Dextrocardia poses challenges in the percutaneous coronary intervention, particularly through radial access. The presence of chronic total occlusion further adds to the technical difficulties in such cases due to unfamiliar orientations of the coronary arteries, guide catheter instability, and problems in advancing the hardware across the occluded lesions.We report here a successful percutaneous intervention in a chronic total occlusion of the left anterior descending coronary artery, done through right radial access in a patient with situs-inversus and dextrocardia.The trans-radial percutaneous intervention approach is safe and feasible in patients with dextrocardia. Pre-planned imaging strategies and the choice of appropriate hardware tremendously help in successfully completing the intervention in such cases. Percutaneous coronary intervention (PCI) through trans-radial access (TRA) is favored by the interventional cardiologists across the globe, but the presence of situs-inversus-totalis makes it challenging, mainly due to the difficulties encountered in achieving co-axial positioning of the guide catheters. Right TRA further alters the catheter course at the subclavian artery take-off from the aortic arch because of the unusual angular relationship between the two vessels.We report here a successful PCI in chronic total occlusion (CTO) of the left anterior descending (LAD) coronary artery, done through right TRA, in a patient with situs-inversus and dextrocardia.A 59-year-old gentleman, a known case of mirror-image dextrocardia, presented with chronic stable angina that was partially responsive to medical therapy. The pain was retro-sternal and radiated to the right shoulder. There were no conventional risk factors for ischemic heart disease. A 12-lead electrocardiogram was consistent with dextrocardia and was otherwise unremarkable. Coronary angiography was done through the right radial access using 5F TIG- Optitorque® catheter . It demonstrated a 100% stenosis in the mid-segment of LAD with Rentrop grade 2 collaterals Figures , Video 1We decided to perform PCI to LAD through right radial access. Cannulation of the left coronary artery (LCA), situated on the right side in this case, was attempted using a 6F 3.5 curve Extra-backup coronary guide-catheter  by maneuvering it with counter directional rotations, i.e. wherever clockwise rotation works in normal situs, the counter-clock rotation was performed and vice versa. This method failed to position the catheter selectively into the coronary ostium. In order to achieve selective LCA cannulation, the catheter was advanced into the respective sinus with counter-clock rotation and then was pushed up from the aortic root with simultaneous clockwise rotation. This maneuver positioned the catheter in the aortic sinus in a way that it faced the LCA ostium Video .Following this, a 0.14 inch-180 cm Sion Blue  guidewire was advanced into the septal artery and used as an anchor, over which the catheter could be advanced to a desirable coaxial position into the LCA ostium Video .In order to make the CTO anatomy clearer and to achieve vessel orientation closer to normal, we acquired further images with right-left image inversion on the screen  and, at the same time, reversed the horizontal angles of image-intensifier (camera) position, while maintaining the conventional cranial-caudal angles. In this way, the camera position in caudally tilted right-anterior-oblique (RAO) angle provided coronary image resembling spider view Figure , while iAfter adequate imaging, crossing of the CTO was attempted using another 0.014 inch-180 cm Sion Blue wire. The initial failure of this wire necessitated the support of a 1.25x6 mm semi-compliant balloon, using which the proximal cap of the CTO could be penetrated  double inversion modification while imaging, i.e. use of right-left image inversion in combination with camera positioning at horizontally opposite angles, substantially improves the ease of angiographic interpretation; (b) back-up catheters should always be preferred; in case of encountering difficulty in coaxial catheter positioning, support techniques  should be employed instead of switching to catheters with a sub-optimal back-up; (c) counter directional rotation of catheters is instrumental in cannulation of coronary ostia; (d) extension catheters like Guideliner™ or Guidezilla™ may provide extra support if needed; (e) lubricious wires with soft tips are good for approaching the proximal cap, but need balloon or microcatheter support for penetrating and traversing the CTO.Right transradial access for PCI in dextrocardia is safe and practical. The knowledge of the atypical presentation of angina pectoris and other difficulties associated with the diagnosis of IHD in dextrocardia patients may help in the early identification and management of the disease. Pre-planned imaging strategies and appropriate choice of hardware tremendously help in successfully completing PCI in such cases.


Rapid global COVID-19 pandemic response by mass vaccination is currently limited by the rate of vaccine manufacturing. This study presents a techno-economic feasibility assessment and comparison of three vaccine production platform technologies deployed during the COVID-19 pandemic: (1) adenovirus-vectored (AVV) vaccines, (2) messenger RNA (mRNA) vaccines, and (3) the newer self-amplifying RNA (saRNA) vaccines. Besides assessing the baseline performance of the production process, impact of key design and operational uncertainties on the productivity and cost performance of these vaccine platforms is quantified using variance-based global sensitivity analysis. Cost and resource requirement projections are computed for manufacturing multi-billion vaccine doses for covering the current global demand shortage and for providing annual booster immunisations. The model-based assessment provides key insights to policymakers and vaccine manufacturers for risk analysis, asset utilisation, directions for future technology improvements and future epidemic/pandemic preparedness, given the disease-agnostic nature of these vaccine production platforms. This pipeline has the following main parts: (1) pre-clinical development and testing, (2) clinical development and testing, (3) production process development, scale-up and technology transfer for the manufacturing of the vaccine active ingredient , (4) sourcing of raw materials and consumables for manufacturing both the DS and the final packaged vaccine product filled into glass vials or other containers (fill-to-finish processes), (5) DS production under current Good Manufacturing Practices (cGMP), (6) fill-to-finish processes under cGMP, (7) vaccine distribution and (8) vaccine administration to the population4.The COVID-19 pandemic, caused by the SARS-CoV-2 virus, created an unprecedented demand for rapid, large-scale vaccine deployment that the world is struggling to meet. This urgency and scale of immunisation against a new disease poses enormous challenges on the entire vaccine deployment pipeline6. In response to this, vaccine manufacturing for pandemic-response production started “at risk”, before the completion of clinical trials7 and before the development, optimisation and scale up of production processes1, leading to large uncertainty in the DS amount per dose and number of doses per person. Tackling future virus variants will furthermore require new vaccine designs, while manufacturing needs to be low-cost to enable rapid mass immunisation worldwide8.Global COVID-19 vaccination programmes have been constrained by vaccine manufacturing capacity, particularly in low- and middle- income countries14. Because only the genetic instruction and not the antigen is produced, the vaccine production processes serve as platform technologies. A platform technology implies that once validated and established at production scale, the same production process can produce a wide range of different vaccines and vaccine candidates against both known and future pathogens. The AVV and mRNA vaccine platforms have matured in terms of technology development and have reached a technology readiness level (TRL) of 8 C or higher15. On the other hand, the saRNA vaccine platform is currently in clinical development (TRL between 6 C and 7B)15, as currently no saRNA vaccine has demonstrated efficacy against SARS-CoV-2 or any other disease. To enable rapid vaccine development it is also crucial to enable fast antigen identification and design, ideally by using prioritisation and prior knowledge from prototype pathogens17. For this, antigenic target knowledge, virology knowledge, assays for pre-clinical and clinical development, animal models and other learnings can be transferred to develop vaccines against similar pathogens, for example from the same family, genus, species or group17.The focus of this paper is on the manufacturing processes for adenovirus-vectored (AVV), messenger RNA (mRNA), and the newer self-amplifying RNA (saRNA) vaccines. These vaccines contain genetic instructions, in the form of DNA for the AVV vaccine and RNA in case of the mRNA and saRNA vaccines, based on which the cells of the human body produce the vaccine antigen, such as the spike protein of the SARS-CoV-2 virus20.Herein, key uncertainties and their impact on COVID-19 vaccine production are analysed and the production process scales, timescale and manufacturing resources required for producing 1 billion COVID-19 vaccines per year are estimated. These estimates can serve as a basis for calculating the requirements to produce vaccines for global demand. Three fill-to-finish technologies are also evaluated with respect to their pandemic-response manufacturing performance: conventional fill-to-finish in 5-dose or 10-dose vials, blow-fill-seal in single-dose vials, and the new 200-dose bag Intact™ Modular Filler22. Because the relevant technologies and their productivity  vary enormously across the three vaccines, two key performance indicators (KPIs) are used for their comparison on an equal basis: annual production (doses per year), and cost per dose (USD per dose). The effect of key model input uncertainties on these KPIs are also quantified using global sensitivity analysis25. Finally, the batch production rates are estimated for each technology, as the shorter these are, the faster vaccines can be made available for administration. The results of this study can inform policy makers and vaccine manufacturers on how to improve manufacturing and asset utilisation against COVID-19 and its variants, but also against future outbreaks due to the disease-agnostic nature of these vaccine production platforms26.The mathematical models used to conduct the assessment are representative of industrial COVID-19 vaccine manufacturing processes and compliant with cGMP regulationsThe AVV, mRNA and saRNA DS production processes (primary manufacturing) and fill-finish processes are described in Supplementary Section 29 was conducted to quantify how uncertain input factors propagate to KPIs, then aportion the resulting KPIs variation ranges back to each input factor as sensitivity indices to reveal any synergetic/antagonistic effects29  and total effect (St) sensitivity indices indicates that all input factors have predominantly separable (additive) effects on the KPIs, that is, interactions between multiple factors on the KPIs are minor.In both mRNA and saRNA cases, the annual production amount depends mostly on the RNA amount per dose, followed by the production scale cf. Fig. . The smaThe sensitivity analysis reveals that process scale is the key lever for increasing the AVV vaccine annual production amount and reducing its cost per dose, followed by the production titre and the AVV amount per dose. Scaling up the AVV production process would further increase the already high