Percutaneous mitral valve repair (PMVR) provides an available choice for patients suffering from secondary mitral regurgitation (SMR), especially those whose symptoms persist after optimal, conventional, heart-failure therapy. However, conflicting results from clinical trials have created a problem in identifying patients who will benefit the most from PMVR.To pool mortality data and assess clinical predictors after PMVR among patients with SMR. To this end, subgroup and meta-regression analyses were additionally performed.We searched PubMed, EMBASE, and Cochrane databases, and 13 studies were finally included for meta-analysis. Estimated mortality and 95% confidence intervals (CIs) were obtained using a random-effects proportional meta-analysis. We also carried out a meta-regression analysis to clarify the potential influence of important covariates on mortality.p = 0.009), an effective regurgitant orifice (ERO) , and a mineralocorticoid receptor antagonist (MRA) use . Subgroup analysis indicated that patients with preexisting AF  were associated with decreased mortality if they received a mitral annuloplasty device. Among the edge-to-edge repair device group, a higher left ventricular (LV) ejection fraction, or lower LV end-systolic diameter, LV end-systolic volume, and LV end-diastolic volume were proportional to lower mortality.A total of 1,259 patients with SMR who had undergone PMVR were enrolled in our meta-analysis. The long-term estimated pooled mortality of PMVR was 19.3% (95% CI: 13.6–25.1). Meta-regression analysis showed that mortality was directly proportional to cardiac resynchronization therapy (CRT) . Further meta-regression indicated that AF was associated with a better outcome in conjunction with the use of a mitral annuloplasty device, while better LV functioning predicted a better outcome after the implantation of an edge-to-edge repair device. Secondary mitral regurgitation (SMR), which is most commonly seen in dilated or ischaemic cardiomyopathies, is associated with significantly poor clinical outcomes and quality of life , 2. AlthThe COAPT  trial  and its Long-term follow-up outcomes from the COAPT and MITRA-FR trials, and other recent research, including those providing extra data or using new transcatheter systems, provided us with a tremendous opportunity to pool all the evidence of PMVR for patients with SMR. As it is necessary to recognize patients who might benefit from PMVR the most, a meta-analysis and meta-regression were performed to identify these clinical predictors.We registered our meta-analysis in the International Prospective Register of Systematic Review (CRD42022321423), and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was used to design our manuscript .in vivo experiments, and echocardiographic studies were not reviewed for inclusion  patients who had severe SMR still suffered heart failure symptoms when optimal medical therapy was prescribed, (2) provided mortality and available baseline characteristic data, and (3) at least one transcatheter device was studied. We excluded review articles, duplicate studies or data, human secondary or functional mitral regurgitation, transcatheter mitral valve repair, MitraClip, and mitral annuloplasty device to search PubMed, EMBASE, and Cochrane databases through the final search date of 30 December 2021  using the Cochrane Collaboration tool in . Given tMortality was the only endpoint in our meta-analysis. Two reviewers independently extracted data on the study design and PMVR device , and basP ≤ 0.05),  of included studies. Statistical heterogeneity among studies was examined using the Cochran Q statistic and the I2 statistic, with I2 being considered substantial when it was >50% . Leave-o≤ 0.05),  and thesFinally, 1,259 patients with SMR from 13 studies, including 3 randomized trials [COAPT , MITRA-FDemographic data, functional characteristics, history, echocardiography parameters, and medication history are summarized in The long-term estimated pooled mortality of PMVR was 19.3% (95% CI: 13.6–25.1) . A subgrp = 0.009) and larger ERO , while a decrease in patients prescribed MRA .A meta-regression analysis was performed to assess the impact of potential baseline characteristics on pooled mortality. As shown in p = 0.018) were associated with lower mortality if they had been subjected to a mitral annuloplasty device  is becoming well-accepted with reference to patients with AF suffering significant mitral regurgitation without LV systolic dysfunction . Althougpost-hoc analysis from a COAPT trial also revealed that a higher baseline NYHA functional class was strongly associated with a greater risk for adverse events (We identified LVEF as a positive variate associated with lower mortality among patients who had undergone the use of an edge-to-edge repair device. LVESD, LVESV, and LVEDV were identified as negative variates, suggesting that patients with poor cardiac function might not benefit from PMVR. A former meta-analysis  of RCTs e events . Therefoe events  in orderThere are some limitations requiring attention. First, only 3 randomized data were enrolled, and the limitations of a retrospective study design could not be avoided. Second, because of the limited number of studies reporting the vital baseline characteristics, we were unable to conduct a meta-regression for these variates. We also failed to perform a multivariate regression analysis for the same reason, and confounding bias for the conclusion cannot be ignored. Third, although we discarded the data from the control group in controlled trials, data from single-arm designs may have resulted in bias in our meta-analysis. Nevertheless, meta-regression analysis is helpful in understanding heterogeneity and providing a perspective according to which patients may be stratified in terms of who may be best able to benefit from PMVR.The original contributions presented in the study are included in the article/WS: drafting of the manuscript, had full access to all of the data in the study, takes responsibility for the integrity of the data, and the accuracy of the data analysis. WS and CD: concept and design, statistical analysis, administrative, and technical or material support. WZ, DZ, and GY: acquisition and analysis or interpretation of data. WZ and CD: supervision. All authors: critical revision of the manuscript for important intellectual content.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.


RNA is the key player in many cellular processes such as signal transduction, replication, transport, cell division, transcription, and translation. These diverse functions are accomplished through interactions of RNA with proteins. However, protein–RNA interactions are still poorly derstood in contrast to protein–protein and protein–DNA interactions. This knowledge gap can be attributed to the limited availability of protein-RNA structures along with the experimental difficulties in studying these complexes. Recent progress in computational resources has expanded the number of tools available for studying protein-RNA interactions at various molecular levels. These include tools for predicting interacting residues from primary sequences, modelling of protein-RNA complexes, predicting hotspots in these complexes and insights into derstanding in the dynamics of their interactions. Each of these tools has its strengths and limitations, which makes it significant to select an optimal approach for the question of interest. Here we present a mini review of computational tools to study different aspects of protein-RNA interactions, with focus on overall application, development of the field and the future perspectives. Central to their role in fundamental biological processes are RNA-protein interactions (RPI) that primarily involve modular RNA-binding proteins (RBP), although exceptions exist  and structure-based methods that use structure-derived features (such as solvent-accessible surface area or secondary structure) to make predictions. Walia et al., have reviewed tools for sequence-based methods  while stin vivo data and to identify deleterious genomic variants. With over 2000 citations, this scalable and modular pattern discovery method is a popular application of ML-based learning methods with important applications in predicting protein-RNA interactions   , CLIPZ (atabase)  and RBPDatabase) . Other matabase)  use a geTools like RBind (Binding sites on RNA) , NAPS n and PRIdProtein-RNA interactions can be predicted using structure-based information. These methods became possible as the number of protein-RNA complex structures deposited in the PDB increased in numbers. Here, either the availability of structures or structure predictions of protein, RNA or both as a complex have been employed to develop several approaches.16% of the tools to predict RPI have been developed based on the structure of a protein . InitialAnother popular method is PRNA  which emThe shape and geometry of RNA can significantly influence RBP binding. Zhang and co-workers developed DeepNet-RBP  which usGraphProt  is a fleetc.  were available in the Protein Data Bank (PDB) . Howeveretc. . Both teetc. . PRIME  of at least 2.0 kcal mol─1, are defined as hotspot residues . Given tab initio and empirical methods, modified electrostatic, van der Waals (vdW), and torsional parameters to accurately reproduce the energetics of nucleobase stacking, base pairing, and key torsional conformers. CHARMM modified its forcefield parameters to make it suitable for nucleic acids  simulations have been successfully used to characterize complex conformational transitions in proteins. In principle, MD simulation is a powerful tool for characterizing such conformational changes in RNA molecules, which depends on force-field parameters. AMBER force field  uses a cic acids . OPLS-AAic acids . Apart fic acids . Martiniic acids  helps inic acids  complex E. coli strains. Among the above databases, NPInter, PRD, RNAct, CLIPdb and RBPDB provide and extract information from experimental techniques. In future, an exhaustive interaction database which could store detailed and multi-dimensional information about an interaction entry, such as a binding region/motif, structure detection method, interactions, etc. would add more value to such efforts. Furthermore, the ability to predict potential RPI is based on availability of such catalogued information, making such databases necessary and valuable.Various databases provide comprehensive repositories of RNA-protein interaction data that have been gathered from experiments, literature and other databases and computational predictions. PRD , NPInterThis review provides a comprehensive survey of computational tools for the analysis of protein-RNA interactions. The availability of mathematical models and profiles, together with sensitive search algorithms, enable effective association of new genes into pre-existing families of RNA-binding proteins from mere sequence information. Repositories such as protein sequence families (PFAM)  and in-bRBPs are modular and may possess more than one RBD that are connected with flexible linkers or may occur as isoforms. Automatic tools are not available to provide accurate assignment of domain boundaries and nomenclature. Which of these domains bear sequence signatures of functionally important residues, how they co-operate in exhibiting function and their relative affinity for RNA still are open questions. Several proteins that contain RNA-binding domains also contain substantial stretches of disordered regions. Their structural and functional regulation are hard to capture and remain a treasure-house of knowns. Despite the choice of objective mathematical models, presence of spatial motifs of RNA-binding residues or RNA that acquire three-dimensional structure might escape detection. Some RBPs are known to bind both DNA and RNA and this might cause sufficient confusion in prediction since the results may be viewed as false positives.The success of computational algorithms is usually measured using statistical parameters such as accuracy, sensitivity and specificity. The performance of algorithms to recognize RNA-binding proteins is challenged by the absence of a comprehensive and reliable gold-standard to look upon. It is now accepted that different databases of RNA-binding proteins that use different high-throughput experimental approaches and platforms do not agree very well with each other . It woulFinally, RNA-binding proteins play important roles in diverse biological roles such as developmental processes and ageing. They are also amenable to functional regulation such as phosphorylation switches and expression levels. In future, meta-analyses are required to assimilate such functional information.


