Stigma undermines all aspects of a comprehensive HIV response, as reflected in recent global initiatives for stigma‐reduction. Yet a commensurate response to systematically tackle stigma within country responses has not yet occurred, which may be due to the lack of sufficient evidence documenting evaluated stigma‐reduction interventions. With stigma present in all life spheres, health facilities offer a logical starting point for developing and expanding stigma reduction interventions. This study evaluates the impact of a “total facility” stigma‐reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff in Ghana.We evaluated the impact of a total facility stigma‐reduction intervention by comparing five intervention to five comparable non‐intervention health facilities in Ghana. Interventions began in September 2017. Data collection was in June 2017 and April 2018. The primary outcomes were composite indicators for three stigma drivers, self‐reported stigmatizing avoidance behaviour, and observed discrimination. The principal intervention variable was whether the respondent worked at an intervention or comparison facility. We estimated intervention effects as differences‐in‐differences in each outcome, further adjusted using inverse probability of treatment weighting (IPTW).p = 0.06). Respondents at intervention facilities were 19.0% (95% CI 12.2 to 25.8) more likely to report that staff behaviour towards PLHIV had improved over the last year than those at comparison facilities.We observed favourable intervention effects for all outcome domains except for stigmatizing attitudes. Preferring not to provide services to people living with HIV (PLHIV) or a key population member improved 11.1% more in intervention than comparison facility respondents (95% CI 3.2 to 19.0). Other significant improvements included knowledge of policies to protect against discrimination ; belief that discrimination would be punished ; and knowledge of and belief in the adequacy of infection control policies . Reported observation of stigma and discrimination incidents fell by 7.4 percentage points more among intervention than comparison facility respondents, though only marginally significant in the IPTW‐adjusted model (These results provide a foundation for scaling up health facility stigma‐reduction within national HIV responses, though they should be accompanied by rigorous implementation science to ensure ongoing learning and adaptation for maximum effectiveness and long‐term impact. The health facility offers a logical place to develop and scale‐up a national response to stigma for multiple reasons. It is, in most places, the gateway into HIV treatment and often prevention. As a chronic condition, HIV requires lifelong engagement with the health system. In addition, health care workers are members of their communities and are often looked to for guidance on health and other issues , 31, 32.The prevalence , 38, 39,In Ghana in particular, stigma and discrimination remain a pervasive issue, as documented both through measurement of stigmatizing attitudes in the general population  and throIn its contribution to literature outlining potential interventions within health facility stigma‐reduction, this study evaluates the impact of a “total facility” stigma‐reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff in Ghana.22.1We evaluated the impact of a total facility stigma‐reduction intervention in five health facilities in Ghana compared to five non‐intervention facilities selected to be broadly comparable with regard to facility size (staff complement and patient load); subnational region; and type of facility . The initial phase of the study collected stigma data from the four highest HIV‐caseload civilian facilities in five regions – Ashanti, Brong Ahafo, Eastern, Greater Accra and Western – for a total of 20 facilities. From these, a subset of 10 facilities were selected for the second phase, with one intervention facility and one comparison facility selected from each region based on staff size  and facility interest to participate. There was no randomization of facilities.After baseline data collection in June 2017 from health facility staff, we conducted participatory data dissemination and review workshops with staff from all 20 first‐phase facilities in August/September 2017. In these workshops, staff identified stigma and discrimination challenges and then generated potential solutions. Non‐intervention facilities received no further intervention via the study during this period, though some facilities independently conducted stigma‐reduction activities. After the evaluation reported in this manuscript, the non‐intervention facilities are in the process of receiving the intervention approach through scale‐up led by a local Ghanaian organization with support from The Global Fund.Targeting the whole facility beyond HIV services, the intervention approach included a two‐day participatory stigma‐reduction training for all staff levels  with delivery by staff and clients from the facilities who were trained as stigma‐reduction facilitators. Trainings were delivered between September and November 2017 to all categories of staff, with a target of reaching 70% of the facility workforce. The trainings were based on pre‐existing global training materials that are available online . These a2.2We conducted repeated cross‐sectional surveys, stratified by health facility and job category, of a random sample of staff at the five intervention and five comparison facilities two to three months before and five to six months after the training portion of the intervention. The total sample size was 2308 participants (1154 in each of the pre‐ and post‐intervention periods). To preserve anonymity, we did not attempt to identify the same participants for the follow‐up survey. The sample was designed to provide 80% power to detect a 10‐percentage point change in the only indicator for which pre‐baseline estimates were available: observation of colleagues gossiping about PLHIV. The sampling frame consisted of a complete listing of all staff from which an off‐site statistician generated the target sample. If respondents were unavailable or declined to participate, substitutes were chosen in order from a predetermined list. The survey was designed to be self‐administered if participants could read and to be administered by interviewers to participants who could not read or preferred the administered survey.2.3Survey instruments are provided in Data Survey questions were developed by adapting a globally validated tool for health worker stigma and discrimination . Items wThe primary outcomes outlined below were composite indicators for each domain, dichotomized from a series of items.2.3.1One variable for reporting knowledge that facility guidelines protect PLHIV, men who have sex with men (MSM), and sex workers from discrimination; one variable for believing that the respondent would be punished if discriminating against PLHIV and all of four key populations ; and one variable for agreeing or strongly agreeing that the facility has adequate infection control policies and personal protective equipment and knowing that the facility has both a posted post‐exposure prophylaxis (PEP) policy and PEP access.2.3.2Reporting being a little worried, worried, or very worried to conduct one or more of four care activities with clients living with HIV, for fear of HIV acquisition.2.3.3Three variables for agreeing or strongly agreeing with one or more stigmatizing statement about PLHIV in general, women living with HIV, and MSM; and one variable for agreeing or strongly agreeing that the respondent would prefer not to provide services to one or more key population.2.3.4Reporting usually avoiding physical contact, wearing double gloves, wearing gloves during all aspects of care, or using extra precautions with PLHIV but not other patients.2.3.5Observing one or more instances of healthcare workers at the same facility being unwilling to care for, providing poorer care quality to, talking badly about, or disclosing status about PLHIV or one of four key populations in the last six months.A secondary outcome was participant’s general perception about whether behaviour towards clients had changed in the facility over the year prior to the endline survey, dichotomized as a little/much better versus no change or a little/much worse.The principal intervention variable was whether the respondent worked at an intervention or comparison facility. Analyses were by intention to treat, so participants were classified as at intervention facilities even if they did not individually receive training, as intention‐to‐treat analysis was expected to capture the effect of average programme implementation. We also collected demographic variables for use in adjusted analyses: age ; region; sex; staff category ; tenure at the facility ; whether the respondent has ever worked in an HIV‐specific department; and quintiles of the number of PLHIV the respondent reports personally providing care to in the past month.2.4We present basic descriptive statistics of the sample in Table Intervention effects are presented in Table In addition to unadjusted estimates, we estimate intervention effects using inverse probability of treatment weighting (IPTW) , 69. Thepost hoc. Because some readers might expect adjustment; however, we present an analysis in Data In the main analysis, we did not adjust for multiple comparisons because all outcomes were theoretically informed and predetermined and no analyses were added The institutional review boards at Health Media Labs and the Ghana Health Services Ethical Review Board approved the study, and all participants provided written informed consent.3Characteristics of the analytical sample of 2308 participants (1154 in each of the pre‐ and post‐intervention periods) are in Table As expected, exposure to trainings and other activities to reduce stigma and discrimination was higher among intervention than comparison staff during the post‐intervention period, with each of the trainings reaching at least three‐quarters of intervention respondents, and about two‐thirds being exposed to at least one additional intervention activity Table . More thp = 0.06). Results were very similar in the unadjusted analyses.Using intention‐to‐treat analyses, we observed favourable intervention effects for all outcome domains except for stigmatizing attitudes in both the full sample and the medical staff‐only subsample Table . In the We found comparable improvements in the subsample composed only of medical staff Table . Here top‐values does not meaningfully change conclusions.When asked whether there had been a change in behaviour towards PLHIV over the last year, intervention facility respondents were 19.0 percentage points (95% CI 12.2 to 25.8) more likely to say it was better in IPTW‐adjusted analyses Table . Results4Evidence continues to grow of the negative relationship of stigma to pre‐exposure prophylaxis , HIV tesThis evaluation of the Ghana “total facility” intervention found strong and consistent evidence of improvements, across indicator domains, apart from stigmatizing attitudes. Fear of acquiring HIV while providing care for clients living with HIV improved significantly in intervention versus comparison facilities, as did associated stigmatizing avoidance behaviours such as double gloving. These findings mirror results of interventions in China  and VietThere are limitations to this study that should be noted. The short‐time frame of the evaluation did not allow for assessment of longer‐term intervention effects and therefore, could overestimate more transient effects of the intervention or underestimate those that require longer intervention periods. The nature of the setting, design and funding did not allow for randomization of the facilities to intervention or comparison. However, facility selection, the DID approach and IPTW should substantially account for differences between the intervention and comparison groups. Some stigma‐reduction activities did occur in the comparison group of facilities, which likely diminishes some of the intervention effect. All facilities received their baseline results before the intervention began in the intervention sites, as required by ethical guidelines, which may have spurred some comparison facilities to begin addressing their baseline results. As presented in Table The rationale for addressing stigma for an effective HIV response and to achieve national and global targets is clearly underscored by the evidence of the negative link between stigma and testing , 3, trea5Addressing HIV stigma is not only a public health imperative but a human rights one. Tackling HIV stigma in the health system is a logical place to develop and scaleup a national response to HIV stigma. This paper adds to the small but growing literature demonstrating that HIV stigma can effectively be addressed in health facilities and is a challenge welcomed by facility staff and management. This evidence provides a solid foundation for developing and testing the feasibility and efficacy of scaling up health facility stigma‐reduction within countries. It will be critical that these efforts are accompanied by rigorous implementation science to ensure ongoing learning and adaptation to maximize effectiveness and long‐term impact.The authors declare that they have no competing interests.LN, NAA, KA, NA, EG, SJ, PM, CS and RV conceived, designed, and implemented the study. JDK and RV analysed the data. LN, ML, PM and JDK drafted portions of the manuscript. All authors provided data interpretation and revised the manuscript critically for intellectual content. All authors approved the final version of the manuscript.Data S1. Survey questionnaires.Click here for additional data file.Data S2. Inverse probability of treatment weighting models.Click here for additional data file.Data S3. Replication log for Ghana facility intervention Diff‐in‐Diff. 21 August 2019**.Click here for additional data file.Table S4. False discovery rate q‐values that account for assessing multiple, correlated outcomesClick here for additional data file.


