QALY gained and $5050 per LY gained for males, and $2050 per QALY gained and $4100 per LY gained for females. Results were most sensitive to the hazard ratio of mortality for former and current smokers, the probability of quitting smoking through participation in the program and smoking‐attributable costs. The study results suggested that a best practice smoking cessation program could be a cost‐effective option. These findings can support and guide implementation of smoking cessation programs.Quitting smoking after a diagnosis of cancer results in greater response to treatment and decreased risk of disease recurrence and second primary cancers. The objective of this study was to evaluate the potential cost‐effectiveness of two smoking cessation approaches: the current basic smoking cessation program consisting of screening for tobacco use, advice, and referral; and a best practice smoking cessation program that includes the current basic program with the addition of pharmacological therapy, counseling, and follow‐up. A Markov model was constructed that followed 65‐year‐old smokers with cancer over a lifetime horizon. Transition probabilities and mortality estimates were obtained from the published literature. Costs were obtained from standard costing sources in Ontario and reports. Probabilistic and deterministic sensitivity analyses were conducted to address parameter uncertainties. For smokers with cancer, the best practice smoking cessation program was more effective and more costly than the basic smoking cessation program. The incremental cost‐effectiveness ratio of the best practice smoking cessation program compared to the basic smoking cessation program was $3367 per  Smoking is a leading cause of mortality and the leading cause of preventable death in Canada Illnesses that result from smoking are responsible for considerable health care costs, as well as loss of productivity from work. The societal cost of tobacco use in Canada in 2002 was estimated to be approximately 17 billion Canadian dollars Pharmacological interventions and counseling are important components of a smoking cessation program and evaluations of these programs have consistently demonstrated the effectiveness and importance of physician based‐interventions. Cancer Care Ontario, the provincial agency responsible for improving cancer services in Ontario, is currently implementing a best practice smoking cessation intervention for new ambulatory cancer patients presenting to its 14 Regional Cancer Programs. All 14 Regional Cancer Programs are currently screening patients for smoking status, advising on the benefits of quitting and offering referrals to smoking cessation resources. Smokers are advised that quitting tobacco use will benefit their general health, improve cancer treatment outcomes, and reduce the chance of developing comorbidities. Data on screening and other performance metrics have been collected but do not include information on physician follow‐up rates, quit rates, or the use of pharmacological interventions Value for money is an important consideration in public policy decisions and influences decision‐makers in how to allocate resources across the health care system. An economic evaluation can help inform the costs and effects of implementing a smoking cessation initiative within Regional Cancer Programs. Much has been published on the cost‐effectiveness of smoking cessation at the population level but there is almost no information related to the oncology setting. A recent systematic literature search found only one study examining the cost‐effectiveness of a smoking cessation program implemented at the time of surgery for lung cancer The objective of this study was to evaluate the potential cost‐effectiveness of two smoking cessation programs: the current basic smoking cessation program and a best practice smoking cessation program to guide implementation of smoking cessation programs across Ontario's cancer system.We compared two smoking cessation programs: the current basic approach to smoking cessation in Regional Cancer Programs, which includes only screening, advice and referral; and a best practice approach, which includes the basic program plus pharmacological therapy , counseling (once a week for 15 min with a smoking cessation nurse over 12 weeks), and follow‐up Fig.  12. Our A Markov model, with yearly cycle lengths, was developed to simulate lifetime health profiles and to compare the two cessation programs in a cohort of 65‐year‐old current smokers with cancer Fig. . There wThe 12‐month abstinence rate as a result of the best practice smoking cessation program was obtained from a study examining the impact of motivational interviewing, regular follow‐up and pharmacotherapy among patients diagnosed with potentially curable cancer We assumed that all‐cause mortality in cancer patients included cancer and non‐cancer related death. As the probability of a cancer death differs between males and females, we separated the analysis by sex. As there was no direct source of Canadian cause‐specific mortality stratified by smoking status, we took the following steps to calculate the mortality rate by smoking status for cancer patients: Step 1, identified the age‐specific probability of death for male and females in Ontario; Step 2, identified the age‐specific percentage of cancer and non‐cancer deaths from all‐cause mortality life tables; Step 3, calculated the probability of death for cancer and non‐cancer status using non‐cancer death for all‐cause mortality; Step 4, identified the mortality by age, smoking status, and years of abstinence from literature; Step 5, calculated the relative risk of mortality by age and smoking status; and Step 6, derived the adjusted mortality rates by age, sex, and smoking status. Data for the Ontario population were obtained from Statistics Canada and the Canadian Vital Statistics Death database. We obtained the hazard ratio of mortality at 12 months related to tobacco use among patients with lung cancer and by smoking status n = 13,241) n = 17,626) reported in the National Population Health Survey We incorporated health‐related quality of life into the model using utilities as a measure of the health state value for each year by smoking status, age, and sex. Health state values were obtained from a study that measured the EQ‐5D among smokers, former smokers, and never smokers in a general population in the United Kingdom  with a smoking cessation nurse We conducted deterministic and probabilistic sensitivity analyses to assess the uncertainty of all parameters. We conducted a one‐way sensitivity analysis on key model parameters such as time horizon, abstinence rates, quit rates, relapse rates, relative risk of mortality, utility decrement, and costs  and more costly  than the basic smoking cessation program. For males, the incremental cost‐effectiveness ratios of the best practice smoking cessation program was $3367 per QALY gained and $5050 per LY gained and for females, $2050 per QALY gained and $4100 per LY gained (Table One‐way sensitivity analysis revealed that the results were most sensitive to the hazard ratio for mortality for former and current smoker cancer patients, the annual health care cost of cancer patients after diagnosis, the probability of quitting due to the basic smoking cessation program, and smoking‐attributable cost Fig. . The impProbabilistic sensitivity analysis revealed that the 10,000 simulated ICERs were located in either the northeast quadrant meaning that the intervention was both more costly and more effective or the southeast quadrant meaning that the intervention was less costly and more effective Fig. . If one Our results are consistent with previous economic evaluations that used a similar model structure and intervention This study should be interpreted in light of its strengths and limitations. First, this study was exploratory in nature as data were based on a smoking cessation pilot project with limited data on physician follow‐up and quit rates. We selected the studies that were most applicable to the smoking cessation programs offered at the Ontario regional cancer center. As such, we relied on clinical evidence from broad populations in other countries. We believe these studies closely reflect the services offered at the cancer centers. This study may not be generalizable to other regions that have a different program. Second, we used the hazard ratio of current and former smokers’ mortality compared to never smokers to show the benefit of the smoking cessation program. This parameter was quite sensitive and, therefore, splitting the risk of death between cancer attributable and non‐cancer death could have had a major effect on our results. Third, the model did not take into consideration the outcomes and cost of other diseases and their comorbidities, such as stroke, chronic obstructive pulmonary disease, and cardiovascular diseases associated with smoking. If these comorbidities were taken into consideration, the best practice smoking cessation program could be even more economically attractive, as smokers are more likely to have other smoking‐related comorbidities and higher health care costs, which we have not included in our model. As well, our model considers the cancer patient in “general,” without specifying the particular cancer type or severity. Healthcare resource utilization and mortality vary widely depending on the type of cancer and severity, which could affect the cost‐effectiveness of the smoking cessation intervention. Lastly, the model did not take into account any of the potential benefits from the reduction in “second‐hand smoke” exposure to others Further research on smoking‐attributable mortality in cancer patients is required to improve the validity of the parameters used in the model. This is an exploratory analysis with many assumptions. It would be important to conduct an economic evaluation based on observed data from a specific Regional Cancer Program site in order to better understand the value for money of a best practice smoking cessation intervention.In conclusion, a best practice smoking cessation program for cancer patients has the potential to be an economically attractive option when compared to a basic smoking cessation program over a broad range of assumptions. From this analysis, it appears that public funding for a best practice smoking cessation program for cancer patients in Ontario might be a promising way to reduce economic and healthcare burden from smoking in the ambulatory oncology setting.There is no conflict of interests to declare.Figure S1. Smoking cessation programs.Click here for additional data file.