Juvenile Scleroderma is a rare autoimmune disease of the connective tissue. Its concurrence with COVID-19 can lead to limb ischemia as both disease entities are pro-inflammatory and pro-thrombotic. To date, there is no case report describing the symptomatology and course of disease in patients with juvenile Scleroderma and COVID-19.An adolescent with acute limb ischemia presented with a history of generalized hypo-and-hyperpigmented skin lesions and mild, non-productive cough. She tested positive for SARS-CoV-2 on nasopharyngeal swab RT-PCR. Further work-up revealed elevated anti-phospholipid antibodies, anti-nuclear antibody, and D-dimer; low Protein S activity; and evidence of peripheral arterial disease on imaging studies. She was started on peripheral vasodilators, Methotrexate, and anticoagulation. Close monitoring of the affected limbs and other organs involved was done. Control of limb ischemia was achieved after 4 months of regular Cyclophosphamide infusion. Continued multi-disciplinary care was ensured for this patient.There is evolving knowledge about the interplay of COVID-19 hyperinflammatory state and rheumatologic disorders. COVID-19 is thought to exacerbate cutaneous manifestations of autoimmune disorders via antigen protein mimicry and cytokine imbalance. Moreover, COVID-19 is characterized by complex hematopathologic processes that put a patient in a hypercoagulable state. Elevated D-dimer can be seen in both COVID-19 and systemic sclerosis owing to their pro-thrombotic sequela. There is scarcity of data on the association of Protein S activity with COVID-19 and systemic sclerosis. More studies need to be carried out to ultimately arrive at a consensus on thrombosis prophylaxis for patients with Scleroderma and COVID-19. Coronavirus disease 2019 (COVID-19) is a novel disease caused by the SARS-CoV-2 virus that originated in Wuhan, China. By the end of October 2022, the reported confirmed cases of COVID-19 reached 627 M, with about 6.5 M deaths globally [An adolescent female with acute limb ischemia tested positive for COVID-19 at the emergency room. Her history of present illness started 1 year and 8 months prior to admission when she presented with generalized erythematous skin patches that progressed to generalized hyper-and-hypopigmentation . She had intermittent arthralgia, weight loss, and cyanosis of the distal digits when exposed to cold temperatures. The cyanotic digits were tender but eventually became erythematous and painless. She also had persistent skin dryness, which prompted a consult with a dermatologist. Systemic sclerosis was initially suspected, and a skin biopsy revealed sclerosing dermatosis , and she tested positive. She was subsequently admitted for limb-salvaging interventions. Radiographic imaging of the bilateral hands and feet was negative for joint space or osseous abnormality. Doppler studies were done for the ischemic limbs and showed triphasic bilateral radial, ulnar, and brachial pulses. No surgical intervention was contemplated for the patient at the time of admission, and maximization of medical management was prioritized. Iloprost was the initial drug of choice for ischemic ulcers but was not started due to its unavailability in the institution. She was then started on Nifedipine 0.4 mg/kg/dose every 6 hours, Sildenafil 2 mg/kg/dose three times a day, and Nitroglycerin patch over the affected digits. Prednisone and Naproxen sodium were started for anti-inflammation and analgesia, respectively but were eventually discontinued.The concurrence of COVID-19 with juvenile systemic Scleroderma was postulated to have triggered the limb ischemia. Additional tests done for this patient revealed normal PT-INR, elevated D-dimer levels, normal protein C, low protein S, and normal Fibrinogen levels. To date, there is no international protocol in the initiation of venous thromboembolism prophylaxis for patients with systemic Scleroderma with concomitant COVID-19. This patient, however, was started on Enoxaparin 0.5 mg/kg/dose subcutaneously every 12 hours and was carefully monitored for signs of bleeding and heparin-induced thrombocytopenia. While at the COVID ward, she had worsening sensory deficits on the 4th and 5th digits of the left hand but had no progression of the ischemia. She also had no new-onset pain or pallor in the uninvolved digits. While awaiting for the peripheral angiography, she underwent arterial doppler studies with digit-brachial index measurement. The examination revealed monophasic to biphasic signals at the distal bilateral radial and ulnar arteries and monophasic signals of the left anterior tibial artery and bilateral peroneal arteries; which suggest peripheral arterial disease of the bilateral upper and lower extremities.After finishing 14 days of isolation at the COVID ward, she was subsequently transferred to the non-COVID ward for the continuation of management. She was started on Methotrexate 0.3 mg/kg/dose twice a day weekly and Folic acid 0.2 mg/kg/dose for the diffuse cutaneous disease. Because she had persistent and progressive skin involvement, she was started on Cyclophosphamide 500 mg per body surface area (BSA) and Uromitexan 40% of the cyclophosphamide dose. No hematuria was noted during the course of therapy. She was seen by the orthopedics service and was advised to undergo left small distal interphalangeal joint disarticulation; however, the parents did not consent to it. Medical management was then continued, and no untoward reactions were noted while she was on Methotrexate. Peripheral angiography was subsequently done, revealing complete occlusion of the proximal right dorsalis pedis artery, diminutive left ulnar and interosseous arteries, and diminutive left 4th and 5th digital arteries. Vasodilators were continued, and she was noted to have improvement of the distal extremities after 4 weeks. No progression of ischemia was noted in the interval, and she was discharged with regular follow-up for Cyclophosphamide infusion on outpatient basis.Our patient was managed in a tertiary COVID-19 referral institution. She was classified as having mild COVID-19 because of a history of non-productive cough but with unremarkable chest radiograph. Immunologic work up for systemic Scleroderma was done, revealing positive Anti-nuclear antibody and elevated Anti-phospholipid antibodies. Detection of Systemic sclerosis-selective autoantibodies was not done due to its unavailability in the institution. The following adjunctive tests were also done: Protein C , Protein S , and Erythrocyte sedimentation rate . D-dimer was elevated at 0.79 μg/mL . Low Protein S activity and elevated D-dimer were attributed to the pro-thrombotic state of the patient.Investigations for vascular pathology using Arterial Doppler with segmental pressures and waveform studies revealed peripheral arterial disease. Four-extremity angiogram showed luminal narrowing of distal arteries only on the bilateral upper extremities.To date, there is no established guideline for the initiation of anti-thromboembolic prophylaxis for patients with Scleroderma and concomitant COVID-19 infection. However, because of the predominantly hypercoagulable state of COVID-19 patients on top of the vascular pathology in Scleroderma, it was deemed prudent to start the patient on Enoxaparin. For the Scleroderma-related Raynaud phenomenon, the goals were to increase comfort and prevent secondary ischemic sequelae, which can be achieved using arteriolar vasodilators , 8. The On follow-up, the patient still experienced Raynaud phenomenon, but there was no progression of the digital ulcers. She has had a total of 5 cycles of Cyclophosphamide infusion, and her previously cyanotic but non-ischemic digits have significantly improved. The adolescent medicine, child psychiatry, rehabilitation medicine, and gastroenterology services were actively managing this patient to help her cope with the burden of chronic autoimmune disease. Adherence to treatment was ensured by providing regular online, and face-to-face clinic consults, providing free medicines and diagnostics through the medical social services, and involving the family in the patient’s care.Juvenile systemic Scleroderma is an autoimmune disease characterized by vasospasms that lead to digital ischemia and ulcers. Moreover, it is thought to cause vascular endothelial injury that may increase the risk of thrombosis , 12. The


Patients with cirrhosis are a risk factor for coagulopathy and bleeding complications. Thromboelastography (TEG) guided therapy is available to rapidly assess and guide blood product transfusion in this population.This study aims to determine if TEG-guided therapy is able to decrease the administration of blood products and reduce adverse events such as bleeding and mortality compared to standard coagulation testing (SCT).We performed a systematic review and meta-analysis of literature in PubMed, EMBASE, and The Cochrane Library and pooled six randomized-controlled trials comparing thromboelastography versus standard coagulation testing in patients with cirrhosis. A total of six studies were pooled (n= 386). Primary outcomes were mean platelet transfusion units and fresh frozen plasma (FFP) transfusion units. Secondary outcomes were mortality and bleeding events.Compared to SCT, there was a significant standard mean decrease in platelet (P<0.00001) and FFP (P<0.00001) administration compared to TEG perioperatively prior to a liver transplant. However, there was no significant difference in the pooled odds ratio between TEG and SCT in patients receiving both platelets and FFP . Recurrent variceal bleeding was significantly reduced in the TEG group compared to SCT for platelet transfusion  or FFP transfusions . With regards to the 5-day, 28-day, 42-day, and 90-day mortality, there was no significant difference between the pooled odds ratio between the TEG and SCT groups . The 24-hour, 48-hour, 5-day, and 42-day rebleeding rates were significantly lower in TEG versus SCT groups ].The use of TEG-guided therapy favors a reduction in platelet and FFP transfusion compared to SCT in patients with cirrhosis. Additionally, TEG-guided therapy is able to improve patient care by reducing the rebleeding rate of patients with cirrhosis compared to SCT. However, this same effect was not seen for mortality.NoneNone Declared