Sylvia atricapilla) during their autumn migration, and quantified their crown reflectance. We detected robust correlations between migratory and molt condition indices, and the correlation structure was similar in the two sexes. Furthermore, the across‐season measure of body condition was positively related to the darkness of the black crown in males, while being unrelated to reflectance traits of the reddish crown in females. Our results reinforce the possibility that some melanin‐based ornaments may be year‐round indicators of individual quality via their dependence on nutritional condition.Sexually dimorphic ornamental traits are widely regarded as indicators of nutritional condition. However, variation of nutritional condition outside the reproductive and the ornament production seasons has rarely been considered, although it affects the generality of information content, especially for ornaments that may be used across the year. We measured several indicators of migratory and molt condition in male and female blackcaps ( We found a positive correlation between the expression of a melanin‐based plumage ornament and an across‐season measure of body condition. These findings support a mixed interpretation of the information content of melanin ornamentation, with the simultaneous presence of condition‐dependence and pleiotropy. Costs of mate choice  necessitate benefits that outweigh these costs. A major group of benefits arises from condition‐dependence, which means the adjustment of signals to the physiological state of the individual, as a consequence of the costs of expressing elaborate signal values  during their autumn migration  in relation to aspects of body condition during the summer molt and actual body condition at migration. Blackcap cap reflectance has rarely been examined as a signal trait and little is therefore known about its phenotypic variability and possible information content .2.1We sampled migrating blackcaps at Ócsa Bird Ringing Station, Hungary . The second measure taken from these feathers was feather mass, a measure of overall material investment into a single rectrix by the bird . Feather mass as a second feather growth axis may provide important additional information over feather growth rate, for example, due to the repeatedly demonstrated trade‐off between growth rate and feather quality  in the middle section of the feather under direct illumination, using a calliper (nearest 0.1 mm). Feather growth bar width is an index of feather growth rate and thereby body condition during molt . We first constructed the correlation matrix of all six condition measures across seasons for males and females, and compared these matrices between sexes using the software CPC . These variables were calculated directly from raw spectral data instead of relying on the results of the spectral band PCA because, while well representing the main directions of reflectance differences, spectral band PCs seem to provide an inaccurate representation of the relative contributions of particular wavelengths to spectral shape variation . Before using the first condition PC as an independent variable across sexes, it was standardized  for year in females and for the whole group in males. The second condition PC was standardized for year. We finally assessed the relationship between condition PCs and the reflectance measures using Pearson correlations  and a general linear model . The latter model consisted of brightness as a dependent variable, sex as a factor, the two standardized condition PCs as continuous predictors, and the two‐way interactions between the sex and the PCs. Statistical analyses were done in Statistica 5.5 .We included body mass, fat score, and muscle score as measures of actual, migratory condition . PC1 (standardized as described in the Methods) showed a significant interaction with sex in determining crown brightness , but not significant in females . PC2 (year‐standardized), on the other hand, showed little relationship with crown brightness in either sex  was unrelated to our main condition axis. Interestingly, our finding is consistent with the stimulatory effects of experimental antioxidant intake on male but not female crown color in the same species  and pheomelanin in females ; Data curation ; Formal analysis ; Funding acquisition ; Investigation ; Methodology ; Project administration ; Supervision ; Writing‐original draft ; Writing‐review & editing . Miklós Laczi: Conceptualization ; Data curation ; Formal analysis ; Investigation ; Writing‐review & editing . Dóra Kötél: Data curation ; Investigation ; Writing‐review & editing . Tibor Csörgő: Data curation ; Investigation ; Writing‐review & editing .Appendix S1Click here for additional data file.


Although herpes zoster is known to occur in some patients with lung cancer, generalized (disseminated) herpes zoster is an uncommon form whereby hematogenous dissemination of the virus occurs and leads to the development of widespread cutaneous lesions. Similarly, skin is an uncommon site of metastasis in patients with lung cancer. Here, we report a clinical case of a 53‐year‐old male patient who developed generalized herpes zoster during chemotherapy for non‐small cell lung cancer (squamous cell carcinoma) and subsequently developed cutaneous metastasis of lung cancer after generalized herpes zoster was cured by treatment with intravenous aciclovir. The coincidence of these two conditions, generalized herpes zoster and cutaneous metastasis, in the patient during lung cancer treatment might be associated with an impaired or dysregulated immune system partly due to repeated chemotherapy, indicating a poor prognosis. Close observation and accurate diagnosis of changes in the skin of patients with lung cancer are important when evaluating their immune status and considering their therapy and prognosis. A case of generalized herpes zoster and cutaneous metastasis found in a lung cancer patient undergoing chemotherapy Herpes zoster, which is caused by reactivation of the varicella‐zoster virus (VZV), occurs in immunocompromised patients such as cancer patients and is related to their disease or treatments.The skin is an uncommon site of metastasis from internal malignancies. The overall incidence of cutaneous involvement is approximately 5% and may indicate advanced disease and a poor prognosis.3 area. Bronchoscopy was performed, and he was diagnosed with non‐small cell lung cancer (squamous cell carcinoma) . After first‐line chemotherapy with weekly carboplatin and paclitaxel plus radiation therapy (60 Gy), 14 cycles of second‐line chemotherapy with durvalumab were performed. However, because the lung cancer indicated progressive disease (PD), the third‐line chemotherapy was changed to docetaxel. F18‐fluorodeoxyglucose (FDG)‐positron emission tomography (PET)/CT indicated increased primary tumor, left pleural effusion and left subclavian lymphadenopathy. Biopsy of left subclavian lymphadenopathy was performed with a subsequent diagnosis of metastasis of squamous cell carcinoma, indicating a PD.A previously healthy 53‐year‐old man was admitted to our respiratory department with a history of exertional dyspnea and left shoulder pain for eight weeks. He had no underlying disease, no surgical history and no regular medications, but had smoked two packs a day between the ages of 14–40 years. Chest computed tomography (CT) revealed a 36 mm mass in the left SThe patient was hospitalized for the fourth‐line chemotherapy. During the first to fourth‐line chemotherapy, he was hospitalized for 7 to 14 days and then discharged for 7 to 14 days, for each chemotherapy course. The total length of his hospital stay before the fourth‐line chemotherapy was 203 days. During that period, the only adverse event was grade 1 radiation pulmonary inflammation (CTCAE 4.0) after the first‐line chemotherapy plus radiation therapy. Chest X‐ray showed extensive opacification in the left lung with massive pleural effusion indicated by chest CT Fig . ResultsOn the night of the day of hospitalization, exanthema with vesicles was evident on the left lateral region of his chest Fig . BecauseHowever, two weeks later, he was rehospitalized suffering from the effects of the chemotherapy. A 3 mm subcutaneous nodule was observed in the left sternal clavicle (bone) Fig . UltrasoAbout three weeks later, during the fourth‐line chemotherapy, he died of respiratory failure due to progressive lung cancer and massive pleural effusion. The clinical course of this patient is summarized in Fig et al.Associations between the incidence of herpes zoster and malignancies have been reported.As with other internal malignancies, cutaneous metastasis from lung cancer is rare; for example, 1.7% of 1223 cases have been reported in the USA,These two rare conditions of generalized herpes zoster and subsequent cutaneous metastasis might be associated with impaired or dysregulated immunity of the host. Cellular immune function is critical for suppressing VZV replication and carcinogenesis.In conclusion, generalized herpes zoster and subsequent cutaneous metastasis during chemotherapy should not be regarded as a coincidence of two rare conditions, but rather as an impaired or dysregulated immune system in the patient. Close observation and accurate diagnosis of changes in the skin of patients with lung cancer are important when evaluating their immune status and considering their therapy and prognosis.DisclosureThe authors declare that there are no conflicts of interest.