Fever is a fundamental response to infection and a hallmark of inflammatory disease, which has been conserved and shaped through millions of years of natural selection. Although fever is able to stimulate both innate and adaptive immune responses, the very nature of all the molecular thermosensors, the timing and the detailed mechanisms translating a physical trigger into a fundamental biological response are incompletely understood. Here we discuss the consequence of hyperthermic stress in dendritic cells (DCs), and how the sole physical input is sensed as an alert stimulus triggering a complex transition in a very narrow temporal window. Importantly, we review recent findings demonstrating the significant and specific changes discovered in gene expression and in the metabolic phenotype associated with hyperthermia in DCs. Furthermore, we discuss the results that support a model based on a thermally induced autocrine signalling, which rewires and sets a metabolism checkpoint linked to immune activation of dendritic cells. Importantly, in this context, we highlight the novel regulatory functions discovered for IGFBP‐6 protein: induction of chemotaxis; capacity to increase oxidative burst and degranulation of neutrophils, ability to induce metabolic changes in DCs. Finally, we discuss the role of IGFBP‐6 in autoimmune disease and how novel mechanistic insights could lead to exploit thermal stress‐related mechanisms in the context of cancer therapy. In both cases, the organism needs to activate a complex system composed of warning signals, cellular receptors to respond, signalling pathways and outputs in the form of physiological responses. Endogenous signals that alert the immune system on cell and tissue damage are called “alarmins,” whereas pathogen‐associated molecular patterns (PAMPs) flag the presence of intruding pathogens. Together, alarmins and PAMPs constitute the larger family of damage‐associated molecular patterns, or DAMPs.The immune system of vertebrates is organized to respond either to pathogens or to It is well‐known that exogenous PAMPs are recognized by cells of the innate and adaptive immune systems through quite a number of receptors, called pattern recognition receptors (PRRs), which include Toll‐like receptors, RIG‐I‐like receptors, NOD‐like receptors and C‐type lectin receptors.The insulin‐like growth factor (IGF) system is essential for growth and development, and it has been implicated in several diseases.Fever, a hallmark of infection and inflammation, is comprised of physiological and neurological circuitries that have been conserved in warm and cold‐blooded vertebrates for over 600 million years of evolution. Significantly, fever represents a fundamental systemic response which stems from the recognition of PAMPs by PRRs, determining the production of cytokines, among which IL‐6 is the most important mediator for fever induction and orchestrating lymphocyte trafficking to lymphoid organs.In this review, we have highlighted new findings related to the effect of fever‐range hyperthermia on the immune system, in particular DC activation and metabolic reprogramming, monocyte and T cell chemotaxis, and neutrophil activation. A novel role for insulin‐like growth factor binding protein 6 (IGFBP‐6) is also discussed in this hyperthermia‐induced rewiring of the immune system. Implications for the inflammatory response in autoimmune diseases and cancer are also presented.2Febrile temperatures  boost the effectiveness of the immune response during infections by stimulating both the innate and adaptive arms of the immune system.A wealth of data on the role of metabolic pathways controlling immune cell function have shed new light on both the innate and adaptive immune response, and led to the discovery of “immunometabolism” as an important area of research.2+ uniporter (MCU) inhibition prevents mt‐OxPhos inhibition and cytokine release. Figure Recently, we explored how a short‐term mild hyperthermal activation of monocyte‐derived dendritic cells (MoDCs) intertwined with changes in the metabolic phenotype.Strikingly, the same hyperthermic conditioning, that in MoDCs cause a significant change in the mitochondrial physiology, resulted in no change at all in mitochondrial respiratory activity of undifferentiated monocytes, which mainly rely on glycolysis.2+ homoeostasis. This clearly points to a cell‐specific sensitivity of the mitochondrial activity to the thermal stress and suggests that metabolic pathways under thermal control are of pivotal importance in DCs physiology. Our priority in fact has been to study DCs‐specific response to hyperthermia as a mean to better understand fundamental mechanisms controlling immunity.And in fact, in monocytes we observed no variation in OxPhos‐related respiratory activity and of the redox and CaImportantly, re‐conditioning of the 39°C‐treated MoDCs to normothermia did not appreciably recover the mitochondria‐related activities showing the irreversible nature of this observation. Again this fact suggests that response to fever in DCs is a fundamental and solid process which rapidly activates complex and important pathways in DCs, not easily inhibited after activation.2+ homoeostasis comparable with that attained in thermally challenged MoDCs. The relevance of our findings was even magnified as we discovered that a relatively small number of genes vary in expression upon brief exposure to mild hyperthermia in DCs when we studied a small group of bona fide normal subjects. In our hands, IGFBP‐6 was in fact the only specifically up‐regulated under hyperthermic conditions by MoDCs.As activation of immune‐competent cells is also known to be accompanied with changes in the cell secretome,Therefore, we explored in our recent publications3Insulin‐like growth factors (IGFs) have a key role in normal growth and development,IGF2 is an imprinted gene, meaning that one of the two parental alleles of a locus is expressed. Loss of imprinting of IGF2, resulting in abnormal expression of IGF‐II, occurs in a number of cancers, sporadic Wilms’ tumour and often in patients with Beckwith–Wiedemann syndrome, characterized in the neonate by overgrowth with risk of developing Wilms’ kidney tumours.Insulin‐like growth factor actions are regulated by a family of six high affinity binding proteins (IGFBP 1‐6). All IGFBPs have been shown to inhibit the IGF‐associated actions by preventing IGF‐I receptor binding; however, IGF‐independent cellular effects of IGFBPs have also been demonstrated. Strikingly, IGFBP‐6, which is the focus of the present review, binds and inhibit IGFs, with a relatively higher propensity towards IGF‐II than IGF‐I. As for the cognate IGFBP 1‐5, IGFBP‐6 presents two domains at the N‐ and C‐terminal of the 240 amino acids long chain.Here we briefly review the main IGFBP‐6 categories of actions: IGF‐I and IGF‐II dependent, as well as IGF independent functions.3.1Growth hormone (GH) is the major factor stimulating IGF‐I biosynthesis and release, and IGF‐I mediates many, but not all, of its activities.3.2IGF‐II has been implicated in mitosis, growth and organ development by paracrine and endocrine pathways in cell culture studies and animal models.3.3IGFBP‐6 is capable, however, of actions independent of IGF‐II, including regulation of proliferation, apoptosis, angiogenesis and cell migration.3.4Some IGFBPs are also nuclear proteins with independent functions from IGFs, and their actions drive the cell fate. IGFBP‐3 and IGFBP‐5 are translocated into the nucleus via the importin‐5 subunit.The specific impact of IGFBP‐6 on cell metabolism largely relies on its ability to modulate the bioavailability of IGFs thereby antagonizing their receptor(s)‐mediated signalling. A part from their effects on growth and development, IGFs also have insulin‐like effects on metabolism with different tissue‐specific outcomes. However, although IGFs exert an established control on glucose and lipid homeostasis as well as a net anabolic effect on protein metabolism, the molecular mechanisms of their actions are not completely understood. Recent evidences suggest the involvement of the IGF‐IR‐mediated signalling in preserving the mitochondrial structure and function achieved by controlling mitochondrial biogenesis and mitophagy as well as reactive oxygen species homeostasis.Moreover, more recently other functions of IGFBP‐6 related to the immune system have been discovered Figure , as we fAs hyperthermia could induce an increased expression of IGFBP‐6 by at the level of dendritic cells (DCs), as well as their metabolic reprogramming, we are currently testing the ability of IGFBP‐6 to induce metabolic reprogramming in DCs. The implications of all these findings for cancer biology and pathogenesis of inflammatory disorders are further discussed below.4IGF2The involvement of the IGF system in cancer is multifaceted. IGFs in general and IGF‐II in particular are involved in promoting tumour growth in situ in an autocrine or paracrine fashion once the tumour has been established. Many cancers overexpress As we have outlined above, the role of IGFBP‐6 in cancer is complex and stems from its primary role as a modulator of IGF‐II bioavailability and hence as a negative regulator of cancer cell growth. Indeed, it has been considered a tumour suppressor gene. On the other hand, IGFBP‐6 inhibits angiogenesis and induces apoptosis of cancer cells in an IGF‐independent manner.5The tumour microenvironment (TME) plays a fundamental role in tumour cells’ acquirement of cancer hallmarks, thus being involved in cancer formation but also in its progressive and invasive phases.A complex network of chemokines regulates chemotaxis of tumour cells in TME, and both cancer and inflammatory cells produce several cytokines and chemokines that attract and activate tumor‐infiltrating cells, including tumour‐associated macrophages (TAMs) and T cells.IGFBP‐6 is likely involved in the attraction of inflammatory and immune cells in this context.IGF‐II, wild‐type (wt) and mutated IGFBP‐6 were shown to determine alteration in the migration of ovarian cancer cells.6Inflammation and innate immunity are complex phenomenon that are apparently redundant but that may be evolutionarily driven to comply with encounters with diverse damaging and infectious agents.Neutrophils are the main cell type involved in the acute inflammatory response. Upon bacterial product release or cytokine production, these cells are primed in the circulation, are attracted into the inflamed tissue where they exert their main defence actions by phagocytosis, ROS production and release of the their granule content.P < .05 as compared to cells migrating in the absence of IGFBP‐6). T cell chemotaxis was also significantly increased, showing a peak at 4 nmol/L , with a behaviour similar to SDF‐1. Concentrations of IGFBP‐6 lower than 4 nmol/L had no chemotactic activity for T cells. The specificity of the chemotactic effect was shown by the preincubation of IGFBP‐6 with an anti‐IGFBP‐6 antibody that abolished its chemotactic activity.Recently, we have shown that IGFBP‐6 has chemoattractant properties towards monocytes and T cells but not B cells.Rheumatoid arthritis (RA) is a chronic inflammatory disorder, where pannus development and cartilage and bone damage at the joint level recall tumour development and invasion. In a recent study,7In summary, recent findings are consistent with the emerging notion that any immunological response to external stimuli needs to cope with a specific metabolic rewiring of the immunocompetent cells. The consequence of hyperthermic stress discussed here in MoDCs, mimicking physiological febrile temperatures in humans, unveiled that the sole physical input is sensed as an alert stimulus triggering a transition in dendritic cells from a quiescent state into a pre‐activated state. Such a transition occurs in a narrow temporal window and is accompanied by a significant change in the metabolic reprogramming which therefore is a very early event in the immune response functioning.Finally, IGFBP‐6 seems to play an important role in the control of cell‐specific immunologic adaptation following hyperthermia. In vivo experiments are warranted to fully explore the role of IGFBP‐6 in pathology and to discover how we might exploit its functions in diagnosis and therapy.The authors declare no conflict of interest.