capital expenditures  with each technology and the corresponding productivities are compared in Fig. In a facility with a single production line cf. Fig. , the AVV6 doses L−1 yr−1) is predicted to be 20 times more productive than the mRNA platform , which is itself 200–300 times more productive than the AVV platform . This large productivity difference between RNA and AVV platforms is due to the highly concentrated, cell-free nature of RNA production and its considerably shorter batch cycle times. The productivity difference between mRNA and saRNA vaccines is due to the substantially lower amount of RNA per dose of saRNA vaccine. The right skew of the probability distributions in Fig. The AVV platform relies on cell-based production, which introduces more biological variability and is more prone to failure compared to the mRNA and saRNA platforms. This was taken into account through a uniform failure-rate distribution between 0 and 15% for AVV production and 0–10% for mRNA and saRNA production. To capture the difference in production scale across the three vaccine platforms, another comparison in terms of their specific productivity (expressed in million doses produced per year and unit bioreactor working volume) is presented in Fig. 34, in which case fill-to-finish would be further delayed relative to the start of production campaign. Bottlenecks in the DS manufacturing depend on the specific vaccine platform technology. For AVV, the bottleneck is caused by the time needed by the mammalian cell culture to reach sufficient amount for the production bioreactor. For mRNA and saRNA, the bottleneck lies in the LNP formulation operations. The equipment used for the LNP formulation can be microfluidics36, impingement jet mixers31, T-junction mixer36, multi-inlet vortex mixers37 or pressurised tanks30. Herein, the LNP unit operation was modelled based on times required for parallelised microfluidics LNP formulation devices and the cost of the four lipids was estimated. But substantial additional license fees might be payable for the ionisable lipid. This bottleneck may be removed by increasing the size  or the number  of parallel equipment for the formulation unit operation. In addition, mRNA vaccine production is most effectively enhanced by reducing the mRNA amount per vaccine dose, given the multiplicative-inverse relationship between annual production amount and amount per dose  framework could help streamline vaccine manufacturing by building quality assurance into the design and operation of the production processes, which is currently limited by lack of suitable process analytical technology (PAT)20 may also shift the production bottleneck. In combining a single AVV DS production line with a single 10-dose vial filling line , the bottleneck is in the DS production under the baseline scenario . Lastly, combining one saRNA DS vaccine production line with a single fill-to-finish line into 5-dose vials  would shift the production bottleneck to the fill-to-finish stage. This saRNA fill-to-finish bottleneck could in principle be removed in the future by using technologies such as the new 200-dose bag Intact™ Modular Filler20.Importanly, fill-to-finish technologies . Since the AVV platform is commonly deplayed at scales of 2000 L bioreactor working volume or above, it requires a low number of batches to meet the production target .Of the three technologies, the AVV platform is predicted to have the highest CapEx  to produce 1 billion vaccine DS doses per year. The AVV platform also requires the largest production scale , and second highest OpEx , highest OpEx , second highest CapEx  and second highest production scale . These cost and productivity KPIs are based on 30 µg mRNA per dose (cf. BioNTech/Pfizer) and would thus be less favourable for a higher mRNA amount per dose , given the inverse proportional relationship between annual mRNA DS production and amount per dose . It would furthermore require the lowest production scale  and, depending on the uncertainty realisation, the smallest number of batches  as well.An saRNA platform would require both the lowest CapEx  and lowest OpEx  instead of the 5' capping analogues46. All of these raw material costs are expected to decrease over time as technologies and supply chains mature.The OpEx of the mRNA and saRNA vaccines is driven by the high material costs, due to the novelty and limited supply of some of the specialised raw materials. These include the 5' capping reagents , modified nucleotides (e.g. pseudouridine triphosphate used for the manufacture of Moderna and Pfizer/BioNTech Covid-19 vaccine), cationic lipids used in the LNP formulations, plasmid DNA and T7 RNA polymerase enzymes−1, cf. Table The production cost per dose, including fill-to-finish, is 0.54 USD for AVV vaccine in 10-dose vials and 2.39 and 0.39 USD for mRNA and saRNA vaccine, respectively, in 5-dose vials 50.In principle, the DS amount per vaccine dose could be reduced, not only for mRNA vaccines but also AVV vaccines, which would improve manufacturability of second and third generation vaccines. This could be achieved by (i) designing more effective mechanisms to deliver the RNA or DNA payload into the cells, by improving the synthetic (e.g. LNP) and viral vectors, respectively, or (ii) enhancing antigen expression levels from the RNA or DNA for example by codon optimisation and by designing more effective untranslated regions on these genetic constructs52. These deleterious impacts can be mitigated by comparatively small investments to cover the capital and operating costs of vaccine manufacturing, as well as complementary investments for pathogen/antigen-specific research and development, pre-clinical and clinical development, distribution, storage, and administration of vaccines53. Ideally, such investments should be made in anticipation of a pandemic, considering the timescale required to build such manufacturing capacity over several years1. Manufacturing capacity based on platform technologies such as RNA and AVV could also be used for producing a wide range of vaccines over their lifetime. Besides financial resources, key raw materials , expertise and facilities are also in limited supply. Refer to43 for an analysis of the material, consumables, labour and facility requirements for mass-producing mRNA vaccines for pandemic response.The cost of establishing new production capacity based on any of the three platform technologies outweighs pademic-associated costs by several orders of magnitude when considering the mortality, healthcare burden, and economic recession caused by the COVID-19 pandemic. In particular, the pandemic cost on the global economy has been estimated at over 10 trillion USD55. It is crucial, therefore, to manufacture and supply lifesaving vaccines against all vaccine-preventable diseases and to minimise the disruption in manufacturing of non-COVID-19 vaccines. This is even more important in the likely scenario of needing seasonal COVID-19 booster doses to immunise adults at risk of severe COVID-19 and frontline workers in the foreseeable future56. The global population that is vulnerable to COVID-19, including people aged over 60 and adults with underlying medical conditions, adds up to around 2.2 billion57. With an additional 200 million frontline personnel needding to also be immunised for preventing the spread of the disease57, an estimated 2.4 billion COVID-19 vaccine doses would be required annually in the single-dose booster scenario. The resource required to produce this many annual booster vaccinations using either of the three platform technologies are illustrated in Supplementary Fig. A large share of the COVID-19 vaccine shortfall is likely to be met by adapting or re-purposing manufacturing facilities used to manufacture other vaccines and biopharmaceuticals pre-pandemic. However, the healthcare impact of not sustaining routine childhood immunisations could quickly outweigh that of the COVID-19 pandemic, especially in Africa58. For instance, it was found that the concomitant COVID-19 vaccination (ChAdOx1 or BNT162b2) with seasonal influenza vaccines raises no safety concerns and preserves the immune response to both vaccines in adults59. The UK Joint Committee on Vaccination and Immunisation recently advised that the flu vaccine may be co-administered with a booster or third dose of a COVID-19 vaccine60. In the longer term a multivalent COVID-19—influenza vaccine could also be developed. Although manufacturing multivalent vaccines comes with similar complexities and costs as manufacturing several monovalent vaccines, this would allow for the influenza vaccine itself to be produced on demand for the strain in circulation, without the need of forecasting the 3–4 most prevalent influenza strains more than 6 months ahead of the vaccination campaign62.By investing in dedicated COVID-19 vaccine production facilities for supplying the annual COVID-19 booster vaccination, the severe healthcare impact of other vaccine-preventable diseases could be minimised by reinstating the production scale of other vaccines and biopharmaceuticals. Using the RNA and AVV platforms, booster COVID-19 vaccines may be produced relatively quickly, as may the production of new vaccines against emerging variants . A feasible option would be to combine the annual COVID-19 booster dose with the annual influenza vaccine into a multivalent vaccineHow financially viable maintaining surge vaccine manufacturing capacity during non-pandemic times is, depends on the ratio between the fixed and variable costs of a vaccine technology. Fixed costs, such as facility-dependent costs and labour, dominate AVV vaccine manufacturing as well as other cell-based vaccines and biopharmaceuticals stability of RNA vaccines could furthermore improve their deployability across the globe51. Overall, such model-based assessments could inform policymakers and vaccine manufacturers on the level of risk and on how to improve manufacturing and asset utilisation against COVID-19 and its variants. Finally, deployment of platform technologies dedicated to COVID-19 vaccine production could prevent a reduction in manufacturing throughput of other, non-COVID-19 vaccines and therapeutics, while enabling rapid-response vaccine development and production against a future epidemic or pandemic outbreak.The model-based assessment herein predicts that investments ranging from hundreds of millions to a few billion USD would be necessary to meet the current global projected vaccine shortfall and annual booster vaccination production. Albeit substantial, these investments remain marginal in regard to the mortality, healthcare and economic cost of the COVID-19 pandemic, estimated at over 10 trillion USDThe modelling of AVV, mRNA and saRNA DS production as well as drug product fill-to-finish was carried out using SuperPro Designer  by Intelligen, Inc. Further details are available in the Supplementary Information document.70, patent databases73, from cGMP grade material suppliers75 and from experts78. Information regarding mRNA DS amount per dose was based on clinical trial databases82 and the scientific literature83. For saRNA vaccines the DS amount per dose was obtained from the clinical trial registry84. Information on AVV vaccine production was obtained from the scientific literature88. The AVV vaccine production process was modelled based on the manufacturing of the replication-deficient chimpanzee adenovirus-vectored (ChAdOx1) vaccine which was co-developed by Oxford University and AstraZeneca plc. Information on AVV DS amount per dose was based on clinical trial databases95. Similar process and cost modelling analyses of AVV and mRNA COVID-19 vaccine production processes have also been recently and independently published97. Information on fill-to-finish technologies was obtained from the literature100, equipment suppliers102 and industry experts104. Additional production process data for all DS and drug product manufacturing processes were retreived from the equipment, materials, utilities and cost databases in SuperPro Designer105. The annualised CapEx is included in the OpEx. The CapEx value is also presented individually, in order to illustrate the financial requirements for building new facilities.Information regarding mRNA and saRNA vaccine production processes and costs was obtained from the scientific literature106 under MatLab R2020a. 10,000 quasi-random scenarios were generated using Sobol sequences107 according to the process parameter ranges and distributions in Table 109 based on which the main-effect and total-effect Sobol indices were derived24. A further 1250 uncertainty scenarios were simulated in SuperPro Designer to test the predictions of the metamodel. The link between SobolGSA and SuperPro Designer was enabled by a Component Object Model interface in MS-Excel VBA available from MS-Office 365 Enterprise. Further details are available in the Supplementary Information document. Data processing and visualisation/plotting is also described in the Supplementary Information document.Variance-based global sensitivity analyses were conducted using SobolGSA Version 3.1.1Further information on research design is available in the Supplementary Information DocumentREPORTING SUMMARY