Overuse injuries of the tendon – ‘tendinopathy’ – account for 30%–50% of all sporting injuries and a high proportion of orthopaedic referrals from primary care physicians. Tendinopathies often have a multifactorial aetiology and injury can be due to a combination of both acute and chronic trauma which contributes to loss of tissue integrity and eventual rupture. Our incomplete understanding of the mechanisms surrounding tendon pathophysiology continues to cause difficulties in treatments beyond loading regimes which can be unsuccessful in up to 30% of cases. We describe an uncommon case of tendinopathy affecting the periscapular muscle/tendon unit in a 35-year-old female with persistent pain around the inferior posterior pole of her right scapula. Magnetic resonance imaging findings confirmed oedema of the muscles around the inferior scapular margin in keeping with enthesopathy/tendinopathy and she was treated with radiofrequency coblation to the area. This case highlights radiofrequency ablation as a surgical option should non-operative treatments fail in the rare diagnosis of periscapular tendinopathy. Manifestations range from mild pain and swelling to complete loss of function and diagnosis is usually based on a thorough history and physical examination;3 however, imaging modalities such as ultrasound and magnetic resonance imaging (MRI) can be useful, especially for identifying tears.4 The main goal in tendinopathy treatment is to reduce pain and allow return to activity – first-line treatment comprising several modalities ranging from relative rest and progressive loading to invasive pharmacological interventions continues to be the mainstay of treatment,3 while surgical options remain the last option owing to their morbidity and inconsistent outcomes.5Overuse injuries of the tendon – encompassed by the term ‘tendinopathy’ – represent an underestimated group of musculoskeletal disorders accounting for annual cost of US$3 billion to the US healthcare system highlighting the huge burden of disease.6 and has been previously used in musculoskeletal surgical procedures. When applied to tendons, it is called microtenotomy and it involves the ablation of small segments of the tendon and leaving the remainder intact; this stimulates release of angiogenic factors – vascular endothelial growth factor (VEGF) and αV integrin – which promote tendon healing.7Radiofrequency (RF)-based plasma treatment is where the charged plasma breaks down molecular bonds in soft tissuesA 35-year-old Caucasian female presented with a 1-year history of persistent atraumatic onset of pain over the inferior corner of her right scapula. She was referred to our upper limb tendon clinic after persistent right scapular pain and tenderness of periscapular muscles at the point of insertion following previous non-resolution with physiotherapy instigated by her primary care physician.Past medical history included left ulnar neuritis and anterior right knee pain. Prior procedures include right and left ovarian cystectomy and emergency appendectomy.On examination, there was no evidence of muscle atrophy. She was able to forward elevate her right shoulder to 160° and 180° on contralateral left side; abduct to 160°, externally rotate to around 50° and internally rotate to T12 on affected side and T6 on contralateral side. There were no signs of impingement with unremarkable functioning tests on rotator cuff muscles and no sign of scapular winging. Point tenderness was over inferior aspect of medial and lateral borders of scapula.MRI scans of her right scapular region indicated ‘resolving enthesopathy’ with the presence of reduced bony oedema around inferior border of her scapular serratus anterior and teres major insertion  and 2. NInitial management involved the use of glyceryl trinitrate patches (GTN5 μg/24 h) along with referral to a shoulder physiotherapist for rotator cuff strengthening and periscapular muscle patterning exercises. The patient reported reduced symptoms with GTN patches at 8 weeks post commencing therapy; however, benefits subsided after stopping use for 6 weeks. Another 6-week course of GTN patches was continued, but the patient noted that the response had diminished.Following these two injections into the periscapular region at the point of maximal tenderness with steroid (40 mg depomedrone) and local anaesthetic showed reduced symptoms for approximately 4 months. Intermittent numbness in right C5/C6 region was discovered with normal neurological tests and unremarkable findings on MRI of cervical spine. The patient was additionally referred to a rheumatology clinic.Following discussion of the risk and benefits of surgery, the patient agreed to undergo RF ablation of the tendinous insertion of serratus anterior/teres major region. The surgery was carried out in the lateral decubitus position, and the skin was prepared with alcoholic chlorhexidine. No prophylactic antibiotics were administered. Posterior inferior lateral border of scapula was marked, and a small transverse incision was made . DissectThe patient was reviewed in clinic 2 weeks later and noted to have a fully healed wound without any surrounding erythema or discharge. Minor swelling was present at this point, and a reported 90% reduction in pain symptoms around right scapular region was noted by the patient. The patient was referred to ESP shoulder physiotherapy. At 10 weeks’ follow-up, a reported 80% improvement in symptoms with excellent range of motion and no tenderness were observed, and at 6 months, the patient was discharged from care with no return of symptoms and continued improvement of approximately 80%.7 and recently, coblation has been used for chondroplasty, meniscal repair, lateral epicondylitis, rotator cuff tendinopathy and tendinopathy of the foot and ankle.8 The plasma created is an electrically conducting gas made up of free electrons, ions and neutral chemical radicals and has sufficient energy due to the electrical fields to break down water molecules into excited H and OH radicals.9 By exciting water molecules, a chemical process begins which breaks molecular bonds in soft tissue at relatively low temperatures.6RF has been used historically to resect, coagulate or ablate tissue,V integrin – which promote tendon healing.7 Ahmed et al.10 postulated that tendon rupture occurs in the most hypovascular areas where the nutrition required by tenocytes for repair is compromised and thus cannot synthesize extracellular matrix to repair and remodel the damaged tendon.When applied to tendons, it is termed microtenotomy and it involves the ablation of small segments of the tendon, leaving the remainder intact; this stimulates release of angiogenic factors – VEGF and α7 supraspinatus tendons from eight patients with rotator cuff tears were compared with six healthy tendons – the altered exhibited lack of vascularity, expressed by lower level of markers such as VEGF and αV integrins. Another study performed RF-based microdebridement on the Achilles tendon of New Zealand white rabbits, demonstrating that coblation can trigger a healing response, providing increased tissue vascularity and number of organized fibroblastic cells.11 In another study of 20 patients, coblation was used for treatment in tendinopathy of Achilles tendon, patellar tendon and lateral epicondylitis – this showed improved pain symptoms in the short term.8In a study review by Tasto et al.,8 Another study comparing RF-based plasma microtenotomy with subacromial decompression in rotator cuff tendinosis noted that pain and functional symptoms associated with the condition were successfully treated through 1 year. Clinical outcomes in the RF group were equivalent to those receiving the ‘gold standard’ arthroscopic subacromial decompression.12A clinical study examining a prospective case series showed that the RF-based plasma microtenotomy approach is safe and effective through at least 2 years for alleviating symptoms associated with chronic tendinosis in the lateral elbow.Tendinopathy in the periscapular region of the shoulder is an uncommon location representing a challenging treatment dilemma. In this case report, we demonstrate that RF coblation is a viable treatment option for periscapular tendinopathy with good clinical outcomes. This is in line with clinical studies conducted, where RF-based microtenotomy has been used safely and effectively in Achilles tendinopathy, lateral epicondylitis and rotator cuff tendinopathy. We maintain that RF treatment may be a useful surgical adjunct in patients who have failed non-operative treatment for persistent periscapular tendon pathology.


