To investigate the alterations of basal ganglia (BG)-cortical structural and functional connectivity induced by subcortical silent lacunar infarct (SLI), and their associations with cognitive impairment in SLI subjects. All participants were recruited from communities, including 30 subcortical SLIs and 30 age-, gender-, and education-matched healthy controls. The structural and functional connectivity of BG-cortical circuits using diffusion and resting-state functional magnetic resonance imaging data were obtained. Diffusion abnormalities of the white matter tracts connecting the BG and cortical areas were observed in SLI subjects, including the BG-lateral frontal, BG-orbital frontal, and BG-insula tracts. Multiple regions showed a reduced BG-cortical functional connectivity in SLI patients, including direct connectivities with the BG, such as the BG-limbic, BG-insula, and BG-frontal connectivities, and others that showed no direct causation with the BG, such as the insula-limbic, insula-parietal, and frontal-parietal connectivities. Coupling of structural and functional BG-cortical connectivity was observed in healthy controls but not in SLI patients. Significant correlations between structural and functional BG-cortical connectivity and cognitive performance were demonstrated in SLI patients, indicating the potential use of BG-cortical connectivities as MRI biomarkers to assess cognitive impairment. These findings suggest that subcortical SLIs can impair BG-cortical circuits, and these changes may be the pathological basis of cognitive impairment in SLI patients. SLIs mainly appear in the basal ganglia (BG) and occur in 11–25% of individuals older than age 65 without psychiatric symptoms or neurological disorders –5.Stroke can induce injuries ranging from a single neuron or synapse  or adjunct neuronal tissues or connections  to different brain regions or even a module composed of multiple brain regions or connections among these modules  , 7. ThroPrevious studies have described the anatomy and function of BG-cortical circuits that contribute to human primary and advanced cognitive functions , 11. In n = 4), putamen (n = 12), globus pallidus (n = 2), internal capsule (n = 13), and thalamus (n = 7). In present study, we recruited elderly subjects from communities, which could decrease the bias of a clinical referral study that tends to recruit patients with more severe impairments. To exclude the confounding effects of white-matter lesions, we therefore only recruited patients with pure lacunar infarcts in the present study.A total of 60 (30 SLI patients and 30 controls) right-handed, native Chinese participants were used in this study . The datAll participants received a battery of neuropsychological tests assessing general mental status and several cognitive domains. The general mental status was assessed with MMSE . The coThe neuropsychological characteristics for each group are presented in 2, acquisition matrix = 256 × 256]. . The resting acquisition lasted for 8 min, and 240 image volumes were obtained.The MRI data were acquired on a 3.0T Siemens Trio Tim MRI scanner at the Imaging Center for Brain Research, Beijing Normal University. Each participant laid in the supine position with the head snugly fixed by a belt and foam pads to minimize head motion. The following procedures were employed to acquire each set of MRI images.  T2-weigh 2 mm3].  During thttp://cmrm.med.jhmi.edu). The preprocessing comprised the following steps: eddy current and motion artifact correction of DTI data, estimation of diffusion tensor, fractional anisotropy (FA) calculation, and diffusion tensor tractography.The DTI data preprocessing and fiber tracking were performed using DTI Studio (http://www.fil.ion.ucl.ac.uk/spm/software/). Preprocessing procedures included slice timing, within-subject interscan realignment to correct possible movement, spatial normalization to a standard brain template in the Montreal Neurological Institute coordinate space, resampling to 3 × 3 × 3 mm3, and smoothing with an 8 mm full-width half-maximum Gaussian kernel. Finally, the functional data were high-pass filtered with a cutoff frequency of 0.01 Hz, whereas resting functional imaging data were processed with linear detrending and 0.01–0.08 Hz bandpass filtering.Functional data were preprocessed and statistically analyzed using SPM8 package  procedure to correct the multiple comparisons at a q-value of 0.05.Prior to group comparisons, the correlation coefficients were converted to z-scores using the Fisher r-to-z transformation. To test the between-group differences, two-sample Finally, we investigated the relationship between structural and functional BG-cortical connectivity and between BG-cortical connectivity and cognitive performance for SLI and control groups, respectively. Of note, the correlation analyses were performed only among the structural connectivity, functional connectivity, and cognitive scores.There were no significant differences in age, years of education, smoking habits, or medical history of hypertension between SLI and healthy groups. In the SLI patients, cognitive function in the domains of general mental status, memory, and attention were significantly worse than controls .Multiple white matter tracts connecting nodes between BG and cortical regions showed significantly lower FA values in SLI patients, especially for the connections between the BG and the bilateral lateral frontal area, left orbital frontal cortex, and right insula .q < 0.05).We investigated cognitive specific BG-cortical network connectivity between SLI patients and healthy controls. As shown in We found significant positive correlations between BG-cortical white matter integrity and functional connectivity in controls, but not in the SLI patients . The sigThe structural and functional BG-cortical connectivity measures were correlated with the performance on neuropsychologic tests. For structural connectivity, correlation analyses indicated that the FA value of the BG-Insul.R was positively correlated with the symbol digit modalities test (SDMT) performance and that the FA in the BG-Lateral Frontal.L was significant associated with performance on the auditory verbal learning test (AVLT)-delay recall, the AVLT-total, and the Stroop color and word test part B (SCWT-B) in the SLI patients but not in the controls . In addiThe focus of this study was to evaluate small lesion-induced changes in structural and functional connectivity and network topology in the BG-cortical system in patients with subcortical SLI. SLI disrupted the structural integrity of the BG-cortical tracts, including the BG-frontal areas and the BG-insula integrity. We found that SLI leads to damage of direct functional connectivity with BG regions, such as between the BG and frontal, limbic regions and insula connectivity, and remote connectivity, such as to the frontal and parietal areas. Moreover, structural and functional BG-cortical connectivity were correlated in controls but not in SLI patients. We also found a significant association between structural and functional BG-cortical connectivity and several cognitive scores, including performance on the MMSE, the AVLT-delay recall, the AVLT-total, the SCWT-B, and SDMT. Therefore, studying the BG in SLI patients provides an opportunity to investigate the impact of information exchange in the BG-cortical network on cognitive decline.BG, as an important structural region of the brain, is mainly involved in motor control and cognitive function , 27. HowPatients with lacunar infarcts have more severe white matter changes than patients with non-lacunar infarcts among patients with ischemic stroke , which iWe also assessed the intrinsic connectivity within the cognitive specific BG-cortical network. In SLI, a majority of connectivities including the BG-limbic, BG-insula, BG-frontal, insula-limbic, insula-parietal, frontal-parietal connectivities, and the connectivity between BG areas showed disconnection. By applying a longitudinal and lesion-restricted approach, a recent study observed secondary neurodegeneration in remote cortices after a subcortical stroke . ConsideSignificant correlations between structural and functional BG-cortical connectivity in controls, supporting the notion “functional connectivity reflects anatomical connectivity.” The decoupling of structural and functional connectivity were observed in SLI patients may due to several pathological changes. Decreased perfusion in penetrating arteries may lead to an SLI . Feng etA recent study in a stroke cohort showed that advanced cognitive functions such as visual and verbal memory deficits are better predicted by functional connectivity than by the lesion location, and primary functions such as visual and motor deficits are better predicted by the lesion location than by functional connectivity . This fiDespite the interesting findings in the present study, a few limitations need to be addressed. First, a longitudinal dataset is highly desired to verify the current results. Next, the heterogeneity of lesion location may result in different cognitive impairment and functional disconnection patterns. Therefore, stratification of patients according to lesion location should be considered for future work.In summary, this study demonstrated a structural and functional disconnectivity of the BG-cortical network in the elderly with silent small lesions around the BG. Focal lesions can spread beyond the sites of initial injury to remote regions throughout specific interconnected networks. Both structural and functional BG-cortical connectivity strength were predictive of cognitive dysfunction. Taken together, the study opens up a new avenue for investigating lesion-induced network dysfunction, highlighting the importance of early damage to the structural and functional connectivity as a potential manifestation of preclinical small vessel disease.All datasets generated for this study are included in the manuscript and/or the This study was carried out in accordance with the recommendations of the institutional review board of BNU imaging center for brain research, national key laboratory of cognitive neuroscience and learning, BNU with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the institutional review board of BNU imaging center for brain research, national key laboratory of cognitive neuroscience and learning, BNU.HZ, WW, and HL designed the entire study and contributed to the study equally. HZ also analyzed the cognitive data. WW and HL analyzed the neuroimage data and wrote the main part of the manuscript. KC guided the data analysis and participated in the revision of the article. PL and XL participated in data analysis and discussion. JZ and DW wrote part of the article. YC participated in the coordination of the study and reviewed the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The difficulty of the case is compounded by these factors.•Appropriate methodology is required to perform and interpret I-OPTH, which includes specific and consistent location of sampling , and application of verified protocols.