Diaphragmatic assessment by ultrasound (US) is a non-invasive and useful method in the clinical management of patients with Amyotrophic Lateral Sclerosis (ALS). The aim of our observational study was to evaluate the impact of serial assessment of the diaphragmatic function by US on long-term outcomes in a series of patients suffering from ALS and to correlate US indices of diaphragmatic function and respiratory function tests with these outcomes.A cohort of 39 consecutive patients has been followed up to 24 months. Both lung volume  and diaphragmatic pressure generating capacity  and by both US thickening fraction, ΔTdi, and the ratio of the thickening fraction between tidal volume and maximal lung capacity, ΔTmax) were recorded at baseline and every 3 months. Parameters were then correlated with outcomes , and death at 1 year) over time.p = 0.001) and to die  compared with patients maintaining lower values. Moreover, compared with the occurrence of FVC < 50% of predicted, ΔTmax > 0.75 appeared slightly better correlated with NIV commencement within 6 months.The occurrence of ΔTmax > 0.75 increased the risk to start NIV  contains supplementary material, which is available to authorized users. Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disease involving the motor neurons of the cortex, brainstem and spinal cord. The leading cause of death in these patients is the onset of hypercapnic respiratory failure due to progressive respiratory muscle involvement, including diaphragmatic dysfunction .The early assessment of diaphragmatic function might therefore be essential to prompt non-invasive mechanical ventilation (NIV) with the aim of increasing survival and improving quality of life in these patients . OverallThe routinely used evaluations of both lung volumes (namely FVC by spirometry) and diaphragmatic pressure generating capacity ) require the patient’s full collaboration and coordination, thus very often they are not very informative , 7 in thRecently, diaphragmatic assessment by ultrasound (US) has been used to distinguish between normal status and dysfunction –13 in diPinto et al. demonstrated that diaphragm thickness by US correlated with compound motor action potential of the phrenic nerve . Our groThe aim of this study was therefore to evaluate the impact of serial assessment of ΔTmax on long-term outcomes in a series of patients suffering from ALS and to correlate US measurements of diaphragmatic function and respiratory function tests with these outcomes.possible, probable, probable laboratory-supported or definite diagnosis of ALS (sporadic or familiar) according to the revised El Escorial criteria  × 100) and the ratio between Tdi at the end of Vt and Tdi after maximal inspiration up to TLC (ΔTmax = end-inspiratory Vt Tdi / end-inspiratory TLC Tdi) were determined. According to previous data, ΔTdi < 20% and ΔTmax > 0.75 were considered thresholds for diaphragmatic dysfunction .2 above 45 mmHg [The association between occurrence of pathological ΔTmax and NIV initiation and mortality were the primary outcomes considered for analysis. The decision to start NIV was taken by a multidisciplinary team unaware of the results obtained by diaphragmatic US assessment and rigorously following the specific criteria set by the American Academy of Neurology with particular regard to respiratory function tests . During  45 mmHg . Among pp value lower than 0.05 was considered to be statistically significant.The statistical package GraphPad Prism 7.0  was used for statistical analysis. A Descriptive statistics were used for demographic, clinical and instrumental variables. Kaplan–Meier curve analysis was used to investigate the impact of ΔTmax > 0.75 or < 0.75 on NIV start and mortality compared to FVC > 50% or < 50%. Linear regression analysis of covariance was applied to ΔTmax time course in the whole sub-group of patients who started NIV and according to their survival within 1 year (survivors and non-survivors). Contingency table analysis for relative risks was used to compare the traditional FVC and SNIP metrics with the proposed new ultrasound guided indices (ΔTmax and ΔTdi) in predicting the onset of recorded clinical outcome measures .In total, 66 consecutive outpatients with ALS were referred to our Unit. Out of these, 39 subjects fulfilled entry criteria and were enrolled in the study; 27 already presented an abnormal ΔTmax (> 0.75) and were therefore excluded see Fig. .Fig. 1FThe general characteristics and clinical features of the population at study baseline are presented in Table Ten out of the 39 patients (26%) had normal ΔTmax values during the follow-up Fig. . Among tp = 0.001) and to die  was several-fold increased in patients with ΔTmax > 0.75 and/or with FVC below 50% compared with others. In addition, change over time of average ΔTmax in the 25 patients who started NIV and according to survival is shown Fig. p = 0.027) between patients who survived or died following NIV.Figure Contingency table analysis for relative risks of respiratory function  and US  variables in predicting the onset of the outcomes considered is summarized in Table With this prospective observational study, we have demonstrated that serial diaphragmatic assessment by ultrasound may be useful to predict initiation of NIV and death in patients with ALS. The occurrence of an abnormal ΔTmax value over time preceded the decision to start NIV.From technical point of view, the site of US exploration of the diaphragm changes among studies. For example Pinto et al.  used theA ΔTmax value > 0.75 has previously been demonstrated by our group as the threshold limit of normal diaphragmatic function in patients with ALS . In partIn addition, the occurrence of abnormal ΔTmax over time correlates with mortality similar to the occurrence of abnormal FVC, still the best respiratory prognostic indicator of survival and disease progression in ALS . Moreoven = 9). Therefore, though ΔTmax and ΔTdi, as a surrogate measure of diaphragmatic pressure generating capacity, might seem similar in describing diaphragmatic function, they could provide different information on muscle status.In our study, we have shown that the occurrence of an abnormal thickening fraction of the diaphragm ΔTdi < 20%)  is a sig0%  is a Muscle fatigue can be defined as a condition characterized by a reduction in muscle capacity to generate force when subjected to a given load. This condition is reversible following rest for a certain period of time, and it is different from the concept of muscle weakness where the ability to restore strength after rest is compromised [When the change in diaphragm thickness (ΔTdi) in the area of apposition is lower than 20%, diaphragmatic dysfunction should be considered very severe and close to paralysis . As suchpromised , 25.In neuromuscular diseases, the elastic load of the respiratory system increases due to different factors causing the reduction in lung distensibility: 1) loss of gas-containing alveoli (patchy atelectasis), 2) generalized increase in surface tension of the alveolar lining layer caused by breathing at low volume, 3) alteration in lung tissue elasticity . TherefoWith this scenario, the non-invasively obtained ΔTmax, as a surrogate measure of Pdi/Pdimax ratio, could be used to provide specific information about the fatigue status of the diaphragm in patients with ALS. Despite this assumption presenting obvious limitations, it is possible to deduce that, when the thickness of the diaphragm at the end of the tidal breath approaches the thickness at TLC, we are probably close to the area of “fatigue/weakness” of the muscle .p = 0.32). We thus believe that the two groups may be considered homogeneous at the beginning of assessment. Patients treated with long-term ventilator support and with better prognosis showed a stabilization of ΔTmax over time following the beginning of NIV , Tidal Volume (Vt), Functional Residual Capacity (FRC). (PNG 508 kb)


Therefore the MTL appears to perform a specific computation: binding disparate features that belong to a memory. These results echo findings from previous studies, which have identified a role for the MTL in relational binding for LTM, and support the proposal that MTL regions perform such a function for both STM and LTM, independent of the retention duration. Furthermore, these findings and the methodology employed here may provide a simple, sensitive and clinically valuable means to test memory dysfunuction in MTL disorders.Classical views of the medial temporal lobe (MTL) have established that it plays a crucial role in long‐term memory (LTM). Here we demonstrate, in a sample of patients who have undergone anterior temporal lobectomy for the treatment of pharmacoresistant epilepsy, that the MTL additionally plays a specific, causal role in short‐term memory (STM). Patients (n=22) and age‐matched healthy control participants (n=26) performed a STM task with a sensitive continuous report measure. This paradigm allowed us to examine recall memory for object identity, location and object‐location binding, independently on a trial‐by‐trial basis. Our findings point to a specific involvement of MTL in object‐location  These findings are consistent with results from investigations that have identified a role for the MTL in relational binding for LTM, supporting the proposal that MTL regions perform such a function for both STM and LTM  have established that it plays a crucial role in long‐term memory  or gender . Overall patients performed significantly less well on the cognitive screening test, Addenbrooke's cognitive examination or ACE‐III , and had less years of education  than healthy controls. For all STM analyses, both overall ACE‐III score and years of education were added as covariates. Any differences between patients with right and left lobectomy were examined using side of resection as a between‐subject factor. There was no main effect of side of temporal resection or any interaction between this factor and any of the experimental factors reported below. For further analysis, we have included all patients as one group. For identification and localization memory performance analysis, repeated measures ANCOVA with number of items (1 or 3) and delay (1 or 4 s) as within‐subject factor and participant group  as a between‐subject factor was used.The groups  did not differ significantly in age . Importantly however, there was neither main effect of group nor a significant interaction between delay or set size with group  of 3% and patients with mean of 96% and SD of 4%; identification accuracy for set size 3: healthy controls with mean of 90% and SD of 7% and patients with mean of 89% and SD of 9%). For the remaining analyses, only trials where participants had previously selected the correct item were included.Identification performance was significantly worse for larger set sizes and longer delays  and in patients . Post hoc t‐tests revealed larger errors in patients for set size 3 after a 4‐s delay . This is also demonstrated in the histogram of responses centered on the nonprobed item locations. On longer trials, there is a peak of responses centered on the location of the nonprobed items in patients but crucially reduced in control participants  just as well as controls when examined by a traditional, binary (correct/incorrect) recall measure. However, a deficit emerged when their location memory was assessed using a continuous, analog measure. The lack of a significant increase in swap or misbinding errors with 1 s retention delays demonstrates that impairment in patients cannot be explained by deficits at encoding. Rather, this deficit could be accounted for entirely by an impairment in maintaining object‐location binding. Finally, these deficits were observed at set sizes below putative item capacity limits of STM. Importantly, the deficit emerged when controlling for ACE‐III scores and years of education, thus the differences cannot also be attributed to baseline differences in education or overall cognitive ability between the two groups.Others have proposed a role for the MTL in relational binding of features belonging to an episode in LTM Davachi, . HoweverThe involvement of the MTL in STM has not always been observed . Similar to lesion studies, AD patients and those with familial AD—in whom MTL atrophy has been identified to be a key imaging finding—have difficulty maintaining binding of information even for very short periods of delay  and individuals with familial AD due to genetic mutations in In summary, in this study, we demonstrate a causal role of MTL in retention of bound information in visual STM. These findings suggest the MTL is not exclusively involved in LTM but rather supports processes—such as retention of bound features—that are likely to be shared across several cognitive functions. The findings and methodology presented here have important clinical potential. The task provides a quick and easy to administer test of STM that is sensitive to MTL disorders and thereby has the potential to inform clinical practice, by, for example, enabling better detection of subtle memory impairments preoperatively (to enable appropriate counseling of risk) and postoperatively providing targets for interventions to maximize recovery.