Physa acuta snail. We expected that the offspring phenotypes result from a three‐way interaction among grand‐parental, parental and offspring environments. We exposed three generations of snails without and with predator cues according to a full factorial design and measured offspring inducible defences. We found that both grand‐parental and parental exposures to predator cues impacted offspring antipredator defences, but their effects were not cumulative and depended on the defences considered. We also highlighted that the grand‐parental environment did alter reaction norms of offspring shell thickness, demonstrating an interaction between the grand‐parental transgenerational plasticity and the within‐generational plasticity. We concluded that the effects of multigenerational exposure to predator cues resulted on complex offspring phenotypic patterns which are difficult to relate to adaptive antipredator advantages.Phenotypic plasticity can occur across generations  when environments experienced by the previous generations influenced offspring phenotype. The evolutionary importance of transgenerational plasticity, especially regarding within‐generational plasticity, is a currently hot topic in the plasticity framework. How long an environmental effect can persist across generations and whether multigenerational effects are cumulative are primordial—for the evolutionary significance of transgenerational plasticity—but still unresolved questions. In this study, we investigated how the grand‐parental, parental and offspring exposures to predation cues shape the predator‐induced defences of offspring in the  Physa acuta snails without and with predator cues according to a full factorial design and measured offspring inducible defences. We found that both grand‐parental and parental exposures to predator cues impacted offspring antipredator defences, but their effects were not cumulative and depended on the defences considered.How long an environmental effect can persist across generations and whether multigenerational effects are cumulative are primordial—for the evolutionary significance of transgenerational plasticity—but still unresolved questions. We exposed three generations of  Moreover, such combinations of grand‐parental and parental effects can also depend on the offspring environmental context. Plaistow, Lapsley, and Benton (Sancassania berlesei that the persistence of past environments (across four generations) differed between high‐ and low‐food offspring contexts. In this study, our aim was to investigate how the grand‐parental, parental and offspring exposures to predator cues combine to shape the predator‐induced defences of offspring.However, while the main effects of parental environment and even grand‐parental one on offspring phenotype are now widely observed  were renewed for all experimental snails twice a week. Predator‐conditioned water with predator cues was obtained by individually rearing crayfishes (Procambarus clarkii) in 4L reconstituted water and feeding with one crushed P. acuta adult one day before water change  snails. We assessed escape behavior three times in 70 days old F3 snails through three consecutive days starting one day after the water change. We recorded the position above/on or below the water surface in the rearing vials with predator cues present or absent according to the treatment. Crawling‐out of the water (position above water surface) is considered as allowing to escape from benthic predators like crayfishes  with an electronic scale at the nearest 0.001 mg. A photograph of each snail aperture upwards was taken with an Olympus SC50 camera installed on an Olympus SZX9 binocular and its Olympus DF PLAPO 1X‐2 objective at a ×8 magnification. Shell and aperture length and width were measured on these photographs with the software ImageJ  were analyzed using generalized linear mixed models (GLMM) assuming a binomial distribution (logit link function). Grand‐parental (E1), parental (E2), offspring (E3) environments, and all interactions were considered as fixed effects. Family and individual identity  were considered as random effects. We tested significance of fixed and random effects with likelihood ratio tests.The multigenerational effects of predator cues on escape behavior , both explaining 96% of the variance.F‐tests , parental (E2), offspring (E3) environments, and all interactions were considered as fixed effects. Family was considered as a random intercept. We used restricted maximum likelihood estimation and Kenward and Roger's approximation for degrees of freedom. We tested significance of fixed effects with type II All statistical analyses were performed with R 3.4.1  significantly increased by 105% the proportion of snails crawling‐out the water  and a relatively sedentary lifestyle  is the only one to investigate predator‐induced transgenerational plasticity over many generations (>25). They found that the defensive phenotype—a high frequency of winged aphids in the population—persists for one generation after removing predators whatever the induction time is, that is, the previous number of successive generations experiencing the novel environment (predator presence). However, three generations are needed after removing predators for the frequency of winged phenotypes to come back to the control level, and this number of generations increases with the induction time. Together, these results suggest that multigenerational environmental effects on inducible defences are broader than just a parental effect and could persist for many generations.How long can persist transgenerational effects on anti‐predator responses remains an open question. To our knowledge, the study of Sentis et al.  on the p4.2We showed that the offspring phenotype results from a combination of multigenerational effects , similar to theoretical and other experimental studies . Behavioral traits, which are often labile and exhibiting reversible within‐generational plasticity within developmental or adult stages, are predicted to be influenced by current environment rather than by past environmental experience (Dingemanse & Wolf, The authors of this preprint declare that they have no conflict of interest with the content of this article.All authors contributed to study design, data collection, analysis, and interpretation. All authors drafted, revised, and approved the article for publication.http://dx.doi.org/10.5281/zenodo.3573840This article has been awarded Open Materials, Open Data Badges. All materials and data are publicly accessible via the Open Science Framework at


Despite the recognition of food allergies as a significant cause of morbidity and a growing public health burden worldwide, there are no epidemiological studies addressing food sensitization and allergy in Jordan.To conduct an epidemiological study that retrospectively analyzes sensitization data from 3463 patients with suspected immunoglobulin E (IgE)‐mediated food allergic reactions who performed specific IgE tests in our laboratories in Jordan.Specific IgE (s‐IgE) tests were analyzed for patients who performed enzyme allegro‐sorbent testing based on either self‐reported food allergy or upon physician's request.2.3% of the analyzed samples were cross‐reactive to carbohydrate determinants. A quarter of the patients were sensitized to one or more food allergens, with males having higher odds of being s‐IgE positive. Furthermore, a higher prevalence of sensitization was seen in infants and children compared with adults. s‐IgE was most frequently found against cow milk (11.2%), pistachio (4.9%), soybean (4.6%), cherry (4.4%), and orange (4.4%). Interestingly, the s‐IgE class distribution profile of pistachio differed from the rest of the top hits being skewed away from the weak class 1 leaning more towards higher IgE classes. Food allergen sensitization was age group‐dependent: milk, tree nuts, and eggs were the main food groups causing sensitization in infants, while it was fruits followed by milk in children and adults.Our work represents the first epidemiological study addressing food sensitization in Jordan. This study lays a solid foundation for future studies that can help better guide food allergy diagnosis, patient dietary modifications, and food elimination plans, as well as assist decision‐makers in the region to develop national strategies for an efficient and sustainable healthcare system. This is the first epidemiological study to investigate the prevalence of food sensitization in Jordan, and one of very few in the Middle East region. We report food‐specific immunoglobulin E (IgE) sensitization and carbohydrate determinant prevalence to a large number of food items in a sizeable and representative cohort of patients suspected of IgE‐mediated food allergic reactions in Jordan. This study reveals gender and age group‐dependent differences in the prevalence of food IgE sensitization, as well as a unique s‐IgE class distribution profile for pistachio, being skewed towards higher IgE classes. Nevertheless, ingested food may cause adverse immunological responses, especially to protein elements.FA incidence is increasing worldwide.There are no epidemiological studies regarding FS and FA in Jordan, and data on the prevalence of FA in the Middle East is fragmented and limited.In this manuscript, data collected retrospectively over the span of 5 years (August 2014‐August 2019) about the age, gender, and s‐IgE FS of patients in Jordan were analyzed. This study is the first epidemiological study coming from Jordan regarding IgE sensitization to a wide range of allergens belonging to foods consumed in the country.22.1Food allergen s‐IgE levels were determined semi‐quantitatively via in vitro EAST, using the IVD‐approved and CE‐certified EUROLINE immunoblot strip “Food Turkey 1” . All strips were incubated in a semi‐automated fashion using EUROBlotMaster (Euroimmun) according to manufacturer's instructions. Briefly, test strips coated with 34 food allergens , in addition to a cross‐reactive carbohydrate determinant (CCD) and an indicator band were moistened and then incubated with 400 µL of undiluted patient serum to bind s‐IgE antibodies present. Subsequently, the bound s‐IgE antibodies were detected using an enzyme‐linked anti‐human IgE catalysing a color reaction. Strips were scanned and then analyzed for EAST class using EUROLineScan software (Euroimmun). A negative result where no s‐IgE is detected was denoted by class 0, while positive results were denoted by class 1 to 6, with low levels classified as class 1 and extremely high levels as class 6.2.2In accordance with the ethical approval number IRB/7/2019 issued by the Cell Therapy Center (CTC), existing patient‐related data used in this study, namely gender, age, and s‐IgE test results were collected retrospectively from Biolab Diagnostic laboratory's laboratory information management system (LIMS), in such a manner that participants cannot be identified directly or through any identifiers linked to them. Inclusion criteria involved patients of both sexes and all ages with a suggestive history of IgE‐mediated FA, tested for s‐IgE upon their request (69%), or that of their treating physician (31%), during the period from August 2014 to August 2019. Samples were obtained from patients who either physically presented to any of the 18 Biolab Diagnostic Laboratory branches in Jordan , or presented to any non‐Biolab laboratory in Jordan that refers blood samples for s‐IgE testing to Biolab's immunology department . All CCD‐positive patients were excluded from the study (83 CCD‐positive tests out of 3647 tests performed during the indicated study period).2.3χ2 goodness of fit test with Yates' correction). The significance of the difference in IgE positivity between age groups was calculated using a one‐way analysis of variance followed by multiple comparisons. P less than .05 and lower were deemed statistically significant.All graphs and statistical analyses were performed using GraphPad Prism (Version 8.0.2), 2019. Significance of the correlation between gender and IgE positivity was tested using contingency table analyses , while 53.8% were females , to account for any new sensitizations appearing between tests due to possible dietary modifications or pollen sensitization. Results indicated that cow milk was the top hit , followed by cow milk, UHT (5.2%), pistachio (4.9%), soybean (4.6%), cherry (4.4%), and orange (4.4%). Lowest s‐IgE prevalence was seen for gluten (0.3%), fish mix (0.4%), olive (0.4%), cocoa bean (0.5%), and onion (0.8%). s‐IgE prevalence data for the various food allergens in all age groups combined was reported in descending order  and hazelnut in infants and children, peanut in infants and adults, and peach and apple in adults (Table S1).3.3The s‐IgE class distribution for the top three food allergens of all ages combined as well as for the individual age groups was then analyzed Figure . In the Furthermore, to shed light on the potential clinical relevance of our data, the top ten food allergens obtained in Figure 3.4To achieve a broader picture of the FS results obtained, we