Epidemiological observational studies have investigated the relationship between rheumatoid arthritis(RA) and pre-eclampsia, but no consistent conclusions were obtained due to various limitations. Hence, we conducted a two-sample mendelian randomization analysis to evaluate the potential causal effect of RA on pre-eclampsia.Summary-level statistics for RA were derived from a large-scale meta-analysis of datasets of genome-wide association studies(GWAS) which involved 14,361 cases and 43,923 controls. Moreover, summary statistics for pre-eclampsia or eclampsia were sourced from the Finn biobank which contained 3,903 cases and 114,735 controls. The inverse variance weighting (IVW) as well as other four effective methods including MR-Egger, weighted median, weighted mode, and simple mode were applied to deduce the potential causal relationships between RA and pre-eclampsia comprehensively.The two-sample MR analysis suggested a strong causal relationship between RA and pre-eclampsia. The OR estimates obtained from the weighted mode and weighted median were similar to those from the IVW method, but there was no significant association observed in MR Egger and simple mode analysis.This MR analysis provides evidence of a positive causal association between RA and pre-eclampsia genetically. Our findings highlight the importance of more intensive prenatal care and early intervention among pregnant women with RA to prevent potential adverse obstetric outcomes. Moreover, our study provides clues for risk factor identification and early prediction of pre-eclampsia. Hypertensive disorders of pregnancy(HDP) are common pregnancy complications, which are comprised of gestational hypertension, pre-eclampsia or eclampsia, pre-eclampsia superimposed on chronic hypertension, and chronic hypertension. HDP, especially pre-eclampsia, complicate 2-8% of pregnancies and account for a substantial proportion of maternal and perinatal mortality , 2. WorlRheumatoid arthritis(RA) is a systemic autoimmune disease with a chronic inflammatory process, which has a female predominance . SeveralMendelian randomization(MR) is an emerging analysis method that uses genetic variants as instrumental variables (IVs) to evaluate the causal effect of modifiable exposures on outcomes . BecauseIn this study, we conducted a two-sample MR to evaluate the causal association between RA and pre-eclampsia. SNPs were used as instrumental variables . To maxiDatasets of genome-wide association studies(GWAS) provide reliable instruments for MR analyses. In our study, summary-level statistics for RA were derived from a large-scale meta-analysis of GWAS which involved 14,361 cases and 43,923 controls . And sumThe linkage disequilibrium (LD) in selected SNPs was tested to ensure the data were valid. We conducted the clumping procedure to filter independent SNPs within a window size of, 5000kb and r2<0.01 threshold. Then, the F-statistics were calculated to evaluate the strength of each IV and exclude weak instruments. The following rigorous mathematical formula was adopted:where R2 indicates exposure variance explained by each IV, N refers to the sample size of the GWAS, and K denotes the number of SNP for MR analysis. F>10 indicated sufficient strength of the instruments, which meant the IVs had enough estimated effect for the subsequent MR analysis without weak-tool bias. In this study, we used 65 SNPs as eligible IVs after eliminating ten SNPs with minor allele frequency (MAF) less than the threshold of 0.01. Finally, according to alleles and allele frequencies, we harmonized the SNPs of exposure and outcome by removing or adjusting SNPs with inconsistent alleles to ensure they have corresponding alleles.In this study, we used the inverse variance weighting (IVW) method as the main approach to deduce the potential causal relationships between RA and pre-eclampsia. Other four effective methods including MR-Egger, weighted median, weighted mode, and Simple mode were also applied to evaluate the possible relationship comprehensively.Characterized by using the inverse of outcome variance as weight and not taking the intercept into account, the IVW method can provide unbiased causality estimates in an ideal state where all selected genetic variations are assumed to be valid IVs without pleiotropy . In termFirstly, several sensitivity analyses were conducted to assess pleiotropy. We performed the mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO) to detect potential outlier variants . FurtherAt last, scatter and forest plots were provided to visualize the result of the MR analysis. We did all the analyses on the R software  and RStudio, and R package TwoSampleMR and MR-PRESSO were used.2< 0.01) and genome-wide significant (p< 5e-08) SNPs were identified as qualified IVs with all F-statistics above 10. Detailed information is available in Supplementary Data Sheet 1.Sixty-five independent . Based on the calculation, 20.4% of the excess preterm birth that happened to women with RA was due to pre-eclampsia/hypertension and it also accounted for more than 10% of the excess cesarean delivery . InteresA chief strength of our study is the two-sample MR design which allowed us to evaluate the potential causal effect based on large-scale GWAS with credible sample sizes. In the meanwhile, because SNPs are randomly distributed at conception, biases caused by potential confounders and reverse causation can be reduced significantly in this design. It is worth mentioning that our result can present a lifelong pregnant risk for women with RA since genetic variants could not be changed from the time you were born.The limitations of our study should be noted as well. Firstly, we only enrolled European ancestry populations in our study which means all related data were sourced from studies that separately analyzed only populations of European ancestry. The uniformity of participants eliminates demographic stratification bias and ensures the accuracy of MR analysis results, but whether our findings can be applied to other populations or not remains to be validated. Therefore, further analyses involving other populations require being conducted to confirm whether our findings can be generalized or not. Secondly, the data on outcome was collected from the population with pre-eclampsia or eclampsia and no more specific information was given to describe the severe degree of disease. Further studies are warranted to research the association between RA and subtypes of pre-eclampsia.This is the first MR analysis conducted to explore the causality of RA on pre-eclampsia. We find a positive association between RA and elevated risk of pre-eclampsia. Our findings highlight the importance of more intensive prenatal care and early intervention among pregnant women with RA to prevent potential adverse obstetric outcomes. Moreover, our study provides clues for risk factor identification and early prediction of pre-eclampsia.The original contributions presented in the study are included in the article/DZ and SY designed the research. WG and DZ collected and analyzed the data. LY, YL, TO, SY, YZ, and YH performed the literature search. DZ and YH drafted the article. YS, WG, YZ, and YH corrected and edit the article. All authors contributed to the article and approved the submitted version.


Escherichia coli guide work with Mycobacterium tuberculosis. Lethal action, which is mechanistically distinct from blocking growth, is associated with a surge in respiration and reactive oxygen species (ROS). Mutations in carbohydrate metabolism that attenuate ROS accumulation create pan-tolerance to antimicrobials, disinfectants, and environmental stressors. These observations indicate the existence of a general death pathway with respect to stressors. M. tuberculosis displays a variation on the death pathway idea, as stress-induced ROS is generated by NADH-mediated reductive stress rather than by respiration. A third approach, which emerges from lethality studies, uses a small molecule, N-acetyl cysteine, to artificially increase respiration and additional ROS accumulation. That enhances moxifloxacin lethality with M. tuberculosis in culture, during infection of cultured macrophages, and with infection of mice. Addition of ROS stimulators to fluoroquinolone treatment of tuberculosis constitutes a new direction for suppressing the transition of MDR-TB to XDR-TB.With tuberculosis, the emergence of fluoroquinolone resistance erodes the ability of treatment to interrupt the progression of MDR-TB to XDR-TB. One way to reduce the emergence of resistance is to identify heteroresistant infections in which subpopulations of resistant mutants are likely to expand and make the infections fully resistant: treatment modification can be instituted to suppress mutant enrichment. Rapid DNA-based detection methods exploit the finding that fluoroquinolone-resistant substitutions occur largely in a few codons of DNA gyrase. A second approach for restricting the emergence of resistance involves understanding fluoroquinolone lethality through studies of antimicrobial tolerance, a condition in which bacteria fail to be killed even though their growth is blocked by lethal agents. Studies with  Antimicrobial treatment of tuberculosis has led to widespread emergence of resistance, particularly to the two most effective first-line agents, rifampicin and isoniazid. The resulting disease, called multidrug-resistant tuberculosis (MDR-TB), increased in prevalence by over 20% annually between 2008 and 2016 . TreatmeM. tuberculosis is likely to remain a problem until ways are developed to suppress it.We are focusing on improving the effectiveness of fluoroquinolones, the most potent of the second-line drugs used against MDR-TB. Addition of a C-8 methoxy group to ciprofloxacin-like agents, as found with moxifloxacin and gatifloxacin, improves lethal action, especially against resistant mutants . HoweverM. tuberculosis have led to a way to enhance moxifloxacin-mediated killing. These studies of fluoroquinolones are likely to be of broad interest, because some of the principles appear to apply to antimicrobials in general. For example, heteroresistance is a general property of bacteria, and the death pathway appears to be common to antibiotics, disinfectants, and environmental stress  . Many liM. tuberculosis , the bacteria failed to respond to a colistin treatment that protected mice infected by a fully susceptible strain. Thus, massive enrichment can occur during drug exposure.For many bacterial pathogens, heteroresistant infections often respond favorably to antimicrobial treatment, largely because the dominant, susceptible portion of the population is controlled well enough for host defense systems to clear infection. In such situations, heteroresistance is a problem mainly for immunocompromised patients. However, a heteroresistant infection can evolve to full resistance. An