Biomarkers of tobacco exposure are known to be associated with disease risk but previous studies are limited in number and restricted to certain regions. We conducted a nested case–control study examining baseline levels and subsequent lung cancer incidence among current male exclusive cigarette smokers in the Golestan Cohort Study in Iran. We calculated geometric mean biomarker concentrations for 28 matched cases and 52 controls for the correlation of biomarker levels among controls and for adjusted odds’ ratios (ORs) for lung cancer incidence by biomarker concentration, accounting for demographic characteristics, smoking quantity and duration, and opium use. Lung cancer cases had higher average levels of most biomarkers including total nicotine equivalents (TNE-2), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and 3-hydroxyfluorene (3-FLU). Many biomarkers correlated highly with one another including TNE-2 with NNAL and N-Acetyl-S-(2-cyanoethyl)-L-cysteine (2CYEMA), and N-Acetyl-S-(4-hydroxy-2-buten-1-yl)-L-cysteine (t4HBEMA) with N-Acetyl-S-(3-hydroxypropyl-1-methyl)-L-cysteine (3HMPMA) and N-Acetyl-S-(4-hydroxy-2-methyl-2-buten-1-yl)-L-cysteine (4HMBEMA). Lung cancer risk increased with concentration for several biomarkers, including TNE-2  and NNN , and estimates were significant after further adjustment for demographic and smoking characteristics for 2CYEMA , N-Acetyl-S-(2-carbamoylethyl)-L-cysteine (2CAEMA) , and N-Acetyl-S-(2-hydroxypropyl)-L-cysteine (2HPMA) . Estimates were not significant with adjustment for opium use. Concentrations of many biomarkers were higher at the baseline for participants who subsequently developed lung cancer than among the matched controls. Odds of lung cancer were higher for several biomarkers including with adjustment for smoking exposure for some but not with adjustment for opium use. For example, Church et al.  conducteThis study examines urinary biomarker levels and lung cancer risk utilizing the resources provided by the Golestan Cohort Study (GCS), a population-based prospective cohort study conducted in the Golestan Province of northeastern Iran . Prior aSlightly more than 50,000 residents of the Golestan Province aged 40 to 75 years were recruited for the GCS between 2004 and 2008 . ApproxiGCS participants were monitored after the study enrollment through annual telephone interviews and home visits through the end of 2017 . In the This analysis used the resources provided by the GCS to perform a nested case–control study examining the relationship between biomarkers of exposure and lung cancer risk. Up until 1 January 2018, a total of 116 probable cases of lung cancer accrued in the cohort. We used risk-set sampling to randomly select two controls for each case, matched by tobacco use, age, sex, place of residence , enrollment period, and duration of the follow-up in the cohort. For the duration of the follow-up, the cases were matched with the controls from the same enrollment period who did not have lung cancer at the time of lung cancer diagnosis. The analysis was limited to current exclusive cigarette smokers who reported daily or non-daily smoking, smoked at least once a week for at least six months, and never used a waterpipe tobacco or nass at the time of enrollment. Participants could not have been diagnosed with lung cancer and were free of other cancers at baseline. A previous study of mortality risks among tobacco users in the GCS found that the exclusion of cases occurring during the first two years of the follow-up did not affect estimates , as wereThe measurement of biomarkers in the baseline urine samples was conducted at the Division of Laboratory Sciences of the National Center for Environmental Health at the CDC and detailed information about the assay methodology has been presented previously . Panels 2). Opium is used in various forms in the region and can be ingested, injected, or smoked [Ever regular use of a substance including cigarettes, opium, and alcohol was defined as having ever used at least once a week for at least six months. Socioeconomic status was assessed using quartiles of a previously developed wealth score based on characteristics such as occupation and ownership of property, vehicles, and appliances . Other cr smoked .P-values were calculated using two-sided chi-squared tests for differences of frequencies and two-sided t-tests for differences of means. Values less than 0.05 were considered statistically significant. Multiple comparisons of biomarker concentrations were controlled for with Benjamini and Hochberg’s False Discovery Rate procedure [p-value, 0.05 * , was calculated and the null hypothesis of no difference between log-transformed means was rejected if the unadjusted p-value was less than or equal to the adjusted p-value. The correlation between biomarker values for controls was calculated as the Pearson correlation coefficients of creatinine-corrected and log-transformed biomarker values. Associations between log-transformed biomarker concentrations and lung cancer incidence were analyzed using conditional logistic regression analysis. This analysis involved accounting for the matching and adjusting for the log-transformed creatinine values as a covariable and then sequentially adjusting for the demographic characteristics of education and ethnicity; demographic characteristics and the regular use of opium; demographic characteristics, CPD, and years of cigarette smoking; and demographics characteristics, opium use, smoking quantity, and duration. The results represent the change in lung cancer risk associated with one log-unit change of the relevant biomarker.The distribution of demographic and substance use characteristics, mean age at smoking initiation, mean CPD, and geometric mean biomarker concentrations were calculated for the cases and controls. Biomarker concentrations were adjusted by dividing by urinary creatinine as a measure of hydration. The means and 95% confidence intervals of the log-transformed values were calculated and exponentiated to obtain geometric means and confidence intervals. Biomarker levels below the limit of detection were replaced by the limit of detection divided by the square root of 2 . For mosrocedure . An adjuIn this study of male exclusive cigarette smokers in Iran, the majority of whom were from rural areas, concentrations of most tobacco-related biomarkers including TNE-2, NNAL, and 3-FLU were higher among the lung cancer cases than controls. Many of the biomarkers were highly correlated with one another, including TNE-2 with NNAL and 2CYEMA and t4HBEMA with 3HMPMA and 4HMBEMA, as nicotine NNAL, and the VOC parent compounds are found in substantial quantities in cigarette smoke . Odds ofThis analysis provides additional evidence and information concerning the relationship between tobacco biomarker concentrations and lung cancer incidence, using a cohort study in the Middle East, notably an area that has not been previously studied for this purpose. Previous studies utilized data from the PLCO, Shanghai, and Singapore cohorts ,12,13,14There are some differences between these results and those of the previous studies, especially for the TSNAs and PAH metabolites. Some of these biomarkers have previously been found to be associated with lung cancer risk even after adjusting for smoking history and levels of other biomarkers. For example, previous studies have found significant associations between NNAL and lung cancer risk among smokers in the PLCO cohort , the ShaOne particularly important aspect of these results is the prevalence of regular opium use especially among the cases and the lack of significant results in the regression analyses adjusted for opium use. Opium use has been found to be associated with the incidence of lung cancer and cancer overall in the Golestan study  and has Other characteristics of the present study’s population could also account for some of the differences between these results and those of previous studies. Particular characteristics of nicotine and other biomarker metabolism among study participants could affect results given that certain genetic alleles have been linked to nicotine metabolism and lung cancer risk in regions such as China and Japan . NNAL coAssociations between biomarkers of exposure and lung cancer risk, controlling for smoking exposure, could have various interpretations. They could suggest that variations in concentrations of specific biomarkers have particular effects on cancer incidence even with adjustment for the effects of smoking generally. They could also suggest that there is a misclassification of the smoking status or there is residual confounding due to insufficient characterization of smoking exposure, or that sources other than smoking contribute to the biomarker concentrations.This study has certain limitations. As noted, the sample size of lung cancer cases and thus matched controls was limited, reducing power to detect statistically significant results. Many of the biomarkers in the same classes such as TSNAs and PAH and VOC metabolites were highly correlated with one another, resulting in a difficulty to isolate and identify the portion of increased lung cancer risk that was due to particular biomarkers. Biospecimens were collected at baseline and biomarker concentrations may not reflect the total exposure to constituents over time. A subset of GCS participants provided a follow-up urine sample after an average of five years and biomarker concentrations among continuing smokers were highly correlated . FinallyFuture research could expand on this analysis in this and other cohorts, ideally with a larger sample size. Research of this nature on the association between biomarkers of tobacco exposure and disease risk is informative for public health organizations and government agencies as it provides information on the contribution of specific constituents and toxicants regarding the health effects of tobacco products. Such results can thus be used to inform tobacco control efforts as well as government policies and regulations concerning tobacco products.Levels of several biomarkers were higher in lung cancer cases than among the controls in a study of male exclusive cigarette smokers in the Golestan Cohort Study in Iran. Some of these biomarkers were associated with lung cancer risk after adjusting for smoking duration and quantity but not after adjustment for opium use.