arranged the food items found in the immunoblot panel into food groups (Table S3). Results of patients from all age groups combined revealed that the food group with the highest sensitization rates was fruits (25.3%) (top two fruits being cherry and orange) followed by milk (16%), while the lowest sensitization rates towards cereals (6.3%) and vegetables . Interestingly, these two cities alone host around two‐thirds of the total Jordanian population, making our patient cohort both relevant and representative.Patients with positive IgE antibodies against CCDs were excluded from the study since these antibodies are frequently nonspecific and often lack clinical relevance.Close to a quarter of our total study population was IgE‐sensitized to one or more food allergens. This finding is very similar to a report from Lebanon where 21% of patients with suspected IgE‐mediated food allergic reactions were positive for s‐IgE when tested upon their physician's request.As far as FA is concerned, an imbalance in the direction of infant and childrenThe most commonly encountered s‐IgE antibodies for all age groups combined were against cow milk (including UTH processing), pistachio, and soybean. Interestingly, cow milk and pistachio were seen among the top three hits in infants and children but not adults, while soybean was consistently observed in the top 10 list of all three age categories .Several recent studies shed light on the significance of sesame seed allergy in the Middle East,Very few studies explored the most commonly used tools in the diagnosis of FA in the Middle East. A Lebanese study published in 2015 found out that medical professionals mainly ordered s‐IgE blood tests (55%), followed by food elimination based on clinical history (25%), followed by skin prick testing (20%).This heavy dependence on s‐IgE testing in FA diagnosis calls for the design of customized panels that account for the particularities of the society in question. In this study, we used the EAST panel customized for nearby Turkey because all the food items it featured were popular in the Jordanian diet (with the exception of the fish mix items). This panel, however, understandably lacks some food items highly consumed in Jordan such as chickpeas, pine nuts, thyme, and certain spices. To address this, our group is currently working on generating an s‐IgE panel relevant to Jordan, building on the prevalence data obtained in this study and our knowledge of the country's dietary habits.Despite the usefulness of our findings, this study has some limitations. The retrospective nature of this study makes it very difficult to correlate the sensitization data to patients' clinical history. It is also not possible to provide numerical data regarding the clinical manifestations which ultimately led our patients to perform the food s‐IgE tests.Nevertheless, given that it is generally accepted that an s‐IgE class greater than 2 is interpreted as clinically significant,Finally, new studies to assess the FS and FA status in Jordan at the population level are warranted. Skin prick test results will help corroborate our s‐IgE findings, while double‐blind, placebo‐controlled food challenges are much needed to establish the prevalence of FA in Jordan. Such studies are crucial in identifying the most common food allergens taking into consideration the cultural and nutritional habits of the Jordanian people. Our study represents an important starting point for future work that can facilitate the diagnosis of food allergies in Jordan and the Middle East, and better guide patients' dietary changes and food elimination plans. This study is a significant step forward towards a better understanding of the nature and magnitude of FS in Jordan. Future studies stemming from it will undoubtedly aid in the better assessment of FA in Jordan and can help the Jordanian health authorities make informed decisions as they formulate long‐term strategic health plans concerning FA in the country. We also hope this study and similar ones will prompt the decision‐makers in Jordan to make epinephrine autoinjectors commercially available to all those whose life might depend on it.Ethical approval  to conduct the study was obtained from the clinical research office of the Cell Therapy Center, University of Jordan.Supporting informationClick here for additional data file.Supporting informationClick here for additional data file.Supporting informationClick here for additional data file.Supporting informationClick here for additional data file.Supporting informationClick here for additional data file.


Head and neck cancer (HNC) survivors experience head and neck lymphedema (HNL), which requires treatment to prevent morbidity. We explore the self‐reported outcomes and satisfaction of patients with HNC receiving treatment for HNL with an advanced pneumatic compression device (APCD).HNC survivors (n = 205) prescribed with an at‐home Flexitouch head and neck APCD completed pretreatment and posttreatment self‐reported assessments addressing efficacy, function, and symptoms. Participant average age was 60 years with 74% male. Pre‐post responses for ≥25 days of use were assessed via the non‐parametric Wilcoxon Signed Rank test.P < 0.00001). Compliance with prescribed therapy (at least 30 minutes daily) was high with 71% of participants reporting daily use and 87% reporting overall satisfaction.Analysis revealed statistically significant improvement in all symptoms and all function items (The reported improvements in function and symptoms, and high compliance rate, provide a rationale for a subsequent randomized controlled trial. This physician‐prescribed device is provided to patients for at‐home treatment, with or without therapist‐administered compression and follow‐up. It is contraindicated for patients with active cancer, acute injuries to the skin that may be irritated by stretching or pressing, and a range of symptomatic or uncontrolled cardiovascular or other diseases for which compression or increased circulation would be of concern.An APCD designed specifically for HNL treatment and well accepted by users may augment current therapies by reducing the significant barriers to self‐care faced by HNC survivors. These barriers include limited use of compression garments, a routine component of lymphedema self‐care that presents unique challenges to HNL patients2A retrospective analysis was conducted on prospectively gathered survey responses from patients across the United States who were prescribed a Flexitouch system for the at‐home treatment of cancer‐related HNL between October 2016 and September 2017. Patients were required to have a signed consent authorizing use of data for research purposes and to have completed both a pre‐device treatment survey and a follow‐up survey after consistent at‐home device use . The study was exempt from IRB oversight by Chesapeake Center for Institutional Review Board Intelligence (CIRBI).2.1The Flexitouch system has previously been shown to effectively treat lymphedema in the extremities by stimulating lymphatic function using automated techniques similar to MLD techniques.Upon receipt of the device, patients received in‐home instruction from Tactile Medical trainers on device operation per standard company practice. Training included donning/doffing garments, prescribed treatment, and customer care contact information. This training did not include lymphedema care, which is covered by the patient's clinical care team.2.2Tactile Medical routinely asks all patients who are prescribed a Flexitouch system to complete a pretreatment survey during their at‐home device training visit and to complete the same survey approximately 1 month after starting treatment. This survey is designed to assess the effects of APCD treatment on symptom control and functional complaints commonly experienced by patients with HNL, including patient‐perceived changes in ability to control lymphedema through at‐home treatment, ability to perform daily activities, level of head and neck pain or discomfort, and difficulty in swallowing or breathing.Patients who did not return the follow‐up questions were contacted by phone and asked to complete the survey during an interview with Tactile Medical clinical services personnel. Additional demographic information and aspects of medical history, including type of cancer and cancer treatment, were obtained through review of the medical record.2.3P‐value deemed to represent a statistically significant change was a priori set to P < 0.01. For the additional five compliance and satisfaction questions, patient responses were analyzed and their frequency distribution was characterized for each question. Results are generally represented as mean ± SD except where specifically noted.All responses to survey questions were ranked from 1 to 5 with pre‐survey to post‐survey analyses conducted via the non‐parametric Wilcoxon Signed Rank test for each of the posed questions to determine the statistical significance of pre‐to‐post changes. The survey was designed so that in all cases higher numbers represented better or improved conditions. Because there were five symptom questions, a 3A total of 499 eligible patients received the head and neck APCD during the study period, with 239 patients completing both a pretreatment and posttreatment survey (48% response rate). Of those, 232 (97%) patients had used the device for at least 4 weeks. Seven participants were excluded due to having HNL that was unrelated to HNC. Twenty patients were excluded from the pre‐to‐post analysis due to missing survey responses. The final study population included 205 patients with HNC‐related HNL. Patients were predominantly male  with a mean age of 60 (range 13‐83), the majority having squamous cell carcinoma. The most common tumor sites were the oropharynx and oral cavity, accounting for 67% of patients studied. More than half the study patients (59%) received combined modality cancer treatment, which included primary tumor resection and radiotherapy. Payers frequently require patients to have tried and failed conservative therapy before receiving an APCD; thus the majority of patients had received CDT and/or used compression garments or bandaging for 4 to greater than 8 weeks before use of the APCD . Nearly half (48%) of this patient population initiated APCD use within 6 months of HNL diagnosis; other patients initiated use 6 months to 1 year (34%), 2 to 5 years (11%), or greater than 5 years (7%) after diagnosis. The average duration of APCD use at the time of post‐APCD treatment survey completion was 90 days (range 25‐288). A summary of patient demographics and characteristics is provided in Table The pre‐to‐post APCD symptom question responses demonstrated statistically significant improvements in all of the five queried symptom questions as summarized in Table P < 0.00001). There was also a decrease in how often the participant's lymphedema prevented or limited their ability to perform daily activities . Participants also reported improvement in the level of head and neck pain or discomfort  and decreased difficulty with swallowing  as well as improved ability to breathe .Expressed as pre vs post responses there was a positive shift reported in the ability to control lymphedema symptoms through at‐home treatment  experienced less improvement in pain reduction and swallowing difficulties, although small patient populations in these cohorts prevented statistical significance. These observational findings would seem to align with previous reports years exThere are several limitations to this study. Primarily, the lack of a control group does not allow for conclusions on efficacy. However, the study met its primary aim of exploring patient‐reported outcomes and satisfaction with the Flexitouch system for home use. The survey results will be used to inform the design of a future randomized trial. As an observational study, additional limitations include wide variation in the time interval (25‐288 days) between the pretreatment and posttreatment assessments. Finally, data were collected via a Tactile Medical customer survey and not a validated patient‐reported outcomes (PRO) questionnaire. Although this questionnaire provides valuable insight into patient satisfaction and device usability, use of a validated survey would strengthen future prospective studies. Strengths include the large number of patients included in the analysis.5Studied parameters, such as ability to perform activities of daily living and functional improvements in swallowing and breathing, demonstrated statistically significant positive changes from pre‐ to post‐device use. Our findings suggest the potential utility of at‐home use of this device in contributing to improved quality of life in this patient population and provide a rationale for a subsequent randomized controlled trial to objectively assess improvement in symptoms with the use of a head and neck APCD.Ron J. Karni, MD, serves on the Scientific Advisory Board and Speakers Bureau for Tactile Medical. Harvey N. Mayrovitz, PhD, is a scientific consultant to Tactile Medical.