example is seen with colistin resistance of iewed in ). An isoM. tuberculosis in both HIV-positive and HIV-negative patients . If colM. tuberculosis: resistant colonies can be recovered, but they are rare  takes approximately 15–30 days. Second, subculturing from sputum samples can alter the size of the mutant subpopulation due to selective advantage or disadvantage (M. tuberculosis (sl) is 1–2 days . The resistance alterations map in narrow regions of the two subunits of gyrase, GyrA and GyrB .Most clinically relevant fluoroquinolone resistance derives from amino acid substitutions in the target protein, DNA gyrase  can be detected with M. smegmatis and M. tuberculosis in “low-level resistant” mutants, the A to S substitution also likely affects bacteriostatic activity . Thus, E. coli also associate GyrB substitutions with resistance to some quinolones . These gyrB alleles are likely responsible for resistance, since they reduce fluoroquinolone sensitivity when present in purified, recombinant gyrases  is readily selected on drug-containing agar  and second-line injectable drugs in samples from MDR-TB cases . Another challenge for PCR-based methods arises from laboratory contamination by amplicons from previous assays. Cross-contamination using open-tube assays is estimated to be almost 4% . Closed-When DNA samples are amplified by PCR and nucleotide sequences are determined for the regions of interest, results are obtained rapidly. Many laboratories have access to the Sanger sequencing method, making it a popular assay. However, sensitivity is a problem, since in some cases the mutant frequency needs to be above 50% for detection . In one Sensitivity is improved by performing the sequencing with very large numbers (millions) of parallel determinations (deep or next-generation sequencing). The general strategy uses reversible-terminator sequencing-by-synthesis technology to provide end-to-end sequencing and many short reads. In this method, genomic DNA is extracted from bacterial cells, enzymatically sheared into small fragments, and tagged with Illumina-specific DNA identifiers. These unique identifiers allow multiple DNA fragments to be sequenced at the same time. The short, tagged fragments of DNA are purified, samples are normalized to specific concentrations, pooled, and loaded into the sequencer. The data are then computationally analyzed. When the method is extended to the whole genome, sensitivity is below 5% for resistant mutants, perhaps as low as 0.2% . A disadMolecular beacons are oligonucleotides in which a probe sequence is situated between ends that are complementary and form base pairs. One end contains a fluorophore and the other a quencher. Hybridization of the probe with its target sequence destabilizes the base pairing of the ends, separating the quencher from the fluorophore. The probe-target interaction is seen as fluorescence. Sloppy molecular beacons have unusually long probe sequences that allow hybridization to long target regions that can have considerable mismatch. The mismatches lower the melting temperature of the probe-target interaction as an indicator of different gyrase alleles .M. tuberculosis gyrA QRDR using asymmetrical PCR. Then probing was with two sloppy molecular beacons that spanned the entire QRDR. By testing DNA targets corresponding to all known QRDR mutations, the Alland laboratory .Another strategy, also from cancer diagnosis, employs SuperSelective primers for real-time PCR assays . In thisM. tuberculosis . They tend to occur where tuberculosis and resistant disease are common.Heterogeneity can arise from co-infection with multiple, dissimilar infecting strains of 6110 RFLP or VNTR patterns)  . In a reatterns) , sputum 9 bacilli . This phenomenon is common when super-infection is rare and treatment of individual patients is poor. In this scenario, intermittent drug exposure, due to suboptimal dosing and/or factors that affect compliance, allows cycles of bacterial population expansion followed by selective reduction. Spontaneous heterogeneity is expected, because the bacterial burden can be high: some tuberculosis patients harbor on the order of 10 bacilli . Bacteribacteria ).M. tuberculosis having a single IS6110 RFLP type and spoligotype pattern: superinfection was not observed.The complex dynamics of clonal heteroresistance are illustrated by a South African study . The stugyrA, embB, and katG over 56 weeks of therapy. At the start of sampling, the three genes were wild type, while at weeks 4 and 6, the katG marker was resistant. It later returned to wild type. The embB marker became resistant by week 6 and remained resistant throughout the observation period. The gyrA gene showed a mixture of alleles at week 6; in later samples, transient changes occurred among several gyrA resistance forms, often mixed with wild-type alleles. After 48 weeks, gyrA was a mixture of resistant and wild-type alleles. By week 52, a different gyrA allele (D94G) became dominant. Isolates from two other patients also contained different alleles of drug-resistance genes. These marker fluctuations illustrate the dynamic and varied nature of clonal heteroresistance with M. tuberculosis.Nucleotide sequence analysis for several genes showed that resistance patterns for infections changed during the course of sampling. For example, one patient was tested for mutations in 6110 fingerprints were identical for M. tuberculosis from different lung regions: the isolates within individual patients appeared to be clonally related  bacteria from apparently normal lung tissue had wild-type genes for embB, katG, and rrs, 2) cells from sputum and four pathological sites had embB and katG resistance markers but wild-type rrs, and 3) bacteria from another pathological site exhibited resistance for all three genes. These findings, plus similar observations in another study . That knowledge should also lead to strategies for restricting the selection of tolerant mutants. A key idea, based in part on quinolone studies, is that lethal stress elicits a general stress response in which ROS accumulates and damages macromolecules (reviewed in ). Below E. coli , increasing ROS-mediated death  to the agents. The pan-tolerance (anti-death) phenotype demonstrated the existence of a death pathway common to many, if not all lethal stressors.Many aspects of Collins’ early work were challenged  as summaptsI (phosphotransferase) and cyaA (cAMP), thereby defining a novel activity of these genes as upstream regulators of the stress-mediated death pathway. The anti-death effect was reversed by genetic complementation, exogenous cAMP, or a Crp variant that bypasses cAMP binding for activation. Moreover, mutations in the same genes were obtained when screening was performed using multiple challenges with antimicrobials rather than with phenol. Downstream events that were blocked by the mutations included a metabolic shift from the TCA cycle to glycolysis and the pentose phosphate pathway, suppression of stress-mediated ATP surges, and reduced accumulation of ROS. Thus, the tolerance genes showed that upstream signals from diverse stress-mediated lesions stimulate shared, late-stage, ROS-mediated events that damage macromolecules. Cultures of these stable, pan-tolerant mutants grew normally and were therefore distinct from tolerance derived from growth defects (described below).Characterization of the mutants revealed genes involved in carbohydrate metabolism . In partPhenol, alcohol, and chlorhexidine are commonly used disinfectants. Thus, pan-tolerance leads to the idea that massive, unrestricted disinfectant use could contribute to antibiotic tolerance and eventually resistance. The recent surge in disinfectant use due to the COVID-19 pandemic may provide retrospective evidence that disinfectant consumption contributes to tolerance and ultimately resistance. Particularly insidious is the possibility that pan-tolerance weakens host defenses − the lethal activity of three agents used by the immune system  is reduced by pan-tolerance. Since tolerance can arise as single-gene mutations, it may be more common than we realize: tolerance could threaten the widespread use of disinfectants.S. aureus  exposure is to decrease it  while its combination with isoniazid more dramatically lowers dissolved O2 (from 80% to 40% in 300 seconds)  . Isoniazre media . These ore media . Howeverre media  and patire media .in vivo labelling study with mice indicates that NAC uptake and deacetylation may not be adequate to maintain the cellular pool of cysteine and the downstream production of glutathione, an antioxidant that would protect from stress-mediated lethality. Instead of being an active source of cysteine, NAC is readily desulfurated to produce hydrogen sulfide (H2S)  . H2S is piration . It is pM. tuberculosis to the spleen, perhaps due to a protective effect of NAC on lung vasculature and reduction of lesion necrosis (both lesion necrosis and loss of vascular integrity are important for extra-pulmonary dissemination of M. tuberculosis)  increasing the production of the cytokines interleukin-2 (IL-2), interleukin-12 (IL-12), and interferon-gamma (IFN-γ), 2) decreasing other interleukins  and tumor necrosis factor alpha (TNF-α), and 3) elevating host glutathione and S-nitrosoglutathione levels . The netculosis) .M. tuberculosis. In one study, the safety profile of the combination was similar to that of ATT alone , increased smear conversion from 58% to almost 96% after three weeks of treatment . RadioloTT alone . These rM. tuberculosis , we found that moxifloxacin treatment of THP-1 macrophages, infected with Mtb-roGFP2, oxidizes the biosensor. Supplementation with non-toxic concentrations of NAC (1 mM to 2 mM) increased biosensor oxidation more than moxifloxacin alone, and a combination of moxifloxacin + NAC increased the level of oxidative stress by 2-fold beyond that observed for moxifloxacin alone , the moxifloxacin + NAC combination reduced bacterial burden by 4- and 12-fold more than moxifloxacin alone for lung and spleen, respectively. NAC alone had no effect on lung and spleen bacillary load .M. tuberculosis, as expected for induction of resistance by the quinolones   . TherefoM. tuberculosis cultures treated with each of the combinations from 5-10 days to only 3-7 days (NAC reduces treatment time: when combined with two first-line (isoniazid + rifampicin) or three second-line anti-TB drugs (ofloxacin + kanamycin + ethionamide or with moxifloxacin + amikacin + clofazimine), NAC reduced the time necessary to sterilize 3-7 days . Thus, NWe noticed that the influence of NAC on moxifloxacin lethality differs from its effect on isoniazid and rifampicin when cells are cultured in synthetic medium. For example, with moxifloxacin the killing effect of NAC was evident at days 1 to 2 post-treatment : with isS. aureus where interference of ROS accumulation (treatment with bipyridyl plus thiourea) delayed killing by moxifloxacin (15 x MIC) for about 60 min and elevated survival by 20-fold after 120 min without an effect on minimal bactericidal concentration (MBC), a measurement involving a long incubation time , a derivative of NAC having higher bioavailability . This aginations . NeverthMany fluoroquinolone-related questions remain unanswered. For example, what is the prevalence of tolerance and is it a major cause of relapse? Measuring tolerance on a large scale is labor intensive (MIC plus kill curves); thus, it is not readily implemented by clinical laboratories. A bigger question that extends beyond tuberculosis is whether our massive use of disinfectants is applying sufficient selective pressure for widespread emergence of tolerance and subsequently even more resistance.All authors listed have made a substantial, direct, and intellectual contribution to the work, and each approved it for publication.The authors’ work has been supported by the Wellcome Trust/DBT India Alliance Grants, IA/S/16/2/502700 (AS); Department of Biotechnology (DBT) Grants ; the Revati and Satya Nadham Atluri Chair Professorship (AS), and the National Natural Science Foundation of China .We thank Bo Shopsin for critical comments on the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationship that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Bacillus thuringiensis (Bt), numerous field experiments have been conducted worldwide. Field data are often variable and influenced by uncontrolled factors and meta-analyses can recognize general effects with increased statistical power compared to individual studies. This database represents a comprehensive collection of experimental field data on non-target invertebrates in Bt and non-Bt maize. It was created for a systematic review with the question if growing Bt maize changes abundance or ecological function of non-target animals compared to growing of non-GM maize. Systematic literature searches identified relevant data. Authors were contacted for additional information or raw data if needed and a critical appraisal scheme was developed and applied to each data record.To assess potential non-target effects of genetically engineered/modified (GM) maize that produces insecticidal proteins from The database contains 7279 records of non-target invertebrate abundance, activity density, or predation or parasitism extracted from 120 articles. Records for individual species and life stages, but also aggregated data are available. Each record represents a comparison of invertebrates in Bt and non-Bt maize and includes means, standard deviations and sample sizes. Additional variables characterize publication details, experimental setup, cultivars, Bt proteins, geographic location, field management, insecticide treatments, sampling details, and taxonomy. Bacillus thuringiensis (Bt) compared with non-Bt maize, numerous field experiments have been conducted worldwide over the past 25 years. Field data are often variable and influenced by numerous uncontrolled factors. Meta-analyses have the potential to increase statistical power compared with individual studies, so that general effects over multiple years and locations can be identified. The body of literature has been growing rapidly and a comprehensive, publicly available, and up-to-date database on non-target field data is lacking. The database presented here builds on previous meta-analyses on non-target invertebrate field studies with Bt crops [To assess potential non-target effects of genetically engineered/modified (GM) maize that produces insecticidal proteins from Bt crops –3. It waBt crops , 5 The rBt crops . It is lBt crops . LiteratThe database contains records of non-target invertebrates collected within Bt and non-Bt maize fields or plots . In some experiments multiple Bt maize lines were compared to the same non-Bt control. In those cases, the database contains separate records for each Bt line while the data for the non-Bt line are used repeatedly.Critical appraisal was applied to each record in the database (Table The database contains 7279 records from 233 experiments and 120 articles (Table For some experiments that were identified in the systematic literature search, data suitable for inclusion into the database could not be obtained, despite the effort of contacting authors . Data no


Hypoxia and ischemia cause inflammatory injury and critically participate in the pathogenesis of various diseases in various organs. However, the protective strategies against hypoxic and ischemic insults are very limited in clinical settings up to date. It is of utmost importance to improve our understanding of hypoxic/ischemic (H/I) inflammation and find novel therapies for better prevention/treatment of H/I injury. Recent studies provide strong evidence that the expression of microRNAs (miRNAs), which regulate gene expression and affect H/I inflammation through post-transcriptional mechanisms, are differentially altered in response to H/I stress, while δ-opioid receptors (DOR) play a protective role against H/I insults in different organs, including both H/I-sensitive organs  and H/I-insensitive organs . Indeed, many studies have demonstrated the crucial role of the DOR-mediated cyto-protection against H/I injury by several molecular pathways, including NLRP3 inflammasome modulated by miRNAs. In this review, we summarize our recent studies along with those of others worldwide, and compare the effects of DOR on H/I expression of miRNAs in H/I-sensitive and -insensitive organs. The alternation in miRNA expression profiles upon DOR activation and the potential impact on inflammatory injury in different organs under normoxic and hypoxic conditions are discussed at molecular and cellular levels. More in-depth investigations into this field may provide novel clues for new protective strategies against H/I inflammation in different types of organs. MicroRNAs (miRNAs) are a class of 21∼25-ribonucleotide single-strand non-coding RNA molecules which is endogenously expressed in eukaryote cells . It has Hypoxic/ischemic injury is a process in which blood flow cessation and oxygen deprivation occur in the body, organs, or cells. Metabolic waste products are accumulated due to the starvation of oxygen and nutrients, leading to profound tissue dysfunction and damage . More spBecause of energy imbalance, H/I insult induces pro-inflammatory events including microglia activation, cytokines production, and immune cell development via various biological processes such as apoptosis and oxidative reaction . DiffereOpioid receptors belong to the large family of seven-transmembrane G protein-coupled receptors with three major sub-types known as MOR, KOR, and DOR . It is wIn this review, we highlight some of the recent updates about the effects of H/I and DOR activation on miRNA expression in the current literature, along with our recent work in this field. In particular, we intend to summarize and compare differential regulation of miRNA expression in different organs and discuss potential clinical significances in terms of specific DOR treatment against H/I inflammation.Although blood flow to the kidney accounts for 20% of the cardiac output, the kidney is vulnerable to H/I injury because of the renal vascular anatomy and the high energy consumption of renal tubular epithelial cells . H/I-indHeart is a H/I-sensitive organ with active metabolism. H/I-induced myocardial injury is closely associated with cardiac disorders such as myocardial infarction and heart failure . MicroRNHypoxic and/or ischemic injuries are well-documented entities in the pathogenesis of cerebrovascular diseases such as stroke. The effects of H/I on miRNAs in the brain have been widely investigated in patients as well as animal ischemic models with middle cerebral artery occlusion (MCAO). Our previous reviews have summarized the regulation of brain miRNAs in response to hypoxic and ischemic conditions  and theiAlthough liver is regarded as one of the hypoxia-insensitive organs, oxygen is also important for liver function maintenance. The insufficiency or deprivation of oxygen and blood flow in hepatic microenvironment due to respiratory/circulatory disorders leads to hepatocellular damage. Indeed, hypoxia activates multiple hypoxia mediators and in turn accelerate or antagonize hepatic damage , such asMultiple studies have illustrated the H/I injury-induced miRNA changes in liver inflammation, hepatocellular oxidative stress and apoptosis. Meanwhile, altered miRNAs are closely associated with hypoxia-induced HCC pathogenesis by modulating HCC cell angiogenesis, viability and metastasis . For exain vitro studies, pulmonary artery smooth muscle cells (PASMCs) have been used to investigate H/I-induced muscle miRNA alternations. An H/I down-regulation of miR-98 was observed to modulate inflammation and PASMC apoptosis by directly targeting pro-inflammatory cytokine IL6 , including miR-347, miR-101b, miR-466b, miR-29a, miR-363*, and miR-31 . The majδ-Opioid receptor activation can also modify hypoxia-induced changes of miRNA expression in the kidney. The changes in several miRNAs could be detected upon DOR activation in the kidney exposed to a continuous hypoxia for a prolonged period. For instance, the down-regulation of miR-511 and miR-298 expression was observed upon DOR activation followed by a continuous exposure to hypoxia for 5 to 10 days . In the Unlike other hypoxia-sensitive organs, the majority of altered miRNAs in the heart was up-regulated under 1 day hypoxia. The administration of UFP-512 to the hypoxic heart induced a further upregulation in terms of the expression of miR-141-3p, miR-376a-3p and miR-134-5p. Moreover, the expression of miR-134-5p and miR-7b was increased throughout the entire time course after DOR activation under hypoxia, suggesting their important roles in the regulation of renal adaptation to hypoxic stress .in vivo and hypoxia/reoxygenation injury in vitro by directly suppressing IRAK1 and TRAF6 in the liver . After prolonged hypoxia (10 days), the expression of some miRNAs turned back to the baseline level. There is evidence suggesting that a mild/moderate H/I stress may induce pro-inflammatory cytokine release and causes a quick inflammatory response, whereas a severe/prolonged stress eventually causes cell apoptosis and necrosis . The difAlthough various miRNAs can exhibit very different responses even in the same organ under similar H/I condition, there are several H/I sensitive miRNAs that display common changes among different organs. These miRNAs were named “hypoxamiRs,” including miR-21, miR-210, and miR-199a . AccumulAging is a key factor affecting H/I inflammation and miRNA expression. In contrast to the immature and young organs, the aged ones are more sensitive to H/I stress. The oxygen-deprived conditions (hypoxia and ischemia) lead