The impact of Covid-19 pneumonia caused by SARS-CoV-2 on transplanted populations under chronic immunosuppression seems to be greater than in normal population. Clinical management of the disease, particularly in those patients worsening after a cytokine storm, with or without allograft impairment and using available therapeutic approaches in the absence of specific drugs to fight against the virus, involves a major challenge for physicians. We herein provide evidence of the usefulness of high-dose intravenous immunoglobulin (IVIG) combined with steroid pulses to successfully treat a case of Covid-19 pneumonia in a single-kidney transplanted patient with mechanical ventilation and hemodialysis requirements in the setting of a cytokine storm. A rapid decrease in the serum level of inflammatory cytokines, particularly IL-6, IL-8, TNF-α, MCP-1 and IL-10, as well as of acute-phase reactants such as ferritin, D-dimer and C-reactive protein was observed after the IVIG infusion and methylprednisolone bolus administration with a parallel clinical improvement and progressive allograft function recovery, allowing the patient’s final discharge 40 days after the treatment onset. The immunomodulatory effect of IVIG together with the anti-inflammatory and immunosuppressive potential of steroids could be an alternative strategy to treat severe cases of Covid-19 pneumonia associated with an uncontrolled inflammatory response in transplanted populations. Although the majority of Covid-19 disease clinical manifestations range from asymptomatic to mild respiratory infections, an important number of patients undergo symptomatic or severe pneumonia with acute respiratory distress syndrome (ARDS) and concomitant life-threatening complications . In suchcytokine-storm) may be associated with a worsening of the clinical syndrome involving multiple organ failure and higher rates of fatal outcomes. Accordingly, a reasonable therapeutic approach should be addressed to limit the collateral host-tissues damage promoted by the hyperinflammatory state, beyond the use of drugs specifically targeting the virus or advanced life-support measures.One of the most relevant findings amongst patients with more severe forms of the disease is the presence of high levels of circulating cytokines and subsequent acute-phase reactants , suggestth March with a 5-day history of fever and dyspnea unresponsive to paracetamol and levofloxacin intake  and everolimus (EVE), baseline serum creatinine of 1.2 mg/dL and estimated glomerular filtration rate of 67 mL/min, was admitted to Emergency Room on 19n intake Figure 1cytokine-storm. In this setting, a three-day consecutive course of high-dose intravenous immunoglobulin (IVIG) 65 g/day (an accumulated 2.2 g/kg) and 125 mg/day of 6MP were administered . At that point, all immunosuppression was discontinued, only maintaining 6-methylprednisolone (6MP) 40 mg IV/24h. A total of 4 doses of lopinavir/ritonavir and 1 dose of β-Interferon (250 µg on day +7) were given. In the first 48h at ICU, the patient’s general condition worsened, presenting oliguric acute kidney failure with an active urine sediment, which was treated with continuous renal replacement therapy (CRRT). The global clinical course linked to radiologic deterioration and biochemical findings 2 regions. On one hand, high-doses of IVIG can saturate Fcγ-receptors performing an inhibitory role on innate-immune cells, decreasing their migration capacity and responsiveness to soluble mediators and also can sequester circulating complement molecules . On the  1 cells , 18.Further than being one of the mainstays to prevent rejection since the inception of solid-organ transplantation, corticoids have been widely used in managing inflammatory and autoimmune diseases, even showing clinical benefits to treat disseminated intravascular coagulation, sepsis or ARDS . In turnIn conclusion, together with previous reports, the study of this case evinces that IVIG at immunomodulatory doses in combination with steroids could be an alternative successful strategy to control the cytokine-storm triggered by SARS-CoV-2 infection, improving the course of the disease and offering protection against immunological rejection in transplanted patients off their maintenance immunosuppression regimes. Since this is a single-case, more studies evaluating the effectiveness of this therapy would be necessary to extrapolate it to similar scenarios. Future studies designed to explore whether the administration of IVIG-6MP at early stages of the disease may provide a prophylactic effect by blocking the Covid-19 progression towards an hyperinflammatory syndrome would merit consideration, especially in view of the current lack of efficient treatments against the virus and the delicate equilibrium within the host immunity status required for both overcoming the infection and avoiding allograft rejection.Being a renal transplant patient taking immunosuppressive medication, I became very worried for my life when I was notified to have Covid-19 disease, but also for losing my kidney allograft. During my first days at the hospital, I rapidly worsened and was therefore transferred to ICU under artificial breathing. Of that horrible period, I only vaguely remember having nightmares. After regaining consciousness, I started a slow recovery, during which I often felt depressed and anxious, but I finally could leave the hospital off dialysis and with my kidney improving day by day. I am very thankful to the cooperative and multidisciplinary work that experts in different areas of knowledge performed and the treatment and the personal attention I received, and very especially to my daughter who, being a nurse in training, stayed long days of room isolation looking after me and working towards my recovery.atorresnefro@yahoo.es.The data analyzed in this study is subject to the following licenses/restrictions: Patient’s clinical record. Requests to access these datasets should be directed to Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.PRG, ATR, and CLM participated in the diagnosis and treatment of the patient. PRG and ATA collected clinical data. JM, AN, and ATA conducted cytokine measurements. PRG, ATA, JM, AN, and ATR wrote the draft. AJ and ARB reviewed the final version and made significant conceptual contributions to the manuscript. All authors contributed to the article and approved the submitted version.The publishing of this work was financed by Asociación Medicina e Investigación (A.M.I.).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.


