Neisseria meningitides, which induces neutralizing antibodies against EGF. In the last 15 years, it has been extensively evaluated in advanced NSCLC patients. CIMAvax-EGF is safe, even after extended use, and able to keep EGF serum concentration below detectable levels. In a randomized phase III study, CIMAvax-EGF increased median overall survival of advanced NSCLC patients with at least stable disease after front-line chemotherapy. Patients bearing squamous-cell or adenocarcinomas and serum EGF concentration above 870 pg/ml had better survival compared to control patients treated with best supportive care as maintenance, confirming tumors’ sensitivity to the EGF depletion. This manuscript reviews the state-of-the-art NSCLC therapy and proposes the most promising scenarios for evaluating CIMAvax-EGF, particularly in combination with TKIs or ICIs. We hypothesize that the optimal combination of CIMAvax-EGF with established therapies can further contribute to transform advanced cancer into a manageable chronic disease, compatible with years of good quality of life.Advanced non-small cell lung cancer (NSCLC) has faced a therapeutic revolution with the advent of tyrosine kinase inhibitors (TKIs) and immune checkpoints inhibitors (ICIs) approved for first and subsequent therapies. CIMAvax-EGF is a chemical conjugate between human-recombinant EGF and P64, a recombinant protein from  Advanced non-small cell lung cancer (NSCLC) remains a major health problem. Despite all scientific advances of the last decades, a substantial fraction of lung cancer patients are diagnosed at advanced stages of disease, accounting for roughly 1.2 million deaths per year worldwide  is one of the most important ligands of the EGFR, which is produced mainly in a paracrine fashion . EGF conAdvanced NSCLC has recently faced a therapeutic revolution with the advent of new drugs registered for first and subsequent therapies , 20. TheNeisseria meningitides  and 23% vs 0%   of the advanced NSCLC patients that had at least stable disease after front-line chemotherapy . Median trol arm . Survivatrol arm . Moreoveal rate) .+CD28− T cells, CD4 T cells, and the CD4/CD8 ratio after chemotherapy correlated with the clinical benefit of CIMAvax-EGF. Vaccinated patients with CD4+ T cells counts greater than 40%, CD8+CD28− T cells counts lower than 24% and a CD4/CD8 ratio > 2 after first-line platinum-based therapy, achieved a significantly larger survival, as compared to controls with the same phenotype . ICI lessens the control loops of the immune system, allowing the expansion of the antitumor immune response –45. The The evolving landscape of advanced NSCLC therapy from conventional chemotherapy to EGFR TKIs and checkpoint inhibitors is depicted in Progressively, molecular stratification according to driver mutations (actionable mutations) and PD-L1 expression has gained preeminence, even over the classical histological classification. The identification of actionable mutations and the level of expression of PD-L1 have divided the current landscape of NSCLC into several therapeutic scenarios Figure 5Actionable mutations appear in roughly 40% to 50% of adenocarcinoma patients and are rare in squamous cell carcinomas . The detIn patients with EGFR-mutated tumors, the use of specific TKI as first line has significantly increased the response rate and progression free survival (PFS) when compared with standard chemotherapy. First- and second-generation TKIs, such as gefitinib, erlotinib, afatinib, and dacomitinib, are used continuously until evidence of tumor resistance, which happen frequently by the selection of a secondary mutation in the kinase domain of the EGFR, particularly T790M . OsimertCombination of ramucirumab, an anti-VEGFR2 monoclonal antibody (MAb), with erlotinib has also shown significant PFS improvement as compared with single first- and second-generation TKI therapies in the first line . HoweverIn tumors with unknown or no actionable mutations, ICIs blocking the interaction between PD-1 and PD-L1 ligand, ICI alone, or in combination with chemotherapy dominate the therapeutic landscape currently Figure 5vs its combination with chemotherapy  in an attempt to explain the complexity of cancer biology . These hEGF immune deprivation (with CIMAvax-EGF) targets the extracellular domain of EGFR, while TKIs recognize the intracellular cascade controlling cell proliferation and resistance to apoptosis. ICIs target the capacity of cancer cells to evade the immune system control. In the following sections, we debate potential combinations of CIMAvax-EGF with TKI or ICI in the treatment of advanced NSCLC.in vitro studies showed that this might not be absolute. Codony-Servat et al. showed that EGF induces a basal signal on EGFR mutated tumors, even while treated with potent TKI, such as gefitinib, erlotinib, afatinib, and osimertinib  and the lack of a strategy for selecting patients most likely to benefit. Therefore, the addition of CIMAvax-EGF to TKI is an appealing alternative, given CIMAvax-EGF excellent safety profile and the possibility of preselecting patients with high EGF concentration in serum Table 3.in vitro induced the upregulation MHC class I expression . Safety profile was good with no significant toxicities added by CIMAvax-EGF to the anti-PD1. A fast induction of anti-EGF antibodies and a reduction of EGF concentration in patient’s serum were also observed . RemarkaHowever, this specific niche of patients (ICI second line, CIMAvax-EGF can be used for prolonged periods as maintenance treatment without cumulative toxicity . This fiOther alternative is to position CIMAvax-EGF in combination with pembrolizumab or atezolizumab, as starting therapy in stage IV NSCLC with 50% overexpression of PD-L1, irrespective of histology Table 3.The last alternative would be to combine CIMAvax-EGF with durvalumab in stage III NSCLC after completing front-line concurrent radio and chemotherapy Table 3.CIMAvax-EGF is a new class of therapy aiming to induce antibodies against self-growth factors. It targets the EGF-EGFR pathway, a validated target on tumorigenesis. However, its larger impact will depend on the smart insertion of immune EGF deprivation into the complex algorithm of