•Appropriate use of I-OPTH can reduce operative time, cost and complications. Intra-operative parathyroid hormone (I-OPTH) levels are an adjunct used in parathyroid surgery which provides assurance that parathyroidectomy surgery is complete and has removed the hypersecreting gland.A 78 year old female with no localisation on pre-operative imaging and had previous hemithyroidectomy. I-OPTH was used to guide the side and timing for completion of exploration, factors which reduced operative time, operative cost and avoided potential complications.Routine and selective I-OPTH may be used to guide parathyroidectomy, and this case highlights the methodology of use in a selective challenging case. Appropriate application and interpretation of results must be achieved to ensure adequate completion of surgery and cure for the patient.Selective use of I-OPTH guides parathyroidectomy in challenging cases, and can be time and cost-effective when used appropriately. Surgical resection is the only curative treatment for primary hyperparathyroidism, and identification of abnormal glands are the key to successful surgical management . PTH hasOur institute has reviewed local data regarding its routine use via a duel criteria protocol  with gooI-OPTH has been recommended for routine and/or selective use depending on institute equipment availability and expertise. Consensus from the American and European society of endocrine surgeons recommend I-OPTH use in challenging cases, such as when pre-operative localisation is not concordant, or in re-operative neck surgery. This case report outlines a particularly challenging case of where preoperative localisation was uncertain in a patient with previous neck surgery. It highlights the value of I-OPTH as decision making tool in selected cases of parathyroid surgery. The case report has been prepared in line with the SCARE criteria .2A 78 year-old female had a previous right hemithyroidectomy 12 years ago. Unfortunately, the histopathology from the previous operation was not available, but it was presumed that no parathyroid glands were removed in this operation. She was subsequently diagnosed with asymptomatic hypercalcaemia  and primary hyperparathyroidism (PTH 21 pmol/L). Pre-operative imaging and biochemical studies  failed to localise the hyperfunctioning parathyroid gland.As re-operative neck exploration carried a high risk of recurrent laryngeal nerve injury, lateralisation was therefore attempted via intra-operative bilateral jugular venous rapid PTH sampling . Samples were taken from the same junctional location bilaterally , and preFinally, a left hemithyroidectomy was completed due to a presumed intra-thyroidal hyperfunctioning gland. Post I-OPTH taken from only the left internal jugular vein at 10 min appropriately reduced to 9 pmol/L, and therefore a right exploration (which would have been in scarred tissue) was not performed. Post-operative PTH at Day 1 and Day 7 were normal at 4 pmol/L and 3 pmol/L respectively and calcium also return to normal. She did not have any complications and normal voice at Day 1 and Day 7. Histopathology subsequently identified an intra-thyroidal parathyroid adenoma in normal thyroid tissue . She was3This case highlights the value of selective use of I-OPTH in a challenging case. I-OPTH is used as an adjunct to confirm that the hypersecreting parathyroid gland/s have been removed. In this case report, the patient had a non-localised, ectopically located parathyroid adenoma where the risk of complications is greater due to previous neck surgery. Therefore, I-OPTH can be useful in such situations to guide operative management and avoid complications. In addition, it may also be useful in routine focussed parathyroidectomy.Focused parathyroid exploration is a safe and effective procedure with high cure rates in experienced centres. It has been reported to have shorter operating time, shorter hospital stay, lower hospital costs, and reduced incidence of hypocalcaemia and other complications . EffectiAlternatives to I-OPTH are not yet in routine clinical practice and require specialised expertise or equipment. Indocyanine green fluorescence guidance  or laserHowever, I-OPTH has been criticised as not cost effective nor value adding, particularly in routine, localised cases . Some stIn challenging cases, such as the one described, selective use of I-OPTH with appropriate test interpretation has been advocated as beneficial for patient care . In the I-OPTH may be selectively used in situations to avoid complications. Re-operative neck surgery carries a high risk of recurrent laryngeal nerve (RLN) injury. Avoidance of uni- or bilateral RLN injury has been reported to have significant morbidity on cost-benefit analysis . This ca4In conclusion, the benefits of I-OPTH in routine cases are institute specific but are generally well-established. However, its selective use is most beneficial in challenging cases such as non-localised and re-operative surgery for operative guidance, which improves safety and cost-effectiveness. Where possible and correctly utilised, I-OPTH is a good adjunct and should be used accordingly.None.None.Exception from ethical approval – case report only, consent from patient provided at request.See text in manuscript.Henry To: conceptualisation, methodology, software, validation, formal analysis, investigation, resources, data curation, writing – original draft, writing – review and editing, visualisation, project administration, funding acquisition.Greg Otto: conceptualisation, methodology, writing – review and editing, supervision.Not required.Henry To and Greg Otto.Not commissioned externally peer reviewed.


The impact of evidence-based medicine (EBM) training techniques in primary healthcare professionals remains to be determined.A non-randomized controlled trial (NRCT) was performed aiming to assess the two methods of evidence-based medicine training for primary healthcare professionals by assessing evidence based practice (EBP) related knowledge (EBP-K), attitude (EBP-A), personal application (EBP-P), anticipated future use (EBP-F), and community management of hypertension. Participants were recruited and assigned to either an EBM training group that receiving a weekly face-to-face EBM training course, or an EBM self-instruction course for eight weeks. A validated instrument was applied to evaluate the four aspects of EBP. Additionally, community management of hypertension was assessed by comparing the the rate of detection, blood pressure control, standard management, grading management and patient satisfaction between 2015 and 2016 to measure training efficacy. The difference between the impact of these two interventions was assessed statistically.P < 0.05), EBP-Personal application , and EBP-Future use . EBP-Attitude scores  were lower in the EBM training group. Stratified analyses showed that the results were consistent regardless of the participants’ gender, professional role (doctors & apothecaries or nurses), rank (junior or senior doctors & apothecaries), or specialty . Assessment of community hypertension management revealed that the rate of blood pressure control, standardized hypertension management and patient satisfaction was significantly better in group A than group B .One hundred fifty-one participants (69 in the face-to-face EBM training group and 82 in the self-instruction group) were included. Compared to self-instruction, the face-to-face EBM training was associated with significantly improved EBP-Knowledge  contains supplementary material, which is available to authorized users. Evidence based medicine (EBM) is defined as a conscientious, explicit, and judicious use of the current best evidence to inform decisions about the care of individual patients . The posIt has been suggested that EBM curricula should be developed into a 5-step model including translation of uncertainty to an answerable question, systematic retrieval of the best evidence available, critical appraisal of the clinical relevance and applicability of evidence, application of results in practice, and evaluation of performance . Also, iTo compare the impact of a face-to-face EBM training strategy and EBM self-instruction on a validated instrument definition of EBP knowledge (EBP-K), attitude (EBP-A), personal application (EBP-P), and future anticipated use (EBP-F), and to develop optimal EBM learning strategies in primary healthcare professionals; andTo compare the rate of hypertension management  achieved by these two community health service centers.Thus, in this study, we carried out an entry-level EBM training program based on the 5-step model for primary health care professionals. The clinical context and specific objectives of the study were:This non-randomized controlled trial was performed with primary healthcare professionals, including doctors, apothecaries and nurses, from the Mi-shi Lane Community Health Service Center and Xiao-he hu-shu Lane Community Health Service Center of Gongshu district in Hangzhou city, and each center has 7 service stations, 106 and 112 medical staffs respectively. Primary healthcare professionals provided basic medical services, prophylactic immunization, women healthcare, and rehabilitation therapy for the community in China. To cater to the professionals working schedule, those who from the same center were allocated to the same group to participate into either a face-to-face EBM training group (group A), or a self-instruction group (group B) by tossing a two-sided digital coin. The participants allocated to group A received a weekly 2-h EBP-structured presentation covering EBP approaches to patient care experiences offered by the EBM faculty team of the second hospital affiliates to Zhejiang Chinese Medical University. The general practice department of the hospital was founded in 2011, and responsible for the tutorship of medical students in the 4th to 5th years of medical school, residents in post-graduate training and continuing medical education for general practice. Participants of group B were assigned to receive a weekly self-instruction course covering the essentials of EBM, which was uploaded by a research assistant through the center’s own network. Blinding and allocation concealment were not possible in the present study because teachers and participants were all aware of the courses they were going to attend. However, study hypothesis had not been disclosed to all participants. This study was based on the provincial fund project, and written informed consent was obtained from each participant. ;nurses;Primary healthcare professionals were recruited from two Community Health Service Centers, which have intimate association with the second hospital affiliates to Zhejiang Chinese Medical University. To meet the eligibility, participants were required to be:Participants who were unwilling to participate in the study or did not wish to provide consent were excluded from the study. The following variables were recorded for each participant: age, gender, professional role (doctors & apothecaries or nurses), and rank (junior or senior doctors & apothecaries), or specialty .The face-to-face EBM course for group A was developed by a physician and an EBM professor at the second hospital affiliated to Zhejiang Chinese Medical University (Yanhua Li and Junwei Li). This course was intended to provide an interactive forum for participants to improve the clinical implementation of EBM. The primary outcome of this study was knowledge, attitudes, personal application, and anticipated future use, which was measured by using the previously validated EBP-KAB tool . Unlike In China, the government attaches great importance to the management of hypertension, because, if not treated early, hypertension can become a devastating disease with poor prognosis. Hypertension has been highlighted by the Ministry of health, and in order to improve the management of hypertension, patients’ health records must be available to primary health service professionals. As the management of hypertension is dependent largely on early diagnosis and risk stratification, the case of hypertension in the final session was designed to focus on the application of updated evidence-based hypertension screening, diagnosis and control guidelines, . Management of hypertension was assessed by comparing the rate of detection, blood pressure control, standard management, grading management and patient satisfaction between 2015 and 2016. All these five items are included in the patients’ health record, and each item was recorded by medical teams at the service stations at each follow-up.Four principle components of EBM, including EBP-K, EBP-A, EBP-P, and EBP-F , were meTo estimate the sample size, we assumed that the standard deviation of the two types of intervention was the same when within the two groups, and the probability of alpha = 0.05, beta = 0.10, and the difference between the two increases is 60% of the standard deviation. Known to the delta/sigma = 0.6, the two sides of alpha = 0.05, mu 0.05/2 = 1.282. The input formula is N1 = N2 = 60, so the two groups need 120 people to detect a statistically significant difference. A 10% drop out rate was estimated, so at least 66 participants were required for each group.P < 0.05 was considered to indicate statistical significance.All statistical analyses were conducted using SPSS version 17.0. Continuous variables