Following publication of the original article , the autThe incorrect author name is: Daverio Marco.The correct author name is: Marco Daverio.p = 0.028).The incorrect Results section in the Abstract reads: Seventy-one percent of PICUs stated to use protocols for analgosedation management, more frequently in high-volume PICUs .It should instead read: Seventy-one percent of PICUs stated to use protocols for analgosedation management, more frequently in low-volume PICUs (77% vs 63%, The author group has been updated above, and the original article  has been


Finding My Way-Advanced (FMW-A), a web-based self-guided psychosocial program for women with MBC. This study aims to assess its efficacy in improving mental and other QOL domains, distress, fear of progression, unmet needs, and health service utilisation.Women living with metastatic breast cancer (MBC) are at risk of significantly impaired quality of life (QOL), symptom burden, distress and fear of progression, and unmet needs, yet they face barriers to accessing evidence-based psychosocial treatments. Our group therefore developed FMW-A (intervention), or Breast Cancer Network Australia’s (BCNA) online/app resource My Journey . This is a single-blind study, with randomisation computer-generated and stratified by site. FMW-A is a 6-module program addressing some of the most common issues experienced by women with MBC, with BCNA control resources integrated within the ‘resources’ section. All modules are immediately accessible, with an additional booster module released 10 weeks later. The primary outcome is mental QOL; statistical criteria for superiority is defined as a 4-point difference between groups at post-treatment. Secondary outcomes include other QOL domains, distress, fear of progression, health service use, intervention adherence, and user satisfaction.The multi-site randomised controlled trial (RCT) will enrol 370 Australian participants. Eligible participants are adult (18 years +) women diagnosed with MBC, with a life expectancy of 6 months or more, with sufficient English-language literacy to provide informed consent. Participants will be identified, screened and referred from one of 10 Australian sites, or via self-referral in response to advertisements. Participants complete four online questionnaires: prior to accessing their program (‘baseline’), 6 weeks later (‘post-intervention’), then 3 months and 6 months post-intervention. Consenting participants will be randomised to either FMW-A will help address two national key priorities for management of MBC – enhancing QOL and reducing symptom burden. FMW-A has the potential to address unmet needs and overcome access barriers for this overlooked population, while reducing health system burden.This will be the first adequately powered RCT of a self-directed online intervention for women with MBC. If efficacious, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382714&isReview=trueThe study was registered prospectively with the ANZCTR on 29/10/2021. Trial ID ACTRN12621001482853p. The online version contains supplementary material available at 10.1186/s12885-022-10410-z. In 2020 alone, 2.3 million women globally were diagnosed with breast cancer, and 7.8 million women alive were diagnosed with breast cancer in the past 5 years, making it the world’s most prevalent cancer . Of thosWomen receiving a diagnosis of MBC experience significant challenges; in addition to managing their awareness of premature mortality, they also face a more proximal future of progressing illness; physical symptoms, including pain, fatigue, and insomnia; and resulting functional limitations, such as reduced mobility or ability to undertake usual occupation/roles , 5. ClinYet the high levels of unmet needs, distress, symptom burden, and impaired QOL that women with MBC experience remain largely unaddressed, with research finding these women are underserviced and receive less support than women with early-stage disease . Indeed,While psychological interventions have an arguably prominent role in managing all three of these unmet needs, few resources have been developed for this population, particularly resources that utilise self-care and support self-management. Indeed, our 2018 systematic review of interventions for MBC identified only 15 RCTs that have been conducted to date : Overallearly-stage cancer populations for improving distress [Digital health tools, such as web-based therapy, could address these barriers. Given digital health tools provide 24/7 access at a time and place convenient to the patient, and reduce obligations to spend valued time and money in healthcare settings, this mode of providing psychosocial care has particular pertinence to women with MBC . Furtherdistress , 24, depdistress , fear ofdistress , QOL [27distress , and heaFinding My Way-Advanced (FMW-A) [Finding My Way web-program for people with early-stage cancer [Our team recently developed and usability-tested an online program to support women with MBC:  (FMW-A) . FMW-A we cancer , 28. Thee cancer . Pragmate cancer , which we cancer .Digital health tools have the potential to facilitate scalable access to cost-effective interventions and address inequity, however none have been trialled in a large-scale RCT in MBC. While digital health solutions have proliferated in the general community, they lack the required essential evidence of efficacy, safety, acceptability, accessibility, and content-relevance for this vulnerable population .This study aims to address the unmet needs of women diagnosed with MBC to improve their QOL and wellbeing, and ultimately reduce the health system burden –6.Finding My Way-Advanced randomised controlled trial (RCT) is to evaluate the efficacy of the intervention (‘FMW-A’) compared with an online minimal-intervention attention control (‘control’) in improving mental QOL, as measured by the ‘emotional functioning’ subscale of the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ C-30), in women with MBC. The term ‘mental QOL’ was selected for this study to enable easier comparison to the broader QOL literature where mental QOL is the predominant term.The primary objective of the i.Evaluate the efficacy of FMW-A compared to control in improving other health-related QOL domains, psychological distress, fear of progression, unmet needs, and health service utilisation in women with MBC.ii.Describe uptake to the RCT and adherence to the program.iii.Evaluate the cost-effectiveness of the program.Secondary objectives are to:Intervention participants will report greater improvements in the primary outcome of mental QOL (MQOL) compared to minimal-intervention control participants from baseline to post-intervention, with effects sustained at 3- and 6-month follow-ups.Primary hypothesis:Intervention participants will report greater improvements from baseline to post-treatment in secondary well-being outcomes, i.e., physical, social, cognitive, role and global QOL domains; fear of progression; psychological distress; and unmet needs, compared to control participants, with effects sustained at 3- and 6-month follow-ups.Intervention participants will have lower health service utilisation and public hospital admissions  over the 6-month follow-up period, compared to control participants.Secondary hypotheses:A multicentre, single-blind parallel RCT, with randomisation at the participant level and stratification by recruitment site. This trial adopts the SPIRIT guidelines for clinical protocols , and FigAll RCT participation will occur via two web programs. Research survey data will be collected on Qualtrics (hosted by Flinders University) and the FMW-A web program will be hosted on ManageWP with oversight by Flinders University staff.Women (1) with a diagnosis of MBC, (2) aged 18 years or older, with (3) estimated life expectancy longer than 6 months (as per treating clinician’s estimate) and (4) sufficient English for informed consent and program comprehension, will be eligible.No internet access or active email address, or previous medical history of dementia or cognitive impairment. Women currently receiving face-to-face psychological services are still eligible to participate . Women currently enrolled in other active psychosocial intervention trials will be excluded to avoid contamination effects, while those enrolled in observational studies will remain eligible.This study has received ethical approval from the Southern Adelaide Clinical Human Research Ethics Committee (SAC-HREC 2021/HRE00407). Study participants provide online written consent via selecting check-box options for each component of participation, followed by confirming overall consent by clicking the ‘Submit Consent’ button.Eligible participants will be recruited via two methods.Direct approach: Women will be screened for eligibility by cancer clinicians then approached by research assistants (RAs) at the 10 participating health sites ; National Capital Private Hospital, ACT; Peter MacCallum Cancer Centre, Victoria; Lake Macquarie Private Hospital, New South Wales (NSW); Maitland Private Hospital, NSW; Mater North Sydney Hospital, NSW; Chris O’Brien Lifehouse, NSW; Campbelltown Hospital, NSW). CIs and AIs are affiliated with each of these recruitment sites and research assistants will be employed in each state to facilitate and oversee recruitment at each recruiting hospital. Women who are screened as ineligible will receive standard care as usual.Self-selection: In response to advertisements and promotion through professional networks , breast cancer advocacy groups / agencies , and research databases . Participants who self-refer to the study will self-confirm their eligibility as part of the online consent process.Resources section of the intervention, which also provides links to, and information about, other cancer organisations and websites.FMW-A is a 6-module psychosocial program that addresses commonly experienced concerns raised by women with MBC  Resources that provide links to information from other cancer organisations and websites. My Journey covers all stages of breast cancer, but is tailored to the cancer stage at sign up, such that control participants will receive MBC-relevant content only. My Journey for MBC incorporates and extends the gold-standard “Hope & Hurdles” resources previously made available to women upon diagnosis with MBC in Australia. It provides comprehensive information