SARS-CoV-2 vaccines are a key step in fighting the pandemic. Nevertheless, their rapid development did not allow for testing among specific population subgroups such as pregnant and breastfeeding women, or elaborating specific guidelines for healthcare personnel working in high infection risk specialties, such as otolaryngology (ORL). This clinical consensus statement (CCS) aims to offer guidance for SARS-CoV-2 vaccination to this high-risk population based on the best evidence available.A multidisciplinary international panel of 33 specialists judged statements through a two-round modified Delphi method survey. Statements were designed to encompass the following topics: risk of SARS-Cov-2 infection and use of protective equipment in ORL; SARS-Cov-2 infection and vaccines and respective risks for the mother/child dyad; and counseling for SARS-CoV-2 vaccination in pregnant, breastfeeding, or fertile healthcare workers (PBFHW). All ORL PBFHW were considered as the target audience.Of the 13 statements, 7 reached consensus or strong consensus, 2 reached no consensus, and 2 reached near-consensus. According to the statements with strong consensus otorhinolaryngologists—head and neck surgeons who are pregnant, breastfeeding, or with childbearing potential should have the opportunity to receive SARS-Cov-2 vaccination. Moreover, personal protective equipment (PPE) should still be used even after the vaccination.Until prospective evaluations on these topics are available, ORL-HNS must be considered a high infection risk specialty. While the use of PPE remains pivotal, ORL PBFHW should be allowed access to SARS-CoV-2 vaccination provided they receive up-to-date information.The online version contains supplementary material available at 10.1007/s00405-021-06794-6. The coronavirus disease 2019 (COVID-19) is one of the most important worldwide pandemics of the last decades [Many clinical studies reported that a large number of physicians had to face increased infectious risk and contamination during the delivery care process , 3. AmonThe development of two mRNA vaccines for SARS-CoV-2 appeared to be a key step in the abating process of the pandemic. Furthermore, the first two vaccines were rapidly joined also by an adenoviral vector vaccine and a recombinant vaccine. Nevertheless, the rapid development of these vaccines raised safety concerns not only from the public  but alsoIn that way, some experts from the Society for Maternal–Fetal Medicine Health Policy Advocacy Committee recently supported that the vaccination of pregnant, breastfeeding, and fertile health workers (PBFHW) makes particularly sense (see Online Resource 1) .The aim of this clinical consensus statement paper (CCS) is to offer, through a modified Delphi process, specific guidance, and advice based on the best evidence presently available.The development of this CCS followed the modified Delphi protocol proposed by Rosenfeld et al.  which isThe panel was composed of 33 collaborators from 18 countries (see Online Resource 2 for a map of contributions to the CCS). The development group consisted of a chair (AMS), assistant chair (JL), and methodologist (FA). ORL-HNS authors were recruited regarding their expertise among the Young Otolaryngologist—International Federation of Otorhinolaryngological Societies (YO-IFOS) research group and the Confederation of European Otorhinolaryngology—Head and Neck Surgery (CEORL-HNS) board. The panel was composed of 27 ORL-HNS, one epidemiologist, two infectious disease specialists, one vaccinologist, one gynecologist, and one neonatologist. All of them are working in the field of COVID-19. A single case of conflict of interest emerged among the authors, which was deemed as not relevant to the paper by the development committee. The focus of the CCS was to offer specific guidance to ORL-HNS PBFHW for SARS-CoV-2 vaccination.A PRISMA-compliant systematic review of the literature was conducted around four topics: (1) vaccines for SARS-CoV-2 for ORL-HNS PBFHW; (2) vaccines for SARS-CoV-2 for all PBFHW; (3) risk and prevention of SARS-CoV-2 infection in ORL-HNS; and (4) SARS-CoV-2 infection in PBFHW. MEDLINE, EMBASE, and Web of Science databases were searched on December, 28th for studies in English, Italian, German, French, or Spanish that reported data obtained from human subjects. Example search keys are shown in Online Resource 3. Searches for topic 1 delivered no results. Due to a lack of high-quality studies on topics 2 and 3, the systematic review was extended from what has been recommended for CCSs  to incluUpon evaluating the literature recovered through the systematic review, a collection of 84 articles, representing the highest and most recent evidence on the topics, was prepared and distributed to all authors to be revised over 1 week (see Online Resource 4 for the full references of the distributed literature).Based on the literature review and the aim of the CCS, the chair and assistant chair developed the core clinical statements for the survey, which were further discussed and expanded by the ORL-HNS group, and finally edited by the methodologist.Statements were developed based on the literature review and the development group’s perception of important clinical scenarios. A final 13-statement survey was, therefore, created and distributed to authors using Google Forms . Authors were instructed to complete the survey anonymously. Authors were asked to report their agreement with each statement according to a nine-point Likert scale from strongly disagree (1) to strongly agree (9). As defined by Rosenfeld [After the first survey round, 4 of 13 statements reached a consensus, and 9 reached no consensus. No statement reached near-consensus. The seven no consensus items with a mean score > 6.5 were reworded based on anonymous comments from authors. While the ultimate content of each statement was not changed, the statements were improved formally in terms of clarity. The second survey round included seven statements, of which three reached a consensus, two reached near-consensus, and two did not reach consensus. As there were not enough comments to guide the third Delphi round and timely publication of results was preferred, the Delphi round was closed with the second round.The first Delphi round was completed by all panelists, while the second round was completed by 30 out of 33 panelists. After the two Delphi rounds, 7 out of 13 statements reached a consensus, two reached near-consensus, and 4 did not reach consensus. The evolution of statements from the first round to their final version is reported in Online Resource 5. Delphi process results for all statements along with their mean score, score range, and the respective number of outliers are reported in Table Two statements reached a strong consensus: statement 6 (on the opportunity for receiving vaccines for pregnant ORL-HNS), and statement 12 (suggesting ORL-HNS maintain the use of PPE even after the vaccination).Also, all near-consensus scoring rated > 7.5 on average, mirroring a general trend towards consensus in the context of few variable opinions.A multidisciplinary group of experts involved in research on the COVID-19 pandemic and with significant experience in the management of the disease contributed to this CCS. There was a positive general attitude towards the opportunity for vaccines for SARS-CoV-2 vaccination in ORL-HNS PBFHW. Nevertheless, the response from the panel mirrored a mixed attitude. In the present paper, a consensus was reached for more than half of the statements. This represents a more than satisfactory result, given the strict criteria required by the modified Delphi method as proposed by Rosenfeld et al. .As no study has yet to be able to delve into the role of SARS-CoV-2 vaccines for ORL-HNS specialists, this CCS fills out a gap in the current literature on the subject. The main result of this CCS is recognizing the risk of infection for ORL-HNS specialists and the importance of vaccination for pregnant colleagues. Moreover, the opportunity for vaccination for breastfeeding ORL-HNS reached only a near-consensus, albeit with an extremely high score. Last, the panel felt as evidence was not sufficient to build a consensus towards colleagues with childbearing potential. Nevertheless, it is worth reiterating that, above anything else, adhering to the SARS-CoV-2 vaccination campaign should always represent an option and not an obligation for any pregnant, breastfeeding, or childbearing age woman. On the other hand, having access to information to make this free choice also a conscious choice is mandatory. This aspect is highlighted when comparing the results of statements 6 and 7 . While allowing the opportunity for vaccination reached a strong consensus, the encouragement for vaccination failed to reach any consensus among experts.In the context of a high rate of SARS-CoV-2 infection in healthcare workers , ORL-HNSSARS-CoV-2 represents a risk for pregnancy with indirect negative effects on the newborns . SARS-CoThe vaccines for SARS-CoV-2 may not represent a risk for the mother–baby dyad during pregnancy and breastfeeding. No specific trials have been conducted yet in these two populations, despite a sound request by the scientific community , 37, 38.This CCS reflects the simple, yet not predictable, rationale briefly presented in the introduction. Such reasoning is based on the data collected from the available literature in the systematic review. Such data will be briefly covered in this article to maximize its informative content.This CCS acquires a specific role if we frame it in the complex picture of public reaction to vaccines for SARS-CoV-2, a topic that has shifted from scientific debate to media sensation no differently than for any news related to COVID-19, from infection rates to containment measures and potential therapies. Despite that the vaccines for SARS-CoV-2 development represent a long-awaited scientific breakthrough, the expected response rate to the call to vaccination is variable, even among healthcare professionals , 8. ThisStill, there are other aspects to take into account when evaluating the relationship between SARS-CoV-2 infection and human fertility. Such topics have not been covered in this CCS as they concern the vaccine issue only marginally and there is little pertinent scientific information is available. First, we currently do not have any conclusive data on the role of SARS-Cov-2 infection and human fertility. Another important issue is the unexplored role of this pathogen in maternal immunization. Beyond maternal protection, maternal immunization against SARS-CoV-2 might contribute to the protection of the neonate in the postnatal period, as already demonstrated with other vaccines such as pertussis . Lastly,Last, it is helpful to recall that this study, albeit structured with the utmost scientific rigor and based on all available evidence, still represents an opinion paper on a rapidly evolving topic. While we confirm our commitment to providing information and guidance to all ORL-HNS PBFHW, we cannot underestimate the role of future prospective evaluations on these topics which we hope will be soon available for scrutiny from the scientific community.Supplementary file1 (PDF 207 KB)Supplementary file2 (PDF 290 KB)Supplementary file3 (PDF 256 KB)Supplementary file4 (PDF 313 KB)Supplementary file5 (PDF 248 KB)Below is the link to the electronic supplementary material.