lung cancer management. Exploring the overlapping zone between interventions in the control of cell proliferation and immune evasion should be a priority of the current therapeutic algorithms.Understanding the therapeutic potential of CIMAvax-EGF will demand a series of clinical trials devoted to identify the highest impact niches, potentiation with other treatment, optimal schedules, and new biological markers. The potential role of CIMAvax-EGF in increasing the clinical response achieved with other treatments like TKI or ICI is particularly attractive. Alternatively, CIMAvax-EGF can also help subgroups of patients who are not benefiting from the current therapies, like PD-L1 negative or EGFR wild type individuals.In summary, CIMAvax-EGF is a therapeutic approach that has already been proven to be safe and efficacious, mainly in patients with high EGF levels and wild-type KRAS. We hypothesize that the smart combination of CIMAVax-EGF with the established EGFR TKI and ICIs can further contribute to the transition of advanced cancer to a chronic disease, compatible with years of quality life.All authors contributed to the article and approved the submitted version.This research was funded by the Center of Molecular Immunology and the Cuban Ministry of Health.Authors TC, OS, KL, AL currently work for the Center of Molecular Immunology, the institution that generated and originally patented CIMAvax-EGF.The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In this work, we proposed a virtual laboratory based on full-field crystal plasticity (CP) simulation to track plastic anisotropy and to calibrate yield functions for multiphase metals. The virtual laboratory, minimally, only requires easily accessible EBSD data for constructing the highly-resolved microstructural representative volume element and macroscopic flow stress data for identifying the micromechanical parameters of constituent phases. An inverse simulation method based on a global optimization scheme was developed to identify the CP parameters, and a nonlinear least-squares method was employed to calibrate yield functions. Mechanical tests of advanced high strength steel sheet under various loading conditions were conducted to validate the virtual laboratory. Three well-known yield functions, the quadratic Hill48 and non-quadratic Yld91 and Yld2004-18p yield functions, were selected as the validation benchmarks. All the studied functions, calibrated by numerous stress points of arbitrary loading conditions, successfully captured both the deformation and strength anisotropies. The full-field CP modeling correlated well the microscopic deformation mechanism and plastic heterogeneity with the macromechanical behavior of the sheet. The proposed virtual laboratory, which is readily extended with physically based CP models, could be a versatile tool to explore and predict the mechanical property and plastic anisotropy of advanced multiphase materials. The superior mechanical properties and the high strength-to-weight ratio of AHSS are primarily attributed to their synergetic enhancing mechanisms of strength and plasticity through the sophisticated control of the microstructure-property relationship3. The complex microstructure, typically consisting of multiple phases over a wide range of length scale, renders their rather different macro-/micro-mechanical responses and plasticity behaviors. Specifically, plastic anisotropy of deformation and strength is one of the most concerns in the community of sheet metal forming4.During the past decades, advanced lightweight structural metals and alloys, represented by advanced high strength steel (AHSS), are increasingly used to meet the demand for energy conservation and environmental protection5, for instance, is the tacit yield criterion for orthotropic materials in most commercial FEM softwares. However, this yield criterion is short of simultaneously capturing deformation anisotropy  and strength anisotropy6. With the emergence of progressive metals and alloys, especially materials with multiphase structure or low-symmetric crystal structure, advanced non-quadratic yield functions have received great attention. Hosford7 proposed an isotropic yield criterion without shear stress based on polycrystalline calculation and further extended it to the planar anisotropy8. Whereafter, improved yield functions14 based on linear transformation of stress tensor were introduced to more reasonably describe the anisotropy of materials. Barlat et al.12 and Aretz and Barlat15 introduced advanced yield functions for general stress state, namely, Yld2004-18p and Yld2004-27p, which require up to 18 and 27 material parameters to describe plastic anisotropy. These yield functions are mostly featured with lots of material parameters and growing alliance with crystallographic texture12.Describing the plastic anisotropy of metal sheets is a long-standing research focus and challenge. Phenomenological yield functions, which define a convex yield surface to separate the pure elastic and elastoplastic deformation states, are widely employed to predict the macroscopic plastic anisotropy of rate-independent metals for their user-friendly implementation and high computational efficiency. The classic quadratic yield function Hill4817.The increased number of material parameters causes the tough calibration of the advanced yield functions; the necessary mechanical experiments are time-consuming and sometimes impossible to perform, such as probing the out-of-plane properties of metal sheets. Besides, the phenomenological yield functions are insufficient of physical mechanism and do not consider the microstructural heterogeneity. This weakens their efficiency in predicting the plastic anisotropy of metal sheets with multiphase microstructure, of which the plastic heterogeneity and stress/strain partitions among microstructures and phases should not be ignored12 used a mean-field visco-plastic self-consistent (VPSC) polycrystal plasticity model to evaluate the out-of-plane mechanical property of 2029-T3 Al-Li alloy sheet under different deformation modes; by combining with experimental results, they further identified the complete parameters of the Yld2004-18p yield function