about diagnosis, information specific to metastatic sites, hormone and HER-2 positive MBC, treatments, support options, practical issues, planning ahead, information for loved ones, podcasts, and personal video stories of women with MBC. If FMW-A efficacy is demonstrated, control participants will be given first access to the program as part of the planned post-trial public dissemination.Consistent with other web-intervention trials in cancer , the conFigure A subset of participants from intervention and control groups will be contacted by telephone at 10-weeks post baseline to schedule a telephone interview for the purposes of obtaining qualitative feedback on user satisfaction with the intervention and/or resources offered as the control condition. Approximately 20 participants will be approached in order of enrolment until saturation of themes occurs. Consenting participants will then be sent a topic guide via email 2 weeks prior to their scheduled interview. Telephone interviews will be conducted and audio recorded, and participants can review their transcripts if requested.This study is planned to occur over 3 years, with a recruitment window of 18 months to recruit the full sample of 370 participants. The proposed timeline includes 20% of the sample being recruited in Year 1 (2022); 60% in Year 2 (2023); and the final 20% in Year 3 (2024), with the remainder of Year 3 devoted to collection of follow-up data and analysis.Table The demographic, clinical and treatment characteristics will be captured via self-report and confirmed via chart review (where available), and are outlined in Table Mental QOL will be measured using the EORTC QLQ C-30 emotional functioning subscale . Total sSecondary outcome measures assessing QOL, psychosocial and health-economic outcomes, and covariates are summarised in Table User satisfaction will be assessed using single Likert-style items in the follow-up questionnaire asking participants how helpful they found aspects of the program, and how confident they felt they could apply the program to their everyday life, and through qualitative interviews.operational oversight of the trial is managed by the Coordinating Centre, comprised of principle coordinating investigators  and affiliated students working on the project. Bi-monthly Project Management Group meetings, comprised of coordinating centre members and three named consumer investigators, oversee governance and recruitment aspects of the trial. The Steering Committee, comprised of all investigators, associate investigators, consumer representatives and site coordinators, meet bi-annually at a minimum to provide strategic oversight and broader project management and planning. Finally, data management for the trial is managed by the Data Management Team, comprised of coordinating centre members, biostatistician (RW) and health economist (BKa). A separate data monitoring committee is not required, due to the automated and self-report nature of the data. Trial conduct will not be externally audited; the trial oversight committees will conduct regular internal audits.The trial has four levels of oversight. Routine Participants will be closely monitored throughout the study by the Coordinating Centre through questionnaires and feedback comments delivered via the website. Participants are free to withdraw from the trial at any time. Reasons for withdrawal will be documented (where provided), and withdrawing participants will still be offered the opportunity to participate in a qualitative interview substudy. Significant adverse effects  will be monitored and reported to the Southern Adelaide Clinical Human Research Ethics Committee (SAC-HREC).Only Coordinating Centre investigators and web developers will have administrative access to the website and data. All data will be kept in a re-identifiable form using a patient identification code. Electronic data will be stored on secure Flinders University password-protected servers. Data will be used for research publications in academic journals and presentation at scientific meetings and conferences. No data linkage or secondary use of data is planned or anticipated.n = 147 subjects per group will provide 80% power to detect a clinically meaningful difference in MQOL between treatments of 4 points. Based on attrition rates observed in low-intensity MBC interventions (range 4-20%) and our pilot data to date, we will recruit and enrol 185 subjects per group  to allow for 20% attrition. Based on our pilot data where 71% of eligible women consented, 530 women will be approached , to reach the final sample size of 370.The sample size calculation is based on a repeated measures ANCOVA approach, which takes into account the within-subject correlation across measures, using STATA’s “sampsi” routine and our primary outcome of MQOL. Assuming a between-subject SD of 20 points, 1 baseline measure, and 3 post-baseline measurements per subject  and a within-subject QOL rho = 0.6, Linear Mixed Models (LMM) will be employed following completion of data collection to examine the efficacy of the intervention, in line with the statistical methodology utilised in previous trials our group has published , 28. AnaWithin-trial incremental costs associated with the intervention when compared to the control will be estimated using Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS) and Australian Refined Diagnosis Related Groups (AR-DRG) data. Costs related to the intervention itself will be determined from administrative data collected as part of the trial. The primary health economics outcome will be the incremental cost per unit change in the EORTC QLQ-C30 mental functioning subscale, while the secondary outcome will be the incremental cost per quality adjusted life year (QALY) gained. Within-trial cost-effectiveness with respect to both outcomes will be analysed, allowing for bivariate uncertainty with bootstrapping of participant costs and effects to maintain the covariance structure. To estimate QALY gains, participants will complete the EQ-5D-5L instrument at each assessment. Patient-level measures of utility derived from the EQ-5D-5L instrument will be integrated with survival curves using the quality-adjusted survival analysis (QASA) method. This analysis will include cost-effectiveness, acceptability, net benefit and expected net loss curves to inform decision makers of the optimal strategy at any given threshold for different patient subgroups. Sensitivity analysis will include estimating the incremental cost per unit change in the number of practitioners seen in the previous 3 months based on health services data . Of note, given that FMW-A encourages help-seeking, increases in health service utilisation may be observed in a subset of participants; this will be explored qualitatively.Qualitative interview data will be analysed using thematic analysis to identify salient themes in participants’ experience of using the web-based intervention.The study will be conducted in full conformance with principles of the “Declaration of Helsinki”, Good Clinical Practice (GCP), the Australian National Statement on Ethical Conduct in Human Research , Australian Code for the Responsible Conduct of Research (2007) and with the laws and regulations of Australia. All study documentation has received ethical approval from the Southern Adelaide Clinical Human Research Ethics Committee (SAC-HREC 2021/HRE00407). Site Specific Assessment (SSA) approval will be sought and obtained from local research governance offices of all participating sites. During the study, the CIA will submit documents recording any serious adverse events or any amendments to this protocol to SAC-HREC. At the conclusion of the study, the CIA will notify SAC-HREC that the study has ended by submitting a final report.Finding My Way-Advanced is unique in addressing this research and resource gap.Digital health tools offer one means of addressing the significant access barriers experienced by women with metastatic breast cancer, where symptom burden or physical incapacity, social or geographic isolation, or financial strain preclude participation in face-to-face therapy. However, no RCT has been published to date on the efficacy of a digital health program for this population. While digital health solutions have proliferated in the general community, none have been specifically developed for women with MBC, thus lack the required essential evidence of efficacy, safety, acceptability, accessibility, and content-relevance for this vulnerable population ; RCTs ofefficacy of the program in improving mental and overall quality of life, reducing distress including fear of progression, unmet needs, and health service use. Furthermore, this study offers the opportunity to evaluate potential moderators of change and determine how they overlap or differ to those identified in our earlier Finding My Way program for those treated with curative intent [The large-scale nature of this national multi-site RCT will enable examination of the e intent . This inIf the intervention efficacy is evidenced, this program has individual, system-level, national and international significance. For individuals, the program provides an accessible and cost-effective method of obtaining therapeutic benefits. By improving mental QOL and distress, the overall burden of their disease is reduced via potentially reducing their severity of side effects/toxicities , 7, and Finding My Way-Advanced in Australia via the national body, BCNA. There is also strong potential for international scaling, as demonstrated by our group’s prior history of trialling adaptations of the original Finding My Way digital health program in the USA [Nationally, the already developed and approved implementation and dissemination plan will ensure immediate and ongoing population-level scaling of  the USA  and the  the USA , and a cIn summary, this study is significant in providing an innovative method for providing psychological treatment for a high-need but underserved population, while evaluating the benefits to the health-system and patients. It brings strong methodological rigour to the research design, will provide important contributions to the digital health evidence-base and, most importantly, addresses the recognised paucity of psychological interventions developed specifically for women with MBC.Additional file 1.