Although plasmids play an important role in biological evolution, the number of plasmid families well‐characterized in terms of geographical distribution and evolution remains limited, especially in archaea. Here, we describe the first systematic study of an archaeal plasmid family, the pT26‐2 plasmid family. The in‐depth analysis of the distribution, biogeography and host–plasmid co‐evolution patterns of 26 integrated and 3 extrachromosomal plasmids of this plasmid family shows that they are widespread in Thermococcales and Methanococcales isolated from around the globe but are restricted to these two orders. All members of the family share seven core genes but employ different integration and replication strategies. Phylogenetic analysis of the core genes and CRISPR spacer distribution suggests that plasmids of the pT26‐2 family evolved with their hosts independently in Thermococcales and Methanococcales, despite these hosts exhibiting similar geographic distribution. Remarkably, core genes are conserved even in integrated plasmids that have lost replication genes and/or replication origins suggesting that they may be beneficial for their hosts. We hypothesize that the core proteins encode for a novel type of DNA/protein transfer mechanism, explaining the widespread oceanic distribution of the pT26‐2 plasmid family. Recently, the whole genome of P. abyssi strain GE2 was sequenced in the framework of a large project on comparative genomics of Thermococcales, and we were only able to detect the integrated plasmid from the assembly.In order to expand the diversity of plasmids of the pT26‐2 family, each of the seven previously identified core genes  of the plasmids of the pT26‐2 family (TKV2 and TKV3), are not identical and are unexpectedly mixed  of available Thermococcales genomes and 45% (10 of 22) of available Methanococcales genomes containing at least one of them  or from volcanic back‐arcs in the Mediterranean Sea. The available genomes originate mostly from strains isolated in the northern hemisphere. In addition, the six Methanococcus maripaludis strains (out of seven) whose genomes contains a plasmid of the pT26‐2 family were isolated from neighbouring sites in the Gulf of Mexico  and SiLiX (SIngle LInkage Clustering of Sequences) described in Methods section]. The comparative analysis of plasmids of the pT26‐2 family by RBH analysis Fig.  reveals t26‐4p to t26‐15p; Figs. et al., Sulfolobus Turreted Icosahedral Virus 2. The Phyre‐2 analysis of the t26‐6p protein, containing the five predicted transmembrane helices, showed a confident structural similarity with the bacterial colicin B protein. In bacteria, this protein is a cytotoxic protein that forms a pore in the bacterial membrane that depletes the electrochemical potential of the membrane and results in cell death. The analysis of the protein encoded by the high conserved region suggests that these proteins could be involved in the translocation of DNA through membranes.Plasmids of the pT26‐2 family present a highly conserved region of 12 genes with conserved synteny  proteins among plasmids of the pT26‐2 family, one corresponding to hypothetical proteins specific for plasmids of this family and two corresponding to various proteins of the minichromosome maintenance (MCM) family that includes both archaeal and eukaryotic replicative helicases.et al., Sulfolobus neozealandicus . Together, these methods allowed us to identity a putative ori for 24 of the 29 plasmids of the pT26‐2 family  was predicted by cumulative GC skew analysis for the prototype plasmid pT26‐2 between the ori are located in intergenic regions or in regions containing multiple small open reading frames, which are potentially non‐coding , the ori was located nearby the gene encoding one of the three types of putative Rep proteins.Overall, both the location and sequence of putative et al., et al., et al., et al., et al., et al., pT26‐2) but encoded by plasmids and/or viruses from different MGE families. Clustering analysis was performed using SiLiX with a minimum threshold of 25% identity over 40% of the protein  exhibit identical sequences on the plasmid (attP) and the host chromosome (attB). Close examination of the att sites of the pT26‐2 family plasmids and of their integrase‐encoding genes confirmed the two different recombination strategies used by these plasmids. In Thermococcales, the attP site is located inside the coding sequence of the integrase gene, as expected for type I integrases, whereas in Methanococcales, the att sites are often located close to the integrase gene as expected for type II integrases. However, in some cases, the att site of type II integrases was located further away from the et al., et al., et al., For both types I and II integrases, the attB sites are usually located at the 5′ or 3′ regions of tRNA genes  All CRISPR spacers directed against plasmids present in strains of one order  are specific for plasmids detected in this order; (ii) phylogeny of the Rep proteins shared between pT26‐2 plasmids of these two orders (MCM) also show a clear‐cut separation between them, and non‐MCM Rep proteins are specific either for Thermococcales (t26‐22p‐like protein) or Methanococcales (the distantly related MCM‐like protein and PCNA) and (iii) Thermococcales and Methanococcales plasmids of the pT26‐2 family are characterized by different types of integrases (types I and II respectively) and different integration specificities.et al., et al., Two observations suggest that ancestral plasmids of the pT26‐2 family were already present in the last common ancestor of Thermococcales and in the last common ancestors of Methanococcales. Firstly, the plasmids of the pT26‐2 family and CRISPR spacers which target them are widespread in both orders, and secondly, our phylogenetic analysis indicates that the core proteins have co‐evolved with their hosts without inter‐order transfers. Taken together our results lead us to propose two evolutionary models for the pT26‐2 family Fig. . The firThermococcus and Methanocaldococcus was previously described for the pTN2 family, based on comparative genomics  negatively effects growth ‐based method  than the free form established several years ago. The difference corresponds to the presence of an insertion sequence (IS) of 1,825 bp containing two genes, encoding a resolvase  and a transposase  respectively. This IS element belongs to the IS family IS200/IS605  and was also detected in the P. abyssi GE2 genome, suggesting that the copy found in the episomal form of pGE2, originated from the host chromosome.The pGE2 integration site in a tRNA gene was determined using an inverse PCR strategy, and confirmed by the whole‐genome sequencing of the et al., In order to identify new members of the pT26‐2 family (Soler pT26‐2). Genomes were searched by tblastn using as query the N‐ter or C‐ter region of IntpT26‐2 and the subsequently identified integrases. Attachment sites (att) were identified as identical region on the border of integrase N‐ter and C‐ter coding regions. Up to three mismatches were accepted in the middle of the att site to take into account sequence degenerescence after integration. N‐ter coding sequences were defined from a start codon (ATG or GTG) to the last non att codon. C‐ter coding sequences were defined from the first att codon to a stop codon. Complete integrase genes were reconstructed by adjoining N‐ter and C‐ter coding regions. The N‐ter and C‐ter region did not have matching open reading frames only for TKV2 and TKV3.In Thermococcales, integrase genes were identified by homology with the integrase of the plasmid pT26‐2 . At the time of the analysis, the database contained 232 complete archaeal genomes, including 27 and 15 genomes of Thermococcales and Methanococcales respectively at the time of the analysis. The nucleotide sequences of all identified plasmids of the pT26‐2 family were compared by blastn approach against the spacer‐sequences in the CRISPR database.The host specificity was determined by the presence of a CRISPRspacer against each pT26‐2 element in the archaeal genomes present in the CRISPRdb database . In order to find densely connected communities in a graph via random walks, we used the cluster_walktrap function of the igraph package.SiLiX  was used with the best model as suggested by the best model selection option (Wong et al., et al., et al., For the maximum likelihood analysis, IQ‐TREE v1.6 (Appendix S1: Supporting InformationClick here for additional data file.Appendix S2: Supporting InformationClick here for additional data file.Appendix S3: Supporting InformationClick here for additional data file.