Absolute bioavailability is defined as a measure of the extent to which the administered drug is absorbed systemically and becomes available in the general circulation compared with intravenously administered drug.Despite the clear usefulness, absolute bioavailability determination is not mandatory and therefore not a routine part of clinical drug development.The microdose trial design may aid overcoming these problems by making use of an intravenous microdose formulation, defined as less than 1/100th of the therapeutic dose with a maximum of 100 μg. Because microdose studies involve exposure to very small amounts of drug, additional safety testing of the intravenous formulation is not required. Furthermore, drug solubility issues are most often no longer a problem, as only a 100‐μg amount needs to be dissolved into an intravenous formulation.In this review, we describe the way clinical absolute bioavailability trials are conducted using both a conventional trial design and a microdose trial design. The use of a stable isotopically labeled microdose (SILM) in combination with ultrasensitive liquid chromatography–tandem mass spectrometry (LC‐MS/MS) as an analytical technique is described in more detail. For the group of orally administered small‐molecule protein kinase inhibitors (smPKIs), we investigated whether absolute bioavailability was determined during clinical drug development and if a SILM trial design in combination with LC‐MS/MS would have been feasible. We conclude by discussing how the use of SILM studies can affect the execution of absolute bioavailability trials in the future.The absolute bioavailability of novel oral anticancer agents is normally investigated using a 2‐period crossover trial design.The conventional absolute bioavailability trial design is limited in 2 ways. First, an intravenous formulation at therapeutic strength is required, which is not always available for drugs that are poorly soluble in aqueous solutions, and, if available, requires additional safety testing. Second, the 2‐period crossover trial design assumes linear pharmacokinetics and equal clearance between the 2 dose events, which is not always the case. A potential way to overcome these problems is provided by the microdosing trial design.14C‐radiolabels or stable isotope labels. Depending on the isotope label used, different analytical techniques are required. For 14C‐labeled drug, traditional accelerator mass spectrometry (AMS) is most often used, in which the 14C:12C ratio is calculated, with no regard to the molecular structure of the compound. For quantification of an SILM, LC‐MS/MS is used, in which analysis is based on the mass difference between isotopically labeled and unlabeled drug.A microdose is defined as 1/100th of the therapeutic dose with a maximum of 100 μg. In an absolute bioavailability microdose trial, the oral therapeutic dose intended for clinical use is administered, after which the intravenous microdose is administered concomitantly at the estimated maximum plasma concentration of the oral dose . Already in the early 1980s, the use of SILMs for clinical pharmacokinetic investigations were discussed by Browne et al.14C‐radiolabeled drug in combination with AMS to perform clinical microdose trials.Initially, microdose trials were performed exclusively using a combination of AMS and 14C‐radiolabeled drug material is normally also required for preclinical and clinical absorption, distribution, metabolism, and excretion trials . In this case, additional synthesis efforts for the intravenous 14C‐radiolabeled microdose formulation is not required, which might save time and money. Furthermore, the use of a 14C‐radiolabeled microdose does not require additional radiosafety testing, as the extreme sensitivity of AMS requires only minute amounts of 14C administered to humans in a clinical study.14C‐labeled drug molecule from metabolites bearing the 14C‐label is required to allow for correct calculation of parent molecule exposure. Some of the technical issues associated with current AMS applications may in the future potentially be overcome by the use of more compact AMS systems with direct liquid chromatography interfacing (LC‐AMS) and automatic sample handling. At the moment, however, these technological improvements of AMS are not yet considered ready for implementation in clinical practice.14C‐radiolabeled microdose analysis is that the calculation of the exposure to unlabeled drug still requires an LC‐MS/MS method next to an AMS method, complicating sample processing and analysis and prolonging study duration.Both LC‐MS/MS and AMS have their own advantages and disadvantages when used as an analytical technique for the support of absolute bioavailability microdose trials. An advantage of using AMS is that 14C‐radiolabeled drug is that in principle LC‐MS/MS analysis can be used for the simultaneous analysis of both isotopically labeled and unlabeled drug, circumventing the use of 2 different techniques for drug analysis following concomitant intravenous and oral drug administration. A drawback of LC‐MS/MS can be that required sensitivity levels for accurate quantification of plasma drug exposure following intravenous microdose administration cannot be reached. Furthermore, the use of stable isotopically labelled drug for the intravenous microdose may result in a kinetic isotope effect (KIE), caused by increased bond strength of the carbon‐deuterium bond compared with the carbon‐hydrogen bond. The KIE may result in altered pharmacokinetics  of the stable isotopically labeled drug, with incorrect calculation of the absolute bioavailability as a result.A major advantage of using stable isotopically labeled drug instead of The group of orally administered smPKIs forms a promising and rapidly expanding class of drugs in oncology.For each oral smPKI granted market approval by the FDA up to 2019, we identified if an absolute bioavailability trial was performed at the time of drug licensing. In case an absolute bioavailability trial was performed, we assessed whether a 2‐period crossover trial design or a microdose trial design was executed. We searched for published articles as well as FDA clinical pharmacology and biopharmaceutics reviews to assess whether these studies have been performed and what type of study and isotope drug label were used to determine absolute bioavailability. If not performed, we identified the reasons for this and investigated the feasibility of using the SILM trial design in combination with LC‐MS/MS to assess the absolute bioavailability.There are 2 critical parameters to assess whether a SILM trial approach is technically feasible for the drug of interest. First, a sensitive LC‐MS/MS assay is required with an adequate lower limit of quantification (LLOQ) following administration of a 100‐μg microdose. This was defined as the concentration at 3 times terminal elimination half‐life after administration of 100 μg of intravenous drug. Second, the amount of isotope labels required to differentiate between isotopically labeled and unlabeled drug in plasma after concomitant administration of an oral therapeutic and an intravenous microdose needs to be established. The production of stable isotopically labeled drug with a sufficient amount of isotope drug labels is an important component as well, but the synthesis of stable isotopically labeled drug was outside the scope of this review.d/Fss) at steady state, the theoretical maximum plasma concentration (Cmax) after intravenous administration can be calculated.To be able to calculate the required LLOQ of the LC‐MS/MS assay, information on certain drug‐specific pharmacokinetic parameters is required. At the start of clinical drug development, phase 1 first‐in‐human trials often provide data on different pharmacokinetic parameters of the drug of interest after administration of a known extravascular dose at the intended therapeutic concentration. Using the apparent volume of distribution (V½) to be able to accurately extrapolate the area under the plasma concentration‐time curve to infinity (AUC0‐inf). The concentration at this time is the Cmax × 0.53. This is the required LLOQ of the LC‐MS/MS assay to accurately quantify the intravenous SILM up to the last point of collection. Based on available literature, we searched for the Vd/Fss of the therapeutic extravascular dose at steady‐state plasma pharmacokinetics. Using this parameter, the required concentration of the LLOQ (CLLOQ) of the intravenous microdose could be calculated using the following equation:Ideally, you would like to be able to measure drug concentrations at least up to 3 times the terminal phase half‐life  was an SILM approach used.Supplementary Table 1 shows the FDA registered smPKIs up to 2020 for which an absolute bioavailability trial study has been performed and what study design was used. Of the 41 smPKIs, for only half the drugs (21 of 41) was an absolute bioavailability trial executed. The median absolute bioavailability found was 46% . In case an absolute bioavailability trial was performed, the traditional 2‐period crossover design was still most often used . For 7 drugs an intravenous 14C‐radiolabeled microdose approach (dabrafenib and trametinib) and 2 trials using a 2‐period crossover trial design (gefitinib and pazopanib).As seen in Supplementary Table 1, most absolute bioavailability trials were performed in healthy volunteers . For the 5 studies performed in cancer patients, 3 trials were conducted using a The LLOQs of the LC‐MS/MS method required to accurately quantify stable isotopically labeled drug and the minimum number of isotope labels required per drug can be found in Supplementary Table 2. For each smPKI the required LLOQ was calculated to determine plasma levels following a 100‐μg intravenous microdose bolus injection up to 3 times the drug elimination half‐life. Using the arbitrary LLOQ of 1 pg/mL, the SILM design would have been feasible for all 41 investigated drugs. For 26 drugs, an LLOQ ≥10 pg/mL would already be sufficient to perform an SILM trial. For the 2 drugs for which an SILM trial design was used (abemaciclib and ibrutinib), the calculated LLOQ was 18.1 and 1.3 ng/mL, respectively.13C8 and ibrutinib‐13C6), respectively, were used.The median amount of stable isotope labels required to distinguish the orally administered drug from the concomitant intravenously administered microdose at the estimated maximum plasma concentration of the oral dose was 6 . For abemaciclib and ibrutinib, stable isotopically labeled drug containing 8 and 6 isotope labels (abemaciclib‐An important finding