Statins can play an essential role in the tertiary and primary prevention of cardiovascular events by reduction of cholesterol in a stroke patient. This meta-analysis aims to assess statin therapy's effect on mortality and recurrence of Intracranial Hemorrhage (ICH) in patients with spontaneous ICH. The current meta-analysis was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search was performed using PubMed, EMBASE, and Cochrane Library to identify studies assessing the use of statins in patients with ICH. The primary outcome assessed in the current meta-analysis was a hemorrhagic stroke. The secondary outcomes included cardiac-related events and all-cause mortality. A total of 9 studies were included in the current meta-analysis enrolling 49027 patients, with 8094 patients on statin therapy and 40933 patients in the control group. The risk of recurrent ICH was significantly lower in patients receiving stains  compared to placebo. However, no significant differences were observed regarding all-cause mortality  and cardiovascular events . In ICH patients, statins can reduce the risk of recurrent ICH in patients with a history of ICH. However, statins had no significant effect on all-cause mortality and cardiovascular events. Intracerebral hemorrhage (ICH) is the second most common cause of stroke, followed by an ischemic stroke. Nearly 15% of all acute strokes are caused by ICH, which has a high case fatality rate . Initial The best way to treat ICH is to limit any further neurologic damage, which includes controlling hematoma growth and taking care of any neurologic issues as soon as they arise. The function of surgical and medical treatment is still up for debate . The penStatins can play an important role in the tertiary and primary prevention of cardiovascular events by reducing cholesterol in stroke patients . One ranTwo meta-analyses, including RCTs, found no significant relation between statin use and recurrent intracerebral hemorrhage. However, these meta-analyses reported a significant decrease in all-cause mortality and all-stroke types -12. SeveCurrently, the present recommendations for statin management in patients with ICH are unclear, and the evidence of its risks or benefits is insufficient. American Stroke Association and American Heart Association guidelines for ICH management recommended that insufficient data are there to recommend restrictions on the utilization of statins in patients with ICH that do not change from the past guidelines .Additional analysis is required to provide the highest recommendations or guidelines on statin utilization in ICH patients. The current meta-analysis will provide the most up-to-date and comprehensive evidence for managing patients with ICH, aiding in updating recommendations, putting light on future studies' direction, and guiding the selection of clinical strategies for healthcare professionals worldwide. This meta-analysis aims to assess statin therapy's effect on all-cause mortality and recurrence of ICH in patients with spontaneous ICH.MethodologyThe current meta-analysis was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.Search strategyA systematic search was performed using PubMed, EMBASE, and Cochrane Library to identify studies assessing the impacts of statins in patients with spontaneous ICH. The key terms used to search for relevant articles included: "statins", "intracerebral hemorrhage", "mortality," and "outcomes". The search was limited to RCTs, retrospective cohort and prospective cohort studies up to September 2022. Two investigators searched published studies independently, screened the abstracts and titles, and then identified potential studies as per the prespecified inclusion criteria to be included in the current meta-analysis. Eligibility issues were resolved via discussion. A search was also repeated to make sure completeness and accuracy.Eligibility CriteriaWe included all studies, including RCTs and prospective and retrospective cohorts, that treated individuals with ICH, including initiating, restarting, or discontinuing statins after ICH onset. Studies were included in the current meta-analysis if the patients' age was 18 years or more with a history of ICH. The intervention group included patients who received statin therapy, whereas, in the current group, patients received the standard treatment of a placebo. Studies with fewer than six months of follow-up periods were excluded from the current meta-analysis. Lastly, case-control studies, case reports, case series, editorials, and review articles were also not included in the current meta-analysis. The primary outcome assessed in the current meta-analysis was a recurrence of ICH, and the secondary outcomes included cardiac-related events and all-cause mortality.Data ExtractionData were extracted using a prespecified data extraction form developed on Microsoft Excel. Data extracted from the included studies for the meta-analysis included: first author name, year of publication, study design, groups, sample size, follow-up period, and outcomes. Data were extracted by two authors independently, and any disagreement between them was resolved by discussion.Data AnalysisData analysis was performed using Review Manager (version 5.4.0). Pooled treatment effects for binary endpoints were compared using risk ratios (RRs) and their 95% confidence intervals (CIs). Summary RRs were computed using Mantel-Haenszel random-effects models. The most cautious strategy is the random-effects model since it accounts for both within- and between-study heterogeneity. Forest plots were also drawn, demonstrating the estimates of each study and pooled estimates. A p-value less than 0.05 was considered significant. Heterogeneity was assessed using I-square statistics. Cochran-Q statistics were used to test heterogeneity, and a p-value less than 0.1 was considered significant.ResultsFigure The study characteristics are shown in Table Risk of Recurrent ICHA total of five studies reported data on recurrent ICH. The recurrent ICH was observed in 9.09% of patients -20,23-24Risk of All-cause MortalitySeven studies compared all-cause mortality between ICH patients who received statins and those who did not -22, 25. Risk of Cardiovascular EventsIn the two studies reporting on cardiovascular events -20, the DiscussionIn the current meta-analysis, we included nine studies enrolling 42193 patients. We found that statin use in patients with ICH had a beneficial impact in reducing recurrent ICH. For risk of all-cause mortality and cardiovascular events, no significant differences were between the patients who received statins and those who did not.ICH is a fatal disease with no particular treatment for improving the prognosis. The primary etiology of ICH can be categorized into cerebral amyloid vascular disease (CAA) and hypertension. Secondary risk factors of ICH are brain trauma, coagulation abnormalities, arteriovenous malformation, aneurysm, brain tumors, etc. . In clinThe anticoagulant and antiplatelet impacts of statins have raised questions that they may enhance the hazard of ICH. Statins have also been speculated to have potentially negative effects in acute ICH, where their varied pharmacological characteristics may help to increase hemorrhage . In two Predictably, among physicians, stroke utilization in patients after ICH remains argumentative. American guidelines recommended the use of statins in ICH patients because of insufficient data for advising restriction . On the other hand, European recommendations do not address this issue . The onlThe current meta-analysis has certain limitations: The sample is deficient for both observational studies and RCT for generating adequately powered pooled effects, particularly in the ICH cohort; More data was needed to analyze the type of statin and statin; High heterogeneity was reported in the study outcomes because of differences in study designs, follow-up periods, and population type; Due to the non-availability of individual-level data, we could not do a sub-group analysis. To form future guidelines, more RCTs need to be carried out to understand the impact of statins on patients with ICH. The current meta-analysis was conducted to discuss the effect of statins on the risk of ICH in patients with a history of ICH. The current meta-analysis found that statins can reduce the risk of recurrent ICH in patients with a history of spontaneous ICH. However, the current study did not find any significant effect of statin on all-cause mortality and cardiovascular events. The findings of the current meta-analysis were based on observational studies with only one post hoc analysis of RCT. Given that observational studies are subjected to biasness, future randomized control trials are required in patients with ICH survivors to clarify the impact of statins on the future risk of ICH.


This study aims to synthesize the empirical economic evidence of pharmaceutical therapies for people with dementia.Systematic review and meta-analysis. Literature evaluating the costs and effects of drug therapies for dementia was indexed until December 2021. Quality of study was assessed using the Cochrane Risk of Bias Tool and Consensus on Health Economic Criteria list. Cost data were standardized to 2020 US dollars and analyzed from healthcare service and societal perspectives. Random-effects models were used to synthesize economic and clinical data, based on mean differences (MDs) and standardized MDs.Ten unique studies were identified from 11,771 records. Acetylcholinesterase inhibitors (AChEIs) and memantine improved dementia-related symptoms, alongside nonsignificant savings in societal cost . Despite decreases in cost, antidepressants of mirtazapine and sertraline and second-generation antipsychotics were limited by their significant side effects on patients’ cognitive and activity functions. Subgroup analysis indicated that the impacts of AChEIs on cost were affected by different analytical perspectives, follow-up periods, and participant age.AChEIs and memantine are cost-effective with improvements in dementia-related symptoms and trends of cost-savings. More empirical evidence with non-industrial sponsorships and rigorous design in different settings is warranted.The online version contains supplementary material available at 10.1186/s12962-022-00354-3. Dementia is affecting over 47 million people worldwide, and it brings an economic burden of over US$1 trillion per year . BecauseBesides the clinical benefit of different medications for dementia, the cost-effectiveness of them is also a crucial issue for decision and policy making, especially when confronting the imbalance of growing healthcare needs and constrained resources in an aging society , 9. GiveThis review followed the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) , Centre Literature was searched from PubMed, Web of Science, EMBASE, Cochrane Library Database, Science Direct, SCOPUS, PsychoINFO, CINAHL, EconLit, NHS Economic Evaluation Database and three Chinese databases , from their inceptions to December 2021. Grey literature was retrieved from the OpenSIGLE website and the early detection and timely INTERvention in DEMentia website. Medical Subject Headings and natural terms related to “dementia”, “pharmacological” and “economic evaluation” were used in the search strategies, and the search results are presented , analytical perspective, sensitivity analysis, and quality of study. Cost data were compiled based on different perspectives and re-categorized into three types: intervention cost, healthcare utilization cost, and indirect cost of productivity loss or informal care , 15. TotThe quality of RCTs and non-randomized trials was assessed by the revised Cochrane risk-of-bias tool , 16 and Two investigators  independently screened the records for eligibility. Data were extracted by one investigator (Z.H) and double checked by another investigator (J.L). Quality of study was also assessed independently by the two same investigators. Any disagreements were first discussed by the two reviewers, and if unresolved, referred to the study team for consensus.The primary outcomes of interest were the incremental cost and effects of interventions relative to the controls. Heterogeneity across studies was examined through Cochran’s Q tests, with a cut-off P-level of 0.10. Publication bias was investigated through funnel plots and Egger's tests . QuantitPotential factors associated with the costs and effects were investigated in subgroup analyses, including participant characteristics, follow-up period, and social context. Univariate meta-regression was performed if there were enough studies. One-way sensitivity analysis was performed, where only RCT-based studies, only industry-sponsored studies, and only self-rating HRQoL scales were included in the analysis. Sensitivity analysis was also performed for economic evaluations that calculated cost data as a function of cognitive or activity scores based on clinical trials. Quantitative analyses were performed using the Meta procedures in STATA 16  . P-valueA total of 11,585 records were identified. The titles and abstracts of 10,616 unique records were screened, and 10,472 of them were excluded mainly due to irrelevance. The full text of 144 articles were retrieved. Of these, 134 were excluded due to duplications, inappropriate types of study, modeling studies, insufficient data, or other reasons. Ten publications based on ten unique studies were finally included , activity of daily living (n = 10), global deterioration (n = 7), BPSDs (n = 7), and HRQoL or quality-adjusted life years (QALYs) gained (n = 4); only one study investigated participants’ destination of institutionalization. Six studies employed full economic evaluations: two were cost-effectiveness analyses, and four performed both cost-effectiveness and cost-utility analyses. For cost collection, five studies adopted societal perspectives, two adopted healthcare service or payer perspectives, and three adopted both. In addition, three studies measured the healthcare utilization of informal caregivers.Among nine RCTs, five showed a low risk of bias, while three showed some concerns, and one showed high risk of bias   and the Five studies reported cost information from both healthcare and societal perspectives. After considering informal care among AChEIs, the direction of incremental cost of drug interventions altered from positive to negative, and the number decreased at a significant level    were more effective in BPSD symptoms , while these drugs used among older patients (mean age ≥ 75 versus < 75 years) were more cost-saving from societal perspectives  , the nuFor clinical practice, our findings support the routine use of AChEIs and memantine for patients with dementia. However, antipsychotics or antidepressants for patients with dementia should be prescribed with caution in the limited benefits on clinical and economic outcomes, accompanied by the significant side effects. For policy making, with aging populations and increasing new drugs approved for treating AD , the demands and related expense of dementia-related drugs will be predictably expanding. The clinical and cost-effectiveness of different dementia drugs requires re-scrutiny before updating recommendations or compensation policies. Although our results revealed the cost-effectiveness of AChEIs and memantine for treating dementia, the validity could be diluted by unexplored sources of heterogeneity and most studies sponsored by industrial entities. These should be considered in decision making. For future studies in this area, since current AD drugs have become parts of clinical guideline and placebo-control can be ethically prohibitive, more focus can be turned towards other innovative drugs , combined use of different drugs for severer dementia, combination of drug and non-drug therapies, and head-to-head comparisons between different medications. For example, the US Food and Drug Administration approved a new amyloid beta-directed antibody aducanumab  for treating AD recently in July 2021 . The cosAcetylcholinesterase inhibitors and memantine were found cost-effective with significant improvements in patients’ dementia-related symptoms, alongside nonsignificant savings in total societal cost. Antipsychotic and antidepressant drugs for patient with dementia had less impacts on cost; and they were limited by the side effects on patients’ cognitive or activity functions. Heterogeneity in the incremental cost and effects of AChEIs could partly be explained by different analytical perspectives, follow-up periods and baseline characteristics of participants. Future empirical studies independent from industrial entities were warranted on the cost-effectiveness of innovative drugs, combined use of different drugs, long-term impacts of interventions, and drug use in residential care settings and developing countries.Additional file 1. Supplementary contents.