Seasonal variation exists in disease incidence. The variation could occur across the different regions in a country. This paper argues that using national household data that are not adjusted for seasonal and regional variations in disease incidence may not be directly suitable for assessing socio‐economic inequality in annual outpatient service utilisation, including for cross‐country comparison. In fact, annual health service utilisation may be understated or overstated depending on the period of data collection. This may lead to miss‐estimation of socio‐economic inequality in health service utilisation depending, among other things, on how health service utilisation, across geographical areas, varies by socio‐economic status. Using a nationally representative dataset from South Africa, the paper applies a seasonality index that is constructed from the District Health Information System, an administrative dataset, to annualise public outpatient health service visits. Using the concentration index, socio‐economic inequality in health service visits, after accounting for seasonal variations, was compared with that when seasonal variations are ignored. It was found that, in some cases, socio‐economic inequality in outpatient health service visits depends on the socio‐economic distribution of the seasonality index. This may justify the need to account for seasonal and geographical variations. This isTraditionally, reported outpatient service utilisation data are annualised by multiplying them by 12 if the recall period was the last 1 month . This paper uses nationally representative South African Consortium for Benefit Incidence Analysis (SACBIA) survey2It is important to note that relative socio‐economic inequality in health service utilisation will not change when utilisation is multiplied by a uniform scalar  involved annualising public outpatient visits using a seasonality index generated on the basis of aggregate public outpatient visits in each district recorded in the District Health Information System (DHIS), a form of the census on public health service utilisation. Because the DHIS contains data on public facility utilisation, only public outpatient visits disaggregated by health provider level  were considered in this paper. The disaggregation does not contain information on specific diseases.Two forms of annualisation were performed, and the results of socio‐economic inequality in public outpatient health service visits were compared between them. The first, also called uniformly annualised visits, was done by multiplying public outpatient visits by 12 , is defined as follows:Uikl is the total visits to a specified facility type Ujkl>0 is the total visits to facility type SIjkl computed for a given month  against the cumulative percentage of the population, ranked by a measure of socio‐economic status  and socio‐economic inequality in the seasonality indices.μ^H is the weighted average of the health service utilisation or seasonality index, ξ^H=∑i=1nVi2−Vi+12/V12hi, Vi=∑m=inwm. The vector The concentration index (d Duclos :(2)CH=1In this paper, these indices  between the concentration index of the seasonally annualised visits .The “dominance” command written by Owen O'Donnell was used to perform statistical dominance tests ( This is supplemented with a second‐order stochastic dominance test (Araar & Duclos, 5The adult equivalent scale (nd Zaidi , we set As the difference between these indices (l et al. .4The “d3The average values of the seasonality indices increase with household income deciles Table . The aveOn the basis of the socio‐economic distribution of the seasonality indices shown in Table Overall, using data collected between April and July 2008, although some of the results are not significant, they indicate the importance of accounting for seasonal and regional variations in disease patterns within a country. Here, the disease pattern was proxied by reported utilisation obtained from the comprehensive DHIS database. In this case, there is a statistically significant and systematic variation in the distribution of the seasonality indices in favour of the rich. If this variation is not accounted for within a country, socio‐economic inequalities may be overstated in favour of the poor, when an annual generalisation is intended. It is important to note that the prorich pattern obtained in Table 4Theoretically, as shown in Equation The original study from where data are obtained had received ethical approval from the University of Cape Town.


The primary hypothesis of this trial is that an electronic support tool can increase adherence to comedication (primary endpoint) thereby supporting positive lifestyle changes (secondary endpoints). Patients hospitalized with ACS  and treated with ticagrelor coadministered with low‐dose acetylsalicylic acid will be randomized 1:1 to an active group receiving the patient support tool via a smartphone‐based application or to a control group without the patient support tool. Patient questionnaires to evaluate lifestyle changes and quality of life will be used at baseline and at the end of the 48‐week observation phase. Patients are asked to fill out questionnaires to determine their adherence, treatment attitudes, health‐care utilization and risk factors on a monthly basis. The study was started in February 2016 and the completion date is scheduled for October 2019. For final analysis 664 patients are expected be available. Preliminary baseline demographics were unstable angina pectoris (13.7%), NSTEMI (49.9%), STEMI (36.4%), male gender (86.3%), and diabetes mellitus (17.6%). Our study could significantly help to understand how inadequate adherence to antiplatelet therapy in ACS patients could be improved with a smartphone‐based application.A novel smartphone‐based patient support tool was developed to increase the adherence to antiplatelet therapy and lifestyle changes in patients after coronary angioplasty for acute coronary syndrome (ACS). The eMocial study ( However, real‐life comedication adherence seems to be an issue.Current European Society of Cardiology (ESC) guidelines1.2Poor adherence to comedication or lifestyle changes are multifactorial and are the result of an interplay of patient‐, physician‐ and health‐care‐related factors.We sense that there is a need for alternative, cost‐effective methodologies to improve adherence, which can be customized to individual patient's needs and circumstances.1.3A broad range of direct and indirect methods is available to study adherence and persistence of a long‐term, oral drug treatment in clinical practice. However, there is currently no single, “gold standard” approach.Regarding our primary endpoint measure, there are several self‐reported adherence measures. The Morisky scaleThe two major reasons for why we created our own instrument are 2‐fold. Today there are no existing PRO measures that are validated and measure adherence. Secondly, the goal of the study was to measure actual compliance which needed to be specific for antiplatelet therapy.To our knowledge, no available instrument meets today's regulatory standards of being “fit for purpose.” Therefore, we developed a PRO instrument called the Brilique Adherence Questionnaire (BAQ). The BAQ  by combining reminders about medication intake, information on the importance of treatment, motivation by supportive messages, and visualization of the effect of an individual's lifestyle choices on cardiovascular risk . The app is CE (Conformité Européene) marked as a class I medical device. The patient enters baseline information and the tool will then allow the patient to enter data on an ongoing basis and provide individualized feedback to the patient. The app will send daily optional reminders for medication intake, as well as motivational and informative messages every couple of days. The relationship between cardiovascular risks and lifestyle choices is graphically displayed in a qualitative way on a continuous basis.In addition, the “Me & My Heart” app delivers monthly questionnaires to evaluate the trial endpoints. For the control group, the app will deliver only the questionnaires to evaluate endpoints and will not give any of the previously mentioned patient support. To assess if this information has an effect on the patients' lifestyle, we included an in‐house developed instrument, the Lifestyle Changes Questionnaire  is a randomized trial according to §23b Medizinproduktegesetz . The primary objective is to evaluate the effect of patient support delivered through a smartphone‐based app on treatment adherence in ACS patients who received ticagrelor as their antiplatelet agent. More precisely, the primary hypothesis of this trial is that an electronic support tool can increase adherence to comedication (primary endpoint) thereby supporting positive lifestyle changes (secondary endpoints).This “Me & My Heart” study , (c) body weight, waist circumference, body mass index (BMI), and (d) quality of life measures (assessed by SF‐36v2); lifestyle changes questionnaire (assessed by LSQ‐V1 and ‐V2); and (e) health‐care utilization (assessed by BAQ questions 12‐15). Details of the SF‐36v2 and LSQ‐V1 and ‐V2 scores are available in Table Secondary objectives Table  includedBefore hospital discharge, patients diagnosed with ACS and treated with ticagrelor will be offered to participate in the study. It is planned that approximately 680 patients who give informed consent will be randomized 1:1 via an electronic case report form (eCRF) to a 2 × 2 factorial design with equal group sizes to receive the smartphone‐based patient support tool  or a control smartphone‐based app used for data collection only (with no patient support). The detailed inclusion and exclusion criteria are described in Table 2.2The primary outcome variable is the percentage of tablets that patients report to have taken during the 48‐week observation phase, measured by the BAQ. The main secondary outcome variables include the percentage of tablets taken during the 48‐week observation phase, using the information from MEMS. Furthermore, the percentage changes from baseline to the second visit to determine key risk factors (including blood pressure and laboratory parameters), in quality of life . However, post‐hoc analyses may be indicated depending on the findings of the planned study results within the framework of the a priori defined statistical analysis plan. Post‐hoc power calculations are planned for key secondary endpoints such as the percentage of tablets taken during the 48‐week observation phase and the percentage changes from baseline to the second visit in terms of key risk factors.There are no substudies planned in the original protocol ,The use of PRO tools to capture adherence is common, but there are two major challenges with this approach. The first concern is data bias due to, for example, variable patient recall and social desirability . Because we are asking patients to report on something they are supposed to be actively doing (rather than something they experience or perceive), self‐reports on adherence tend to overestimate adherence. The second concern is the validity of current instruments. To our knowledge, there are no currently available adherence tools that would meet regulatory standards of being “fit for purpose” in terms of content and psychometric characteristics.The advantage of using a smartphone‐based app  to judge4.2One limitation of this study is the lack of closely comparable statistical data for study dropout and response rates to PRO tools delivered through the patients' own mobile devices. This means that the assumptions made for the sample size calculations are approximate. Consequently, there is a risk of not being able to establish statistical significance. In addition, because study‐specific health‐care professional interactions are minimized, there is a risk that patients in the study could stop responding to the PRO surveys even if they continue medication.In terms of the postulated rather conservative dropout rate of 30%, as compared to the reference values discussed by Akl et al,In this study, the accuracy and granularity of adherence measurement are balanced with the risk of affecting the adherence by the act of measuring it. This is done by presenting BAQ every 4 weeks  and then asking the patients for their number of missed doses in the past 7 days . The weekly non‐adherence rate is then extrapolated to the full 4‐week period since the previous measurement. The fact that the PRO tools are new and not yet fully validated is also a limitation of this study. Because 50% of the study population use MEMS, cross‐correlation between the PRO and MEMS adherence numbers will be possible.5This study will evaluate how a mHealth solution can support ACS patients and positively impact their adherence to both medication and lifestyle changes over a clinically relevant treatment time of 12 months. If conclusive, our study could significantly help to understand how inadequate adherence to comedication could be improved with a smartphone‐based application.FK received lecture fees from AstraZenecax, MJ‐K, AN, MA are full‐time employees of AstraZeneca during the preparation of this manuscript. All other authors have no conflict of interest.