were presented as means and standardized deviations (SDs) if normally distributed; otherwise, median and interquartile range (IQRs) was presented. The categorized variables were presented as numbers and proportions. Differences in continuous variables and categorized variables were analyzed by independent t-test and chi-square test, respectively. Percentage change in scores was compared using the Mann-Whitney test due to their non-normal distribution. Percentage change = (post-course score – pre-course score)/pre-course score *100%. Stratified analyses were preformed according to participants’ gender, professional role (doctors & apothecaries or nurses), and rank (junior or senior doctors & apothecaries), or specialty . All statistical tests were 2-tailed, and The flow diagram of the study participants throughout the trial is outlined in Fig. Participants’ characteristics such as age, gender, professional role (doctors & apothecaries or nurses), and rank (junior or senior doctors & apothecaries), or specialty  did not differ significantly between the groups Table .Table 2PP < 0.01)  Table . The incP < 0.000), EBP-F , and EBP-K scores  than in with group B. On the other hand, EBP-A scores were significantly lower in group A than B, , indicating an improvement in the attitude to EBM.Both groups had similar EBP-K, EBP-A, EBP-P and EBP-F scores before the intervention. After the intervention, participants in group A had significantly higher EBP-P  in Table To our knowledge, this is the first study in mainland China to assess the impact of an EBM training program in primary health service professionals using a validated and reliable tool. Our study results indicate that practice based face-to-face training may be an optimal strategy to educate primary healthcare professionals with the application of EBM.Currently, EBP is recognized as a core competency that must be acquired by all medical professionals, because it can improve the quality of health care by supporting clinical decision-making . AlthougEBM education should be evaluated and guided by evidence of its own effectiveness . Many toIn this study, we found that an eight-week face-to-face EBM training program improved nurse and physician EBP knowledge, attitudes, personal application and anticipated future, and these measures improved more significantly than a self-instruction training program. Subsequent stratified analyses showed that results were consistent regardless of participants’ gender, professional role, rank, or specialty, which indicates that these factors did not affect the efficacy of EBM training. In addition, as assessed the impact of this training on management of community hypertension and found that measures of community hypertension were improved more significantly following face-to-face EBM training than self-instruction training, which indicate that EBM training can significantly improve primary health service staff EBP competency, and contribute to EBP behavior. Lectures, conferences and small group discussions facilitate more interaction between educators and their audience than self-instruction models, suggesting that these interactions may play an important role in EBM training. It might be difficult to gain sufficient EBM knowledge and skills without appropriate guidance by trainers. Face-to-face interaction can provide a superb opportunity for trainees to discuss the problems with professional educators who may provide solutions. The advantage of these methods was observed in all analyzed groups regardless of participants’ gender, professional role, rank, or specialty.It must be noted that the results of this study may reflect characteristics of particular participants, or the precise training programs applied, and may be limited to interventions of the precise type and duration applied in the current study. In this study, participants were recruited from two community health service centers in Hangzhou city in China. Both sets of participants had the similar EBM background: they had never received formal EBM education but were exposed to EBM through continuing medical education. Second, the EBM training course was designed by EBM professors at the university and teaching hospital, and focused on practical aspects including constructing a clinically relevant question, developing search strategy, assessing the evidence. Third, our training program was implemented for eight weeks. Lengthening or shortening the training duration may change the effects.This study has some strength. First, results of our study can minimize the probability of confounding and selection bias to some content, which, nevertheless, were quite common in most of the other relevant studies and challenged their findings . Second,Some limitations of our study should also be noted. First, this study is not a RCT which may lead to selection bias and we only included two centers in this study for convenience sampling. This may limit the generalizability of our results to other settings in China . Second,In conclusion, a face-to-face EBM training course may improve EBP knowledge, attitudes, personal application and anticipated future use in primary healthcare professionals. Further studies will be required to confirm our results and to optimize the implementation of the face-to-face EBM training.Additional file 1:Consent to participate “Evidence-Based Medicine Training” Project. (DOC 26 kb)Additional file 2:Questionnaires of EBM skills. (DOC 28 kb)


Purpose: To retrospectively identify the relationships between both CT morphological features and histogram parameters with pulmonary metastasis in patients with colorectal cancer (CRC) and compare the efficacy of single-slice and whole-lesion histogram analysis.Methods: Our study enrolled 196 CRC patients with pulmonary nodules . Twenty morphological features of contrast-enhanced chest CT were evaluated. The regions of interests were delineated in single-slice and whole-tumor lesions, and 22 histogram parameters were extracted. Stepwise logistic regression analyses were applied to choose the independent factors of lung metastasis in the morphological features model, the single-slice histogram model and whole-lesion histogram model. The areas under the curve (AUC) was applied to quantify the predictive accuracy of each model. Finally, we built a morphological-histogram nomogram for pulmonary metastasis prediction.Results: The whole-lesion histogram analysis  outperformed the single-slice histogram analysis  and the CT morphological features model . The morphological-histogram model, developed with significant morphological features and whole-lesion histogram parameters, achieved favorable discrimination in both the training dataset (AUC = 0.919) and validation dataset (AUC = 0.895), and good calibration.Conclusions: CT morphological features in combination with whole-lesion histogram parameters can be used to prognosticate pulmonary metastasis for patients with colorectal cancer. Colorectal cancer (CRC) is the third common cause of morbidity and mortality worldwide , 2. PulmHowever, with chest CT applied as part of preoperative routine examination, an increasing number of CRC patients are being diagnosed with indeterminate pulmonary nodules (IPNs) of unknown nature . The repThough early-stage metastatic nodules and benign lesions have similar appearance in images, the importance of morphology should not be underestimated . CT imagTo date, studies concentrating on the morphological and textural features of IPNs 5–20 mm in diameter on contrast-enhanced CT in CRC patients remain limited. This study sought to determine the morphological characteristics and histogram parameters derived from texture analysis for CRC patients with IPNs and to construct a risk model with a combination of independent predictors to facilitate the accurate diagnosis of pulmonary metastasis.-up for the benign nodules; and (iv) complete medical history. The exclusion protocol were as follows: (i) with pretreatment 6 months before initial CT examination (including chemotherapy or pneumonectomy); (ii) obsolete nodules detected 6 months before colorectal cancer was detected; (iii) obvious benign nodules with typical imaging characteristics ; and (iv) adjuvant therapy (including radiation therapy or chemotherapy) applied for no-progress lesions in the process of follow-up. When there are multiple nodules, we choose the largest nodule for morphological and radiomics analysis. Of the 196 people included in the study, 194 of them have been published in our previous research  with lung nodules admitted in our institution between January 2010 and December 2017. The inclusion criteria were as follows: (i) colorectal cancer was histopathologically confirmed; (ii) at least one lung nodule measuring 5–20 mm detected by contrast-enhanced chest CT examination; (iii) available pathology reports with diagnosis of pulmonary metastasis or primary lung cancer for the malignant nodules and at least 2 years follow-up (88 cases) and pathology confirmation (2 cases) or primary lung cancer confirmed by pathology (11 cases). We used a computer algorithm to randomly divide the patients into a training dataset and a validation dataset at the ratio of 7:3. Nodules were divided into two groups: (i) a pathologically confirmed lung metastasis group , and (ii) a non-metastasis (NM) group , including benign nodules (90 cases) with at least 2 years followChest CT examinations were performed at our institution with the Sensation 64 scanner  or the Somatom Definition AS scanner . The Contrast-enhanced CT scan parameters were as follows: contrast medium, inhexol; tube voltage, 120 kVp; tube current, 250–350 mA; slice thickness, 1.5 mm; slice interval, 1.5 mm; matrix, 512 × 512; field of view  for histogram analysis. For each patient, regions of interest (ROIs) were first semi-automatically contoured in the largest-cross sectional area of the tumor outline and then manually delineated by an operator and verified by an expert radiologist. Each ROI was propagated to include the entire tumor volume in each consecutive slice using the same contouring method. In the process of delineation, we excluded the border of the lesion and any other irrelevant tissues or regions, such as pleura, normal tissue, air, peripheral vessels, and surrounding organs. The histogram parameters were automatically measured by the software using a volumetric approach on the ROI of the nodule. Single-slice and whole-lesion histogram parameters were extracted and analyzed. From each segmented tumor, we extracted 11 single-slice histogram parameters and 11 whole-lesion histogram features. More information about the methodology used to extract histogram features can be found in t-tests were used for the continuous variables. To compare the differences between the PM and NM group, chi-square and two-sample t-tests were applied as appropriate for both the training and validation datasets. Two-sided p < 0.05 was considered significant.R software (version 3.3) was applied for statistical analysis. To measure the agreement of CT morphological features between two readers, intraclass correlation coefficients (ICCs) were calculated . To compare the proportional differences between the training dataset and the validation dataset, chi-square tests were applied for the categorical variables, and two-sample The significant factors were introduced into the stepwise logistic regression to select the independent features for the CT morphological model, the single-slice histogram model and the whole-lesion histogram model. The Akaike information criterion (AIC) was employed as the stopping rule. The validation dataset was used to test the diagnostic performance of the models by applying the multivariable regression formula derived from the training dataset to the patients of the validation dataset, and the probability of metastasis was calculated for each. The area under the receiver characteristic curve (AUC) was calculated to quantify the predictive accuracy of the three models in the training and validation datasets. We also calculated the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for each model.We compared the relative strengths of the single-slice and whole-lesion histogram models and then used the more