Coronavirus disease 2019 is a pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that emerged in late 2019 and has activated an ongoing international public health emergency. SARS-CoV-2 was discovered in Wuhan, China, in December 2019 and rapidly spread to other cities and countries. Currently, SARS-CoV-2 diagnostic tests have relied heavily on detecting viral genes, antigens, and human antibodies. Hence, this review discusses and analyses the existing screening and confirmation tests for SARS-CoV-2, including the real-time reverse transcriptase polymerase chain reaction (RT-PCR), lateral flow immunoassay (LFIA), and enzyme-linked immunosorbent assay (ELISA).The illustrations of each testing were presented to provide the readers with an understanding of the scientific principles behind the testing methods. The comparison was made by highlighting the advantages and disadvantages of each testing. ELISA is ideal for performing the maximum population screening to determine immunological capacity, although its inability to provide reliable results on the status of the infection. Recently, LFIA has been approved as a quicker way of determining whether a patient is infected at the analysis time without using particular instruments and non-laboratory settings. RT-PCR is the gold-standard approach in terms of sensitivity and specificity.However, the combination of LFIA or ELISA with RT-PCR is also proposed in this review to obtain an adequate level of sensitivity and specificity. Coronavirus (CoV) is an enveloped virus with a positive single-stranded RNA genome and is pathogenically ranging from 60 to 140 nm in diameter with spike-like projections on its surfaces giving it a crown-like appearance under the electron microscope . The emeSince SARS-CoV-2 replicates in the upper respiratory tract, respiratory transmission is the most dominant mode of transmission . The virThe symptoms of COVID-19 symptoms range from mild to severe. Mild symptoms include fever, headache, nausea, sore throat, fatigue, loss of smell, and a runny nose. In addition to acute respiratory distress syndrome and respiratory failure, COVID-19 causes acute cardiac injury, systemic inflammation leading to sepsis, multiorgan dysfunction in high-risk patients, and heart failure . Many anDue to the rapid transmission and severity of COVID-19, sensitive, fast, and robust diagnostic tests for the detection of SARS-CoV-2 are vital for timely clinical intervention and limiting such infection and transmission. Failure to quickly detect infection and curb transmission would affect healthcare systems, particularly burnout of healthcare workers and overflow of the intensive care unit , 27. Thehttps://www.sciencedirect.com/), Scopus (https://www.scopus.com/), and Google Scholar (https://scholar.google.com/) in the most recent year (from 2019 to 2021) using PCR, RT-PCR, NAAT, LFIA, ELISA, reverse transcription polymerase chain reaction, lateral flow immunoassay, enzyme-linked immunosorbent assay, immunoassays for COVID-19, and COVID-19 diagnostic methods as keywords. Next, we synthesise the literature and provide a critique of selected SARS-CoV-2 detection tests, as well as evaluate the pros and cons of each of them. Lastly, the conclusion was made based on the current literature.In this study, we intend to discuss the methods being established for screening and diagnosis of COVID-19 that can be useful for early detection of SARS-CoV-2 infection and limit its transmission. The articles were first accumulated from ScienceDirect  into complementary deoxyribonucleic acid (cDNA) and amplifying the cDNA in the presence of reverse transcriptase, deoxyribonucleic acid (DNA) polymerase, specific primers, and free nucleotides Fig. . This reRT-PCR can be qualitative, semiquantitative, and quantitative, where qualitative RT-PCR is the most widely used for the diagnosis of COVID-19 . While aThe timeline of positivity by RT-PCR varies across the disease stage, where an infected individual is most likely to be detected positive during early symptom onsets . The intIn terms of tests for infection, RT-PCR is useful for confirming cases even before symptom onset due to its better detection rate (i.e. the ability to yield a positive result) than other diagnostic tools. However, infected individuals who are asymptomatic or presymptomatic may be unlikely to opt for RT-PCR testing due to its invasive swabbing method, costly, and not point-of-care nature. Given the relatively long mean incubation period of 5–6 days and the major infections that occur during the presymptomatic phase for the currently dominant Omicron variant, RT-PCR may not be the ideal test for rapid screening purposes . Nonethe. [Next, to decide whether an infected individual needs to be isolated or discharged from quarantine, tests of infectivity can be carried out through quantitative or semiquantitative RT-PCR. Infectivity is measured by looking at the Ct values from RT-PCR which generally correlate inversely with viral load. Indeed, studies investigating the association between Ct values and infectivity reported higher cell culture positivity (defined as an infectivity marker) for lower Ct values . Thus, d.  and Han . , differeLastly, tests of cure may be conducted to observe the patient’s status for isolation discharge purposes. However, some patients can still be detected as positive by RT-PCR of nasopharyngeal swab more than 8 weeks after symptom onset due to prolonged viral shedding, even though the median time for clinical recovery is only about 14–15 days after the symptom onset . Therefo. [The status of RT-PCR as a gold standard for COVID-19 diagnosis was previously challenged by a study by Wikramaratna et al.  reportin.  on vario. , 46.. [. [n = 39) and unvaccinated (n = 17). They did not observe differences between the two groups as infectious SARS-CoV-2 was detected in nearly all cultured samples. In contrast, a small study by Ke et al. [. [Although RT-PCR is widely used to categorise infectious and non-infectious individuals by relying on the general correlation between Ct values and infectivity, there are several issues with it. Firstly, an individual's viral load can be different among different clinical specimen types such as saliva and throat swab. Therefore, Ct values for infectivity should be used for specimen types that consistently report the highest viral load. A study by Sharma et al.  reported. [.  culturede et al.  and a prt al. [.  reportedAccounting for the mentioned problems associated with RT-PCR, we suggest that a negative result from RT-PCR needs to be interpreted with context and not be blindly taken as a true negative. The reported reduced sensitivity and moderate false negative rate need to be accounted for when using RT-PCR for diagnosing COVID-19 or as a reference standard in research . ClinicaAlternatively, other appropriate reference standards could be clinical suspicion, computed tomography (CT) imaging, serology, or Droplet Digital PCR (ddPCR), which showed a higher sensitivity than RT-PCR –54. ClinThe lateral flow immunoassay (LFIA) has gained increasing interest in diagnostic applications due to its numerous advantages that meet the WHO guidelines for diagnostic tests . LFIA F is generIn recent years, LFIA has gained considerable attention due to its advantages such as ease of use, short analysis time, economical, high sensitivity, specificity, and stability as point-of-care (POC) testing . There aUntil now, no study had described the diagnostic performance in NG-Test LFIA until Nicol et al.  used it In general, an antigen-based LFIA test is convenient for whole blood, serum, and plasma, which also decreases the risks of exposure to viral samples when diagnosing patients with COVID-19. Fingerpricking to obtain the blood of an individual makes this test user-friendly, as no professional personnel is required. These tests can be carried out in any public space at any desirable time. Furthermore, the LFIA test allows the screening of a large number of asymptomatic carriers in a short period. At the moment, with the emergence of the dominant highly transmissible Delta and Omicron variants having a test tool that allows large and quick screenings may appear to be the best option. COVID-19 can be distinguished from other respiratory viral infections, such as influenza, with the help of LFIA . In addiThere are a few limitations of LFIA which are essential to consider. Firstly, due to the low sensitivity of the tests, an antibody response to SARS-CoV-2 could result in a false negative result in the early stages of infection. Sensitivity can also decrease when tested against patients with low or mild symptoms of SARS-CoV-2 infection, as they are only capable of generating a small amount of antibodies. Aside from that, there are no IgG standards available, so assays cannot be improved from semiquantitative to accurate quantification . MoreoveEnzyme-linked immunosorbent assay (ELISA) is a bioanalytical technology that uses an antigen–antibody interaction to detect and quantify an analyte. In 1971, Engvall and Perlmann coined the term ELISA, which provided a method for analysing the concentration of Immunoglobulin G in human serum. Until now, the popularity of ELISA has remained . The sol. [ELISA is commonly used to detect and quantitate molecules  and study their molecular interactions . The des.  designed. [. [. [. [Giri et al.  stated t. , 86, 91.. [.  