for the material. Plunkett et al.18 fitted the material parameters of the CPB05 yield function for zirconium by using VPSC simulations.Apart from the phenomenological yield criteria, micromechanical models and simulation tools based on crystal plasticity (CP) theory play a vital role in exploring the plastic anisotropy of metals as well as calibrating advanced yield functions. For instance, Barlat et al.21 or spectral method (CPSM)23 based on fast Fourier transform as the solver of boundary value problems, has received growing interest in characterizing the anisotropic behavior of polycrystalline materials. Full-field CP modeling, taking both grain microstructure and crystallographic texture as input, can guarantee the stress equilibrium and strain compatibility among grains and has the advantage over the mean-field ones in terms of considering the authentic multiphase/polycrystalline microstructures and describing the stress/strain partitions among phases and grains24. Zhang et al.25 employed various CP-based modeling approaches to investigate the anisotropy of AA1050 aluminum and calibrate the anisotropic parameters of the Yld2004-18p yield function. Zhang et al.23 proposed a virtual laboratory (VL) based on high-resolution CPSM to predict the yield loci and plastic anisotropy of the annealed and cold-rolled AA3104 aluminum alloy sheets. The material parameters of the Yld91, Yld2000-2D, Yld2004-18p, and Yld2004-27p yield functions were determined through many yield stress data under arbitrary deformation paths. Liu et al.26 used the CPSM simulations to calibrate a 3D phenomenological yield function with both in-plane and out-of-plane mechanical anisotropies of strongly textured AA3104-H19 and AA2024-T3 sheets. Han et al.27 employed CPSM combined with FEM simulations to dynamically calibrate the Yld2000-2D and Yld1004-18p yield functions for AA2090-T3 sheet at different deformation stages; FEM simulations were used to track the boundary conditions during the deep drawing process. These hierarchical modeling approaches combine the merits of the computational efficiency of phenomenological yield functions and the accuracy of micromechanical CP models.Recently, full-field CP modeling, either employing finite element method (CPFEM)However, most of the works mentioned above were focused on single-phase materials. This work aims to introduce a full-field CP-based VL capable of characterizing the multiscale mechanical properties of multiphase materials (using DP980 AHSS as an example), including macroscopic mechanical anisotropy and grain-level heterogeneities. Comprehensive experiments were performed for the CP modeling setup and the validation of simulation results. A global optimum inverse simulation procedure was developed to obtain the CP constitutive parameters for the constituent phases of the DP980 sheet. Virtual tests were carried out to obtain adequate stress points of arbitrary loading conditions; these stress points were used to calibrate the exemplified yield functions, i.e., the Hill48, Yld91, and Yld2004-18p, to explore the anisotropy of the DP980 sheet. In the end, the correlation between the grain-level plastic heterogeneity with the macromechanical property of the sheet was investigated.28. The CP model was implemented in a finite strain framework based upon the classical multiplication decomposition of deformation gradient as follows,29,30.For completeness, the adopted phenomenological CP theory is briefly presented; more details can be found in Zhang et al.i.e., With the assumption of hypo-elasticity of most metals, 31 enables the VL to carry out a large number of virtual experiments with low computational cost23.The above CP-based constitutive model in conjunction with an open-source spectral solver DAMASK32 with the processed EBSD data as input. The cubic RVE, as shown in Fig. r-values, the method of rotating Euler angles of grain orientations instead of alternating the load directions is adopted; more details can be found in Ref.22. Following the Bunge convention of Euler angles, the orientation after an in-plane rotation from RD to TD at angle The geometrical model used for the full-field CP simulations and virtual tests, i.e., the multiphase microstructural representative volume element (RVE), was constructed via the open-source code DREAM.3D34 employed the state-of-the-art high-energy X-ray diffraction technique and in-situ tensile tests to measure the lattice strain of each phase; they calibrated the CP parameters by correlating the predicted lattice strains with the experiments. This approach is attractive and persuasive but not easily accessible. In this work, an inverse simulation method evolving global optimization was developed to identify the CP constitutive parameters of the ferrite and martensite phases. First, the elastic constants 35. It is noted that the elastic properties of the constituent phases in multiphase steels are not fully understood. Souissi and Numakura36 gave a comprehensive study on the elastic properties of two types of martensite. The four parameters, 35 and Hamada et al.37, the ratio of The dual-phase steel has a composite microstructure of relatively strong martensite islands dispersed in the soft and ductile ferrite matrix. Both the ferrite and the martensite phases have a BCC crystal structure  with the most easily activated slip system families The inverse simulation method for parameter identification consists of a global optimization platform and full-field CP simulations. The particle swarm optimization (PSO) toolbox of MATLAB® version R2018b) was employed to identify the global optimum material parameters for the ferrite and martensite phases. In the beginning, reasonable bounds of the parameters were provided for the inverse simulation platform. The platform generated different initial guesses for the parameters, launched numerous full-field CP simulations of uniaxial tension parallelly, and finally extracted the predicted true stress–strain data. The obtained true stress–strain data were compared with the experiment ones to evaluate the root-mean-square deviations (RMSD) 018b was Table 5 and non-quadratic Yld919 and Yld2004-18p12 yield functions, were calibrated to predict the