to oxidative stress, cellular damage and protein modifications . H/I infin vitro and in vivo. A recent study showed that miR-363-3p treatment attenuates brain ischemia-induced long-term cognitive deficits in rats (The miRNA expression can be modulated by sequence-specific miRNA mimics (or agomirs) and inhibitors (or antagomirs), both  in rats , suggestThe information in this review suggests that DOR activation is effective in protecting organs against H/I injury, with the capability of modulating miRNAome in both normoxic and hypoxic conditions. Although the direct regulatory mode of DOR on miRNA expression is still unknown, DOR signaling may affect miRNA biogenesis by modulating some key transcriptional factors. For instance, ERK is found to suppress pre-miRNA export from the nucleus to cytoplasm through phosphorylation of Exportin-5, resulting in a global reduction of pre-miRNA loading and miRNA synthesis . Since EDifferent kinds of DOR agonists have been developed in the past. Many of them displayed analgesic, antidepressant, anxiolytic and other opioid effects. For instance, Deltorphin I is an opioid peptide with relatively high affinity and selectivity to DOR and produce centrally mediated analgesic effects in animals . AnotherIn summary, it is possible to develop a new protective strategy against H/I injury by activating DOR signaling and targeting certain miRNAs to suppress H/I inflammation in both hypoxia/ischemia-sensitive and -insensitive organs. However, controversies and ambiguity still persist in the literature, especially regarding the up-regulation versus down-regulation of miRNAs under different conditions and their downstream targets in the different organs. Moreover, the molecular mechanisms involved in the DOR-mediated regulation of miRNAs are largely unknown at present. The controversies may be partially attributed to the differences in the models, species, and experimental approaches among different studies. Nevertheless, the solution of the above-mentioned fundamental issues depends on more reliable and in-depth studies in future.YX initiated the project and made the outline. YC searched the literature and prepare the manuscript. YH, SZ, and XH participated in writing the manuscript. YX and DX supervised the project and revised the manuscript. All authors contributed to the article and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


There are no randomized control trials (RCTs) comparing gemcitabine and nab-paclitaxel (Gem-Nab) and fluorouracil, folinic acid, irinotecan, oxaliplatin (FOLFIRINOX) for advanced pancreatic cancer (APC). Although it is well known that RCT-based efficacy often does not translate to real-world effectiveness, there is limited literature investigating comparative cost-effectiveness of Gem-Nab vs FOLFIRINOX for APC. We aimed to examine the real-world cost-effectiveness of Gem-Nab vs FOLFIRINOX for APC in Ontario, Canada.This study compared patients treated with first-line Gem-Nab or FOLFIRINOX for APC in Ontario from April 2015 to March 2019. Patients were linked to administrative databases. Using propensity scores and a stabilizing weights method, an inverse probability of treatment weighted cohort was developed. Mean survival and total costs were calculated over a 5-year time horizon, adjusted for censoring, and discounted at 1.5%. Incremental cost-effectiveness ratio and net monetary benefit were computed to estimate cost-effectiveness from the public health-care payer’s perspective. Sensitivity analysis was conducted using the propensity score matching method.A total of 1988 patients were identified . Mean survival was lower for patients in the Gem-Nab than the FOLFIRINOX group . Patients in the Gem-Nab group incurred greater mean 5-year total costs . Key cost contributors include ambulatory cancer care, acute inpatient hospitalization, and systemic therapy drug acquisition. Gem-Nab was dominated by FOLFIRINOX, as it was less effective and more costly. Results from the sensitivity analysis were similar.Gem-Nab is likely more costly and less effective than FOLFIRINOX and therefore not considered cost-effective at commonly accepted willingness-to-pay thresholds. Globally, the cost of cancer care is increasing, largely given the rise in cost of anticancer drugs . In 2015Gem-Nab was publicly funded as first-line treatment for APC in Ontario, Canada, in April 2015, and FOLFIRINOX in November 2011 . RecommeP = .001)  . This an = .001) .Drug funding decisions are typically informed by RCTs , howeverUsing routinely collected health-care data from Ontario, Canada (population 14 million), a population-based retrospective cohort study was conducted. Research ethics approval was obtained from Sunnybrook Health Sciences Centre research ethics board .Data collection and analysis was conducted by ICES , an independent, nonprofit research institute funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. As a prescribed entity under Ontario’s privacy legislation, ICES is authorized to collect and use health-care data for the purposes of health system analysis, evaluation, and decision support. Secure access to these data is governed by policies and procedures that are approved by the Information and Privacy Commissioner of Ontario. To mitigate any risk for re-identification, small cell counts (<6 patients) are repressed herein.Patients aged 18 years and older prescribed first-line gemcitabine, nab-paclitaxel, irinotecan, or oxaliplatin for APC between April 17, 2015, and March 31, 2019, were identified through Cancer Care Ontario’s New Drug Funding Program (NDFP) database. NDFP reimburses hospitals for intravenous cancer drugs administered according to clinical criteria. Patients who received Gem-Nab or FOLFIRINOX were eligible for inclusion. Patients who received treatment at least 60 days before their date of cancer diagnosis (recorded in the registry), died prior to their index date (date of treatment initiation), or were not an Ontario resident at the time of diagnosis were excluded. Patients were also excluded if they were missing an income quintile, rurality status, extent of disease , or had an Eastern Cooperative Oncology Group performance status (ECOG PS) of at least 2 or missing. Included patients were then linked to the Ontario Cancer Registry where diagnosis of APC was confirmed using the site code C-25 from the International Classification of Diseases for Oncology (third edition). Patients were followed until March 31, 2020.Patient characteristics were collected from linked administrative databases. Datasets were linked using unique encoded identifiers and analyzed at ICES. Patients were identified across databases using their Ontario Health Insurance Plan number. Demographic characteristics were obtained from the Registered Persons Database. Using postal codes from the Postal Code Conversion File and 2016 Census [Statistics Canada ], neighbBaseline covariates included as variables in the propensity score calculation (logistic regression) included age, sex, prior cancer diagnosis, Charlson-Deyo comorbidity index, total ACG score , health region , income quintile, rurality, time from pancreatic cancer diagnosis, prior pancreatic surgery, prior pancreatic radiation, adjuvant chemotherapy , extent of disease , ECOG PS, and index year. Using propensity scores and a stabilizing weights method ,16, an iThe use of an IPTW cohort was elected to be used for the primary analysis as it provides insight into the average treatment effect among the cohort ,18. As wCosting data was retrieved from linked administrative databases .Treatment effectiveness was measured using life years (LYs) and QALYs. Survival was calculated for each patient from index date to death or to final date of follow-up (maximum 5 years from index). In instances where patients were alive, but without 5-year follow-up from index, they were censored at the last date of follow-up. QALYs were calculated by adjusting 5-year survival with published health utility weights; 0.8 for preprogression (on treatment) and 0.73 for postprogression  to align with existing literature and previously evaluated models ,20-23. TFive-year total costs were estimated for each patient from the public health-care payer perspective [via costing macro from ICES ]. Given ICER and incremental net monetary benefit (INMB) were computed to estimate cost-effectiveness. ICER was calculated as incremental cost divided by the incremental effectiveness. 95% confidence intervals of ICERs were estimated using nonparametric bootstrapping with 1000 samples.INMB was computed using various willingness-to-pay (WTP) thresholds with consideration of total cost and survival by calculating effectiveness for each patient. Net benefit regression was conducted using a linear regression model for INMB (regressed on the treatment variable of Gem-Nab vs FOLFIRINOX) at WTP thresholds beginning at $50 000 per LY and QALY to obtain point estimates and 95% confidence intervals for INMB. A positive INMB suggests that Gem-Nab is more cost-effective than FOLFIRINOX at the respective WTP threshold.Sensitivity analysis was conducted using a PSM cohort. Propensity scores were used to match groups 1:1, with a caliper width of 0.2 standard deviations .Overall, 2498 patients were originally identified. Patients were excluded for receiving gemcitabine alone (n = 300), missing key demographic data, and/or having an ECOG PS of at least 2 (n = 210). Therefore, 1988 patients  were eligible for inclusion in the IPTW cohort .Mean age of patients was 65.7 and 64.8 years for Gem-Nab and FOLFIRINOX, respectively. In the Gem-Nab group, 42.3% of patients were female and 42.7% within the FOLFIRINOX group. All key characteristics were balanced between groups .Mean treatment effectiveness was lower for patients in the Gem-Nab group than the FOLFIRINOX group . Mean incremental effectiveness between Gem-Nab and FOLFIRINOX was −0.28 (95% CI = −0.47 to −0.13) LYs . When acGem-Nab was associated with a greater mean total cost than FOLFIRINOX . Mean incremental cost difference was $2366 (95% CI = −$8851 to $12 200) .Gem-Nab was dominated by FOLFIRINOX . All booAcross all WTP thresholds, the INMB per patient for Gem-Nab  was negative when compared with FOLFIRINOX  were included in the PSM cohort , and mean effectiveness was less . Therefore, Gem-Nab was dominated by FOLFIRINOX. Across all WTP thresholds, the INMB per patient was negative for Gem-Nab when compared with FOLFIRINOX . Gem-Nab was also associated with a higher mean total cost . Gem-Nab was dominated by FOLFIRINOX in the base case and sensitivity analysis.A recent Canadian cost-effectiveness analysis  conducteExisting literature offers a wide range of results when attempting to quantify the cost-effectiveness of Gem-Nab vs FOLFIRINOX. Economic review by CADTH pCODR and NICE both cite uncertainty in evaluation given the lack of robust direct