reported. [. [.  showed t[. [. [. , IgG inc. [. [ELISAs are not as precise as tests identifying viral RNA to detect COVID-19 infection in the early stage. This is because the use of ELISA in the early stage of infection to diagnose the antibody response to the SARS-CoV-2 virus could exhibit false negative results, as the patients' antibodies mostly develop in the recovery phase, which is the 2nd week of infection . As ment. , ELISA t. . Multipl. , and at . . Other t. [.  reported. [Generally, ELISA is appropriate for situations based on the following: (a) COVID-19 infection is suspected in patients who have a negative RT-PCR result but no significant epidemiological or clinical evidence; (b) patients who were detected after their symptoms onset for longer than 7 days; (c) contact tracing; (d) assessing possible immunity and the probability of protection against reinfection; and (e) seroepidemiological research to a better understanding on COVID-19 circulation in the community . As stat. , ELISA i. [Appropriate type and quantity of specimens have a significant impact on the accuracy of diagnostic tests such as RT-PCR, LFIA and ELISA. RT-PCR is generally applicable within a wide range of sample types for the diagnosis of many diseases, including COVID-19. According to several studies, SARS-CoV-2 RNA has been found in a variety of clinical specimens, including upper and lower respiratory tract specimens; faeces; blood serum; blood plasma; anal swab and corneal secretion , 104. Ho.  indicate. [Several lower respiratory tract specimens with high detection rates such as bronchoalveolar lavage, fibrobronchoscope brush biopsy, and endotracheal aspirate are not ideal due to the invasive sample collection method and high risk of infecting healthcare workers. Meanwhile, sputum was recommended in several studies and meta-analyses due to its high detection rate in hospitalised symptomatic patients , 105. Sh.  argued t. [. [Upper respiratory tract specimens, particularly oropharyngeal and nasopharyngeal swabs, have been widely used for community screening and discharge from hospitals. The gold-standard specimen to identify SARS-CoV-2 is a nasopharyngeal swab by RT-PCR, in part due to its high detection rate consistently found in different studies , 97, 98,. . Another. [.  also fou. [. , 107.. [. [. [Saliva specimen is the least invasive and easiest to collect compared to other specimens and allows for self-collection. Several meta-analyses have suggested that saliva is a comparable alternative specimens to nasopharyngeal swabs. An early meta-analysis by Czumbel et al.  suggeste. [.  also sup. [. [.  reported. [. [On the other hand, immunoassays for COVID-19 detection, such as LFIA and ELISA, typically use antibodies in the assay serum that react with SARS-CoV-2 protein in the specimen. According to MacMullan et al. , the Cen. . Saliva . . As ment. [. , IgG antAlthough RT-PCR, antigen-based LFIA, and ELISA have been used during the pandemic, many issues for the respective detection tools need to be addressed. The use of each tool as a screening and confirmatory test needs to be in line with the correct interpretation of the results, within the clinical and epidemiological context. RT-PCR is widely used as a confirmatory test, and many studies have addressed its reliability and sensitivity to detect SARS-CoV-2 infection and to measure the infectivity by Ct values. On the other hand, for immunoassays such as antigen-based LFIA and ELISA, their positivity only increases over time from symptom onset, with a large false negative during the early stages of infection. Therefore, enhancing immunoassays with higher sensitivity detection during the early phase of infection is necessary if they are to be used to detect early infection. With the Omicron variant that is even more transmissible in asymptomatic and presymptomatic individuals, we could not afford to have a screening assay that has a low diagnostic sensitivity. To obtain an adequate level of sensitivity and specificity, combining clinical, molecular, and serological tests may be the best as they can complement each other.


Somatic mutation co-occurrence has been proven to have a profound effect on tumorigenesis. While some studies have been conducted on co-mutations, a centralized resource dedicated to co-mutations in cancer is still lacking.Using multi-omics data from over 30 000 subjects and 1747 cancer cell lines, we present the Cancer co-mutation database (CoMutDB), the most comprehensive resource devoted to describing cancer co-mutations and their characteristics.http://www.innovebioinfo.com/Database/CoMutDB/Home.php.The data underlying this article are available in the online database CoMutDB:  Somatic mutation is one of the major factors of tumorigenesis . Varianthttps://depmap.org/portal/). The numerous subjects or cell lines were grouped by cancer type (TCGA), cohort (ICGC) or tissue site (DepMap), and we kept only datasets with a sample size ≥10.CoMutDB processed mutation data from three sources. Firstly, mutation data of 10 147 subjects from The Cancer Genome Atlas (TCGA) were downloaded from the Genomic Data Commons. Four types of survival data  for the TCGA subjects were extracted from TCGA Pan-Cancer Clinical Data Resource ; on the other hand, we obtain the values for phenotypic variable, survival and, if available, drug sensitivity for the same sample. We employ linear, logistic, or multinomial regression to infer associations between the co-mutation and a phenotypic variable that is continuous, binary, or categorical. We conduct Cox proportional hazard regression model to assess the prognostic value of the co-mutation. With DepMap cell-line data, we perform The CoMutDB database and its web portal were developed using MySQL, HTML, PHP and Javascript. CoMutDB allows the user to download pre-computed analysis results from our related work . For reaAdditionally, CoMutDB responds to user queries with real-time computation. Because CoMutDB absorbed multi-omics data from three distinct sources, we implemented a separate query page for each data source, where the user needs to select one or more datasets  to perform the query. Co-mutation query is enabled at the gene level rather than the position level. The most important input to the query service is a set of genes, from which co-mutation pairs are formed and possible associations with phenotypic variables, survival, and drug sensitivity are examined. CoMutDB can be queried by parameters including cancer type, tissue site, gene name, number of co-mutated genes (up to 4), mutation type .TP53 and KRAS’ is specified, the samples in the mutant group must exhibit mutations in both TP53 and KRAS genes. If ‘TP53 or KRAS’ is specified, the samples in the mutant group must harbor at least one mutation in either TP53 or KRAS. Upon the division of samples based on co-mutation status, CoMutDB integrates survival data, drug sensitivity, and other clinical characteristics  with the co-mutation status variable, and infers the statistical significance of the association between co-mutation and the various clinical characteristics. The outputs of CoMutDB are in tabular format and can be browsed or downloaded.The critical step of CoMutDB computation is to divide samples within one dataset into co-mutation mutant and wild-type groups. While a co-mutation typically involves two individual genes, our query service allows a co-mutation entity to comprise up to four genes. While a co-mutation typically refers to ‘concurrent’ mutations of individual genes, we can alternatively assert a co-mutation as long as any component gene is mutated. For a specific co-mutation, a logical operator  can be specified to define the relationship between the co-mutated genes. For example, if ‘The co-occurrence of somatic mutations reflects the concept of epistasis which describes any relationship of non-additive interaction between two or more genes in their combined effect on phenotype. In cancer, random mutations are jointly selected if they confer a fitness advantage over the existing genomic landscape. Co-mutations with positive epistasis result in a stronger fitness than the additive effects of the individual mutations. Consequently, such mutations are more likely to occur together within the same tumor. On the contrary, negative epistasis indicates that co-mutation has weaker fitness than individual effect. Previous studies have shown overwhelming evidence that the acquisition of multiple somatic mutations simultaneously can lead to substantial biological impacts. In many scenarios, the biological impacts can translate into stronger predictions of prognosis and varied drug sensitivity. CoMutDB is the first database dedicated to the curation and description of the landscape of mutation co-occurrence in cancers.This work was supported by the Cancer Center Support [P30CA118100 and R01ES030993-01A1] from the National Cancer Institute, USA.Conflict of Interest: none declared.