anisotropy of the DP980 sheet.The VL is executed automatically with a Python script. It launches enough full-field CP simulations of the constructed RVE under arbitrary loading conditions generated by a random number generator, post-processes the simulation results, extracts the yield stress points (stress tensors), and then identifies the yield functions. As the illustrative benchmarks, three well-known yield functions, i.e., the quadratic Hill4823. With the analytical Jacobian matrix, this algorithm provides enough robustness to find the solution of strong-nonlinear issues, even though the initial guess starts far off the final minimum. The objective function The nonlinear least-squares method (NLSM) was adopted to identify the coefficients of the studied yield functions. The NLSM problem is solved by using a bounded Levenberg–Marquardt optimization algorithmThe fitting quality is measured via RMSD  and the minimum in both RD and TD. The sheet has a small normal anisotropy with the average r-values with the direction angle r-values obtained by the virtual tests are a little higher than the experiments; this is might because the present CP model did not consider the potential 39, which does not prescribe a specific slip plane for the 40, limited slip systems increase plastic deformation anisotropy, which is advantageous for realizing higher r-values for BCC steels. In other words, a more advanced physically-based CP might be able to yield an even better prediction of the plastic anisotropy for this type of AHSS. In addition, the experimental data evidence that the variation of r-values with deformation is not noticeable. At the deformation stages with the specific plastic work of 3 MPa and 8 MPa, the r-values are hardly distinguishable in terms of deformation; with the deformation increased to 60 MPa, a small decrease of r-values in the directions near DD and the increase of r-values in both RD and TD.As shown in Fig. r-values. Especially, the advanced yield function Yld2004-18p predicts the variation of r-values in a rather good agreement with both the virtual tests and experimental results; other two yield functions, i.e., Hill48 and Yld91, slightly underestimate r-values; this is, to some extent, attributed to the plain variation of the r-values. The discrepancies among the predicted results of these functions can also be associated with the intrinsic characteristics of these functions.The yield functions, as stated, calibrated with the VL generated stress points only, successfully captured the variation tendency of As shown in Fig. r-values and normalized yield stresses with tensile direction. Because of the cost and sometimes the restriction of physical experiments, the conventional calibration process of yield functions employs the equal-number experimental data with the parameter number to identify the anisotropic parameters. As stated by Zhang et al.23, this routine cannot yield an optimum set of parameters. The Hill48 function, for instance, may predict the deformation anisotropy well but the strength anisotropy poorly when calibrated by the experimental data of r-values, and vice versa. By using enough number (60 here) of stress points with arbitrary loading conditions, the studied yield functions, including the classic quadratic function and advanced non-quadratic functions, calibrated by the full-field CP-based VL, can well predict the deformation and strength anisotropies simultaneously.It is noted that the Hill48 yield function, which is well-known for its incapacity of capturing the deformation anisotropy and the strength anisotropy simultaneously, gives a satisfactory prediction of the variations of both r-value were further investigated. Figure r-value. The martensite phase, for its higher strength, shows a larger stress level and a smaller strain level in comparison with the ferrite phase. In contrast, the distributions of r-value in the two phases are quite similar and strongly inhomogeneous. The contour maps of the DP-RVE manifest that strain hot-spots occur in some grains’ interior and phase boundaries in the ferrite phase, whereas stress hot-spots are mainly in the martensitic grains.To study the role of individual phases in affecting the overall plasticity of the sheet, the microscopic distributions of tensile stress, tensile strain, and r-value  exhibits a non-probability distribution of strain, suggesting a statically non-uniform deformation in the steel sheet. On the contrary, the stress frequency distributions of both phases manifest as the typical Gaussian distribution, as shown in Fig. To quantitatively understand the plasticity heterogeneity of the dual-phase microstructure, the histograms of frequency distribution of true strain, true stress, and r-value is rather different from those of strain and stress. For the martensite phase, as shown in Fig. r-value close to zero and ~ 13% with r-value above 5.0, and these values for the ferrite is ~ 20% and ~ 11%, respectively. Apart from these two extreme sides, the r-value frequency distributions of the ferrite and martensite phases are greatly similar; both manifest a power-law distribution. These features solidly imply a significant microscopic deformation anisotropy of the DP980 sheet, although its overall normal anisotropy  in Eq. . In this51. As pointed out by Kodukula et al.43, one of the key reasons for the large discrepancy between measured and calculated r-values of a BCC steel is the strong texture gradient through thickness. Increasing the ratio of r-value of BCC steel52, and this ratio was reported to decrease from the surface to the center of steel sheets53. Figure From the aspect of experiments, the mechanical data presented in Figs. A virtual laboratory (VL) based on full-field crystal plasticity (CP) modeling was presented to investigate mechanical anisotropy and to predict yield surfaces of multiphase metals. The VL consists of four modules, including a CP constitutive model, a highly-resolved representative volume element of multiphase microstructure, an inverse simulation procedure based on global optimization for identifying the CP parameters of the constituent phases, and a local optimization scheme for calibrating yield functions through a large