Aquaporin-4 antibody (AQP4-Ab) Neuromyelitis Optica Spectrum Disorder (NMOSD) is a rare neuroinflammatory syndrome presenting predominantly with optic neuritis and transverse myelitis. We report a case of radiologically isolated longitudinally extensive optic neuritis in an asymptomatic 12-year-old female with positive serum AQP4-Ab, with resolution of imaging changes after immune therapy. By contrast to patients with radiologically isolated syndrome, of which some will never convert to multiple sclerosis, the pathogenicity of AQP4-Ab in the context of sub-clinical disease, supported treatment in our patient. Given the severe morbidity in AQP4-Ab NMOSD, prognostic biomarkers for disease severity are required to guide optimal therapy for patients. AQP4-Ab is detected in the serum using cell-based assay with excellent sensitivity and specificity. Using the latest clinical diagnostic criteria, NMOSD can be diagnosed in the context a central nervous system (CNS) inflammatory event  and AQP-4-Ab positivity; seronegative patients require additional criteria to be met.Aquaporin-4 antibody (AQP4-Ab) Neuromyelitis Optica Spectrum Disorder (NMOSD) is a rare neuroinflammatory syndrome presenting predominantly with optic neuritis and transverse myelitis. The discovery of AQP4-Ab in 2004 allowed expansion of the phenotype to include patients with single or recurrent attacks of optic neuritis, myelitis  and brain/brainstem disease.The clinical features and magnetic resonance imaging (MRI) abnormalities in children with AQP4-Ab are similar to the adult phenotype. Although many children are left with visual or motor deficits after a single attack, children are reported to have less severe disease course, and may take longer to reach disability than adults with AQP4-Ab NMOSD. Nevertheless, the disease course appears more active with a higher annual relapse rate compared to adult-onset disease. In a large multi-centre study of 441 AQP4-Ab positive NMOSD adult and paediatric patients, mathematical modelling demonstrated that younger patients were more likely to have optic neuritis as an initial presentation, while older patients were more likely to have motor difficulties.Here, we report a case of radiologically isolated optic neuritis in a child who was found to have AQP4-Ab, despite not fulfilling 2015 NMOSD diagnostic criteria. Written informed consent for the publication of the case description and figure was obtained.2). She remained asymptomatic and ophthalmologic assessment at 3-month follow-up demonstrated improvement in optic disc swelling, with retinal nerve fibre layer thickness on optical coherence tomography of 101 microns on the right. In addition, repeat neuroimaging showed resolution of the previous changes with no new lesions , a delay in initial immune treatment with IVMP was detrimental to vision, highlighting the importance of early treatment for long-term visual recovery. The radiological resolution seen in our patient following the acute treatment may suggest that the early diagnosis and treatment prevented the incident clinical attack.The majority of children with AQP4-Ab positive NMOSD relapse during their disease course, with higher disability score at 2 years from disease onset compared to multiple sclerosis. Children also suffer from higher visual disability compared to their adult counterparts, with optic neuritis presentation being associated with poor visual outcome.8 in addition to asymptomatic gadolinium enhancement of the optic nerves in the N-MOmentum clinical trial.Interestingly, our patient had an asymptomatic spinal cord lesion in addition to the gadolinium enhancing optic nerve lesion. In AQP-4-Ab NMOSD, new lesions normally only occur in the context of a clinical event, although there have been recent isolated reports of both asymptomatic brain and spinal cord lesions in seropositive NMOSD, With the associated severe morbidity reported in AQP4-Ab NMOSD, prognostic biomarkers for disease severity are required to avoid both under- and over-treatment of these patients.In radiologically isolated syndrome (RIS), a term used to describe individuals with MS-like lesions without a clinical correlate, clinical signs may be present in the absence of a clinical event or neurological symptoms. In fact, there is no mention of clinical examination findings in formal diagnostic criteria. Given our patient had normal visual acuity, despite the presence of optic disc oedema noted on routine examination, and no focal neurology, we would use the same terminology here. By contrast to patients with RIS of which some will never convert to multiple sclerosis, the pathogenicity of AQP4-Ab in the context of sub-clinical disease ), supported treatment in our patient. Our patient was treated with a course of Rituximab for relapse prevention following IVMP initially, and it remains challenging for clinicians to decide on the duration of immunosuppressive therapies for patients who have been in remission with no subsequent relapses. In fact, a study of 17 AQP4-Ab NMOSD showed that the discontinuation of immunosuppressive therapies may increase the risk of relapse in seropositive patients even after 5 years of remission.


There are no head-to-head comparisons evaluating the efficacy of the main polychemotherapy regimens used for patients with pancreatic cancer in the adjuvant setting. We aimed to describe the relative efficacy of modified FOLFIRINOX (mFOLFIRINOX), gemcitabine plus capecitabine (GEM-CAP) and gemcitabine plus nab-paclitaxel (GEM-NAB) in this setting using a Bayesian network approach.We collected data from the ESPAC-4, PRODIGE 24 and APACT trials. Disease-free survival (DFS), according to the investigators, and overall survival (OS) for the three polychemotherapy regimens were compared using gemcitabine as the reference arm. We ran Markov chain Monte Carlo simulations with a fixed-effect model to generate the posterior distribution of the hazard ratios (HRs) using non-informative priors. Relative efficacy was measured by HRs, surface under cumulative ranking and rankograms.mFOLFIRINOX was the chemotherapy regimen most likely to be the most effective in the adjuvant setting . GEM-NAB marginally improved DFS  = 0.77–1.21) and OS  when compared to GEM-CAP. However, GEM-NAB had the highest chances of being the second most active chemotherapy regimen , whereas GEM-CAP was less likely to represent the second most active regimen .For patients eligible and fit enough to undergo adjuvant treatment with mFOLFIRINOX, this constitutes the treatment of choice. For those with contraindications to mFOLFIRINOX, while both GEM-NAB and GEM-CAP can be considered appropriate alternatives, GEM-NAB is likely the most effective regimen. Pancreatic cancer currently stands as the 14th most common type of cancer worldwide, with 458,918 estimated cases in 2018  and deveIn this sense, the ESPAC-1  and the With the rise of polychemotherapy regimens such as FOLFIRINOX and gemcitabine-based combinations in the metastatic setting –13, randAt this moment, there are no randomised trials directly comparing these three chemotherapy regimens and such comparisons are unlikely to be ever pursued in a controlled setting. Thus, we analysed the results of these trials using a Bayesian network meta-analysis framework. This methodology allows us to infer the probable gains  of an intervention over another when formal direct comparisons of therapies through randomised trials are not available. An advantage of this approach is that one can generate probabilistic results that can support the decision-making process . Our aimData regarding the inclusion and exclusion criteria, the characteristics of the studies’ populations and the toxicity profile were extracted from the original publications for the ESPAC-4  and PROD2 for 21 days followed by a 7 days’ rest plus gemcitabine 1,000 mg/m2 once a week for three every 4 weeks. In the PRODIGE 24 study, patients assigned to combination chemotherapy received 5-Fluorouracil 2,400 mg/m2 (46-hour continuous infusion), irinotecan 150 mg/m2, oxaliplatin 85 mg/m2 and folinic acid 400 mg/m2 once every 2 weeks. In the experimental arm of the APACT trial, patients received nab-paclitaxel 125 mg/m2 and gemcitabine 1,000 mg/m2 once a week for three every 4 weeks. In the control arms of the trials, patients received gemcitabine 1,000 mg/m2 weekly for three every 4 weeks. For all treatments, the planned adjuvant treatment duration was 24 weeks.In the experimental arm of the ESPAC-4 trial, patients received capecitabine 1,660 mg/mThe primary outcome was OS in the intention-to-treat population. In all three trials, it was defined as the time from randomisation to death. It was the primary outcome of the ESPAC-4 and the PRODIGE 24 trials. As a secondary outcome, we analysed investigator-assessed disease free-survival (DFS)  in the intention-to-treat population. In all three trials, it was defined as the time from randomisation to death or disease progression. It was a secondary outcome of the ESPAC-4 and PRODIGE 24 trials, and it was a pre-specified sensitivity analysis of the primary outcome of the APACT study (independently assessed DFS). Since comparable depiction of either any severe or any grade 3–4 adverse events across the three studies was not available, we did not perform a Bayesian network meta-analysis on toxicity. Therefore, data on toxicity are summarised using only descriptive statistics.et al [et al [Before data analysis, we assessed the transitivity assumption by inspecting the characteristics of the populations and the inclusion and exclusion criteria of the studies . Data onet al  to convel [et al . Given tl [et al . We usedl [et al . Gemcital [et al . To portl [et al . These pThe network map is shown in p = 0.069). Conversely, patients treated with combination chemotherapy experienced improved investigator-assessed DFS in both PRODIGE 24 and APACT. The relative efficacy in terms of DFS of each chemotherapy regimen is shown in The median duration of follow-up in the three studies ranged from 33.6 to 53.3 months. In all three trials, patients treated with combination chemotherapy experienced longer OS. The relative efficacy in terms of OS of each chemotherapy regimen is shown in There were significant differences in OS across trials for patients undergoing adjuvant treatment with single-agent gemcitabine . PatientIn our study, modified FOLFIRINOX was the chemotherapy regimen most likely to represent the best currently available option in the adjuvant treatment of pancreatic ductal adenocarcinoma. While the PRODIGE 24 had a lower median follow-up compared to the other two studies and had a rather selected patient population in terms of age and post-operative CA 19-9 levels, modified FOLFIRINOX had 98.9% and 89.6% chance of being the most active chemotherapy regimen in terms of investigator-assessed DFS and OS, respectively. These results are in line with the ones found in a previous Bayesian network meta-analysis including patients with more advanced disease . That saHowever, some patients will not be optimal candidates to adjuvant treatment with modified FOLFIRINOX. Notably, among the highly selected patient population enrolled in the PRODIGE 24 trial, roughly one-third could not complete the planned 12 cycles of modified FOLFIRINOX; this rate is likely to be even higher among real-world patients. Also, 33% of all patients diagnosed with localised pancreatic cancer in the USA are older than 80 years at diagnosis  and it iApart from