The goal of this manuscript is to explore the role of clinical proteomics for detecting mutations in chronic obstructive pulmonary disease (COPD) and lung cancer by mass spectrometry‐based technology. COPD and lung cancer caused by smoke inhalation are most likely linked by challenging the immune system via partly shared pathways. Genome‐wide association studies have identified several single nucleotide polymorphisms which predispose an increased susceptibility to COPD and lung cancer. In lung cancer, this leads to coding mutations in the affected tissues, development of neoantigens, and different functionality and abundance of proteins in specific pathways. If a similar reasoning can also be applied in COPD will be discussed. The technology of mass spectrometry has developed into an advanced technology for proteome research detecting mutated peptides or proteins and finding relevant molecular mechanisms that will enable predicting the response to immunotherapy in COPD and lung cancer patients. However, it is interesting to research a possible role of neoantigens in chronic obstructive pulmonary disease (COPD) by using mass spectrometry (MS) technology. This manuscript starts with describing the role of neoantigens, followed by an introduction of COPD and lung cancer and an analysis of the link between COPD and LC.Some data on mortality in COPD and LC give insight differences in developing and underdeveloped regions. A section on genomics is followed by an analysis of how to detect neoantigens by mass spectrometry.2Neoantigens are antigens that deviate from own structures that change into coding protein structures that can be recognized by the immune system. They can be linked to deoxyribonucleic acid (DNA) repair mutations and generate increased tumor infiltrating lymphocytes (TILs). Neoantigens correlate with increased expression of multiple proinflammatory cytokines and immune‐related genes, MI‐polarized macrophage genes, programmed death ligand‐1 (PD‐L1) and programmed cell death‐1 (PD‐1).3COPD is a leading cause of death worldwide, smoke inhalation being widely accepted as one of the most important causes. COPD is characterized by chronic airflow obstruction in the lung and symptoms related to decreased expiratory volume.An important modulator of the immune system is the regulatory T cell (Treg). Tregs are involved in the suppression of smoke induced specific immune response and a diminished presence or function of these cells may underlie the development of specific humoral immune response in COPD.Genome‐wide association studies (GWAS) have associated several SNPs which predispose an increased susceptibility to COPD and LC such as SERPIN2, HHIP, FAM13A, IREB2, CHRNA3, and CHRNA5.Single nucleotide variants in COPD observed in GWAS studies are for a part missense mutations, that generate differences in proteins that are hardly investigated on the protein level. The impracticality to measure large numbers of missense‐mutated peptides chosen from these GWAS studies hampers an assessment from a technical point of view. Also the possible presence of neoantigens in COPD and lung cancer4Lung cancer has become one of the leading causes of death with smoke inhalation as the main etiologic factor.5COPD and lung cancer are interrelated diseases with substantial mortality and most probably an immunological link may exist between the two diseases.Chronic inflammation through the induction of several interleukins and cyclooxygenase‐2 activity may be an important player in the lung tumor formation among patients with COPD. For instance, CCL21 may favor cancer cell migration in the lungs of patients with COPD.STAT3 and its downstream genes, such as CBLN1, CBLN2, FGL1, FOX03, GJB1, HNF4α, TMEM27, and TTR, are differentially expressed in both LUAD and COPD.Mutational signature analysis in a study by Xiao and co‐workersSNP variation‐associated inflammatory genes identified between COPD and lung cancer may play critical roles in a COPD‐LC transformation; activated nicotinic acetylcholine receptor gene in COPD may cause mutation and down‐regulates the expression of the crucial tumor suppressor gene TP53 and P53‐related signaling pathways, causing lung tumorigenesis.Saber and co‐workersGWAS have shown that large numbers of coding variants can have effects on the susceptibility of COPD.6www.jellinek.nl).COPD and lung cancer are heterogeneous diseases that are for a large part  linked causatively by the use of cigarettes  linked7n = 2543) of COPD patients and controls who were not affected by smoke. The criteria used for the patient group were GOLD grades 3 and 4 , age less than 65 years, and for the control group frequency‐matched pack years of cigarette smoking, FEV1 > 80% predicted, age >65 years, no significant emphysema. For instance for proteins CTC1, OR5B12, GTF3C5, BLVRB, SLC7A7, SLC 26A7, and Notch2 coding mutations were associated with COPD.The recently published COPD Gene investigators studyThe risk of developing lung cancer is eight times higher if COPD has been diagnosed.The enormous efforts in GWAS and cohort studies8The presence of a high number of clonal neoantigens in homogeneous LUAD may favor immune surveillance, whereas in lung squamous cell carcinoma immune escape may be more prevalent through human lymphocyte antigen (HLA) downregulation. A high clonal neoantigen burden in LUAD is associated with an inflamed microenvironment with activated T cells, potentially regulated by inhibitory immune checkpoint molecules and their ligands.Recent proteomic approaches provide a comprehensive way to analyze whole HLA ligandomes containing various types of tumor‐associated antigens and direct peptide isolation from live cells using antibodies directed against HLA molecules followed by LC‐MS/MS sequencing is an ideal strategy to map and screen natural T‐cell epitopes presented by cancer cells.Neoantigen loss occurs through elimination of tumor subclones or through deletion of chromosomal regions containing truncal alterations and were associated with changes in T cell receptor clonality. There could be two mechanisms of neoantigen loss in a resistant tumor: 1) through the immune elimination of neoantigen‐containing tumor cells that represent a subset of the tumor population, and 2) through the occurrence of one or more genetic events in a tumor cell that results in neoantigen loss, followed by selection and expansion of the resistant clone.Application of the epitope prediction approach to sequencing data from different cancer types reveals a range of predicted neoantigens per individual tumor, providing evidence that neoantigens are frequent in most human cancers.Mass spectrometry has, in addition to the potential to identify proteins in the presence or absence of databases, the inherently present possibility of quantification of proteins and peptides in a relatively sensitive way.By mass spectrometry coding mutations can be detected and quantified on the protein level and in heterozygous patients the ratio of the wild type and mutated protein can be determined.IDH1) on position 132 of this proteinIt is particularly of interest if the abundance of these variants is influenced by the presence of COPD. Hereafter, an example is given of the detection of a mutation in isocitrate dehydrogenase IDH on positAlthough these missense mutations can be attractive targets for therapy, neoantigens presented on human leucocyte antigens (HLA)−1 biofluid or pg protein per g tissue.For absolute quantitative mass spectrometric analysis of mutated proteins and mutated peptides, a stable isotope labeled peptide or protein needs to be synthesized. In this way, a precise quantification can be reached for a mutated protein. Targeted mass spectrometry  allows the measurement of tens to hundreds of mutated proteins in a single analysis. A disadvantage of this technique is the low sensitivity if no sample fractionation is performed for serum or tissue samples. Without sample preparation, most often microgram per mL biofluid can be reached. If affinity separations  are applied one can reach the ng mLSpecific binders for cancer‐associated pathways can be very instrumental to extract differentially expressed proteins from these pathways in lung biopsies. Mass spectrometry has the advantage that it is possible to define very accurately the ratios of mutated proteins in these pathways and may show proteins that can effectively modulate immunological processes involved in the induction and progression of COPD.9The idea that cancer has pre‐stages is widely accepted (for reviews see refs. The authors declare no conflict of interest.