comparisons ,10, howeIn Canada, the period of data protection for oxaliplatin (component of FOLFIRINOX) ended in 2015 , allowinTo our knowledge, this analysis is the first to use RWE to evaluate the cost-effectiveness of Gem-Nab vs FOLFIRINOX. The use of RWE is an inherent strength, as our results are population based, use individual patient data, and include all patients who are clinically eligible for treatment with Gem-Nab and FOLFIRINOX. Our analysis includes a broad range of cost components, potentially beyond what would be included in model-based analyses, including costs associated with management of serious adverse events, without needing assumptions. Additionally, this analysis applied robust statistical techniques to adjust for differences between groups and address censoring. Typically, drug funding decisions are based on clinical benefit reported in RCTs and model-based economic estimations of drug value . HoweverBecause of the nonrandomized nature of the study design, there is inherent risk of confounding by indication. Using propensity scores to generate IPTW and PSM cohorts, groups were balanced on measured characteristics. Nonetheless, there may be risk of additional unmeasured variables that may contribute to residual confounding, such as symptom burden , surgicaOur results suggest that for patients with APC with an ECOG PS of 0-1, Gem-Nab is dominated by FOLFIRINOX. Base-case analysis suggests that Gem-Nab offers a smaller survival benefit and is likely to be slightly more costly than FOLFIRINOX. Existing model-based cost-effectiveness analyses report a wide range of findings; however, our results are in line with the general conclusions drawn by pCODR and NICE. FOLFIRINOX appears to be superior in providing survival benefits at a lower cost, but there is also likely a subset of Gem-Nab patients for whom may not be suitable to receive FOLFIRINOX (such as those with an ECOG PS ≥2). Overall, as the landscape of oncology therapeutics continues to rapidly evolve, treatment and drug funding decisions will remain challenging. Therefore, reevaluation of cost-effectiveness using RWE is valuable in reassessing and revising existing drug funding decisions initially based on RCT and model-derived evidence.This work was supported by the Canadian Institutes of Health Research (Grant #HRC-154126).Role of thefunder: The funder had no role in design of the study; the collection, analysis, and interpretation of the data; the writing of the manuscript; or the decision to submit the manuscript for publication.Disclosures: No authors have actual or perceived conflicts of interest to disclose.Authorcontributions: Conceptualization: JMB, WI, KWWC; Data Curation: JL; Formal Analysis: JL; Funding Acquisition: KKWC; Investigation: All named authors; Methodology: WI, JMB, JL, WFD, KKWC; Project Administration: VA, JL, KKWC; Resources: JL, KKWC; Supervision: KKWC; Validation: JL; Visualization: VA, JL; Writing—Original Draft: VA, KKWC; Writing—Review & Editing: All named authors.Acknowledgements: ICES is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. The Canadian Centre for Applied Research in Cancer Control (ARCC) is funded by the Canadian Cancer Society Grant #2020-706936. Parts of this material are based on data and information compiled and provided by Cancer Care Ontario, Ontario’s Ministry of Health and Long-Term Care, and Canadian Institutes for Health Information. Parts of this material are based on data and information provided by Ontario Health (OH). The opinions, results, view, and conclusions reported in this paper are those of the authors and do not necessarily reflect those of OH. No endorsement by OH is intended or should be inferred. Postal Code Conversion File (PCCF), Reference Guide, 2016 Census and Statistics Canada 2019 Consumer Price Index data were adapted from Statistics Canada. This does not constitute an endorsement by Statistics Canada of this product. We thank IQVIA Solutions Canada Inc for use of their Drug Information File. Authors would like to acknowledge the contributions of Erind Dvorani.Disclaimers: The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.Prior presentations: This work was previously presented, in part, at the 2022 American Society of Clinical Oncology (ASCO) Gastrointestinal Cancers Symposium and 2022 Canadian Centre for Applied Research in Cancer Control Conference.pkac047_Supplementary_DataClick here for additional data file.


The prognostic value of the tumor burden score (TBS) in patients with combined hepatocellular-cholangiocarcinoma (cHCC-CCA) remains unknown. This study aimed to investigate the impact of TBS on long-term outcomes after surgery.Patients who underwent radical-intent resection between June 2013 and December 2019 were retrospectively reviewed. Kaplan–Meier curves were used to analyze patient survival, and disease-free survival (DFS) and overall survival (OS) were examined in relation to TBS.A total of 178 patients were included in this study, with 119 in the training cohort and 59 in the validation cohort. Kaplan–Meier curves showed that TBS was a strong prognostic indicator in patients with cHCC-CCA. Elevated TBS was associated with poorer DFS and OS  and was identified as an independent prognostic indicator. In addition, the prognostic value of TBS outperformed tumor size and number alone, microvascular invasion, and lymph node invasion. The prognostic significance of TBS was confirmed by the internal validation cohort.The present study suggested the significance of tumor morphology in assessing the prognosis of patients with cHCC-CCA who undergoing curative resection. The TBS is a promising prognostic index in patients with cHCC-CCA. Elevated TBS was related to a lower long-term survival rate and was identified as an independent risk factor for poor DFS and OS. Further research is needed to verify our results. Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare subtype that accounts for less than 5% of all primary liver cancers . HistoloConventionally, the tumor-node-metastasis staging system is applied for the prognostic classification of patients with solid malignancies , 6. To dRecently, a new metric called “tumor burden score (TBS)”, calculated on the basis of tumor size and tumor number, was proposed for risk stratification in multifocal tumors . EmerginThis study was approved by the Ethics Committees of the relevant institutions and was performed in accordance with the Declaration of Helsinki . SurgicaTumor markers and contrast-enhanced ultrasonography were performed every month for the first 3 months following surgery, then every 3 months for 1 year, and every half year thereafter. For patients who opted not to go back to the hospital for re-examination, a telephone follow-up survey was carried out. The patients were followed until December 2021 or death. OS was calculated from the date of hepatic resection to the date of the last follow-up or death. In contrast, disease-free survival (DFS) was defined as the interval between the date of hepatic resection and the earliest evidence of recurrence or last follow-up.2 = (maximum tumor diameter)2 + (lesion number)2. The maximum tumor diameter and lesion number were obtained from preoperative contrast-enhanced CT scan examination and confirmed by the final pathological report. The optimal cutoff value of TBS was determined by X-tile   . PatientVariables were presented as frequency (%), and continuous variables were compared using the student’s t-test or Wilcoxon rank sum test. Categorical variables were analyzed by the chi-square or Fisher’s exact test, as appropriate. Bivariate survival analyses were performed using Kaplan–Meier curves, and their differences were tested by log-rank test. Cox proportional hazard models (enter method) were employed to assess the potential independent prognostic risk factors and to present adjusted hazard ratio. Variables that were statistically significant in univariate analyses  were entered into multivariate analyses. Adjusted hazard ratios identified by multivariate analyses exhibited risk ratios for tumor relapse or death. However, tumor size and tumor number were excluded from multivariate analyses to avoid collinearity bias . The areA total of 203 patients who underwent hepatic resection with curative intent between January 2012 and December 2019 were pathologically diagnosed as cHCC-CCA. Among them, 11 patients were associated with recurrent tumors, five patients with positive surgical margins, seven patients with local organ invasion, and two patients had incomplete clinical data. Finally, 178 patients  were included in the present analysis , as shown in The optimal cutoff value of TBS was identified as 5.2 after calculating by using the X-tile  patients received neoadjuvant therapy, and 52 (29.2%) patients were treated with adjuvant chemotherapy. As displayed in As shown in In the internal validation cohort, patients with solitary tumors were associated with better OS and similar DFS compared with those with multiple tumors. Patients in the low-TBS group were associated with better prognoses. Consistently, Cox regression models identified high TBS as an independent prognostic indicator for poor OS and DFS  staging system in the seventh edition of the AJCC staging manual , in whicTBS was defined as the distance from the origin of a Cartesian plane using maximum tumor size as the X-axis and tumor number as the Y-axis . As prevThe following limitations should be considered when interpreting our results. First, this was a retrospective study with a limited number of cases, which might involve selection bias or unmeasured confounding factors. Second, although the cutoff value for TBS was validated by our internal validation cohort, its applicability to overseas patient populations remains unknown. In addition, as only surgically treated patients with cHCC-CCA  were included in the analyses, the results are only applicable to patients who undergoing curative resection.In conclusion, this study suggests the significance of tumor morphology in assessing the prognosis of patients with cHCC-CCA who undergoing curative resection. The TBS, based on the maximum tumor diameter and lesion number, is a promising index in the prognostic evaluation of patients with cHCC-CCA. Elevated TBS was associated with worse long-term survival and was identified as an independent risk factor for poor DFS and OS. Nevertheless, these results should be verified by further studies.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Seven Affiliated Hospital of Sun Yat-sen University. The patients/participants provided their written informed consent to participate in this study.Conceptualization: GD, TZ, and DT. Data curation: GD, Z-BC, and Y-WF. Formal analysis: GD, J-KR, and Y-JT. Supervision: TZ and DT. Writing—original draft: GD, J-KR, and H-TW. All the authors approved the final version of manuscript.