efficient model in combination with the morphological features to construct the morphological-histogram model. A morphological-histogram nomogram was then constructed for clinical application. A receiver operating characteristic (ROC) curve was used to describe the discrimination abilities of the nomogram. An AUC above 0.75 is considered as good . NomograThe patients characteristics and statistically significant CT morphological features are shown in t-tests revealed that nine CT features were associated with lung metastasis, including lobe location (p = 0.025), size category (p < 0.001), long-axis diameter (p < 0.001), short-axis diameter (p = 0.001), density (p < 0.001), contour (p = 0.043), border (p < 0.001), air bronchogram (p = 0.032), and lymphadenopathy (p = 0.032). After stepwise logistic analysis, long-axis diameter , density  and contour  remained independent predictors in the CT morphological model, as shown in Regarding the CT morphological features, the chi-square tests and t-tests revealed that the S-average ratio (p < 0.001), S-skewness (p < 0.001), S-area (p < 0.001), S-volume (p < 0.001), S-median (p < 0.001), and S-minimum (p = 0.035) were significant variables related to PM. After stepwise logistic analysis, the S-average ratio , S-area , and S-median  were selected as independent predictors for the single-slice histogram model.Regarding the single-slice histogram parameters , t-tests revealed that the W-average ratio (p < 0.001), W-mean (p = 0.002), W-skewness (p < 0.001), W-area (p < 0.001), S-volume (p = 0.001), W-median (p < 0.001), and S-minimum (p = 0.035) were significant parameters associated with PM. After stepwise logistic analysis, the W-average ratio , W-mean , and S-median  were selected as independent predictors for the whole-lesion histogram model. Regarding the whole-lesion histogram parameters, The whole-lesion histogram model (AIC = 130.25) had lower AIC value than the single-slice model (AIC = 130.9) and achieved better discrimination. It yielded an AUC of 0.888 for the training dataset and of 0.865 for the validation dataset, exceeding the AUC values of the single-slice model . The ROC curves of the two models are presented in P = 0.032), contour , the W-average ratio , W-mean , and W-median  were identified as independent risk factors in the model. The integrated model also achieved the best performance among the models, with an AUC of 0.919  for the training dataset and of 0.895  for the validation dataset (We subjected the CT morphological features and the whole-lesion histogram parameters to stepwise logistic regression analysis. Density (OR = 5.434, 95%CI: 1.161–25.440,  dataset . The ROCThe morphological-histogram nomogram was successfully constructed, with good discrimination, based on the morphological-histogram model . The calIn the present study, we investigated the imaging characteristics of IPNs 5–20 mm in diameter on initial CT in CRC patients and compared the predictive accuracy of whole-lesion and single-slice histogram parameters. We then constructed a morphological-histogram nomogram using a combination of morphological features and whole-lesion histogram parameters for IPNs. This nomogram may be clinically useful for discriminating CRC patients who might benefit from early and curable metastasectomy for metastatic lesions or an appropriate surveillance program.CT offers direct visualization of lesions and potentially allows a detailed characterization of the morphologic extent of lesions. The careful evaluation of morphologic features is an essential step in pulmonary nodules assessment . Althougpost-hoc analysis (As reported by many other studies, nodule diameter is a reliable indicator of malignant potential , 23, 25.analysis  found th-up is highly recommended for IPNs larger than 5 mm in diameter with solid components and approximately regular margins detected on preoperative chest CT.In addition, our study found that metastatic nodules tended to be round or oval, consistent with previous research . We specin situ and minimally invasive lung adenocarcinoma subtypes (-up is highly recommended for IPNs larger than 5 mm in diameter with solid components and approximately regular margins detected on preoperative chest CT. This speculation is also in line with another finding of our study that vascular convergence was more common and the enhancement degree was higher in the metastasis group than in the non-metastasis group. However, as texture analysis is a mathematical method, the biological mechanisms underlying the textural features are complex and not completely understood (In addition to the identification of morphological features, the use of texture analysis is a strength of our study. Previous studies have demonstrated that texture analysis can not only distinguish malignant nodules from benign ones  but alsosubtypes . These sderstood . In casederstood .Another finding of our study was that the whole-lesion texture analysis outperformed the single-slice analysis in evaluating pulmonary nodules, consistent with a previous study . Whole-l-risk patients avoid aggressive follow-up and reduce the burden of radiation exposure. We believe that the clinical use of the nomogram can contribute to reliable diagnoses and help clinicians optimize therapeutic plans for IPNs at an early stage after detection.For clinical use, we constructed a risk stratification nomogram for the clinician to predict the risk of PM for an individual CRC patient. As the early and accurate diagnosis of pulmonary metastasis has been recognized as one of the most important steps in treating potential curable lesions with surgery, we propose that patients with a high risk of PM be considered candidates for thoracotomy for resectable lesions to enhance local control and improve the survival rate. We also hope this model can help lowOur study has several limitations. First, as a retrospective study, thin-slice contrast-enhanced CT images from our database were used, which limited the number of cases for analysis. And the inclusion and exclusion criteria also limits the implementation of the study in clinical practice. Second, only histogram parameters were extracted in this study. In our previous research , 203 radIn conclusion, the results of our study demonstrated that histogram parameters may serve as non-invasive imaging biomarkers for differentiating pulmonary metastasis from non-metastatic lesions. When complemented with morphological features, the morphological-histogram nomogram can greatly benefit the diagnosis of pulmonary metastasis in CRC patients.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Medical ethics committee of Fudan University Shanghai Cancer Center. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.TT and SW carried out the concepts and design of the study. DS provided the patients information. YL confirmed the pathology results. XE, YY, HL, and JW provided assistance for data acquisition and statistical analysis. WP provided the permission of imaging acquisition. SW and TH carried our literature research and manuscript editing. TH and SW contributed equally to this work. All authors have reviewed the final version of the manuscript and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer DY declared a shared affiliation, though no other collaboration, with the authors to the handling Editor.


We studied the feasibility of total arathyroidectomy(tPTX)+multi-point transplantation in the forearm for treatment of secondary hyperparathyroidism. Considering the controversial nature of the appropriate timing for and location of this type of surgery, relevant research is relatively rare. Our experience may be a relatively successful one.Our patient was a 28-year-old woman with end-stage renal disease (ESRD), who was on dialysis for 7 years, and a 2-year history of progressively aggravated bone pain. She also had hypercalcemia and hyperphosphatemia.Given the patient's history of long-term dialysis, bone pain, high levels of intact parathyroid hormone(i-PTH) and hypercalcemia, we performed ultrasonography which showed solid nodules in the bilateral parathyroid glands. She was accordingly diagnosed with SHPT.The patient underwent tPTX+multi-point subcutaneous transplantation in the forearm.Her i-PTH level dropped to < 300 pg/mL, and the symptoms of bone pain markedly reduced after surgery.Total parathyroidectomy+multi-point subcutaneous transplantation in the forearm may be a reliable surgical approach for patients with ESRD. Komaba et al. showed in his nationwide cohort of maintenance hemodialysis patients that those who underwent PTX had remarkable survival advantage compared with the matched control with severe SHPT that did not undergo PTX. At present, there are 3 options for the surgical treatment of severe SHPT: subtotal PTX, total PTX with autotransplantation, and total PTX without autotransplantation. A prospective randomized trial that compared total PTX+autotransplantation with subtotal PTX showed better results for the former in terms of postoperative levels of calcium, phosphate, alkaline phosphatase, as well as an improvement in clinical symptoms and osteopathy. Reoperations after total PTX+autotransplantation were less common, and those performed had a lower complication rate.Secondary hyperparathyroidism (SHPT)is one of the major complications in patients with endst-age renal disease (ESRD) maintained on dialysis.2Written informed consent was obtained from the patient for the publication of this manuscript and accompanying images.A 28-year-old woman with ESRD on dialysis for 7 years and with a 2-year history of progressively aggravating of bone pain presented to us. Preoperatively, her intact parathyroid hormone (i-PTH) level was >2500 pg/mL, ionized calcium level was 3.05 mmol/L and serum phosphate level was 1.75 mmol/L. Ultrasound detected no abnormalities with the thyroid or lymph nodes, but three hypoechoic areas were seen in the parathyroid area. The 99mTc-MIBI three-phase imaging confirmed the presence of bilateral, irregular masses under the thyroid lobes on the 15- and 120-minute images. A diagnosis of SHPT was established. The operation time was about 100 minutes. After induction of general anesthesia, we made an arc-shaped incision 3-cm above the sternal notch, freed the flaps layer by layer, cut the anterior cervical anterior muscle group, and exposed the thyroid gland. We could also see the rear abnormal parathyroid gland. Then, we separated the parathyroid gland from the normal thyroid tissue along the envelope and completely removed the enlarged parathyroid gland. Three enlarged parathyroid glands were found during the surgery; all were removed,  or the sternocleidomastoid muscle, and possibly even subcutaneous tissue. This method avoids postoperative hypocalcemia, and can effectively alleviate the symptoms, but also has limitations, as recurrence of SHPT may be induced by the autotransplanted parathyroid glands.,7 While our surgical approach is relatively novel, we cut one of the removed parathyroid glands and transplant them separately to the forearm. Transplantation into the subcutaneous area is beneficial for B-ultrasound-based detection during later follow-up. For recurrent or persistent severe SHPT, reoperation is an invasive procedure with increased incidence of complications, and might not even result in successful treatment for those patients. If sHPT recurs, we can consider ablation of 1 or 2 of the 3 transplant points on the right forearm. The ablation does not require high operational skills.Treatment success was defined as i-PTH  Because of multi-point transplantation, surgical removal of transplanted parathyroid glands is also feasible for this patient, if the condition recurs.In conclusion, we reasoned that tPTX+multi-point subcutaneous transplantation in the forearm may be a reliable surgical approach to treat SHPT. Patients with ESRD diagnosed with SHPT and having hypercalcemia, hyperphosphatemia, and high levels of i-PTH are suitable candidates for this procedure. A prospective randomized trial showed that percutaneous ethanol injection therapy (PEIT) is useful for treating recurrent and persistent hyperparathyroidism after PTX.Writing – original draft: Nan Lin, Yong Chao Fang, Jun Chuan Song, Yu Wang.


Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial damage syndrome that is increasingly identified as a complication of both autologous and allogeneic hematopoietic cell transplantation (HCT) in children. If not promptly diagnosed and treated, TA-TMA can lead to significant morbidity  or mortality. However, as the recognition of the early stages of TA-TMA may be difficult, we propose a TA-TMA “triad” of hypertension, thrombocytopenia (or platelet transfusion refractoriness), and elevated lactate dehydrogenase (LDH). While not diagnostic, this triad should prompt further evaluation for TA-TMA. There is increased understanding of the risk factors for the development of TA-TMA, including those which are inherent , transplant approach-related , and related to post-transplant events . This understanding should lead to enhanced screening for TA-TMA signs and symptoms in high-risk patients. The pathophysiology of TA-TMA is complex, resulting from a cycle of activation of endothelial cells to produce a pro-coagulant state, along with activation of antigen-presenting cells and lymphocytes, as well as activation of the complement cascade and microthrombi formation. This has led to the formulation of a “Three-Hit Hypothesis” in which patients with either an underlying predisposition to complement activation or pre-existing endothelial injury (Hit 1) undergo a toxic conditioning regimen causing endothelial injury (Hit 2), and then additional insults are triggered by medications, alloreactivity, infections, and/or antibodies (Hit 3). Understanding this cycle of injury permits the development of a specific TA-TMA treatment algorithm designed to treat both the triggers and the drivers of the endothelial injury. Finally, several intriguing approaches to TA-TMA prophylaxis have been identified. Future work on the development of a single diagnostic test with high specificity and sensitivity, and the development of a robust risk-scoring system, will further improve the management of this serious post-transplant complication. Hematopoietic cell transplantation (HCT) for pediatric patients has classically been limited by transplant-related mortality (TRM). It has long been recognized that certain patients undergoing HCT are at increased risk for the development of endothelial injury, notably in the sinusoids of the liver, which manifests as sinusoidal obstruction syndrome (SOS). Recently, there has been an increased awareness that endothelial injury outside of the liver sinusoids is also a common occurrence in pediatric HCT recipients. This injury manifests itself as a thrombotic microangiopathy (TMA), with the most common features being hemolytic anemia, thrombocytopenia, hypertension, and renal dysfunction.As a robust single-diagnostic test does not yet exist, the incidence of transplant-associated (TA)-TMA is poorly defined, but likely ranges from 10 to 35% , while iGlobally, TA-TMA fits into the general classification of atypical hemolytic uremic syndromes (aHUS), as complement has shown to play a major role in the pathophysiology of the disorder. While post-HCT thrombotic thrombocytopenic purpura (TTP) has been reported , it is eActivation of endothelial cells to produce a pro-coagulant state. When damaged by conditioning agents and other medications, activated endothelial cells undergo multiple changes:Tissue Factor is expressed on the cell surface. This binds Factor VIIa (FVIIa), which promotes thrombus formation with activated platelets. Increased production of plasminogen activator inhibitor-1 (PAI-1) prevents fibrinolysis of the clot.Decreased levels of NO and prostacyclin (PGI2) leads to loss of suppression of the activation of the coagulation cascade and complement. Hemolysis leads to production of free hemoglobin, which further decreases NO levels.Decreased VEGF levels, in combination with release of ANG2 from endothelial cells and binding to the Tie2 receptor leads to vascular destabilization and vascular leakage.Increased expression of adhesion molecules  permits the local recruitment of antigen presenting cells (APCs) and lymphocytes.Damaged endothelial cells release IL-8.Endothelial cells and cell-derived micro-particles are formed and released into the blood , 11.Activation of antigen-presenting cells (macrophages and neutrophils) and lymphocytes. The activated endothelial cells in turn cause activation of a number of immune effector cells, including:IL-8 activates neutrophils to release NETs (which activate complement via complement factor P/properdin) .APCs express TNF-alpha, IFN-gamma, IL-1, IL-6, IL-8, and IL-12, further stimulating activation of T-cells and monocytes/macrophages.IFN-gamma and TNF-alpha enhance class II HLA-antigen expression on endothelial cells, making them more susceptible to T-cell mediated alloreactivity.Activated B-cells can potentially produce pathogenic antibodies. These include recipient-specific antibodies directed against class II HLA molecules  , or antiActivation of the complement cascade and microthrombi formation. The immunologic response activates both the alternative and classical complement cascades, as well as precipitates the formation of micro-thrombi:Activation of C3 by hydrolysis leads to formation of C3b which covalently binds to an endothelial cell surface. C3b binding is further propagated by endothelial injury.Once C3b is bound to the cell surface, complement Factor B (CFB) binds to C3b and is cleaved by complement factor D (CFD) leading to further amplification of alternative complement pathway, ultimately leading to C5 cleavage to C5a and C5b and formation of the lytic membrane attack complex  on the endothelial cell surface, causing direct endothelial cell lysis.C5a, a potent anaphylatoxin, releases the anticoagulant molecule heparan sulfate from the surface of the endothelial cells.Classical complement activation by antigen/antibody complexes actives C1 to trigger conversion of C4 to C4d, which remains covalently bound to tissues such as the glomeruli and intestines , 15.Tissue damage and inflammation leads to increased endothelial permeability, red cell (RBC) and platelet extravasation, fibrin deposition, and micro-thrombi formation along microvascular wall resulting in affected organ ischemia.The pathophysiology of the vascular endothelial injury found in patients with TA-TMA is extremely complex, but can be simplistically broken down into three major pathways:The end sum of these pathways is the death of endothelial cells and micro-thrombi formation. An excellent illustration of the pathophysiology of TA-TMA can be found in Jodele et al. .In pediatric patients, TA-TMA typically occurs early post-allogeneic HCT, with a median diagnosis at 35–47 days post-HCT, and 88–92% occurring before Day +100 . Howeverex vivo T-cell depleted HCTs should not require any routine anti-hypertensive medications, and initiation of one should trigger consideration of impending TA-TMA.Hypertension is often the first clinical sign of impending TA-TMA, typically proceeding formal diagnosis by a week or more , 19. UnfTA-TMA triad,” akin to the SOS classic triad of hepatomegaly, weight gain, and elevated bilirubin.The other clinical features, including thrombocytopenia , elevatOne of the diagnostic criteria suggests that patients with TA-TMA should have normal coagulation studies  to exclude cases of disseminated intravascular coagulation (DIC) . HoweverAlthough not part of the current criteria, in addition to proteinuria, hemoglobinuria is also commonly present. Rising creatinine can be a late feature of TA-TMA and is fairly concerning that irreversible kidney injury has begun. Cystatin C may be a better indicator of early renal dysfunction, but it is less readily available . With thThe presence of schistocytes on a peripheral blood smear should be the pathognomonic marker of TA-TMA, but because this is a subjective test requiring interpretation from a skilled microscopist, at many institutions it may be of very limited utility and therefore should not be relied upon to verify the diagnosis of TA-TMA . There iWhen all else fails, histologic evidence of microangiopathy on biopsy of an affected organ  is the gold standard to the diagnosis of TA-TMA. In our experience, however, such invasive procedures are rarely required to confirm the diagnosis and, in patients with severe thrombocytopenia from TA-TMA, are associated with a significant risk of serious bleeding.While the hallmark of TA-TMA is kidney involvement, it is important to recognize that other organs may also be compromised in TA-TMA, especially the gastrointestinal tract  , serosalRuling Out Other Diagnoses on the DifferentialOther TMAs: As noted above, documentation of a normal ADAMTS13 level and negative stool Shiga toxin are technically warranted.Autoimmune hemolytic anemia (AIHA): Direct antibody testing (Coombs) should be performed on all post-HCT patients with anemia, elevated LDH, and low haptoglobin. In rare cases, patients may have both AIHA and immune thrombocytopenia (ITP) post-HCT, but even this is typically distinguishable from TA-TMA due to the lack of hypertension and proteinuria in the former setting.Liver SOS: TA-TMA shares certain features with SOS, especially the platelet refractoriness and fluid retention. However, coagulation studies (such as the INR and aPTT) are typically normal in TA-TMA and elevated in SOS. Bilirubin may not always be elevated in pediatric patients with SOS, so a liver ultrasound with Doppler evaluation for reversal of portal venous flow may be useful .Overall, few diseases in HCT patients fully mimic the entire picture of TA-TMA and therefore, in at-risk patients (see below), the development of associated signs and symptoms should be considered TA-TMA until proven otherwise. In other words, when you hear the TA-TMA triad of “hypertension, thrombocytopenia, and elevated LDH,” TA-TMA should be considered a “horse,” not a “zebra.”Evaluating the Extent and Risk of TA-TMA  tract is often involved with TA-TMA and can present with symptoms which mimic GI GVHD, such as diarrhea, vomiting, pain, and bleeding . If the Serosal surfaces: While classically thought of as a manifestation of chronic graft- vs. -host disease (GVHD), in our experience all patients with evidence of pleural and pericardial effusions on chest radiograph and echocardiogram should be evaluated for TA-TMA . If clinCardio-pulmonary: Cardiac evaluation should be performed on all patients with TA-TMA, as they are at increased risk for pulmonary arterial hypertension (PAH), which if not recognized and treated, may be deadly , 28. CliNeurologic: Tight control of hypertension can potentially mitigate neurologic complications, but if such symptoms develop, a brain MRI should be performed. It may demonstrate bilateral white matter abnormalities in the vascular watershed areas consistent with posterior reversible encephalopathy syndrome (PRES) .Immunologic evaluation: Evaluating and trending a CRP can be a useful marker of excessive inflammation . While mGenetics: Primary atypical HUS occurring outside of the setting of HCT is typically mediated by gain-of-function mutations in genes encoding complement or by deficiencies in genes responsible for complement regulatory proteins . These pEspecially in the allogeneic setting, numerous risk factors have been identified. These can be separated into those that are: (1) inherent and non-modifiable; (2) transplant approach-associated; and (3) post-transplant event related .Inherent/Non-Modifiable Risk FactorsGenetics may play an important role in determining who eventually develops TMA following an HCT. Variants in complement genes are commonly found in all races, but when multiple variants are found in an individual, the risk of subsequent TA-TMA is significantly elevated . AfricanAnother report suggested that variants in CD40L, a gene responsible for production of a protein which plays a central role in co-stimulation and regulation of the immune response via T cell priming and activation of CD40-expressing immune cells, may increase the risk of TA-TMA . FinallySurprisingly, females have been noted to have an increased incidence compared to males in several reports , 16, 38,Having severe aplastic anemia (SAA) as an underlying primary disease has been linked to increased rates of TA-TMA . One