Tumor mutation burden (TMB) has been validated as a biomarker to predict the response of immune checkpoint inhibitors (ICIs) treatment in various cancers. However, the effects of different sequencing platforms, cancer types, and calculation algorithms on TMB as well as its cut-off value for predicting immunotherapy efficacy in the East Asian population still need to be further investigated. In this study, the data of 4126 samples generated by targeted panel sequencing or whole-exome sequencing (WES) in different platforms and public sequencing data from 3680 samples that contained targeted panel sequencing, WES and whole-genome sequencing (WGS) were obtained. The impact of different sequencing platforms and methods on TMB calculation was assessed. No significant bias was found in TMB calculated by different platforms. However, TMB calculated from WGS was significantly lower than those calculated from targeted panel sequencing and WES. The distribution of TMB at different sequencing depths and tumor purity were analyzed. There was no significant difference in the distribution of TMB when the sequencing depth was greater than 500, the tumor purity estimated by hematoxylin-eosin (HE) staining was between 0.1-1.0 or estimated by next-generation sequencing (NGS) was greater than 0.4. In addition, the somatic-germline-zygosity (SGZ) algorithm was optimized to calculate TMB from tumor-only sequencing samples in the East Asian population. The correlation coefficient of TMB calculated with the optimized SGZ algorithm and paired normal-tumor sequencing is 0.951. Furthermore, the optimal cut-off value of TMB in East Asian lung cancer patients treated with ICIs was determined to be 7 mut/Mb instead of 10 mut/Mb through the ROC curve and Log-rank analysis in the training cohort and validated in the test cohort. Patients with TMB ≥ 7 mut/Mb had better outcomes than patients with TMB<7 mut/Mb. In conclusion, this study systematically analyzed the factors that influenced the TMB calculation and optimized the SGZ algorithm to calculate TMB from tumor-only sequencing samples in the East Asian population. More importantly, the cut-off value of TMB for predicting immunotherapy efficacy was determined to be 7 mut/Mb instead of 10 mut/Mb in East Asian lung cancer patients, which can help in clinical decision-making. The advent of immune checkpoint inhibitors (ICIs), including anti-programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) and anti-cytotoxic T lymphocyte-associated antigen-4 (CTLA4), have revolutionized cancer therapy . HoweverThe expression of PD-L1 in tumor and/or tumor-infiltrating lymphocytes assessed by immunohistochemistry (IHC) is an established biomarker to predict efficacy in the treatment of ICIs across many cancer types including melanoma, non-small cell lung cancer (NSCLC) and colorectal cancer , 11. HowTumor mutation burden (TMB), which was defined as the number of all non-synonymous somatic mutations per megabase based on the genome examined, has been reported to predict the efficacy of ICIs therapy in multiple tumor types –17. The Currently, multiple platforms and sequencing methods have been used for next-generation sequencing (NGS) . HoweverIn this study, the effect of different sequencing platforms and methods on the calculation of TMB has been systematically evaluated. To calculate TMB for Asian patients with tumor-only sequencing, we optimized the SGZ algorithm and demonstrated the reliability of calculating TMB from tumor-only sequencing samples. Furthermore, the cut-off of TMB in Asian patients was determined and its efficacy in the treatment of ICIs has been investigated.Data for 4126 samples sequenced with different sequencing platforms and methods were obtained from a CAP-accredited laboratory  Table S1Sixty-two samples with matched control were retrospectively obtained to analyze the correlation coefficient of TMB calculated from methods of tumor-only sequencing and paired normal-tumor sequencing S5. To dGenomic profiling was implemented on tumor tissues and matched peripheral blood samples. The GeneReadDNA FFPE kit (Qiagen) and Qiagen DNA blood mini kit (Qiagen) were used to extract DNA from tumor specimens and blood, respectively. For tumor-only sequencing, DNA from the tumor sample was extracted with a GeneReadDNA FFPE kit (Qiagen). DNA quantification was performed with the dsDNA HS Assay Kit . For the platform of Illumina, sequencing libraries were built by SureSelect XT Human All Exon V6 (Agilent) for WES or a customized next-generation sequencing panel targeting exons of 1267 genes for panel sequencing, respectively. Sequencing procedures were utilized by the NextSeq 550AR platform with 150-bp paired-end reads. For the platform of MGI, sequencing libraries were built by Exome Plus Panel V1.0  for WES or a customized next-generation sequencing panel targeting exons of 1267 genes for panel sequencing, respectively. Sequencing procedures were utilized by the MGISEQ-T7 platform with 100-bp paired-end reads.Sequencing reads with > 10% N rate and/or > 10% bases with a quality score of< 20 were filtered using SOAPnuke (Version 1.5.6) . SomaticTMB was determined as the number of all nonsynonymous mutations and indels per megabase of the genome examined.To estimate the tumor purity by hematoxylin-eosin (HE) staining, the sample was fixed in the 10% formalin solution, embedded in paraffin. Then the 5 µm slide was stained with HE. The tumor purity is the value of tumor cells divided by all cells. To estimate the tumor purity by NGS, the sequencing reads were quality controlled using SOAPnuke (Version 1.5.6) , then alMutations from tumor-only sequencing samples were identified by the somatic-germline-zygosity (SGZ) algorithm. For each sample, massively parallel sequencing (MPS) variant analysis was executed to create a genome-wide copy number profile, which is segmented and modeled to estimate the ploidy (Ψ) and overall tumor purity (p), as well as per segment copy number (C) and minor allele count (M). The log-ratio of variants was defined by the following formula:For each variant, the error log ratio was obtained by calculating the absolute value of the difference in log ratio between variant and segments. Finally, the germline variant or somatic variant was identified mainly by frequency, purity and error log ratio. However, the cut-off value of the above parameter was fit to European and American populations, which resulted in a high false-positive rate in the East Asian population . In ordet-test was used to compare TMB values between different groups. Correlation analysis was performed using the Pearson correlation analysis. Roc-curve and Log-rank test analyses were conducted to determine the cutoff of TMB. Categorical variables were evaluated with the Fisher-exact test. Kaplan-Meier curve, Log-rank test, and Cox regression were used to determine the significance of TMB on overall survival (OS) and Progression-Free-Survival (PFS). Statistical significance was set at p-value< 0.05.All statistical analyses were implemented in Python (3.10.1). An independent To study the effect of different sequencing platforms and methods on TMB calculation, data of 4126 tumor samples sequenced with different platforms and methods were obtained. As shown in To investigate the effect of sequencing depth on TMB calculation, TMB calculated from lung cancer at different panel sequencing depths were analyzed. As shown in TMB calculation requires paired normal samples to remove germline mutations, which increases the cost of sequencing. In addition, in terms of clinical accessibility, paired normal samples are sometimes unavailable, which limits the clinical application of TMB. The SGZ algorithm for TMB calculation with tumor-only sequencing samples was designed based on European and American populations. To evaluate the accuracy of the SGZ algorithm for TMB calculation in East Asian populations, tumor tissues and matched peripheral blood samples from 62 patients including 43 lung cancer were collected and performed with targeted panel sequencing. The mean depths of tumor tissues and matched peripheral blood samples were 1027× and 455×, respectively Table S2The cut-off of TMB for predicting the efficacy of immunotherapy in European and American populations is 10 mut/Mb . HoweverTo further validate the TMB cut-off of 7 mut/Mb, genomic and clinical data of sixty-nine East Asian NSCLC patients treated with ICIs were collected . ConsistCurrently, different platforms and sequencing methods have been used to calculate TMB . HoweverMultiple studies have demonstrated that TMB is a predictive biomarker for immunotherapy in several types of cancers –17. HoweWhen sequencing depth increases, mutations with low variant allele frequency (VAF) will be identified, which suggests that sequencing depth may have an impact on TMB calculation. A previous study has reported that multiple mutations were missed when the sequencing depth was between 100× to 200× . In our Due to the costs of sequencing and lack of matched normal samples, many clinical samples are tumor-only sequenced. At present, several algorithms were developed to calculate TMB from tumor-only sequencing samples –24. HoweA previous study has investigated the racial differences in TMB and found that TMB cutoffs less than 10 mut/Mb may be more suitable for predicting response to ICIs in Asian populations . HoweverThere were several limitations in the study. First, the sample size used to correlate TMB calculated from tumor-only sequencing and paired sequencing was not very large, and further studies are needed to validate our optimized SGZ algorithm. Second, due to there was no other cohort that contained sufficient genomic and clinical data for patients with lung cancer in East Asian populations receiving ICIs, more researches are needed to further validate the cut-off value of TMB.In summary, we have systematically evaluated the effect of different sequencing platforms and methods on the calculation of TMB, and optimized the SGZ algorithm. Furthermore, the cut-off of TMB to predict the efficacy of ICIs in the East Asian population has been identified and validated in another independent cohort. Ongoing intense work is needed to further validate and optimize the cut-off of TMB in the East Asian population who are treated with ICIs.https://ngdc.cncb.ac.cn/gsa-human/browse/HRA003220.The datasets presented in this study can be found in online repositories via the following link: The study involving human participants was reviewed and approved by YuceBio Ethics Committee (2021-003-04). The patients/participants provided their written informed consent to participate in this study.Conception and design: DS and HL. Acquisition of Data: DS, MX, and CP. Analysis and interpretation of data: MX, CP, HT, PW, and DW. Wrote the manuscript: MX, CP, and HT. Revised the manuscript: DS and HL. All authors have read and agreed to the published version of the manuscript.This study was supported by Natural Science Foundation of Tianjin (NO.20JCYBJC01350). We would like to thank all the subjects and family members who gave their consent to present the data in this study, as well as the investigators and researchers at all relevant hospitals and study sites.Authors CP, HT, PW, DW, and HL were employed by the company YuceBio Technology Co.The remaining 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.