Whether short-term, low-potency opioid prescriptions for acute pain lead to future at-risk opioid use remains controversial and inadequately characterized. Our objective was to measure the association between emergency department (ED) opioid analgesic exposure after a physical, trauma-related event and subsequent opioid use. We hypothesized ED opioid analgesic exposure is associated with subsequent at-risk opioid use.Participants were enrolled in AURORA, a prospective cohort study of adult patients in 29 U.S., urban EDs receiving care for a traumatic event. Exclusion criteria were hospital admission, persons reporting any non-medical opioid use  in the 30 days before enrollment, and missing or incomplete data regarding opioid exposure or pain. We used multivariable logistic regression to assess the relationship between ED opioid exposure and at-risk opioid use, defined as any self-reported non-medical opioid use after initial ED encounter or prescription opioid use at 3-months.Of 1441 subjects completing 3-month follow-up, 872 participants were included for analysis. At-risk opioid use occurred within 3 months in 33/620  participants without ED opioid analgesic exposure; 4/16  with ED opioid prescription only; 17/146  with ED opioid administration only; 12/90  with both. Controlling for clinical factors, adjusted odds ratios (aORs) for at-risk opioid use after ED opioid exposure were: ED prescription only: 4.9 ; ED administration for analgesia only: 2.0 ; both: 2.8 .ED opioids were associated with subsequent at-risk opioid use within three months in a geographically diverse cohort of adult trauma patients. This supports need for prospective studies focused on the long-term consequences of ED opioid analgesic exposure to estimate individual risk and guide therapeutic decision-making. The opioid crisis continues despite substantial efforts to date , 2. OpioEmergency departments (EDs) commonly encounter patients in pain –20, and Our objective was to use existing data from a multi-center, prospective, observational study of posttraumatic neuropsychiatric sequelae to evaluate the degree to which an analgesic opioid exposure in the ED contributes to at-risk opioid use. We hypothesized that opioid exposure during the initial ED encounter for a traumatic event would be associated with at-risk opioid use within three months.Advancing Understanding of RecOvery afteR traumA) study. AURORA collected a wide array of psychological and biobehavioral data from adult patients recruited from a geographically diverse sample of 29 urban, U.S. emergency departments (EDs) who presented within 72 hours of a physical trauma [This study was a secondary analysis of data collected during the AURORA  any non-medical opioid use after the initial ED visit , or 2) opioid prescription use at 3-month follow-up. Non-medical opioid use was defined by affirmative response to the survey question “heroin, any opioids without a prescription, or taking more than prescribed for euphoria” , 36 ThisExposure was measured as opioid administration for analgesia only during the ED visit, a prescription for opioids at ED discharge, or both at study enrollment. Covariates included self-reported patient gender, sex at birth, age, race/ethnicity, pain score at baseline and at 3-month follow-up, prescription opioid use in the 30 days prior to enrollment, marital status, employment status, income, injury severity score at baseline, and self-reported history of opioid use disorder.Descriptive statistics were used to summarize and assess participant selection characteristics. Summary data are reported as percentages, percentages with 95% confidence intervals (CI), medians with interquartile range (IQR), and means with 95% CI. Crude (unadjusted) odds ratios (cORs) and adjusted ORs (aORs) are presented with 95% CI to assess statistical significance.We first conducted univariable analyses to quantify the association between at-risk opioid use and ED opioid exposure , as well as a wide array of potential confounders of this association and possible risk factors for at-risk opioid use leveraging literature and expert opinion , 40, 41.There were 1441 patients available for analysis in the AURORA 3-month follow-up cohort, and subsequent exclusion criteria are outlined in Of 872 subjects included in the primary analysis, at-risk opioid use was reported by 66 (7.6%) individuals by the 3-month follow-up. In comparison to type of ED opioid exposure, at-risk opioid use was reported by: 33/620  without an ED opioid analgesic exposure, 4/16  with ED opioid prescription only, 17/146  with in-ED opioid administration only, and 12/90  with both ED administration and opioid prescription at discharge .Compared to no ED opioid exposure, the aOR for at-risk opioid use was 4.9  for ED opioid prescription only, 2.0  for ED administered opioids only, and 2.8  for both ED opioid administration and prescription at discharge, when controlling for patient age, prescription opioid use prior to enrollment, pain at initial ED visit, moderate or severe pain at three months, race/ethnicity, marital status, injury severity score, and self-reported history of OUD . Other pExposure to opioids after a traumatic event was associated with increased at-risk opioid use within three months in a geographically diverse cohort of patients who experienced trauma. While the study was observational, data were collected prospectively, and the associations of prescription opioid exposure and at-risk opioid use persisted after controlling for patient and clinical factors. Not surprisingly, ED opioid administration and prescribing was relatively common for these trauma patients, with 12% receiving an opioid prescription at ED discharge, and 29% receiving a prescription, in-ED administration, or both. These percentages equate to millions of exposures annually nationwide. Every year, approximately 35 million ED visits result from injury in the US, so even a small effect from prescription opioid exposure would have significant ramifications for individual and public health . If evenOur findings align with previous studies associating the strength and duration of initial opioid prescription with later use , 43, 44.When controlling for the effects of prior opioid exposure, opioid prescription in the 30 days prior to enrollment was associated with later at-risk opioid use . We do not know if this association was due to misclassification , a direct cause of increased risk, or a marker of pain or opioid response predisposing to at-risk use. It is easy to hypothesize that treatment for acute pain can be a causal event along the trajectory from initial exposure to later at-risk use even if not a triggering event when occurring as a first exposure.Even if short-term low-potency opioid exposure is causally associated with later long-term opioid use, or the development of OUD, it does not mean that initial opioid exposure is necessarily avoidable. All therapy in medicine is associated with potential risks and benefits, and the potential for later harm must be balanced against the potential for unrelieved short-term suffering. Prospective study of opioid exposure for acute pain is necessary so that patients and providers can accurately estimate individualized risk to guide therapeutic decision-making. It is important to realize that scientific developments in this area could simultaneously support both expansions and reductions in opioid therapy depending on the individual patient and the circumstance.While this study capitalized on the availability of a prospective, multicenter cohort, results should be understood in context with important limitations. Most notably, the generalizability of this analysis was limited to measures and sample size available from the parent study which was not specifically designed to assess opioid exposure or long-term opioid use. Bias may have been introduced by our exclusion of a large number of participants with missing follow-up data and well as the voluntary aspect of research participation. These exclusions may limit the number of individuals with later at-risk opioid use due to stigma and the self-reported nature of the survey follow-up. Additionally, due to sample size limitations, we used a composite outcome that did not fully resolve limitations of prior studies in which the reasons for later prescription opioid use are uncharacterized. Our ability to assess causality is additionally limited by its observational design. Finally, due to the categorical nature of of both prior opioid prescription use and later opioid use, we were unable to reduce time-based confounding in our model.Exposure to opioids from an ED visit was associated with increased odds of at-risk opioid use within three months among trauma patients when controlling for age, gender, race/ethnicity, prescription opioid use prior to enrollment, pain, injury severity score, and self-reported history of OUD. These results support the need for prospective study focused on the long-term consequences of ED opioid analgesic exposure to guide therapeutic decision-making.