toxicity concerns, recent data points out that the efficacy of 5-Fluorouracil-based chemotherapy in pancreatic cancer might depend on the patterns of tumour gene expression. GATA6 is a transcription factor associated with cell differentiation in early pancreatic embryogenesis and low levels of GATA6 are associated with basal-like  gene expression profile. While no prospective randomised trial in the adjuvant setting has been specifically designed to assess this hypothesis, a retrospective analysis from the ESPAC-3 trial showed that patients who had tumours with low or medium levels of GATA6 expression who were treated with 5-Fluorouracil had worse survival when compared to those with high-level tumours . The samThe use of gemcitabine-based doublets could match the need for less toxic or non-fluoropyrimidine-based regimens in the adjuvant setting. In this sense, we showed that GEM-NAB is likely associated with the highest probability of being the best gemcitabine-based treatment in terms of both investigator-assessed DFS and OS. GEM-CAP had a slightly worse performance than GEM-NAB in terms of survival outcomes. Also, in the real world, the use of GEM-CAP has been shown to be challenging given its toxicity profile . LikewisDespite these results, one might say that GEM-NAB should not be considered a treatment option in this setting since the APACT trials failed to meet the primary endpoint of DFS as assessed by the independent review. We believe that the conclusion as to whether a trial is considered positive or negative is complex and should not rely solely on the statistical significance of the test for the primary outcome . The APAAnother argument that supports the use of GEM-NAB in the adjuvant setting is the significant OS benefit. This outcome is perceived by many experts in pancreatic cancer as the most important indicator of outcome quality . AccordiPatients treated with single-agent gemcitabine in the ESPAC-4 trial experienced numerically worse OS when compared to those in the PRODIGE24 and APACT trials. That is in line with the distribution of known prognostic factors, such as ECOG and stage, across these studies. This might have favoured the modified FOLFIRINOX and GEM-NAB arms when compared to GEM-CAP, at least in terms of absolute survival benefit. Furthermore, the lack of seemly significant differences in median relapse-free survival across the single-agent gemcitabine arms in these trials suggests that factors apart from the adjuvant chemotherapy regimen might have played a part in determining OS, such as characteristics of the post-progression therapy.Our study has limitations. We did not carry out a systematic search for all the articles comparing different adjuvant chemotherapy regimens for patients with resected pancreatic cancer. Nevertheless, apart from S-1 which is used almost exclusively in Asia, it is largely known by those with expertise in pancreatic cancer that these are the most clinically relevant chemotherapy regimens tested in randomised trials in the adjuvant setting. Furthermore, inconsistencies in the descriptions of the toxicities prevented us from making indirect comparisons of grade 3–4 or severe adverse events. However, we displayed the data from the studies in a way that readers can have an idea of the comparative risks of toxicities. Our study also has merits. As far as we know, this is the first Bayesian network meta-analysis evaluating the comparative effectiveness of these chemotherapy regimens. With this methodology, we were able to rank the efficacy of these regimens using a probabilistic approach that can aid the decision-making process. Moreover, we used matched outcomes, considering differences in independent reviewer-assessed and investigator-assessed DFSs. Furthermore, we present updated results for survival analysis from two of the three studies.Modified FOLFIRINOX is the standard of care for the treatment of pancreatic cancer in the adjuvant setting for patients fit enough to receive this chemotherapy regimen. For those with contraindications or who are not fit enough for modified FOLFIRINOX, GEM-NAB might be the preferred adjuvant therapy, particularly to those patients who have contraindications for fluoropyrimidines.Victor Hugo Fonseca de Jesus received honoraria from United Medical and had travel expenses paid by United Medical in the past 12 months. United Medical is the company responsible for the distribution and sale of nab-paclitaxel in Brazil. Rachel Pimenta Riechelmann received consultancy fees from Astra Zeneca in the past 12 months.This study had no funding source.Victor Hugo Fonseca de Jesus: conceptualisation, methodology, data curation, data analyses, writing and visualisation; Rachel Pimenta Riechelmann: methodology, writing and visualisation.


Does the practice of community-initiated kangaroo mother care (ciKMC), an intervention encompassing skin-to-skin-contact and exclusive breastfeeding, during the neonatal period reduce the risk of moderate-to-severe postpartum depressive symptoms among mothers of low-birth-weight (LBW) infants?In a randomized clinical trial that included 1950 mothers of stable LBW infants from low-income areas in India, the practice of ciKMC resulted in a 25% reduction in the relative risk of moderate-to-severe depression at 4 weeks after delivery. The analysis estimated that supporting 36 mothers to perform KMC at home would prevent 1 mother from experiencing moderate-to-severe postpartum depressive symptoms.These findings suggest that ciKMC can have substantial benefits for maternal mental health, beyond improving the survival of LBW infants. This randomized clinical trial estimates the effect of community-initiated kangaroo mother care on maternal risk of moderate-to-severe postpartum depressive symptoms among mothers of low-birth-weight (LBW) infants. Approximately 1 in 5 women in low- and middle-income countries experience postpartum depression, and the risk is higher among mothers of low-birth-weight (LBW) infants. Kangaroo mother care (KMC) is effective in improving survival among LBW infants, but the benefits of KMC for mothers are not well described.To estimate the effects of community-initiated KMC (ciKMC) on maternal risk of moderate-to-severe postpartum depressive symptoms and on salivary cortisol concentration, a biomarker of stress.This was an unmasked, parallel-group, individually randomized clinical trial. Participants included 1950 mothers of stable LBW infants (weighing 1500-2250 g) in rural and semiurban low-income populations in North India enrolled between April 2017 and March 2018. Data analysis was performed from January to July 2020.Eligible participants were randomly assigned to the intervention or control group by block randomization. The mothers in the intervention group were supported to practice ciKMC until 28 days after birth or until the infant wriggled out of the KMC position . The intervention included promotion and support of skin-to-skin contact and exclusive breastfeeding through home visits.Postpartum depressive symptoms at the end of the neonatal period were measured using the Patient Health Questionnaire–9, with a score of 10 or higher used to identify moderate-to-severe depressive symptoms. Salivary cortisol concentration was measured in a subsample of 550 mothers before and after breastfeeding on day 28 after birth.Of the 1950 participants , outcome assessment was completed for 974 of 1047 participants (93%) in the intervention group and 852 of 903 participants (94%) in the control group. Sixty-four percent of participants (1175 of 1826 participants) belonged to the lowest 3 wealth quintiles. The proportion of mothers with moderate-to-severe postpartum depressive symptoms was 10.8%  in the intervention group vs 13.6%  in the control group. The adjusted relative risk of moderate-to-severe maternal postpartum depressive symptoms was 0.75 , or an efficacy of 25%. There was no difference in day-28 salivary cortisol concentration between the ciKMC and control group mothers before or after breastfeeding. The analysis estimated that supporting 36 mothers to perform KMC at home would prevent 1 mother from experiencing moderate-to-severe postpartum depressive symptoms.These findings suggest that ciKMC practice may substantially reduce the risk of moderate-to-severe maternal postpartum depressive symptoms. This evidence supports KMC as an intervention to be incorporated in essential newborn care programs in low- and middle-income settings.CTRI/2017/04/008430Clinical Trials Registry–India Identifier:  The prevalence of depression is reported to be higher among mothers of preterm compared with full-term infants in the first 12 weeks after birth.11Postpartum depression12 Kangaroo mother care (KMC), an intervention encompassing skin-to-skin contact (SSC) and exclusive breastfeeding, reduces the risk of death and severe infection in low-birth-weight (LBW) infants and is recommended by the World Health Organization and the Government of India.15 In a large randomized clinical trial16 in India among 8402 LBW infants, promotion of community-initiated KMC (ciKMC) improved postenrollment neonatal survival by 30% and infant 6-month survival by 25%. KMC could reduce the risk of postpartum depressive symptoms through mother-infant bonding and possibly via the release of maternal oxytocin and lowering of cortisol secretion.19 Data from observational and quasi-experimental studies23 suggest such a beneficial effect on mothers, but conclusive evidence is lacking.Several psychosocial and psychological interventions have been evaluated for their effect on the risk of postpartum depression. These include postpartum home visits by professionals, telephone-based peer support, and interpersonal psychotherapy. Although promising, they are not widely implemented in the Indian public health system.Our primary objective was to test the hypothesis that the practice of ciKMC during the neonatal period can reduce the risk of moderate-to-severe maternal postpartum depressive symptoms. As a secondary objective, we estimated the effect of ciKMC on maternal salivary cortisol concentration, a biomarker of stress, at the end of neonatal period.NCT02653534).24 Here, we report the outcomes related to maternal mental health  and stress as measured by cortisol. The study was conducted in rural and semiurban low-income populations of Faridabad and Palwal districts in Haryana, India.This unmasked, parallel-group, individually randomized clinical trial was developed as a substudy within a larger primary trial where the effect of ciKMC on neonatal and early infant mortality was estimated  reporting guideline.25Ethics approval was obtained from the institutional ethics committee at the Centre for Health Research and Development, Society for Applied Studies, New Delhi, India, and the Regional Committee for Medical and Health Research Ethics in Norway. For eligible mothers, written informed consent was obtained in the local language prior to enrollment .27The ciKMC intervention comprised promotion and support of SSC and exclusive breastfeeding. Infant-mother dyads allocated to the ciKMC group were visited at home by an intervention delivery team consisting of a pair of trained workers to initiate and support KMC. The team observed breastfeeding and promoted SSC by using photographs and the local term 29 Secondary outcomes were any depressive symptoms, PHQ-9 score, and maternal salivary cortisol concentration at the end of neonatal period. Postpartum depressive