hypTransplant Approach-Associated Risk Factors2. In allogeneic HCT recipients, a prior transplant is reported to increase the risk of TA-TMA . SimilarThe use of HLA-mismatched donors has been routinely associated with higher rates of TA-TMA , 40, 41,The use of myeloablative conditioning is usually associated with higher rates of TA-TMA compared to reduced intensity conditioning (RIC) regimens , 41, 46,In patients with neuroblastoma, early recovery of ANC is associated with increased risk of SOS . AlthougPost-Transplant Event Risk Factors3. In vitro there is evidence that cyclosporine alone is worse than tacrolimus alone and similar to tacrolimus plus sirolimus  DNA viral infections such as CMV and HHV-6, especially when occurring together, have been liked to TA-TMA , 56, 66.Therefore, risk-assessment for TA-TMA has to occur at two time-points, pre-HCT based on intrinsic and transplant-related factors, but also post-HCT in the setting of new triggers such as GVHD or infections. Higher-risk patients would likely benefit from enhanced monitoring and clinicians having a higher index of suspicion for the diagnosis of TMA.Three-Hit Hypothesis” . Fi. FiThree9/L)  by the platelet count (in X109/L) . PatientAnti-hypertensives: All patients with TA-TMA have hypertension and require multiple anti-hypertensives. However, not all agents may be equally beneficial. Because of the involvement of the renin-angiotensin system in mediating hypertension in TA_TMA, blocking this system with ACE-inhibitors or angiotensin 2 receptor agonists may be preferred , 70. HowErythropoietin and Thrombopoietin: Both PRBCs and platelet units contain plasma with significant amounts of complement , 72. TheVarious therapies have been considered for TA-TMA, but overall survival rates remain worse than for the general population of post-HCT patients without TA-TMA , 41. An Question 1: Is the patient actively infected?Certain infections appear to contribute to the endothelial injury of TA-TMA. Anecdotally, this can include low-level viremia from DS-DNA viral infections. All efforts to suppress such viruses to the level of PCR-negativity should be employed, including modulation of immunosuppression, anti-viral agents, and potentially virus-specific cytotoxic T-cells (VS-CTLs). One report demonstrated that TA-TMA will not resolve if the underlying infection is not controlled . UnfortuQuestion 2: Does the patient have active GVHD?There is clear evidence that active GVHD propagates the endothelial injury of TA-TMA. All efforts to minimize alloreactivity should be employed. The mainstay of this would be treatment with corticosteroids, though for patients without full response, consideration of other immunosuppressive agents should be considered, especially those which might target cytokine pathways also implicated in the TA-TMA pathway, such as TNF-a and IL-1 , 74, 75.Question 3: Could the patient have sub-clinical GVHD (or excessive inflammation)?Despite a lack of clinical GVHD, a patient may still have sub-clinical alloreactivity driving endothelial injury. We have anecdotally observed improved response to eculizumab in autologous recipients as compared to those undergoing allogeneic HCT, suggesting that unappreciated GVHD-mediated endothelial injury may exist in some patients. This can be difficult to document, but measurement of the CRP may provide information about the global state of inflammation. Another clue might be the state of donor T-cell chimerism. It has been shown that mixed T-cell chimerism implies a state of tolerance between donor and host, while full donor T-cell chimerism suggests that tolerance has been broken and the patient is at risk for  GVHD , 77. In Question 4: Is the patient on a CNI (or sirolimus)?For patients who develop signs of TA-TMA while receiving CNIs for prophylaxis or treatment of GVHD, the first intervention is typically to rapidly discontinue the CNI . DependiQuestion 5: Could the patient have an autoantibody?One hallmark feature of TA-TMA, unlike TTP, is a general lack of response to therapeutic plasma exchange (TPE) , 79, 80.TPE is invasive, as it often requires placement of a dedicated pheresis line, placement of which can be risky in a severely thrombocytopenic patient. If initiated, TPE should be performed daily at first . Other pIf a patient responds to TPE, it should be continued daily until complete resolution of the abnormal hematologic markers. TPE is then weaned to every other day for a period of about 2 weeks, then to twice weekly, and finally discontinued .Question 6: Does the patient have proteinuria and/or an elevated sC5b9 level?p = 0.003)  level (2). Patients with either abnormality should be strongly considered for treatment with terminal complement blockade, while patients with both should absolutely be started on treatment. Eculizumab is a monoclonal antibody against C5 that prevents formation of the MAC. In patients with elevated sC5B9 levels, use of eculizumab is associated with significantly improved overall survival compared to untreated controls  . Another= 0.003) .While eculizumab levels can potentially be performed and correlate with response, practically, a fully suppressed CH50 is sufficient to demonstrate complete complement blockade . The optIn the US, eculizumab is only available through a Risk Evaluation and Mitigation Strategy (REMS). This entails counseling patients regarding the protective role of terminal complement from the development of meningococcal infections and providing them with a Patient Safety Card. Technically, patients are supposed to undergo meningococcal vaccination 2 weeks prior to initiation of eculizumab. However, this is not practical in the setting of TA-TMA, as patients may drastically worsen during those 2 weeks, but more importantly, early post-HCT, few patients will mount protective antibody titers to vaccines, so this could inadvertently leave patients open to risk. The standard practice in this setting is to provide antibacterial prophylaxis with agents such as penicillin or ciprofloxacin until eculizumab has been discontinued and CH50 levels return to normal .For patients who do respond to eculizumab, a common dilemma is how long to continue the agent. If a pathogenic mutation in a complement gene is located , the answer is “lifelong.” However, most patients who develop TA-TMA do not have a significant mutation, but rather one or more minor gene variants. For these patients, withdrawal of complement blockade can typically be accomplished once all hematologic manifestations of the disease  have resolved , 79. TheTrials are currently underway to evaluate the use of ravulizumab-cwvz (formerly ALXN1210), a long-acting complement inhibitor, in pediatric patients with atypical HUS. The data for this agent are currently limited to patients with PNH, so its use in TA-TMA patients should be applied with caution .The typical TA-TMA patient who discontinues complement blockade will not have recurrence of symptoms , 85. HowQuestions 4–6A: Is the patient responding to the intervention?As noted above, most patients with TA-TMA will not respond to plasmapheresis. One of the critical questions facing a physician caring for a patient with TA-TMA, however, is how long to wait for signs of response to an intervention before deciding it is a treatment failure. As a general rule of thumb, it takes at least 2–3 weeks to observe hematologic responses to therapy , 6, 80.While complement blockade has significantly improved outcomes for patients with TA-TMA, a significant number (30–40%) of patients do not respond , 85. ForOther Complement Blockers: Eculizumab works by blocking the cleavage of C5 into C5a and C5b. However, C3b continues to build up on RBCs, which then can be cleared in the spleen, so extravascular hemolysis may continue . FurtherSoluble Thrombomodulin: TM is a glycoprotein on the surface of endothelial cells that, in addition to binding thrombin, regulates C3b inactivation by factor I. Antibodies against it have been linked to the development of aHUS. A small case series in Japan demonstrated a beneficial role for administration of recombinant TM to patients with TA-TMA . Unfortu9/L. This may be challenging, however, given the general desire to limit platelet transfusions (as noted above).Defibrotide: Defibrotide is a mixture of single-stranded oligonucleotides with endothelial protection properties mediated via inhibition of TNF-alpha and via its pro-fibrinolytic, anti-thrombotic, anti-inflammatory, and thrombolytic properties. It is FDA-approved for the treatment of SOS, another endothelial damage complication of HCT, and it was therefore hypothesized that it would play a role in the treatment of TA-TMA. Several reports suggest a possible benefit , 90, 91.None of the currently available treatments of TA-TMA have resulted in 100% response rates. With the hypothesis that it is easier to prevent a disease than treat it once fully established, there have been many efforts to identify a safe and effective prophylaxis regimen. While some of the TA-TMA risk factors are not easily changed, others may be amenable to modification. These approaches can be divided into those that improve baseline endothelial health, those that decrease the initial endothelial injury, and those that limit the “Third Hit.”Improving baseline endothelial healthIn vitro, it has been demonstrated that Vitamin D supplementation can protect endothelial cells from radiation-induced damage : EPA, one of the active ingredients in fish oil, has been shown in one small trial to decrease TA-TMA, potentially via reduction of cytokines and stimulation of NO production . Larger Limiting/repairing endothelial injury from conditioningIndividualized-Dosing: As the initial injury to the endothelial cells is thought to be mediated by the damage caused by the conditioning regimen, we hypothesize that individualized dosing of these agents to account for patient-specific differences in metabolism could limit TA-TMA. An analogous prototype is busulfan, where high exposures are associated with development of SOS, GVHD, and TRM . PK-direAllopurinol: Uric acid is a product of dying cells, and levels may become elevated following conditioning, especially in patients with high disease burdens coming into transplant. Elevations in uric acid have been shown to mediate endothelial injury, possibly via NET formation . A standIn vitro, defibrotide protects against endothelial injury induced by fludarabine and CNIs : NAC is a synthetic anti-oxidant derived from cysteine that acts by removing reactive oxygen species (ROS) and regulating several functions of the immune system. NAC can act directly, by neutralizing ROS, or indirectly, by increasing glutathione biosynthesis. In a mouse model of shiga-toxin mediated aHUS, NAC significantly limited the endothelial injury mediated via ROS . A smallLimiting the “Third-Hit”ex vivo or in vivo T cell depletion in the matched donor setting have not reported on TA-TMA rates  was recently identified, though it is still only available as a research test at this time .Development of a single diagnostic test with high sensitivity, high specificity, and fast-turn around. One of the major current limitations to rapid diagnosis (and hence treatment) is the current reliance on a complex algorithm devised of clinical and laboratory findings which may not all appear at the same time. Several potential tests have been proposed, including:Establishment of a robust risk-scoring system. Although a number of risk-factors for the development of TA-TMA have been identified, their relative  roles have yet to be conclusively determined to enable robust delineation of patients at very low and very high risk for TA-TMA. Identification of a high-risk group would potentially enable enhanced screening, and if a safe, effective, and  inexpensive prophylactic agent were identified, this would facilitate trials in those highest-risk patients.a priori known variants in complement genes might be candidates for a trial of prophylactic complement blockade during the immediate post-HCT period when endothelial damage is at its peak.Further consideration of routine up-front genetic testing. Theoretically, HCT patients with Formal evaluation of the prophylactic strategies noted above with the best risk-to-benefit profile. The short list for such trials would include vitamin D, EPA, allopurinol, statins, and defibrotide.hypertension , thrombocytopenia (esp. platelet transfusion refractoriness), and elevated LDH” should be constantly kept in mind. All institutions should strongly consider routinely monitoring LDH twice weekly for the first 100 days post-HCT, at least in high-risk patients. Once TA-TMA is diagnosed, a simple treatment algorithm can help guide the combination of interventions required to halt further progression of endothelial injury and allow the healing process to commence. In the future, one or more agents may potentially help improve baseline endothelial health and limit endothelial injury from both conditioning and the “Second Hit.”TA-TMA is the end result of a complex pathophysiologic injury to the endothelium in pre-disposed patients mediated by a combination of conditioning-induced injury and a “Second Hit” from medications (such as CNIs), GVHD, infections, or antibodies. In recent years, there has been an increased awareness of the risk of developing TA-TMA in pediatric HCT recipients. However, given the current diagnostic limitations, a high index of suspicion must be maintained, especially in high-risk patients during the highest-risk time period post-HCT (~21–100 days). This is similar to the careful attention that pediatric transplant physicians have historically paid to the development of SOS and acute GVHD, both of which may overlap with TA-TMA. The clinical TA-TMA triad of “All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.CD has received consulting fees from Alexion, Inc. (manufacturers of eculizumab) and Jazz Pharmaceuticals (manufacturers of defibrotide). CH receives research funding from Jazz Pharmaceuticals. KS has received research funding from Alexion, Inc. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


As large-scale metabolic phenotyping studies become increasingly common, the need for systemic methods for pre-processing and quality control (QC) of analytical data prior to statistical analysis has become increasingly important, both within a study, and to allow meaningful inter-study comparisons. The nPYc-Toolbox provides software for the import, pre-processing, QC and visualization of metabolic phenotyping datasets, either interactively, or in automated pipelines.https://pypi.org/project/nPYc/, source is available at https://github.com/phenomecentre/nPYc-Toolbox. Full documentation can be found at http://npyc-toolbox.readthedocs.io/ and exemplar datasets and tutorials at https://github.com/phenomecentre/nPYc-toolbox-tutorials.The nPYc-Toolbox is implemented in Python, and is freely available from the Python package index  Metabolic phenotyping offers a powerful window into gene-environment interactions  practices and focusing on the interpretability of the output to both data generators and analysts .Dataset object; the NMRDataset encapsulates methods for handling spectral NMR data; MSDataset for discretely measured (peak-picked) hyphenated-MS profiling datasets; and TargetedDataset for targeted, quantified datasets, derived from MS, NMR or any other analytical platform.The toolbox is designed to allow reproducible processing of datasets with minimal reliance on human judgement during the process. It may be used interactively , or as an API in automated workflows. It is coded in Python 3.6. To account for the differing processing workflows expected of the common analytical datasets outlined above, the toolbox subclasses its TM, TargetLynxTM, &c], and associated with study design parameters or metadata read directly from the raw data or from csv files. The csv template is structured so that each row corresponds to a sample, and columns contain a set of mandatory fields, and any other user required metadata. The role that each sample plays in the assay and its pre-processing is delineated using a standardized nomenclature.Dataset objects are initialized from raw (Bruker NMR) or feature-extracted data  through funding for the MRC-NIHR National Phenome Centre, infrastructure support was provided by the NIHR Imperial Biomedical Research Centre and PhenoMeNal, European Commission Horizon2020 programme, grant agreement number 654241.Conflict of Interest: none declared.


We performed dynamic effective connectivity modeling with medial prefrontal cortex (mPFC), rostral anterior cingulate cortex (rACC), and amygdala as regions-of-interest (ROI), and assessed associations between connectivity and clinical variables. HCs exhibited significant within-group bidirectional mPFC-amygdala connectivity, which increased across the blocks, whereas BDD participants exhibited only significant mPFC-to-amygdala connectivity . In contrast, participants with AN lacked significant prefrontal-amygdala connectivity in either direction. AN showed significantly weaker mPFC-to-amygdala connectivity compared to HCs (P = 0.0015) and BDD (P = 0.0050). The mPFC-to-amygdala connectivity was associated with greater subjective fear ratings , eating disorder symptoms , and anxiety  intensity scores. Our findings, which suggest a complex nosological relationship, have implications for understanding emotion regulation circuitry in these related psychiatric disorders, and may have relevance for current and novel therapeutic approaches.Anorexia nervosa (AN) and body dysmorphic disorder (BDD) share distorted perceptions of appearance with extreme negative emotion, yet the neural phenotypes of emotion processing remain underexplored in them, and they have never been directly compared. We sought to determine if shared and disorder-specific fronto-limbic connectivity patterns characterize these disorders. FMRI data was obtained from three unmedicated groups: BDD ( Body dysmorphic disorder (BDD) and anorexia nervosa (AN) are psychiatric disorders with prevalences of ~2% (BDD)  and 1% , 4. HoweIn addition, recent evidence from our laboratory shows that the syndromes display similar brain activation abnormalities in visual systems when viewing faces and houses , supportThe observation that anxious traits emerge early in AN and are familially transmitted , lends cAbnormal fronto-limbic connectivity has been associated with anxious traits . Fronto-The neural response to fearful faces is a well-established laboratory technique for interrogating fronto-limbic modulation of emotion-regulating circuitry . The actWith this as background, we present what is to our knowledge the first study to examine, and compare, fronto-limbic connectivity in these two body image phenotypes. Specifically, we probed fronto-limbic connections evoked by self-labeling of emotional responses , 38, andIn this study, we employed dynamic effective connectivity modeling  to estimn = 32); weight-restored AN (n = 25); and HC (n = 37). The study was approved by the UCLA Institutional Review Board. Informed written consent was obtained from all participants. Please refer to Supplemental Information SI-1.1 for further information.We recruited unmedicated young individuals (aged 14–38 years) in three groups of equivalent age, sex, and education: BDD  , and the*-weighted echo planar imaging (EPI) gradient-echo pulse sequence . Higher resolution matched-bandwidth (MBW) T2 and T1-weighted images were collected for coregistration.Functional MRI data were acquired on a Siemens Trio 3T scanner using a T2T-tests in both cases, P < 0.05, Bonferroni corrected).Fearful face stimuli were presented in a blocked design with 4 unique stimuli per block for three blocks, to assess change in connectivity across the three blocks. Each face stimuli appeared for 4 s with an inter-stimulus interval of 500 ms, and each block was 18 s long. There were also blocks of scrambled faces of the same duration and with the same inter-stimulus intervals. The fearful face and scrambled face blocks alternated, so that the entire run was comprised as follows: fearful face block 1, scrambled face block 1, fearful face block 2, scrambled face block 2, fearful face block 3, and scrambled face block 3. Participants indicated level of fearfulness when viewing faces (subjective fear rating [SFR]) by pressing buttons 1 (minimum) through 4 (maximum), or to indicate the roundness of a scrambled face (as the control task) by pressing button 1 (circle) or 2 . We asked participants to rate their own emotional state during fearful face viewing (vs. rating the degree of fear expressed by the face), in order to engage top-down modulation of emotion processing. For further details, please refer to Supplemental Information SI-1.2. In addition to assessing temporal change in connectivity in this study, we also performed an omnibus ANOVA on SFR with group and fearful face block as factors, followed by an assessment of the within-group change in SFR across the three fearful face blocks and between-group SFR differences , including motion correction (6 parameters), spatial smoothing , high-pass temporal filtering (100 s), and skull stripping. We coregistered participant's functional images to their MBW T2-weighted structural image, which was in turn registered to the MNI-152 average brain. We excluded participants with motion values >2 standard deviations above the group mean as defined by FSL DVARS , and verhttp://users.ugent.be/~dmarinaz/HRF_deconvolution.html), with both inputs and outputs being matrices of size timepoints × ROI × subjects for each group.We next performed hemodynamic deconvolution  on ROI ttimepoints × ROI × subjects matrix) were input to a dynamic multivariate autoregressive (dMVAR) model for estimating effective connectivity between the ROIs, which was solved in a Kalman-filter framework. The dMVAR model coefficients vary as a function of time, giving us the DEC timeseries for every connection. DEC length was identical to the number of time points in the fMRI data; that is, for every connection, one DEC value was obtained for every time point. Using DEC, we obtained the desired block-specific connectivity values (Dynamic effective connectivity (DEC), a measure that provides the directional connectivity value between pairs of regions at every time instant, was evaluated between all ROI pairs by employing Kalman-filter based time-varying Granger causality . Grangery values . Specifiand block2 > block1 . This procedure was performed separately for the three groups to test our hypotheses. We additionally performed exploratory analyses of connectivity between the rACC and the amygdala and mPFC, given its proven involvement during fearful face processing . It is important to note that progressive increases in DEC are independent of changes in brain activation, since effective connectivity modeling normalizes absolute signal strengths in its formulation , and Hamilton anxiety rating scale [HAMA]) .We then sought to identify those connectivities that increased significantly across the blocks, in accordance with our hypotheses, indicating enhanced engagement and contributing to effective top-down modulation and emotion regulation . Our hypocessing . We follmulation . Hence, The three groups did not differ significantly on age, sex or years of education Table . Please F = 4.89, P = 2.3 × 10−4], but no interaction effect between group and block . Additionally, the groups did not differ significantly on SFR , or the shape of scrambled faces . Given the trend for group differences, we performed pairwise comparisons with SFR. There were no significant differences between AN and BDD, or BDD and HC, but elevated subjective fear was observed in AN compared to HC .With the omnibus ANOVA test on reported subjective fear ratings (SFR), we found a significant effect of task block . With follow-up T-tests we found that, independently within each group, SFR significantly increased from block-1 to block-2 , and decreased from block-2 to block-3 .For the analysis of changes in SFR across the 3 fearful face blocks, we found significant within-group change in all groups . AN showed weaker mPFC–to-amygdala connectivity compared to HCs  and BDD   = 0.47, P = 0.24]. Please refer to Supplemental Information SI-2.2 for a detailed presentation and discussion of the changes in effective connectivity across blocks for the remaining significant connections.Between groups, there was a significant difference in mPFC–to-amygdala connectivity ), with