The prevalence of frailty is increased among young adult childhood cancer survivors and is associated with early morbidity and mortality. The aim of our study was to analyze physical fitness, physical activity and the prevalence of frailty in male long-term survivors of pediatric allogeneic hematopoietic stem cell transplantation. We observed significantly lower muscle strength and muscle endurance in the hand-grip and sit-to-stand tests compared to the age and sex matched normative reference values of the tests. Furthermore, 30% of the survivors were considered pre-frail or frail. Chronic graft-versus-host disease, shorter stature, higher body fat mass and hazardous drinking predicted prefrail/frail status. Common cardiovascular risk factors were associated with poor physical fitness and low physical activity level. These results indicate a need for cardiometabolic follow up as well as health education in the decades following HSCT.Purpose and methods: To analyze physical fitness, physical activity and the prevalence of frailty in male long-term survivors of pediatric allogeneic hematopoietic stem cell transplantation (HSCT). We performed a Nordic two-center study of 98 male survivors  treated with pediatric allogeneic hematopoietic stem cell transplantation (HSCT) 1980–2010 in denmark or finland. physical fitness was evaluated by the dominant hand grip-strength, timed up-and-go, sit-to-stand, gait speed and two-minute walk tests. Results: Survivors presented significantly lower muscle strength and muscle endurance in the dominant hand-grip strength  and sit-to-stand tests  compared to age and sex matched normative values of the tests. However, mobility and gait speed were not affected on a group level. The prevalence of frailty (pre-frail 20% or frail 10%) was high among the survivors. In multiple regression analysis, chronic graft-versus-host disease, shorter stature, higher body fat mass and hazardous drinking predicted prefrail/frail status. Common cardiovascular risk factors, such as increased levels of serum triglycerides, higher resting heart rate and diastolic blood pressure, were associated with lower physical fitness. Conclusion: Low muscle strength and a high incidence of frailty were observed in survivors of pediatric HSCT. There is a predominant risk of cardiovascular and metabolic diseases in the long-term. Allogeneic hematopoietic stem cell transplantation (HSCT) as a therapy for numerous severe hematological disorders is increasing. The burden of treatment-related morbidities in the long term remains considerable . Nearly Several treatments affect late outcomes. Anthracyclines, a key component in several childhood cancer treatments, may cause cardiomyopathy ,2,4. TotFrailty is a phenotype generally described in the elderly . The fraIn this study, we investigated physical fitness, physical activity and frailty decades after pediatric allogeneic HSCT in a large population-based cohort of adult male long-term survivors.This study is part of a larger cross-sectional cohort study addressing long-term gonadal function, metabolism, physical fitness, sexual health and quality of life ,11,12,13Treatment characteristics were obtained from the medical records. Cyclophosphamide equivalent doses (CED) were calculated as described in Green et al. . CumulatAt the day of examination, the patients were screened for chronic-graft-versus-host disease (cGvHD) according to the National Institutes of Health criteria as described . TesticuSitting hand-grip strength (kg), with the forearm neutral and the elbow flexed 90 degrees, was measured using a Jamar dynamometer  twice with each hand. The highest value attained with the dominant hand was reported. Results were compared to age- and sex-specific normative reference values for grip strength .The patient was seated on a chair with their back against the chair back. A tape mark was placed on the floor three meters from the front edge of the chair. When timing started the patient walked to the tape, turned around, walked back to the chair and sat down with regular pace. Timing (s) ended when the patient was seated again. Results were compared to age- and sex-specific normative reference values .The patient was seated on a chair with their feet flat on the floor. The patient was to fully stand up and sit down as many times as possible in one minute in their own pace. Results were compared to age- and sex-specific normative reference values .A 4.6-m (15 feet) walking lane was marked on the floor. The patient walked at his regular pace along the walking lane, and the timing was stopped when the patient crossed the 4.6-m mark with both feet. Gait speed (m/s) was compared to age- and sex-specific normative values of four-meter gait speed in the NIH Toolbox Study .A 15.2-m walking lane was marked on the floor. The patient was asked to walk along the lane for two minutes as quickly as possible. The distance walked (m) was compared to age- and sex-specific normative reference values .Physical activity was assessed by The Global Physical Activity Questionnaire (GPAQ) developed by WHO . Total mThe phenotypes of frail and pre-frail, as originally defined by Fried et al. , were mo2) of less than 1.5 SD from the mean in the National Health and Nutrition Examination Study (NHANES) was classified as low lean muscle mass [Body composition was measured by dual-energy X-ray absorptiometry . Appendicular lean muscle mass  version 2.0 was used to classify exhaustion ,24. The For three patients one of the criteria was missing, and the frailty score was calculated based on four criteria.The Mann–Whitney U-test and Fisher’s exact test were used for statistical comparisons between groups. Test scores of physical fitness were transformed into Z-scores based on normative reference values  and Z-scores were used in all data analyses. Physical fitness was compared to expected Z-values with the One-sample Kolmogorov–Smirnov test.p-values < 0.05 were considered statistically significant. Analyses were performed using the IBM SPSS statistical software .Spearman correlation coefficient was used to study correlations between study outcomes  and transplant-related risk factors, clinical outcomes and laboratory assessments presented in Patient characteristics are presented in The survivors had undergone HSCT at a mean age of 9.8  years. Among participants, both hematologic malignancies (75%) and non-malignant diseases (25%) were included. At the time of the study, 28 (29%) patients presented with manifestations of cGvHD; 13 with mild, 12 with moderate and three with severe cGvHD. Three patients were treated with systemic immunosuppressive medication.The measures of the dominant hand-grip muscle strength and sit-to-stand tests were significantly reduced in the HSCT patients compared to the normative reference values of the tests . On the s −0.223, p = 0.028) and two-minute walk tests . Longer follow-up time since HSCT was correlated with several domains of poorer physical fitness . Similarly, older age at examination was correlated with poorer performance .Of transplant related factors, a higher CNS irradiation dose correlated with lower performance in the dominant hand-grip strength  and gait speed . Survivors on testosterone substitution had reduced test results in dominant hand-grip strength , gait speed  and two-minute walk tests . Similarly, survivors on antihypertensive medication had reduced results in the two-minute walk test . In addition, current smokers had decreased performance in the two-minute walk test .Of the clinical outcomes, cGvHD was correlated with poorer performance in dominant hand-grip muscle strength , gait speed , and the two-minute walk test . Decreased physical fitness in the two-minute walk test was correlated with several cardiovascular risk factors including increased levels of serum triglycerides , higher resting heart rate , diastolic blood pressure  and higher glycosylated hemoglobin A1c . Lower performance in the sit-to-stand test was also associated with a higher resting heart rate . Furthermore, higher fat mass percentage and lower lean mass were correlated with poorer dominant hand-grip muscle strength , two-minute walk test  and sit-to-stand test . Survivors with low energy expenditure (MET-minutes <600) had a reduced score in the two-minute walk test .Of the clinical assessments, height and testicular volume were positively correlated with dominant hand-grip strength . None of the clinical outcomes were significantly correlated with self-reported physical activity. Of the laboratory assessments, decreased levels of serum triglycerides , lower fat mass percentage  and higher high-density lipoprotein  were correlated with higher physical activity.Self-reported physical activity, measured as MET-minutes per week, was not related to previously received treatment regimens. Likewise, follow-up time since HSCT was not associated with physical activity, but younger survivors reported higher activity levels , low energy expenditure (<600 MET-minutes per week) was associated with higher levels of serum triglycerides , GHbA1c  and fat mass percentage  as well as lower HDL . Survivors with low energy expenditure were significantly more likely to need antihypertensive medication .For the subgroup of survivors who reported the lowest physical activity levels  and frailty 10% (10/98) was high among the survivors. Frailty components were reported as low lean muscle mass (36%), self-reported exhaustion (15%), low energy expenditure (11%), slowness (6%) and weakness (45%) among all survivors.There was only a trend for TBI treated survivors to have more prefrailty or frailty compared to non-TBI treated survivors . No corrs 0.050, p = 0.622) and follow-up time  were not associated with frail health among HSCT survivors. Furthermore, total bone mass (kg) was compared between the groups and found to be significantly lower in the prefrail to frail survivors  compared to the non-frail survivors .Of the laboratory and clinical assessments, frail to prefrail survivors had significantly shorter height, smaller adult testicular volume, higher resting heart rate, lower lean mass and higher fat percentage compared to non-frail survivors. In our cohort, increasing age , shorter height , cGvHD  and hazardous drinking .A significant regression equation was found, F = 8.05, The present study showed that signs of frail health are prevalent and muscle strength significantly decreased among very long-term survivors of allogeneic HSCT in childhood. Thirty-one percent of the survivors fulfilled two or more components of frail health . Chronic GvHD, shorter stature, higher fat percentage and hazardous drinking were shown to be potential factors contributing to frail health after childhood allogeneic HSCT. Poor physical fitness and low physical activity level were associated with older age at examination and cardiovascular risk factors.The prevalence of the pre-frailty (20%) and frailty (10%) phenotypes in the present cohort were unexpectedly high when considering the young mean age of 28.7 years of the survivors. The prevalence of frailty is known to be 10% among community-dwelling elderly persons above 65 years of age . HoweverWe have previously reported that high-risk pediatric neuroblastoma survivors treated with TBI and autologous HSCT display frail health and signs of premature arterial aging in early adulthood . In the Lower skeletal muscle mass and higher android/gynoid fat ratio has been reported in the present survivor cohort . In the Active cGvHD was shown to be a significant contributing factor to frail health and decreased physical fitness after childhood allogeneic HSCT. This observation is in line with a previous report from adult allogeneic HSCT recipients where active cGvHD significantly increased the risk of frailty . The assA few limitations should be considered when interpreting these results. First, the assessment methods used to define frail health vary substantially between studies affecting the comparability of results. The criteria for frailty can either be defined by different physical tests or by self-reports. In this study, physical tests with age- and sex -specific normative values were used for three of the criteria and standardized self-reports for two . Our criteria for frailty differed slightly from those used by Fried et al. in an aging population. They used unintentional weight loss to define loss of lean muscle mass, and two questions from the Center for Epidemiologic Studies Depression Questionnaire to characterize exhaustion. It is possible that our choice of different measures than were used in the original study affected results on lean mass and exhaustion. Additionally, the definition for prefrail status varies; some studies use the presence of one or two criteria as the cut-off , while oYoung adult survivors of childhood HSCT have a higher-than-expected prevalence of frailty, suggesting that pediatric HSCT recipients may have accelerated aging. Survivors also presented lower physical fitness and several cardiovascular risk factors, which may increase their risk for cardiovascular and metabolic diseases in the future. Some modifiable predictors for frail health and poor physical fitness were found, namely higher body fat mass, regular smoking and hazardous drinking. These results indicate a need for individual monitoring of motor performance with standardized tests, cardiometabolic follow up as well as active health education in the decades following HSCT. Longitudinal surveillance of survivors is needed to identify those at highest risk and provide targeted interventions like home- or hospital-based exercise programs or active video games to promote physical activity and to prevent or alleviate adverse outcomes associated with frailty in this population.


