision, a single VA was not enough to reflect PCO’s impairment on the visual quality of patients. Because some PCO patients reported obvious visual interference, but not accompanied by a decline in VA, the surgical decision-making of these patients is more complicated, so this study divided the patients into logMAR CDVA > 0.1 group and logMAR CDVA ≤0.1 group according to the precapsulotomy VA of PCO patients. This study found that precapsulotomy VA was highly correlated with objective visual quality index (OSI), subjective visual quality index (VF-14), and EPCO score in patients with apparent visual impairment preoperatively. In contrast, in patients with light visual impairment, VA has a low correlation with OSI, VF-14 and EPCO score. Nowadays, acuity is associated with the quality of daily life. However, it has been suggested that other parameters, such as stereopsis, visual field or contrast sensitivity, are more critical than acuity for functional tasks, especially since many cataract patients have relatively good acuity at baseline . PreviouThe main finding of this study for ophthalmic practice is that OSI can be used as a meaningful indicator of the capsulotomy.Zhang H et al. reported that the presence of PCO reduced the patient’s visual quality and was manifested as an increase in image scattering index in the double-pass system ; there wLight-scatter is more sensitive to slight PCO than contrast sensitivity and visual acuity . The relWe firstly proved the high correlation between OSI and VF-14 score in PCO. In the research, 39%41 /105) eyes have good CDVA, but the subjective visual disturbance is noticeable. To complement objective VA information, it is now accepted that evaluating the impact of a disease on quality of life using a patient-reported outcome is important for medical interventions, therapeutic decisions, or outcomes research. De Juan-Marcos et al. found that the VF-14 scores of patients correlate more strongly with their satisfaction with vision than VA, and VF-14 is more sensitive to functional disability caused by PCO and to capsulotomy improvements, however, improvement in VA is slightly correlated with gains in quality of life  eyes hav. The douNd: YAG laser capsulotomy is accepted as the standard treatment for PCO and has been found to be safe and effective . ImproveP = 0.000). In the precapsulotomy logMAR CDVA ≤0.1 group, the AUC of the OSI was 0.943 (P = 0.000), suggesting that the OSI had high sensitivity and accuracy of PCO diagnosis. Thus, the OSI is a useful test for decision-making in PCO surgery. The OQAS provide good repeatability and reproducibility of subjective measurement of intraocular scattering in healthy subjects [The double-pass system has recently been applied to objectively evaluate crystalline lens opacity , 23, 39.subjects , 43, 44.subjects . The repsubjects . Thus, tIn this study, only aspherical monofocal IOL was involved. Some recent studies reported that significantly higher values of OSI and lower values of MTF cutoff and SR were found in the multifocal phakic eyes than monofocal IOL eyes and normal elder , 47. TheIn conclusion, the OSI based on the double-pass system was useful for evaluating posterior capsule opacification and predicting beneficial capsulotomy in monofocal phakic eyes. Especially for patients with slight posterior capsule opacification and better visual acuity, OSI is more valuable than CDVA. Because OSI has a stronger correlation with EPCO score and VF-14 and is a complete objectivity examination. Thus, the OSI based on the double-pass system may be a useful tool for objective PCO evaluation and providing strong evidence for the indication of laser capsulotomy.


Anax parthenope (Odonata: Aeshnidae) is a big dragonfly which can be seen patrolling around ponds, lakes and other still water. In this study, we sequenced and analyzed the complete mitochondrial genome (mitogenome) of A. parthenope. This mitogenome was 15,366 bp long and encoded 13 protein-coding genes (PCGs), 22 transfer RNA genes (tRNAs) and two ribosomal RNA unit genes (rRNAs). The nucleotide composition of the mitogenome was biased toward A and T, with 74.8% of A + T content . Gene order was conserved and identical to most other previously sequenced Aeshnidae dragonflies. Most PCGs of A. parthenope have the conventional start codons ATN , with the exception of cox1 and nad1 (TTG). Except for three genes  end with the incomplete stop codon T––, all other PCGs terminated with the stop codon TAA. Phylogenetic analysis showed that A. parthenope is sister to Anax imperator with high support value. All 15 Anisoptera species constituted a major clade with well support, and Aeshnidae had a close relationship with Gomphidae and Libellulidae. Anax parthenope (Selys 1839), a dragonfly of the family Aeshnidae, is found in south Europe, north Africa, and Asia. This species has a blue saddle which can be seen in flight at the abdomen and the eyes are green. It is most commonly seen from June to September but can still be around in November. After mating, eggs of A. parthenope are inserted into plants or in mud and hatch out in 2 months while larval development takes 2 years.Aeshnidae (Odonata: Anisoptera) is a diverse group with a worldwide distribution. This family comprises 50 genera with approximately 384 species, and all are excellent vagile fliers with confluent compound eyes and a prominent ovipositor  and were stored in Entomological Museum of Gannan Normal University (Accession number GNU-EAP05). Total genomic DNA was extracted from tissues using the DNeasy DNA Extraction kit . A pair-end sequence library was constructed and sequenced using Illumina HiSeq 2500 platform , with 150 bp pair-end sequencing method. A total of 24.8 million reads were generated and had been deposited in the NCBI Sequence Read Archive (SRA) with accession number SRR12805571. Raw reads were assembled using MITObim v 1.7 .Specimens of A. parthenope is 15,366 bp in length (GenBank accession no. MT371045), and containing the typical set of 13 protein-coding, 2 rRNA, and 22 tRNA genes, and one non-coding AT-rich region. The nucleotide composition of the mitogenome was biased toward A and T, with 74.8% of A + T content . Most PCGs of A. parthenope have the conventional start codons ATN , with the exception of cox1 and nad1 (TTG). Except for three genes  end with the incomplete stop codon T−, all other PCGs terminated with the stop codon TAA. The 22 tRNA genes vary from 65 bp (trnC and trnG) to 72 bp (trnK). Two rRNA genes (rrnL and rrnS) locate at trnL1/trnV and trnV/control region, respectively. The lengths of rrnL and rrnS in A. parthenope are 1,299 and 773 bp, with the AT contents of 76.9% and 74.4%, respectively. Gene order was conserved and identical to most other previously sequenced Aeshnidae dragonflies (Yong et al. The complete mitogenome of A. parthenope is sister to Anax imperator with a high support value (A. parthenope sequenced in this study and provide essential and important DNA molecular data for further phylogenetic and evolutionary analysis of Aeshnidae.Phylogenetic analysis was performed based on the nucleotide sequences of 13 PCGs from 23 Odonata species. The phylogenetic tree was constructed through raxmlGUI 1.5 (Silvestro and Michalak rt value . All 15 rt value . In conc