symptoms were defined as PHQ-9 scores of 10 or higher for moderate-to-severe symptoms, 5 to 9 for mild symptoms, and 0 to 4 for no or minimal symptoms.28 A PHQ-9 score of 5 or higher defined any depressive symptoms. The sensitivity and specificity of a PHQ-9 score 10 or higher to diagnose major depression in the postpartum period are reported to be approximately 80% and greater than 90%, respectively.30Our primary outcome was moderate-to-severe postpartum depressive symptoms at the end of the neonatal period (day 28 after birth) measured using a pretested Hindi version of the validated Patient Health Questionnaire–9 (PHQ-9).31 Reported duration of SSC and exclusive breastfeeding were captured by an independent outcome ascertainment team at the end of the neonatal period for all study participants. For the PHQ-9 interviews, an independent team of health workers was trained and assessed by a clinical psychologist. The PHQ-9 assessment was done after day 28, but not later than day 42 after birth. Supervisors conducted random quality checks in 1% of the assessments. Women with PHQ-9 scores 10 or higher were referred to health facilities.Study workers were trained in good clinical practice.We collected salivary specimens from the first 550 mothers on day 28 after birth to measure salivary cortisol. To account for diurnal fluctuations and variability related to breastfeeding, the specimens were collected before and after breastfeeding, not later than noon. The cortisol concentration was estimated by a Cortisol Enzyme Immunoassay Kit  using an automated system  at Clinical and Research Laboratories, Society for Applied Studies, New Delhi. The kit performed within acceptable limits for accuracy, precision, and linearity for values between 1.0 μg/dL and 0.038 μg/dL . Specimens with values less than or equal to 0.037 μg/dL were assigned the lowest acceptable value.9 the total sample size required was 1942 participants according to a 2-sided test  with 95% CIs for maternal moderate-to-severe or any depressive symptoms between the study groups using generalized linear models of the binomial family with a log-link. The efficacy of the intervention against maternal moderate-to-severe depressive symptoms was calculated as (1 − RR) × 100. We conducted multinomial logistic regression to estimate the effect of ciKMC on the risk of different categories of maternal depressive symptoms with no or minimal depressive symptoms (PHQ-9 scores of 0-4) as the reference. To compare salivary cortisol levels, we used the Wilcoxon rank-sum test.32 our approach was to present both unadjusted and adjusted results while avoiding overadjustment. Wealth quintile, mother age, mother education, and birth order were the potentially confounding covariates associated with the primary outcome at P < .10 in univariable analysis. To avoid overadjustment,33 we included the potential confounding factors in the final multivariable regression model only if they were unequally distributed between the study groups at baseline, a priori defined as a relative difference of greater than 10%.34 We used the likelihood ratio test based on deviance statistics to assess goodness-of-fit of the model35 Design effects of infant-mother dyads enrolled from a single household were accounted for using Stata’s robust variance estimator (vce) option. To quantify any biological interaction between ciKMC and preterm birth, we estimated the relative excess risk due to interaction36 using the icp command.Following CONSORT 2010 guidelines,We conducted exploratory subgroup analyses to estimate whether the effect of ciKMC on postpartum depressive symptoms was different in mothers with preterm birth (<37 weeks gestation) compared with full-term birth (≥37 weeks gestation). Data analysis was performed from January to July 2020.Of the 1950 enrolled participants , we completed PHQ-9 assessments for 93% of mothers (974 of 1047 participants) in the intervention group and 94% of mothers (852 of 903 participants) in the control group . In bothIn the intervention group, 99% of the mothers (971 of 974 mothers) reported practicing SSC during the neonatal period vs 4% (33 of 852 mothers) in the control group. In the intervention group, the median (interquartile range) age of the infant at ciKMC initiation was 48 (23-72) hours; the mean (SD) duration of practicing SSC was 27.5 (3.9) days with a mean (SD) of 12.0 (3.7) hours per day. Approximately 2% of mothers continued SSC beyond the 28-day period. Exclusive breastfeeding prevalence  at day 28 was 88% in the intervention group (859 of 974 participants) vs 57% (486 of 852 participants) in the control group. The number of home visits by accredited social health activists for postnatal care were similar in the 2 trial groups  in the intervention group vs 13.6%  in the control group . The RR In the subgroup of mothers with preterm births, the RR of moderate-to-severe postpartum depressive symptoms in the ciKMC group was 0.71  vs 0.86  among mothers with full-term infants. Preterm birth had a relative excess risk due to interaction with ciKMC for the study outcome of 0.19 .Salivary cortisol measurements were done in 92.4% of the mothers (508 of 550 mothers) . The medWe found a 25% lower risk of moderate-to-severe postpartum depressive symptoms among mothers in the ciKMC group than among those in the control group. The RR reduction was somewhat higher among mothers of preterm infants. Our analysis indicated that ciKMC practice for approximately 36 stable LBW infant-mother dyads  would prevent 1 case of moderate-to-severe postpartum depressive symptoms. We found no difference in the day-28 maternal salivary cortisol concentrations between the study groups.16 Selection and follow-up biases are not likely because of effective randomization, allocation concealment, and very low and balanced attrition. Nonetheless, we cannot rule out the possibility of recall bias. However, in the intervention group, information on the duration of SSC captured by the outcome assessment team based on mothers’ history was similar to that obtained by the intervention delivery team during their scheduled visits, suggesting a low likelihood of such bias.16 To minimize the possibility of conscious underreporting of symptoms, the outcome assessment team was extensively trained to conduct PHQ-9 assessment based on a comprehensive interview process in a comfortable home environment and not by asking the questions directly. Despite having an independent outcome assessment team, it might have been possible to guess the group allocation for those who practiced KMC beyond the 28-day period during PHQ-9 interview. However, such a possibility was small because only approximately 2% of mothers continued SSC beyond the 28-day period. Given the low risk of bias, the results are likely to be reliable and representative of the target population, suggesting that ciKMC can substantially reduce the risk of moderate-to-severe maternal postpartum depressive symptoms.Our study was done as a substudy within the primary ciKMC efficacy trial.20 depressive symptoms measured by the Edinburgh Postpartum Depressive Scale scores at 1 week and 1 month postpartum were lower among 30 mothers who practiced SSC compared with 60 mothers who did not. Another quasi-experimental study23 of 50 Iranian mothers demonstrated that practice of KMC for 180 minutes daily for a week compared with when infants were cared for in incubators was associated with improved mean mental health scores assessed by the General Health Questionnaire. An observational study21 in Portugal among 177 low-income mothers with preterm infants showed that the proportion of women with postpartum depression assessed by the Postpartum Depression Screening Scale decreased from 37% after delivery to 17% at hospital discharge with KMC practice. Our trial provides valid evidence of the efficacy of KMC on the risk of postpartum depression in mothers with LBW infants and substantiates the observations from the earlier studies.To the best of our knowledge, this is the first randomized clinical trial to estimate the effect of KMC on maternal depressive symptoms, and the findings substantiate those of previous reports from less rigorous study designs. In a quasi-experimental study in Canada,37 The substantial effect of ciKMC that we observed on postpartum depressive symptoms is likely to be a result of a multitude of complex psychological mechanisms, potentially supported and intensified by enhanced oxytocin release as a result of SSC and exclusive breastfeeding.38 Because of its clinical implications, we chose moderate-to-severe postpartum depressive symptoms as the primary outcome instead of PHQ-9 score. Women with PHQ-9 scores of 10 or higher have a high probability of major clinical depression that needs clinical attention, whereas the milder symptoms are often self-limiting.28 In this context, our findings that ciKMC may reduce the risk of moderate-to-severe postpartum depressive symptoms are pertinent. The potentially greater benefit of ciKMC in mothers with preterm infants in reducing moderate-to-severe postpartum depressive symptoms is relevant given their higher risk of postpartum depression.11 However, we acknowledge the limitations of our subgroup analysis, in that we did not stratify our randomization on whether the birth was preterm and because the statistical precision of the interaction was moderate.KMC may lessen depressive feelings by empowering women in their mothering role and improving infant-mother bonding.39 Salivary cortisol is widely used to capture short-term fluctuations in physiological stress.40 The observed null effect of KMC on day-28 maternal salivary cortisol is similar to that of a quasi-experimental study in Canada,20 where the mean cortisol concentrations among intervention and control mothers at the end of neonatal period were 0.23 and 0.24 μg/dL, respectively. These findings suggest a possible dissociation between acute stress and postpartum depression, as far as the effect of ciKMC is concerned. Further research on the effect of KMC on acute and chronic stress (using markers such as hair cortisol41) may be warranted.Cortisol is a hormone produced by the activation of hypothalamic-pituitary-adrenocortical axis in response to physiological stress.Although this is a large randomized clinical trial where almost all baseline characteristics were well-balanced between the trial groups, a baseline PHQ-9 assessment would have been valuable. Our study population was limited to mothers with stable LBW infants weighing 1500 to 2500 g, and the findings may not be applicable to mothers with unstable or very-LBW  infants. Neonatal survival programs would benefit from further research that also includes such infants.23 suggest substantial benefits of home-based KMC for mothers, beyond improving health and survival of LBW infants. Developing a focused LBW program is identified as one of the important agendas of the Indian Government42 and maybe relevant in other low- and middle-income countries where a high proportion of infants are born with LBW. This evidence supports the integration of KMC into essential newborn care programs for LBW infant-mother dyads.The findings of our study support ciKMC as an intervention to prevent maternal depressive symptoms in the early postpartum period. Research on long-term benefits of the intervention on maternal psychosocial health and child development would be helpful. The study findings together with previous literature