The aim of this case report is to increase the awareness about patient and fetus safety through preprocedure assessment and screening of unrecognized pregnancy for fluoroscopy‐guided procedures. The aim of this case report is to increase the awareness about patient and fetus safety through preprocedure assessment and screening of unrecognized pregnancy for fluoroscopy‐guided procedures. It is well known that radiation exposure during pregnancy can cause detrimental effects on fetus.2A 31‐year‐old female patient, who was a high‐level medical professional, was scheduled for lumbar epidural steroid injection in our institution. The authors have obtained written consent to publish this case report from the patient. Institutional Review Board approval was obtained for this case report on 23 October 2018 (IRB# 2018‐1980). The patient was complaining of severe left‐sided lower extremity radicular pain for over 3‐month duration. In this particular case, the patient had failed conservative therapy with activity modification, home exercises, medication management, and physical therapy for at least 3‐month duration. The patient was evaluated by a spine surgeon, and epidural steroid injection was recommended prior to considering an elective spinal surgery. Fluoroscopy‐guided interventional procedures are used for the treatment of painful conditions after the conservative therapy fails. Therefore, to improve the pain and the activities of daily living, as well as to avoid any unnecessary spinal surgery, fluoroscopy‐guided epidural steroid injection was scheduled.The patient's neurological examination was consistent with left L5 and S1 radiculopathy. MRI of the lumbar spine showed large disk herniation at left L5‐S1 level Figure . The pat3Due to medico‐legal importance of this topic, our hospital has implemented a policy in regard to possible diagnosis of unknown pregnancy prior to fluoroscopy‐guided pain management procedures. All female patients of childbearing age who are scheduled for fluoroscopy‐guided pain management procedures are asked the question about a possible or absolute pregnancy 1‐3 days prior to the planned procedure. If the answer is “yes” for absolute pregnancy, the procedure is canceled, and the medical staff is informed. If the answer is “no” after the preoperative telephone conversation, the patients are allowed to come for the procedure on the scheduled day. Upon arrival to preprocedure area on the date of scheduled procedure, all female patients of childbearing age are again asked for possible or absolute pregnancy. If the answer is “yes” for absolute pregnancy, the procedure is canceled, and the medical staff is informed. If the answer is “no,” as outlined in the hospital policy, the eligible patients will have a point‐of‐care rapid urine pregnancy testing.At our institution, as directed by the policy, a urine specimen is obtained from all females of childbearing age upon arrival in the preprocedure holding area. Preprocedure medications are held until the urine pregnancy test results are available. Exclusion criteria for urine pregnancy testing are menopause , history of hysterectomy or bilateral salpingo‐oophorectomy, and patient refusal. The reported uses of any contraceptive medication/device or history of tubal ligation are not considered as the criteria for exclusion from testing. No one of the procedure team is authorized to waive a pregnancy test. The patient is the only individual who may elect to waive a pregnancy test after being advised of the associated risks. However, this decision requires documentation in the chart. In the event of a positive urine pregnancy test, the attending physician notifies the patient, followed by a cancelation of elective procedure. The patient is then referred to an obstetrician.®20 hCG, Beckman Coulter). The test employs solid‐phase chromatographic immunoassay technology with mouse anti‐hCG monoclonal antibodies to selectively detect elevated levels of hCG. After exposure to the test reagents, specimens produce a color change on the assay membrane if they contain hCG  in the urine sample , the test is then interpreted as positive for pregnancy Figure .4Epidural steroid injection is not considered as a first‐line therapy for lumbar radiculopathy and should be considered after the conservative therapies fail. The risks of epidural steroids injection are radiation exposure, procedural and/or medication‐related side effects or complications.It is well known that radiation exposure during pregnancy can cause detrimental effects on fetus.Therefore, recognition of pregnancy before fluoroscopy‐guided procedures is critical in preventing fetal radiation exposure, and thus to avoid potential medical, psychological, and legal consequences.As per the ACR practice guidelines, for procedures that are expected to involve an unpredictable duration of fluoroscopy especially for the body parts in close proximity to pelvis, such as lumbar‐sacral spinal interventions, it is recommended that all female patients of childbearing age should be screened by questioning and/or a pregnancy test should be obtained within 72 hours prior to commencement of the procedure unless medical exigencies prevent it.As directed by the policy at our institution, urine pregnancy tests are routinely performed prior to fluoroscopy‐guided interventional pain procedures in women of childbearing age, unless a history of menopause, prior hysterectomy or bilateral salpingo‐oophorectomy are reported or documented.Pregnancy tests are based on the measurement of elevated levels of hCG, which is a hormone produced by placenta as early as 7‐10 days after fertilization. The detection of hCG in urine is an easy first method of diagnosing pregnancy. Rapid qualitative point‐of‐care urine pregnancy detection kits are readily available in the market and can be used on‐site prior to the scheduled procedure. Sensitivity and specificity of urine hCG are found to be 99% and 92.2%, respectively. Although the test could result false positive or false negative, such outcomes are infrequent and can easily be corrected by serum tests.A retrospective chart review by Kahn et alAlthough American Society of Anesthesiologists recommends pregnancy testing to be offered to female patients of childbearing age before anesthesia,In our case, the patient had a spontaneous miscarriage approximately around 18 weeks of gestation. This incident was spontaneous for unknown reasons but without any exposure to radiation as the procedure had been canceled after finding out that the patient was 6‐week pregnant. However, the psychological, medical, and legal consequences might have been different, had the patient been exposed to ionizing radiation without being diagnosed as pregnant at 6 weeks of gestation with a routine preprocedure rapid on‐site urine pregnancy test as directed by our hospital policy for pain management procedures.Severe lumbosacral radiculopathy refractory to conservative therapy may be encountered during pregnancy. If the patient had had the continuation of pregnancy with progression of the radicular pain and symptoms, epidural steroid injection might have been considered in this particular patient in the later stages of pregnancy if indicated. As a safe and a real‐time imaging modality, ultrasound guidance may be considered during the performance of caudal epidural injections in feasible cases, specifically if the pathology is at the lower lumbar levels such as L5‐S1 level similar to pathology in this particular patient. The patient's obstetrician should be consulted and included in decision‐making process. While steroids can be administered to women in pregnancy since it may help fetal lung maturity, they should only be administered for short periods of time, since long‐term use poses high risk of negative fetal effects. Steroid preparations with normal doses are usually accepted as safe during the second and third trimester of pregnancy.5Radiation exposure during an unrecognized pregnancy may have medical, psychological, and legal consequences. Therefore, we recommend routine rapid qualitative point‐of‐care urine pregnancy test prior to fluoroscopy‐guided interventional procedures in all women of childbearing age, unless a history of menopause, prior hysterectomy or bilateral salpingo‐oophorectomy are reported or documented. Recognizing a pregnancy allows a woman and her physician to make an informed decision before proceeding with an elective procedure.None declared.SG and EC: contributed to performance of the case, chart review, manuscript preparation, and final approval of the manuscript.


Research on stratification and mobility has consistently shown that in the UK there is a direct impact of social origin on occupational destination net of educational attainment even for degree‐holders. However, only a few studies applied a longitudinal and dynamic perspective on how intergenerational mobility shapes graduates’ working careers. Using multilevel growth curve modelling and data from the 1970 British cohort study (BCS70), we contribute to this research by looking at the emergence of social inequalities during the first ten years since labour market entry. We further distinguish between graduates of different fields of study as we expect social disparities to develop differently due to differences in initial occupational placement and upward mobility processes. We find that parental class does not affect occupational prestige over and above prior achievement. Separate analyses by the field of study show that initial differences in occupational prestige and career progression do not differ between graduates from different classes of origin in STEM fields, and arts and humanities. It is only in the social sciences that working‐class graduates start with lower occupational prestige but soon catch up with their peers from higher classes. Overall, our results indicate no direct effect of social origin on occupational attainment for degree‐holders once we broaden our focus to a dynamic life course perspective. Numerous studies in research in social stratification and mobility have found that social origin and educational attainment are both strong determinants of occupational attainment. The Blau–Duncan model  already between these groups and over time, we contribute to previous research by looking at within‐group differences in occupational careers among degree‐holders. It allows us to evaluate the impact of so‐called ‘qualitative’ differences that are assumed to be increasingly important as more and more individuals attain higher education in the course of educational expansion . For the UK, empirical results by Bukodi and Goldthorpe  initial labour market attainment directly after graduation (differences in intercepts), and (2) career progression over time (differences in slopes). We assume parental resources and support to be particularly helpful at labour market entry when employers hire applicants for the first time, and signals of potential productivity are limited. Later in the career, employers can either observe employees’ productivity directly or evaluate job applicants’ accumulated work experience. Graduates from the lower class of origin may, therefore, compensate for initial disadvantages and catch up with their peers from the higher class of origin across the career. We expect that there are social class differentials at labour market entry. However, these class differentials vanish across the career due to the steeper career progression of those from the lower class of origin  for occupational and career mobility and flexible market segments with high rates of temporary employment. Strong linkages between fields of study and occupational labour markets may, therefore, be advantageous for entry into high‐status occupations and long‐term occupational stability. Summing up, we can expect appropriate high‐status positions at labour market entry for graduates from occupation‐specific fields, such as STEM fields, and less intragenerational mobility over time compared to graduates in social sciences, arts, and humanities.Finally, the third line of theoretical explanations for differences between fields of study in career progression focuses on Hypothesis 2a). On the other hand, if career advancement and promotion in the labour market of arts and humanities still requires social and cultural resources, the advantages of offspring from higher classes may persist or become more significant due to cumulative advantages (Hypothesis 2b).Taking into account social origin, we assume parental resources to compensate for signalling of unspecific skills and parental resources to be particularly crucial at labour market entry. Hence, for graduates from the arts and humanities with the least specific skills, we expect significant social inequalities in initial labour market allocation. However, it is not clear whether and how social gradients develop across the career of graduates from arts and humanities. On the one hand, students from lower classes of origin may