of this review is that for more than half the FDA‐registered smPKIs an absolute bioavailability trial has not been performed. A likely explanation for this finding may be that preparation of an intravenous formulation at therapeutic strength might not have been possible because of poor drug solubility. Another explanation may be that, although requested, data on the absolute bioavailability are not strictly required by regulatory agencies for market authorization.14C‐radiolabeled microdose trial design. Technological limitations of the past, mainly caused by insufficient sensitivity of LC‐MS/MS equipment, are becoming less relevant, as it is now possible to quantify drug concentrations in the low pg/mL range.The retrospective analysis of smPKIs registered for oncological indications demonstrates that the SILM trial design provides a useful alternative to the traditional 2‐period crossover trial design, as well as to the 13C8 and ibrutinib‐13C6 drug concentrations following microdose administration.The SILM absolute bioavailability trials of abemaciclib and ibrutinib demonstrate this finding. In our analysis, we calculated a required LLOQ of 18.1 and 1.3 pg/mL and isotope label number of 5 and 6, respectively, to allow for accurate quantification of the intravenously administered microdose. For these drugs, LC‐MS/MS assays have been developed with an LLOQ of 2 pg/mL for each drug to analyze abemaciclib‐Ideally, while conducting a pharmacokinetic trial, data are obtained that best reflect clinical practice. For drugs that are taken once daily by cancer patients, data on the absolute bioavailability data at steady state plasma pharmacokinetics best reflect clinical drug use. For all investigated smPKIs, the absolute bioavailability trials were performed as single‐dose studies. Furthermore, only 4 trials determined absolute bioavailability in cancer patients.By further implementation of isotopic tracer techniques for the assessment of absolute bioavailability, important gaps in knowledge can be filled with only minor adaptations required to current clinical study designs. Future research can expand to other areas as well, for example, pharmacokinetic studies to investigate any possible changes in pharmacokinetic parameters in special patient populations. The use of improved pharmacokinetic trial designs is especially relevant, as more oral anticancer agents are expected to be developed in the coming years. Only for the group of smPKIs, there are currently already about 175 different orally effective protein kinase inhibitors in clinical trials worldwide.14C‐radiolabeled microdosing trials, paving the way for a more widespread implementation of the SILM approach. For all investigated smPKIs, a SILM trial was considered feasible, but only for 2 drugs was this approach actually used during clinical development. With the increase in the number of oral anticancer agents in clinical development, the stable isotopically labeled microdose strategy may alleviate pressure on the investigation of pharmacokinetic parameters by reducing the amount of resources required as well as patient burden. Our review therefore demonstrates that the use of isotopically labeled drugs in clinical drug development provides many not yet fully exploited possibilities to improve absolute bioavailability trial design in oncology.In conclusion, we found that for more than half the oral smPKIs currently on the market, an absolute bioavailability trial was not performed. The SILM trial design provides a useful approach for conducting absolute bioavailability trials in a more effective way and to generate results with increased validity. The emergence of ultrasensitive triple quadrupole LC‐MS/MS technologies allows for more straightforward trial procedures compared with 2‐period crossover trials and The authors declare no conflict of interest in relation to this study.Additional supplemental information can be found by clicking the Supplements link in the PDF toolbar or the Supplemental Information section at the end of web‐based version of this article.Click here for additional data file.


To estimate county‐level associations between in utero exposure to threatened evictions and preterm birth in the United States.Complete birth records were obtained from the National Center for Health Statistics (2009‐2016). Threatened evictions were measured at the county level using eviction case filing data obtained from The Eviction Lab (2008‐2016). Additional economic and demographic data were obtained from the United States Census Bureau and Bureau of Labor Statistics.z‐score of average case filings over the pregnancy and by trimester. Our primary outcome was an indicator for preterm birth (born < 37 completed weeks of gestation). Secondary outcomes included a continuous measure for gestational length, a continuous measure for birth weight, and an indicator for low birth weight (born < 2500 g). We estimated within‐county associations controlling for individual‐ and time‐varying county‐level characteristics, state‐of‐residence‐year‐and‐month‐of‐conception fixed effects, and a county‐specific time trend.We conducted a retrospective cohort analysis using 7.3 million births from 1,633 counties. We defined threatened eviction exposures as the We merged birth records with threatened eviction data at the county‐month‐year level using mother's county of residence at delivery and month‐year of conception. We supplemented these data with information on county‐level annual 18‐and‐over population, annual poverty rate, and monthly unemployment rate.Increased levels of eviction case filings over a pregnancy were associated with an increased risk of prematurity and low birth weight. These associations appeared to be sensitive to exposure in the second and third trimesters. Associations with secondary outcomes and within various population subgroups were, in general, imprecisely estimated.Higher exposure to eviction case filings within counties, particularly in the latter stages of a pregnancy, was associated with an increased risk of adverse birth outcomes. Future research should identify the causal effect of threatened evictions on maternal and child health outcomes. In 2016, approximately 2.4 million eviction cases were filed in the United States.A developing literature links eviction to harmful effects on health. Several studies have documented associations between increased eviction prevalence and elevated risk of experiencing stress, depression, anxiety, psychological distress, and drug use.Despite mounting evidence of a link between health and eviction, there is less evidence on the relationship between threatened evictions and key maternal and child health outcomes. Evidence from the housing literature suggests that families with small children may be particularly likely to be threatened with evictions and, ultimately, be evicted.We hypothesized that increased prenatal exposure to threatened evictions would increase the likelihood of preterm birth and other adverse birth outcomes. This is because the threat of evictions is a key source of stress and other poor mental health outcomes, and a large literature demonstrates that high levels of prenatal stress are strongly associated with worse birth outcomes.22.1We conducted a retrospective cohort analysis by combining the largest county‐level dataset on legal eviction case filings in the United States to date with restricted‐use national birth records from the National Center for Health Statistics (NCHS).Data on eviction filings were provided by The Eviction Lab at Princeton University and contained county‐month‐year‐level counts of the number of eviction cases filed in local court for 1633 counties between 2008 and 2016.Live birth records from the NCHS represented the universe of live births in the United States between 2009 and 2016. These data contained individual‐level information on each woman's demographics, delivery payment method, self‐reported county of residence at delivery, completed weeks of gestation, birth weight, and day, month, and year of delivery.We supplemented our analysis by using county‐level data from two other sources. From the United States Census Bureau, we used data on annual, county‐level 18‐and‐over population and annual, county‐level poverty rate.2.2For each pregnant woman, we constructed two exposure variables using data on county‐month‐year eviction case filings. The first exposure was defined over the duration of the pregnancy from the month of conception to the month of delivery. The second exposure was defined separately for the first trimester (month of conception to third month of gestation) and together for the second and third trimesters (fourth month of gestation to the month of delivery). We label the first exposure as EP  and the second exposure as ET .To construct EP and ET, we estimated each woman's date of last menstrual period (LMP) using information on the obstetric/clinical estimate of gestational length and the day of week, month, and year of delivery. Next, we assigned a date of conception for each woman in our sample by assuming that conception occurs two weeks after the estimated date of LMP. Finally, we identified the number of eviction cases filed in each month of a woman's pregnancy by using information on her month‐year of conception and county of residence at delivery.casesi,tzscore) ascasesi,tavg,norm represents the average normalized case filings for each pregnant woman i over duration of pregnancy/trimester t, casestavg,norm¯ represents the mean of the average normalized case filings in the entire analytic sample over time period t, and SD(·) represents the standard deviation operator.Having assigned eviction cases to each pregnant woman for each month of their pregnancy, we constructed EP and ET in three steps. First, we normalized the number of cases filed for each county‐month‐year by the county's 18‐and‐over population for the same year. Next, we estimated the average of the population‐normalized eviction case filings over the duration of each woman's pregnancy as well as separately for the first trimester and second and third trimesters combined. Finally, we standardized the average, normalized cases to define a z‐score  completed weeks of gestation defined as a continuous variable and measured using the obstetric/clinical estimate; (2) birth weight (in grams) defined as a continuous variable; and (3) low birth weight defined as an indicator variable which equaled one if birth weight was less than 2500 g and zero otherwise.2.4We constructed our analytic sample by restricting live birth observations based on the following inclusion criteria: (a) had obstetric/clinical estimate of gestation reported; (b) mother resided in a county for which eviction case filing data were available; (c) eviction case filing data were available for each month of gestation; (d) delivery occurred in a state that had adopted the 2003 revised birth certificate in the year of delivery; and (e) the live birth was singleton.To prepare the data for analysis, we merged birth records with the eviction case filing data using information on the estimated month‐year of conception associated with each live birth and each pregnant woman's county of residence at delivery. We similarly merged supplementary datasets on county‐level population, unemployment, and poverty. Finally, for each observation in our data, we estimated eviction exposures EP and ET using Equation . We thenWe computed descriptive statistics of the outcome and covariates of interest in the analytic sample by tertiles of exposure EP. We assumed that covariate data were missing at random and accounted for them by constructing five imputed datasets under the assumption that the observed and unobserved data together followed a multivariate normal distribution. In each imputed dataset, we winsorized exposures EP and ET at the 1st and 99th percentile to reduce the influence of extreme values of the exposure.