EDE in AN , and with HAMA in AN  , we performed a partial correlation analysis between connectivity and these measures and found that mPFC-to-amygdala connectivity in AN had a significant association with the EDE score after controlling for HAMA , and with HAMA controlling for EDE . Thus, eating disorder symptom intensity, and severity of anxious symptoms as well, showed independent associations with mPFC-to-amygdala connectivity in AN, wherein higher symptom severity was associated with stronger connectivity.The left mPFC -to- right amygdala connectivity  had significant association with SFR across all participants  compared to HC and BDD, indicating a lower degree of top-down modulation in AN. The specificity of this to fearful face processing is supported by the absence of significant group differences in connectivity for the scrambled faces control task.There were significant associations between the mPFC-to-amygdala connectivity and subjective fear rating in all participants, and with eating disorder and anxiety symptom intensity in AN participants, underscoring the behavioral and clinical relevance of this connection.In summary, our experimental design of having participants reflect upon, and subjectively rate, their level of fear during fearful face viewing was intended to instantiate the top-down modulation of emotion , 38. In In both the clinical groups, we found, as hypothesized, abnormal connectivity between mPFC and amygdala. These regions are integral to the expression and modulation of fear, which are facilitated through their connectivity . It is wAs depicted in Figure We also observed evidence in both AN and BDD that signals originating in the amygdala may not be instantiating feed-forward information to the mPFC, as evidenced by the lack of significant amygdala-to-prefrontal connectivity. As regards BDD, this may account for previously-observed limbic hypo-responsiveness in participants with BDD during exposure to their own faces, despite their rating of the experience as aversive . While sWe next discuss the connections that were significantly engaged in AN and/or BDD but not in HC. The rACC-to-mPFC connection, which exhibited increased engagement in AN but not in HC or BDD, is known to be elevated during situations of conflict . Hence, Although we hypothesized that mPFC-to-amygdala connectivity would be associated with intensity of anxiety in both clinical groups, it appears only in AN. Increases in this connectivity were associated with an increase in anxiety and with total EDE score. What the association of this connectivity with EDE total score Figure  and inteFurther, the association of the mPFC-to-amygdala connectivity with SFR across all the participants Figure  implies left mPFC -to- right amygdala connection was identified. The right mPFC was not involved in the fronto-limbic network in any of the groups . We did predict this prefrontal-to-amygdala connectivity in BDD, because cognitive behavioral therapy (CBT) techniques, which utilize exposures, are at least moderately beneficial in BDD , this provides empirical support for the idea that connectivity and its dynamics in these circuits may be more clinically relevant and a more direct measurement of important neural communication than the simple regional activation patterns.Concerning subjective fear findings, although there were no significant group differences averaged across trials , of more interest was the observation that all groups exhibited increased subjective fear from block-1 to block-2 and decreased SFR from block-2 to block-3. This suggests a pattern of increased subjective fear during the first part of the experimental run when they were introduced to emotionally arousing stimuli, and decreased subjective fear during the second part when fronto-limbic regulation might have had an increasing impact. If fronto-limbic connectivity and subjective fear are linked, this possibly indicates a time lag between the initial increase in connectivity  and subsequent subjective experience of fear. Why the AN group also exhibited this pattern despite not showing elevated fronto-limbic engagement during the same task blocks is unclear. This mismatch between connectivity and subjective experience might be a cause or consequence of alexithymia , 69; wheThis work contributes to a mechanistic understanding of the neural substrates underlying the similarities and differences in AN and BDD, and may have important clinical relevance regarding treatments that engage fronto-limbic circuitry. As regards the clinical therapeutic implications of these data, weak connectivity to fearful stimuli in both clinical groups may explain, at least partially, why treatments that use exposure and response prevention (ERP), a type of CBT, have relatively small effects in AN , and havFinally, we discus several limitations and future directions. (i) Our AN cohort consisted of weight-restored individuals, in the interest of minimizing the potential confounding effect of weight. Consequently, our findings cannot necessarily be extrapolated to underweight individuals. (ii) We did not acquire participants' emotional ratings of the faces , which may be relevant given the possibility of misinterpretation of emotional expressions that have been observed in BDD  and weigDR, CB, MS, and JF: literature search; DR, CB, SK, MS, and JF: study design; KL, TM, SK, MS, and JF: data collection; DR, CB, TM, FM, and JF: data analysis; DR, MS, and JF: data interpretation; DR: figures; DR, CB, SK, MS, and JF: writing.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Among all malignant tumors that threaten human health, virus-related tumors account for a large proportion. The treatment of these tumors is still an urgent problem to be resolved. The immune system is the “guard” of the human body, resisting the invasion of foreign substances such as viruses. Studies have shown that immunotherapy has clinical significance in the treatment of a variety of tumors. In particular, the emergence of immune checkpoint inhibitors (ICIs) in recent years has opened a new door to cancer therapy. Considering the potential role of ICIs in the treatment of virus-related cancers, we focused on their therapeutic effect in virus-associated cancers and explored whether the therapeutic effect in virus-associated cancers was related to virus infection status. Although there is no clear statistical significance indicates that ICIs are more effective in virus-associated cancers than non-virus infections, the efficacy of checkpoint inhibitors in the treatment of virus-related cancers is promising. We believe that this research provides a good direction for the implementation of individualized precision medicine. Cancer is a major public health problem worldwide. According to the International Agency for Research on Cancer (IARC), there were about 18.1 million new cancer cases and 9.6 million cancer deaths in 2018 worldwide : human pEven though these carcinogenic viruses belong to different genus and use multiple mechanisms to promote cancer development, they may have several features in common , 5. TheyImmune checkpoints mainly including programmed death 1 (PD-1) and cytotoxic T lymphocyte antigen 4 (CTLA-4) are membrane-bound molecules expressed on immune cells. Immune checkpoint inhibitors (ICIs) are predominantly monoclonal antibodies, which have shown to be effective in a variety of cancers –11. TheyThe ICIs approved by the Food and Drug Administration (FDA) include anti-PD-1 (nivolumab and pembrolizumab), anti-PD-L1 , and anti-CTLA-4 (ipilimumab and tremelimumab). There are a series of clinical trials involving the efficacy of ICIs in virus-related cancers. Published clinical trials evaluating the efficacy of ICIs were summarized in Table Human papillomavirus (HPV) is a circular DNA virus, which infects the genital mucosa, the oral mucosa, and the basal keratinocytes of the skin, mainly spreading by sexual contact. It was reported that HPV caused more than half of all infection-attributable cancers in women worldwide . It is aIn 2018, the FDA approved pembrolizumab for recurrent or metastatic cervical cancer based on results from the Keynote-028 trial , providiSquamous cell carcinoma of the anal canal (SCCA) is an uncommon malignancy associated with HPV infection. The treatment of anal cancer depends on accurate staging, and chemo-radiotherapy is the main treatment for most patients . A singlHead and neck squamous cell carcinoma (HNSCC) comprises the majority of head and neck cancers and represents a heterogeneous group of tumors that arise from the squamous epithelium of the oral cavity, oropharynx, larynx, and hypopharynx . In addiCV). Treatment of HCC including surgical resection, liver transplantation, and systemic therapy varies based on the stage of disease. However, only a small number of patients are suitable for surgical resection due to the extent of disease or poor liver function, and systemic treatment with sorafenib has displayed a comparatively modest role [Hepatocellular carcinoma (HCC) is one of the most frequently occurring cancers in the world and ranks third in global incidence . HCC usuest role . TherefoIn a randomized, double-blind, placebo-controlled study (NCT00703469), the antivirus potential of BMS-936558 (MDX-1106/nivolumab) was explored in patients with chronic HCV infection . Of the Studies have shown that the killing of tumors by direct methods (known as ablation) can result in the immune system being activated or switched on , 43. ICIIn September 2017, FDA approved nivolumab for liver cancer as a second line treatment after failure of sorafenib based on the data of CheckMate040 [EBV, also called human gamma-herpesvirus 4 (HHV-4), causes chronic latent infection with lifelong persistence in about 95% of the world population . It is aEBV-associated NPC is one of the most common head and neck malignancies, and unfortunately, 70% of NPC patients have locally advanced disease at initial diagnosis. Nasopharyngectomy is one established treatment option for locally recurrent NPC . SurgicaA multinational study (NCI-9742) evaluated the antitumor activity of nivolumab in NPC . In thisp < 0.001) in EBV-positive (56%) than EBV-negative NHL (11%). It is anticipated that the better therapeutic effect of ICIs in EBV-positive lymphoma may be related to high expression of PD-L1.EBV, originally discovered through its association with Burkitt lymphoma, is etiologically linked to a wide range of lymphoproliferative lesions and malignant lymphomas of B, T, and NK cell origin . In a stIn addition, EBV-positive gastric cancer (GC) is also under our consideration. Most recently, extremely high ORR (100%) of pembrolizumab was reported in six patients with EBV-positive metastatic GC . HoweverOther viruses that induce cancers include HIV, HTLV-1, and HHV-8. Among them, HIV is special in attributable risk calculations because its increased cancer risk only combine with other carcinogenic infectious factors . A systeIn addition, HTLV-1 is a retrovirus of the human T-lymphotropic virus family that has been related with several kinds of diseases including aggressive adult T cell lymphoma (ATL) and HTLV-1-associated myelopathy . HHV-8 iAt present, immunotherapy is widely use clinically, but is not always effective. It is not wise to administer immunotherapy without knowing the genetic background of the patient . We needIn virus-induced cancers, the mechanisms by which viruses induce cancers are different, producing different mutation loads in tumors , 56–58. In addition, the interplay of immune checkpoints and their ligands is complex, occurring at different stages of T cell activation and function. Similarly, they work at different stages of tumorigenesis . In viruThrough the above clinical trials, there is no clear statistical significance indicates whether ICIs are more effective in virus-infected population than non-virus infections. However, the efficacy of ICIs in treating virus-associated cancers is rather promising. These virus-induced cancers present a specific immunological profile that virus-positive cancers often exhibit increased infiltration of cytolytic cell types compared to their virus-negative counterparts, and their responses to ICIs are expected to be different from other cancers . More cl