Stroke rehabilitation teams’ skills and knowledge in treating persons with cognitive impairment (CI) contribute to their reduced access to inpatient rehabilitation. This study examined stroke inpatient rehabilitation referral acceptance rates for persons with CI before and after the implementation of a multi-faceted integrated knowledge translation (KT) intervention aimed at improving clinicians’ skills in a cognitive-strategy based approach, Cognitive Orientation to daily Occupational Performance (CO-OP), CO-OP KT.CO-OP KT was implemented at five inpatient rehabilitation centres, using an interrupted time series design and data from an electronic referral and database system called E-Stroke. CO-OP KT included a 2-day workshop, 4 months of implementation support, health system support, and a sustainability plan. A mixed effects model was used to model monthly acceptance rates for 12 months prior to the intervention and 6 months post.The dataset was comprised of 2604 pre-intervention referrals and 1354 post. In the mixed effects model, those with CI had a lower pre-intervention acceptance rate than those without. Post-intervention the model showed the acceptance rate for those with CI increased by 8.6% (p = 0.02), whereas those with no CI showed a non-significant increase of less than 1%.Proportionally more persons with CI gained access to inpatient stroke rehabilitation following an integrated KT intervention. Despite evidence of its benefits to them , personsThese contributing factors to reduced rehabilitation access are not unique to Toronto. As Ottenbacher and colleagues  identifiSpecifically, we developed, implemented, and evaluated a multi-faceted, supported KT initiative, designed to promote the interprofessional use of the Cognitive Orientation to daily Occupational Performance (CO-OP) . CO-OP iAn interrupted time series design was conducted using referral and acceptance data pre and post implementation of the CO-OP KT intervention in five rehabilitation hospitals in Toronto. An interrupted time series design provides an estimate of the effect of an intervention using a series of measurements of dependent variables, divided into pre-intervention and post-intervention segments . It is uworkshop was followed by a four-month implementation support period. During the support period, an implementation facilitator conducted six face-to-face sessions at each site to advance site-specific implementation goals. A CO-OP instructor visited each site once to support ongoing needs, answer questions, and problem-solve specific issues. Physical resources were provided, including a workbook, posters, and information cards. Regular teleconferences were held with administrators overseeing stroke rehabilitation at each site to facilitate organization and system-level support and alignment. A half-day site-specific consolidation session was held as a capstone to synthesize learning and plan ongoing implementation. Infrastructure support comprised of linking to existing KT resources, such as an established TSNs Virtual Community of Practice (www.strokecommunity.ca) that was utilized as a resource during and after the implementation phase. Following the 4 month implementation support period, a sustainability plan was implemented at each site with quarterly TSNs-facilitated site champion meetings and site leadership meetings.The CO-OP KT intervention is a supported integrated KT intervention aimed at the interprofessional implementation of CO-OP. It has five elements: a workshop, implementation support, a consolidation session, infrastructure support and a sustainability plan. All aspects of the intervention were co-designed with the knowledge users. All healthcare professionals providing direct care were invited to participate, and the research team encouraged sites to include all or most occupational and physical therapists and speech-language pathologists, at least one nurse, and other interested team members who had a direct client care role. Funds were offered to provide coverage for the team members who attended training. The standardized two-day instructional and practice-based CO-OP In the TSNs, access to rehabilitation is coordinated through a common electronic referral system and database called the E-Stroke Rehabilitation Referral System (E-Stroke). Twelve acute hospital sites refer to five freestanding rehabilitation centres that have expertise in stroke rehabilitation and designated stroke rehabilitation beds. Rehabilitation site representatives review and respond to referrals sent to their site. Data elements extracted from E-Stroke were monthly averages of total referrals and admissions to inpatient stroke rehabilitation, cognitive status, and site.The cognitive elements memory, attention, judgement, and executive functioning were coded in the E-Stroke database as no impairment; or mild, moderate, or severe impairment. Using the cognitive element with the most severe level of CI, we created a dichotomous variable (no CI or any CI) and a four category variable . Scores on the MoCA©  more preThe dataset included all cases for the 12-month period prior to CO-OP KT  and the six month post-intervention period (April 2017 –October 2017). The post-intervention period was limited to 6 months, as the health system put an automatic acceptance policy for persons with moderate stroke in place at that point, impacting future acceptance rates.The CO-OP KT intervention began with a workshop October 2016, and post-intervention evaluations for all teams were concluded by April 2017. As the research team began direct communications with the stroke rehabilitation team members about the project in the month prior to the workshops, data from this month were also excluded.Referral, rather than individual patient cases, was used as the unit of analysis, as each patient case could have referrals and acceptances to multiple rehabilitation hospitals. Descriptive statistics were conducted to identify the number of referrals with each level of CI  accepted to each site pre and post intervention. The interrupted time series design was analysed using a linear mixed effects model with random site effects. The outcome of interest was the monthly acceptance rate , with dichotomous predictors for any cognitive impairment, post-intervention and an interaction term. The interaction term is the estimate of the change in acceptance rate post-intervention for those with CI and is the primary parameter of interest. Random effects were used to model variation across sites and a first order autoregressive term was included to model correlation of repeated measures. The full model with an illustration of the model parameters is provided in the online supplement. The nlme package [Data were cleaned to include only cases with complete data.  package  in the R package  was usedThere were 2,707 referrals to inpatient rehabilitation in the 1-year pre-intervention period and 1,372 in the 6-month follow-up period. For the pre- and post-intervention periods, cognitive status was available for 2,604 and 1,354 referrals respectively. This study examined the downstream impacts of a KT study on access to stroke rehabilitation for persons with CI. Results suggest the CO-OP KT intervention was associated with an increased proportion of persons with mild and moderate CI gaining access to inpatient rehabilitation. Controlling for time and site variability, a nearly 9% increase was seen in acceptance for those with any CI compared to those without. Although many factors may have influenced a change in access, significant changes in knowledge, skills, and aspects of self-efficacy of healthcare providers were seen and reported following the CO-OP KT intervention , providiOne impetus for implementing CO-OP KT was to change practice habits and attitudes of providers and decision makers who influence access to rehabilitation; increased acceptances to inpatient rehabilitation for persons with mild and moderate CI suggests this may have occurred. Evidence from the CO-OP KT sub-study that examined provider learning outcomes demonstrated improvements in CO-OP knowledge as well as improvements in aspects of self-efficacy and practice . Improveincluding persons with CI. The intervention did not differentiate between levels of CI severity. Further KT efforts directed specifically at access for persons with severe CI may be required. While there is evidence suggesting that persons with severe CI can benefit from rehabilitation [There were no significant changes in access for persons with severe or no CI. The Evidence Based Review of Stroke Rehabilitation , a now olitation –27 it isno CI, which was an aspect of the intended shift. Several factors beyond baseline acceptance rates and the degree of uptake of CO-OP KT could have influenced these differences, particularly differing internal procedures for reviewing and accepting referrals at each stroke rehabilitation program, including how the interprofessional team is involved in the process.Site-specific differences in acceptance were present, with three sites showing increased access for persons with mild to moderate CI, one site showing no change, and another showing an overall non-significant decline in acceptances driven by a significant decrease in acceptance in those with An interrupted time series uses a control condition that is temporally different from the intervention condition, and system changes may occur in the interim. A non-randomized trial with recruitment at 5 sites introduced a high degree of variability, based on site-specific cultural, management, and staffing issues. To mitigate both the temporal and site variability issues, the study had a large number of cases and used a robust mixed effect modeling analysis. All E-Stroke referrals to five rehabilitation centres were included in the study making the results highly representative of large urban cities. This broad implementation study did not allow for monitoring compliance rates; however, results suggest a shift in acceptance despite this.The CO-OP KT intervention aimed to promote interprofessional team use of a cognitive strategy-based approach in inpatient stroke rehabilitation. Following CO-OP KT, significantly more persons with CI were admitted to stroke rehabilitation, providing them the potential for greater independence and quality of life. Changes in access varied across the five sites, highlighting that access is a complex construct, and improvement requires a multidimensional approach. This study, together with the other CO-OP KT sub-studies, provides evidence that a multifaceted integrated KT intervention, which included regular engagement with clinicians and administrators, may influence attitudinal barriers to access. A future KT intervention targeted at changing knowledge and attitudes about the benefits of rehabilitation for persons with severe CI after stroke may shift access further.S1 Dataset(CSV)Click here for additional data file.