number of simulated stress points.r-value and normalized yield stress  system, i.e., the VEGA 3 XMU (LaB6) field emission SEM (TESCAN) equipped with an Oxford/Nordlys EBSD detector. The SEM-EBSD system was operated at acceleration voltage of 20 kV and working distance of 20 mm; it scanned the area with size of 100 μm × 100 μm and step size of 0.25 μm, i.e., collected 160,000 data points totally. The data was processed by the AZtec® system  and reproduced with the open-source MATLAB® (version R2018b) toolbox MTEX50.To obtain the parameters of the CP constitutive model and to validate the yield functions determined by the full-field CP-based VL, room-temperature mechanical tests, including uniaxial tension, pure shear, and biaxial tension, were conducted for the as-received sheet. The geometric shape and dimension of these specimens are illustrated in Fig. Uniaxial tensile tests and pure shear tests were carried out quasi-statically on an electronic testing machine (Instron Model 8080 with a load cell of 100kN capacity) equipped with a commercial digital image correlation (DIC) system (ARAMIS), as shown in Fig. To facilitate the full-field strain measurements of the DIC system, all the specimens were uniformly sprayed with random speckle patterns prior to the tests. The three-dimensional position change of the speckles was photographed by dual high-resolution cameras at a frequency of 2 Hz; the strain field of the deformed specimens then was computed by the commercial DIC software GOM. The photographing was automatically synchronized with the load cell signal by the DIC data acquisition system.Supplementary Information.


One and half years after its discovery in Wuhan, China, COVID-19 has turned into a global public-health catastrophe . On 13 SIndeed, months after the declaration of the pandemic by WHO, scientists and clinicians started employing several approaches for producing effective or prophylactic vaccines against COVID-19 . Many vahttps://nextstrain.org/ncov/gisaid/global). Timely tracking of the new variants requires sophisticated sequencing instruments and facilities. Wealthy countries have implemented routine sequencing measures to track the viral variants; however, many poor countries lack such expensive facilities to document the circulating viral variants by sequencing.Unfortunately, the number of identified, circulating, SARS-CoV-2 variants is alarming in a relatively large number of countries that struggle with the pandemic . AntiboBriefly, two important factors challenge the success of the vaccination campaigns against COVID-19. First, the surging new viral variants have rapidly disseminated globally and may evade immune responses in already vaccinated or previously infected subjects. Second, the antibody titers wane months or years after immunization or following the first infection. These two challenges are interdependent. The future course of the pandemic will be determined by a balance between emergence of the new variants and production of the vaccines.May 2021 saw growing debates about a booster third vaccine dose against the virus. Presently, no clinical evidence exists to support the third dose in fully vaccinated or previously infected subjects. The rationale behind the prescription of the triple-dosing is supported mainly by the emergence of the various SARS-CoV-2 variants that have started to dominate the pandemic. Rapid emergence and dissemination of the Delta variant with high infectivity and transmissibility has prompted the experts and decision-makers to consider the third dose . Some reUncertainties abound about identifying the target groups for triple-dose vaccination. On 12 August 2021, US FDA announced in a news release that “… this small, vulnerable group  may benefit from a third dose of the Pfizer–BioNTech or Moderna vaccines" . Thus, tThe global number of cases infected with SARS-CoV-2 surpassed 225 million on 13 September 2021. Cumulative epidemiological and public-health evidence along with societal, psychological and economic hardship and turmoil dictate that mass vaccination is the best countermeasure to defeat the COVID-19 pandemic. However, antibody levels are thought to wane in immunized subjects, and the durability of effective immune responses is uncertain and undoubtedly varied among individuals. Variability of individual responses to COVID-19 has been known since the beginning of the pandemic, and such a variability may be coordinated by already complex individual immune responses. Some infected patients show aggravating symptoms requiring hospitalizations, whereas some present mild or no symptoms. Meanwhile, the rationale for a third booster vaccination is supported by the urgency to defeat the circulating SARS-CoV-2 variants that have started to dominate the COVID-19 statistics worldwide. We understand that circulating SARS-CoV-2 variants will increase steadily; thus, triple-dose vaccination, at least for immunocompromised and elderly patients, is advisable. However, the effectiveness or safety of administering a third booster vaccination in fully vaccinated subjects has not been confirmed. We do acknowledge that evidence-based countermeasures are necessary to defeat the emerging viral variants, especially VOCs, and timely responses are warranted to efficiently control the pandemic curve in the coming months. Nevertheless, we tend to postulate that the third dosing would be safe in subjects who have tolerated the previous two doses. Importantly, timing of a booster mass vaccination before emergence or dominance of any new VOC could be crucial in controlling the pandemic. Considering that the SARS-CoV-2 variants will inevitably continue emerging and circulating, administering the third vaccination dose at least to the elderly and subjects with immunodeficiencies or disabilities seems sensible. Documenting the vaccine type, its booster dosing, target populations, optimal dosing intervals and the vaccination timeline is crucial for determining the vaccine effectiveness against the existing or new SARS-CoV-2 variants. Any change in the future statistics of COVID-19 may help us better understand the virus and its potential seasonally emerging variants akin to the seasonal flu or measles.