overcome their initial disadvantages and catch up with those from a higher class of origin as their real productivity becomes visible throughout their career (Hypothesis 3).Graduates from STEM fields have acquired more specific skills and qualifications compared to graduates from other fields. Thus, in the matching occupational labour market, parents from STEM graduates should have less leeway on job allocation procedures than in other partial labour markets. Also, we assume that STEM graduates enter occupations with relatively high task specificity and thus productivity is more dependent on what was taught during graduates’ studies than on pre‐existing skills or resources acquired in the parental home. Therefore, we expect social inequalities among STEM graduates to be small both in initial placement and career progression (Hypothesis 4). Figure In the social sciences , we expect initial inequalities and increasing social inequalities over time as social and cultural capital acquired in the parental home may facilitate access to and promotion in services and higher managerial positions  which follows the lives of people born in England, Scotland and Wales in a single week of 1970  who studied full‐time and graduated from a UK HE institution until the age of 34. We observe graduates’ career progression from their first significant job (lasting at least six months) until up to 10 years in the labour market. We exclude part‐time students from our sample since their educational attainment runs in parallel to their occupational career, and they are likely to have a more stable starting point after graduation when compared to full‐time graduates. We identified 1,347 graduates at age 34 who were full‐time students, for whom information on the timing of graduation was available and who had at least one significant job during the observation period. After listwise deletion, our sample includes 951 complete cases with 99,399 person‐months.Treiman occupational prestige scale (SIOPS) measured at each job across the observation period . To avoid the predefinition of a functional form and to allow for variation in career progression across different stages, we model career progression as five 24‐month splines and estimate linear slopes for each range.We measure part‐time employment, the number of children, and marital status. All these control variables are time‐varying measures to account for changes in family circumstances across the occupational career.Our measure of months since labour market entry does not account for career circumstances, career breaks, and re‐entry into the labour market due to family formation. Therefore, we control for class of origin, with the 7‐class ‘analytical’ version of the National Statistics Socio‐Economic Classification (NS‐SEC), an improved operationalization of the EGP class schema  humanities (including arts), (2) social sciences (including economics and business), and (3) fields in STEM  , and  fields igender and ethnic origin. Due to the small sample size, we only differentiate between cohort members originating from the UK and those originating from elsewhere.We also control for background characteristics such as cognitive ability by totalling all four conducted British Ability Scales (BAS) assessments  and a time‐varying error term ε. The intraclass correlation – which we calculate based on the variances of the error terms (ρ=σμ2/(σμ2+σε2)) – shows us how much of the overall variance in occupational prestige is due to variation between individuals and due to variation within individuals across the early and mid‐career. The stronger this intraclass correlation, the more inequality between graduates in occupational prestige exists, and the fewer within‐changes we can identify across graduate careers.The model includes the five 24‐months splines, dummy variables for the class of origin, ethnic origin, fields of study, type of degree, marital status, part‐time employment and linear specifications for cognitive ability and the number of children. It also contains a person‐specific unobserved factor β1s estimates indicate the average monthly change in occupational attainment within the 24‐month splines. The remaining β coefficients indicate the strength of associations between the respective variables and occupational prestige averaged across the early working career. To test our first hypothesis, we extend our baseline model by including interaction terms between graduates’ class of origin and our five splines for time since labour market entry. To test the hypotheses on field‐specific social inequalities, we run our extended model, including the interaction between graduates’ class of origin and spline for the three different field groups separately.The Table The intraclass correlation coefficient (ICT) as shown in M0 indicates to what extent the total variation in occupational prestige is due to differences between graduates rather than within‐differences across the career. In our sample, the ICT shows that 71 per cent of the overall variance is due to differences in occupational prestige between graduates. Thus, differences in occupational prestige between graduates instead emerge at the beginning of the career, and there is only modest career mobility over time that corrects for these initial differences. Compared to working populations in Germany   qualitative differences such as field of study may have become increasingly crucial for processes of social stratification. By adopting a dynamic approach looking at intergenerational occupational mobility, we wanted to detect whether and to what extent social inequalities in the early career are strengthened or mitigated, and whether initial disparities and differences in career progression vary by field of study.We did not find a substantial direct effect of social origin on graduates’ average occupational attainment throughout ten years after labour market entry. This finding is in line with previous results on UK graduates using the same dataset  that are advantageous for initial occupational positions of graduates from higher classes do not provide a persistent advantage over graduates from working‐class origin throughout the career. It remains open for future research with richer data to test the mechanisms empirically behind the career patterns we have observed. Summing up, our results support the claim that an undergraduate degree is an ‘equalizer’ for labour market outcomes as social origin has no effect on occupational prestige over and above attaining a degree in the long run Torche . WhereasFrom a broader theoretical point of view, our results provide evidence for signalling theory rather than human capital theory. If graduates from higher social origin gained skills through their upbringing such as soft or social skills that increase their productivity in the labour market, they should have advantages both at labour market entry and in later career stages. However, our results show that social inequalities among graduates from the social sciences are limited to the entry stage. It suggests if at all that employers in managerial, sales and personal service occupations use skills that are associated to the social origin as a signal for future productivity when more reliable indicators of work performance are missing.Our paper has several limitations: First, our study is merely descriptive in analysing the career trajectories of graduates from different social backgrounds. A causal interpretation of our estimates rests on the strong assumption that there are no important unmeasured factors that influence degree attainment in different fields of study, occupational attainment, and its progression, and at the same time vary by social origin. Other than previous studies focusing on graduates, our study, however, accounts for cognitive ability differences between graduates from different backgrounds and as such may address a considerable part of the selectivity in our graduate sample.Our second limitation is the weak statistical power primarily when analysing social inequalities in career progression across fields of study. Compared to existing graduate surveys, our birth cohort panel data provide the advantage of looking at graduates’ long‐term career mobility in a more dynamic perspective but at the cost of having smaller  sample sizes. Therefore, we need to consider our results with caution, and future research needs to replicate these results with larger graduate samples.Third, our paper focused on the outcome of occupational prestige and as such, only detected between‐occupational changes across the working career. However, graduates also improve their labour market outcomes by changing positions within occupations. Extending our analysis with income seems to be a promising endeavour for future research as it takes into account within‐occupational career changes and is less prone to ceiling effects. Hence, we cannot exclude the possibility that inter‐ and intra‐generational mobility patterns may be different from what we observe in our analysis when using income Table A.III: Growth curve models predicting occupational prestige by class of origin for humanities , social sciences  and STEM Part II: ISEITable A.IV: Growth curve models predicting ISEI by class of origin Table A.V: Growth curve models predicting ISEI by class of origin for humanities , social sciences  and STEM Figure A.I: Predicted ISEI by parental classFigure A.II: Predicted ISEI by parental class across different fields of studyPart III: Including part‐time studentsTable A.VI: Growth curve models predicting ISEI by class of origin Table A.VII: Growth curve models predicting ISEI by class of origin for humanities , social sciences  and STEM Figure A.III: Predicted SIOPS by parental classFigure A.IV: Predicted SIOPS by parental class across different fields of studyClick here for additional data file.


How does one successfully implement direct observation of residents’ competencies in postgraduate training programs? Renting offers insights into how to make it work. Successful organisation of direct observation of residents by attending physicians may make or break the implementation of competency‐based approaches in postgraduate training programmes. It seems, however, that direct observation of competencies does not readily fit into most postgraduate programmes, as it often happens infrequently and is of poor quality. Direct observation serves three important purposes in competency‐based training. Firstly, direct observation is the foundation of all valid and reliable workplace‐based assessment tools.Promoting assessment, feedback and supervisory relationships are three good objectives that justify the quest for increased frequency and improved quality of direct observationIn this issue, Gauthier et al.By reframing direct observation more broadly, suddenly competency‐based postgraduate training becomes a lot less time consuming and a lot more feasibleI warmly embrace the advice of Gauthier et al.So how can we stimulate more and better direct observation in our training programmes? Direct observation should be approached systematically and achieved with careful consideration of organisational culture and values, in order to be able to tackle inevitable obstructions.Therefore, a system with a solid foundation of planned direct observations and added tailored direct, observations, where needed, seems the only way to go about itAlthough direct observation has great learning potential, learning does not occur simply because an attending physician observes an activity. So how can we make sure direct observation realises its full learning potential instead of being just a waste of valuable time? It may very well be that the term ‘direct observation’ still brings an image to mind of what anthropologists have been doing for over a century: essentially becoming a metaphorical ‘fly on the wall’ by quietly observing and affecting the situation as little as possible. An attending physician can never become this unnoticed fly and is, fortunately, much more valuable for residents’ learning when taking on an active role. Direct observation can be bidirectional, where the resident and attending physician naturally take turns in acting and observing during patient encounters based on the residents’ abilities.So how can we make sure direct observation realises its full learning potential instead of being just a waste of valuable time?So why adopt a competency‐based approach? Because competency frameworks may help to better respond to the changing environment of postgraduate training. Workplace‐based learning increasingly affords fragmented, brief contact of residents with multiple attending physicians, who must attempt to quickly assess the residents’ learning needs and professional abilities.I imagine many of the attending physicians in the study by Gauthier et al.Competency frameworks ideally provide focus during direct observation and become part of a shared language to talk about learning trajectories and performance