β represents the association between eviction filings and adverse birth outcomes, Xi,c,t represents individual‐ and county‐level covariates, δc represents county fixed effects defined based on each woman's self‐reported county of residence at delivery, θs(c),t represents state‐of‐residence‐year‐and‐month‐of‐conception fixed effects, and timec represents a county of residence–specific linear time trend. Equation . Since the effective exposure variation is constrained by our primary specification—that is, we analyze the variation that remains after accounting for county‐level fixed effects, state‐of‐residence‐year‐and‐month‐of‐conception fixed effects, and a linear county‐level time trend—an association of 1.09 percentage points corresponds to a 0.08 percentage point increase, on average, in the risk of preterm birth . Given the effective variation we are working with, a 0.7 percentage point increase in risk corresponds to a 0.05 percentage point increase in the risk of newborns being born low birth weight . After adjusting for the effective variation, this risk difference represented a 0.08 percentage point increase in the risk of preterm birth . The estimated association corresponds to a 0.06 percentage point difference in the risk of low birth after accounting for the effective variation (Figure In terms of the secondary outcomes, we estimated a positive association between threatened evictions in the second and third trimesters and risk of low birth weight (n Figure . The assTable Results from analyses checking for association heterogeneity by racial subgroups and Medicaid payment status were largely consistent with the primary results Tables . We esti4In this study, we investigated the relationship between prenatal exposure to threatened evictions and adverse birth outcomes across 1633 counties in 39 states and the District of Columbia between 2008 and 2016. We also studied if these associations varied by pregnancy trimester. We found that increased exposure to eviction filings during a pregnancy was associated with an increased risk of prematurity and being born low birth weight. We also found some evidence to suggest that risk of preterm birth and low birth weight were particularly sensitive to eviction filings in the second and third trimesters of a pregnancy.Results from various robustness checks largely support our primary results. Coefficients on the prepregnancy exposure variable, which we used as a negative control to conduct a falsification analysis, were small and imprecise. Although prepregnancy threatened eviction exposure may not be the ideal negative control because of its potential direct effect on birth outcomes through prepregnancy health, the falsification check results do provide suggestive evidence to support the claim that our primary results are not driven by spurious correlations. Results from estimating Equation  across tTo the best of our knowledge, our study is one of the first to demonstrate that increased within‐county exposure to eviction filings increases the risk of preterm birth. The positive associations between eviction filings—a source of prenatal stress—and risk of prematurity and low birth weight are consistent with studies that have investigated the impact of prenatal stressors on pregnancy outcomes. For instance, Gemmill et alHowever, the associations we estimate for preterm birth risk and low birth weight risk have relatively wide confidence intervals. For the association between exposure EP and preterm birth, for example, our results are compatible with a 0.05‐2.13 percentage point increase in the risk of prematurity. This relatively wide range of estimates may in part reflect the ecological nature of our analysis which analyzes an exposure at the county level, that is, our analysis treats all pregnant women as exposed to a given level of eviction filings regardless of whether they personally received an eviction notice or were affected by one indirectly. This means that our associations likely capture some combination of the exposure of living in a community where evictions are common combined with the direct experience of receiving an eviction filing. Individual‐level data on eviction filings would allow for the estimation of these associations with a higher degree of precision and could consequently find substantially larger effects for pregnant women who were directly affected by the threat of evictions over the study period. The potential for community‐level effects of housing instability resulting from increased eviction filings would also be consistent with the housing and social epidemiology literatures which have shown the impact of neighborhood quality on health outcomes.Another strength of our study is that we analyze the relationship between threatened evictions and physical health outcomes using data that have wide geographic and temporal coverage. Prior studies looking at associations between threatened evictions, actual evictions, and health outcomes have either come from other countries such as Spain or from very localized geographies within the United States.A final strength of our analysis is that it adds to the literature on the importance of the timing of in utero stressors on the risk of preterm birth and other pregnancy outcomes. In this regard, our finding regarding the relative importance of eviction case filing exposure in the second and third trimesters is consistent with some recent studies such as that by Gemmill et al.A key limitation of our analysis is that we did not have complete geographic and temporal coverage in terms of the eviction case filing data. The United States has over 3000 counties, but we only had data from 1633. Lack of data from all counties is explained by the fact that collection of data on eviction cases is more difficult in some areas due to incomplete or nonstandardized electronic case management systems, limitations on access to paper case records, and restrictions on bulk records requests. It is unclear how these barriers to record collection are associated with case filing volumes, which limits the generalizability of our results. Furthermore, generalizability of our results may also be limited because we could only use approximately 57 percent of the possible 176 364 county‐month‐year observations, not only due to a lack of county‐level data but also because we restricted our analysis to those state‐years in which the 2003 birth certificate revision had been implemented.Another limitation of our analysis is that we only observe residence at time of delivery, and we are therefore unable to determine whether a pregnant woman moved across counties over the course of her pregnancy. Movement across counties would mean that our exposure variable would be subject to measurement error that we expect would attenuate our results. However, there are reasons to believe that movement across counties may be limited in scope: The literature on evictions suggests that individuals who are evicted generally tend to move into worse quality neighborhoods and not necessarily across counties.A final limitation of our analysis is the possibility of selection bias due to exposure to higher levels of threatened evictions resulting in greater loss of fetuses that would have been born premature relative to lower levels of threatened eviction exposure.5The threat of evictions has been increasing over the past two decades, particularly for low‐income Americans. Our analysis shows that for pregnant women, higher levels of threatened evictions are associated with increased risk of adverse birth outcomes in general and premature deliveries in particular. Across the United States, several policies are currently being enacted to offset the threat of evictions—our study suggests that evaluating the causal impact of these policies on parental well‐being and child health is an important area of inquiry.Supplementary MaterialClick here for additional data file.Figure S1Click here for additional data file.Figure S2Click here for additional data file.Figure S3Click here for additional data file.Figure S4Click here for additional data file.Figure S5Click here for additional data file.Appendix S1Click here for additional data file.


Journal of General and Family Medicine, Vol 21, Issue 4.The authors would like to draw the reader's attention to errors in the manuscript, entitled 'Traumatic bilateral fourth nerve palsy: Double vision induced by downward gaze after head injury' which was published in The below text in the paragraph “On Day 1, she developed…with prism glasses.” is to be corrected:T2‐weighted brain magnetic resonance imaging (MRI) on Day 2 revealed an area of slightly high attenuation around the left inferior colliculus of the midbrain .The correct text is as follow:Brain magnetic resonance imaging (MRI) on Day 2 revealed a slightly high‐intensity area around the left inferior colliculus of the midbrain on fluid‐attenuated inversion recovery images .The correct Figure 2 legend is as follow:Brain magnetic resonance imaging. Fluid‐attenuated inversion recovery images revealed a slightly high‐intensity area around the inferior colliculus of the midbrain on the left side (arrows)The authors apologize for the errors and any confusion they may have caused.