C. elegans has six P4-family ATPases, TAT-1 – TAT-6. TAT-1 – TAT-5 are expressed in many tissues and cells. Here we report that, in contrast, TAT-6 is much less broadly expressed and that, within the somatic gonad, expression of TAT-6 reporters is restricted to the spermathecal-uterine core cell (sujc) cells.In healthy eukaryotic cells, the two leaflets that make up plasma membranes are highly asymmetric with respect to the lipids they contain. In both unicellular eukaryotes and metazoans, the asymmetry in the distribution of aminophospholipids is maintained by P4-family transmembrane ATPases, which catalyze the movement of selected phospholipids from the outer leaflet to the inner.  No reports exist presently describing the pattern in which tat-6 is expressed. We generated multiple transgenic lines containing a construct encoding the entire TAT-6 protein fused to GFP . The construct contained tat-6 promoter sequences, all exons and introns as well as intragenic sequences to the left and right of the tat-6 coding region  . Expression was seen in cells in the head and tail but in the center of the worm, expression was restricted to a proximal part of the gonad . Expression in the gonad was absent in early and mid-L4 stage worms but was robust in young adults . Prior to ovulation, fluorescence was seen in a region at the junction between the spermatheca and the uterus . In hermaphrodites in which ovulation had occurred, GFP fluorescence was seen partially surrounding the distal-most egg in the uterus . The valve forming the junction between spermatheca and the uterus consists of a toroidal syncytium, sujn, and a core cell syncytium, sujc, which initially occupies the center of the valve  . During the first ovulation, the core is displaced by the passage of the newly fertilized egg from the spermatheca to the uterus (Kimble and Hirsh 1979). The change in the distribution of TAT-6::GFP fluorescence we observed during the first ovulation suggested that TAT-6 might be expressed in sujc. Since existing GFP markers for cells in the spermatheca were available, to determine in which cells tat-6 was expressed, we first constructed strains containing a tat-6p::mCherry transcriptional reporter . The marker was expressed in the same way as the GFP reporter . In a strain containing the tat-6p::mCherry reporter and a reporter in which GFP expression was driven by promoter sequences from the cog-1 gene active in sujc , the mCherry and GFP signals were seen in the same cell . In contrast, in a strain containing the tat-6p::mCherry reporter and an ipp-5p::gfp reporter, which is expressed in distal spermathecal cells that form part of the junction with the ovary (Bui and Sternberg 2002), the two fluorescent signals did not overlap . Similarly, in a strain containing the tat-6p::mCherry reporter and an let-502p::gfp reporter, which is strongly expressed in sujn cells , the mCherry signal was adjacent to the strong GFP expression rather than coincident with it . To further verify the identity of the cells expressing the tat-6 reporters, we crossed the tat-6p::mCherry transgene into a cog-1(sy607) mutant background. cog-1 encodes a GTX/Nkx6.1 homeodomain transcription factor; in cog-1(sy607) mutant hermaphrodites, cells having the morphology of sujc cells are absent . cog-1 is not expressed in sujn cells . Consistent with the results with the fluorescent markers, no tat-6 reporter expression was seen in the gonad in the cog-1(sy607) mutant .et al. 2002) ). Genetic research in Saccharomyces cerevisiae has revealed that all five P4-family ATPases in this organism, through their actions as phospholipid translocases, promote one or more vesicle transport events in the endosomal or secretory pathways . It is thought that aminophospholipid translocases promote membrane bending that occurs during the formation of transport vesicles . C. elegans tat-1 is required for correct vesicle transport within the endolysosomal system . C. elegans tat-5 is required for endosome to Golgi trafficking of MIG-14 (a C. elegans Wntless homologue) in the QL neuroblast , and to suppress the formation of extracellular vesicles in the embryo . Thus, it is possible that TAT-6 promotes one or more vesicle transport event within sujc. It is worth noting that the plasma membrane of sujc cells is unusual in being highly convoluted . Although it is not known how the extensive folding of the membrane arises, cell autonomous processes that promote membrane folding in sujc cells have not been ruled out. Finally, our studies also shed light on what happens to material from the sujc cells following ovulation. The fate of these cells after the core of the spermathecal-uterine valve has been displaced is presently not known. The fact that some TAT-6::GFP fusion protein (and mCherry) remains in the uterine epithelium even in older hermaphrodites indicates that at least a part of the sujc cells is retained following ovulation.We do not presently know the function of TAT-6 in sujc. Indeed, the function of the sujc cells themselves is not presently known: ablation of sujc cells in the mid-L4 stage causes only a weak effect on brood size  was used to generate svEx940, the extrachromosomal array from which the integrated array svIs144 was derived; pVB652 was used to generate svEx967 and svEx968. Transgenic strains were generated by microinjection (Fire 1986). The DNA clones were microinjected at a concentration of 50 ng/μl. svIs144 was derived from svEx940 by γ-irradiation. Micrographs were made with DM6000 B and DMRB compound microscopes (Leica); confocal micrographs were made with an A1 confocal microscope (Nikon).Standard methods were used in the maintenance of


All autopsy studies demonstrated widespread thrombosis and alveolar-capillary microthrombi as the cause of death among patients with COVID-19. The autopsy studies are the gold-standard for diagnostic accuracy and therapeutic strategies for any clinical scenarios. The author initially observed that patients already taking therapeutic dose of oral direct factor Xa inhibitors for an unrelated reason, have significantly better survival rates than those not taking any anticoagulants. This influenced the author to conduct a retrospective chart review of the hospitalized patients in Jackson Hospital (Alabama) to evaluate the effect of variable doses of anticoagulation among COVID-19 patients. The study found that serum inflammatory bio-marker D-dimer trends are associated with changes in oxygen requirement among patients with COVID-19, if patients present at an early stage, and titration of Enoxaparin (anticoagulation) dose based on D-dimer trends leads to increased patient survival. AutopsyIn addition, Ockham’s Razor, which implies that the simplest explanations accounting for all facts are more likely to be correct, can also shed light on finding the mechanism of COVID-19 infection under very diverse clinical presentations. Symptoms including fever, shortness of breath, and chest pain may be due to microthrombi in the heart and lungs capillary bed. Parallely, abdominal pain, diarrhea, and ischemic colitis may be due to microthrombi in the intestinal capillary bed. While the ARDS and PE may be due to the alveolar-capillary microthrombi and larger thrombi, stroke, seizures, and loss of sense of smell may be due to microthrombi in the capillary bed of the brain.In the clinical setting, venous thromboembolism is seen in up to one-third of intensive care unit (ICU) patients with COVID-19, even when a prophylactic dose of anticoagulation is used. A recent study conducted on 44 ICU patients also found a high rate of thromboembolic events among the study subjects ,6. Yet, It is important to find a biological marker that can predict COVID-19 survival or death. This retrospective case series study focused on assessing the D-dimer trends as a candidate biomarker that is associated with the level of oxygen requirements and responsive to anticoagulation dose, among patients with COVID-19. The goal of this pilot study was to generate effective treatment strategies to prevent COVID-19 mortality and morbidity using traditionally available drugs and biomarkers.2This study retrospectively evaluated the COVID-19 admission at Jackson Hospital, Alabama, USA from June 15th, 2020 to June 15th, 2021. The study considered the patients who received traditional treatments with Remdesivir, convalescent plasma, Plaquenil, intravenous steroids, and prophylaxis dose of Enoxaparin as a control group. Those patients who received a variable dose of anticoagulation  plus the IV Dexamethasone for treating COVID-19 were considered the treatment group.The author’s previous publication did not assess anticoagulants’ variable effects in treating COVID-19 . The goaEthical approval: The research related to human use has been complied with all the relevant national regulations, institutional policies, and in accordance the tenets of the Helsinki Declaration and has been approved by the authors’ institutional review board of Jackson Hospital, Montgomery, Alabama.Informed consent: All patients were admitted to the hospital as they meet hospitalization criteria and gave signed consent to treatments with any FDA approved drugs.3The study reviewed 100 COVID-19 patients treated at Jackson hospital, Alabama (United States) from June 15th, 2020 to June 15th, 2021. The retrospective case series analysis evaluated 100 patients, but chose to show only ten patients to demonstrate different modalities of treatment strategies. 4Three large randomized clinical trials named ATTACC, ACTIV-4a, and REMAP-CAP were terminated early as the investigators found that among noncritically ill patients with Covid-19, an initial strategy of therapeutic dose of anticoagulation with heparin increased the probability of survival to hospital discharge with reduced use of cardiovascular or respiratory organ support as compared with usual-care thromboprophylaxis  . These tPatients who were admitted at the hospital medical floor  have significant mortality benefit with concomitant use of anticoagulation and intravenous steroids. However, those patients who were treated with anticoagulation in the early stage of COVID-19 and later moved from the hospital floor to the ICU have a higher chance of recovery compared to those who did not receive any anticoagulation prior to their critical care unit admission. The reason behind these failures is that anticoagulation does not dissolve microthrombi (blood clots), rather prevents their further growth. Treating patients with anticoagulation only can benefit when capillaries are still open (not clogged due to microthrombi). Bottom line is that patients presenting to hospital for need of nasal cannula oxygen or high flow nasal cannula oxygen and/or patient with low D-dimer, usually survive with anticoagulation and steroid combination treatments.These COVID-19 hospital floor patients provide unique experiences because of their early stages of the disease presentation compared to patients admitted in the ICUs. The study observed that COVID-19 patients presenting in the later stages of COVID-19 were directly admitted to the ICU due to intubation or BiPAP requirement and were more likely to have poor outcomes compared to patients presenting at an earlier stage in the COVID-19 hospital floor.vice versa. There is a dose-effect relationship between the decreasing trends of D-dimer and the used anticoagulation dose. That means, the quicker recovery is directly proportional to the higher amount of anticoagulation used for treating early-stage COVID-19. Hence, D-dimer can be considered to predict patient outcomes based on which healthcare facility needs to tackle COVID-19. The intravenous steroid (Dexamethasone) provided significant benefit when used concomitantly along with anticoagulation for the noncritically ill hospitalized patients. The steroid possibly helped reduce virus-induced immunological response. The study also observed that administering antiviral drugs  or any drugs that suppress viral load  resulted in a negligible mortality benefit. It is possible that patients presented with respiratory failure, reducing the viral load swimming in the bloodstream, may not have an impact because there are millions of copies residing inside endothelial cells. Thus, the strategy to treat COVID-19 patients, when patients present at a later stage of the disease process, is to treat disease outcome (microthrombi) using therapeutic anticoagulation rather than trying to suppress the viral load . The study also observed patients who developed life-threatening bleeding while on anticoagulation related to COVID-19. Thus, one should thoroughly evaluate patients for risk of bleeding before starting therapeutic anticoagulation, discuss with the patient and family members about the risk of bleeding, and, if possible, temporarily hold aspirin and plavix, while treating the patient with therapeutic anticoagulation for COVID-19.According to this study, anticoagulation along with intravenous dexamethasone has significant mortality and morbidity benefits when patients are in the early stage of the disease process. The study observed that increasing trends of D-dimer in any patient were inversely proportional to the survival and/or clinical recovery from COVID-19 and This study also observed a significant decrease in death rates attributed to ARDS, PE, stroke, or any other significant complications among all patients diagnosed with COVID-19 who are already on high dose of anticoagulation. These observations indicate that therapeutic anticoagulation may protect patients from microthrombi related COVID-19 complications. This is because anticoagulants work by interrupting the process involved in the formation of microthrombi and do not dissolve the microthrombi once they are formed. This mechanism of action also indicates that starting therapeutic anticoagulation after the diagnosis of COVID-19 may not work if widespread microthrombi are already formed prior to the initiation of anticoagulation. The study also observed that direct factor Xa inhibitors are superior to vitamin K antagonists (Warfarin) in terms of ARDS and other morbidity prevention (acute kidney injury). This difference may be related to the fact that direct factor Xa inhibitors prevent factor Xa from cleaving prothrombin to fibrinogen only, which might have a benefit over the blocking function of the vitamin K antagonists leading to depletion of all the vitamin K-dependent coagulation factors . It is unknown why Heparin, which works by enhancing the activity of antithrombin, and oral direct Xa inhibitors are less effective when compared to low molecular weight Heparin (Enoxaparin) among hospitalized patients with high D-dimer. It should be noted that Enoxaparin has 100 units of anti-factor Xa activity per mg, which might play a role in the case of COVID-19. The study also observed that if patients present with ARDS while on direct acting Xa inhibitors, switching to therapeutic dose of enoxaparin plus IV steroids provide a better chance of recovery from COVID-19.The study observed that when patients present with a very high D-dimer, even therapeutic anticoagulation is less likely to prevent a catastrophic outcome. If a patient presents at a later stage like needing intubation or requiring BiPAP on admission, despite using therapeutic anticoagulation, they demonstrate very poor outcomes. In addition, this study found that patient on BiPAP for a prolonged period develop pneumothorax. Given that these critically ill COVID-19 patients do not respond to therapeutic anticoagulation, any clinical trial devoted to critically ill COVID-19 patients may fail to show benefits due to an overwhelming burden of microthrombi where anticoagulation does not dissolve it, rather help prevent getting those thrombi larger. To evaluate the effectiveness of anticoagulation, a clinical trial should compare the early stages of COVID-19 patients who are being treated on the hospital’s COVID-19 floor. This study observed a significant reduction in time to ventilation or reduction in mortality, if patients are given anticoagulation at an early stage of the disease process when the patients do not need critical care unit admission. Similar findings were also reported in the New England Journal of Medicine on August 4, 2021 .However, the study observed that patients presenting with a very low D-dimer and a low basic metabolic index (BMI), would respond to a prophylactic dose of Enoxaparin (or intermediate dose) and show a significant reduction in mortality when compared with obese patients. This may be attributed to the therapeutic dose of Enoxaparin possibly being very close to the prophylactic dose, because of the patient’s lower weight. A similar pattern was also observed among patients on direct factor Xa inhibitors. The patient’s weight may be a significant factor in the prevention of ARDS. Drug doses need to be adjusted for the reduction in mortality, while patients are treated with therapeutic anticoagulation. However, low molecular weight heparin resulted in a better survival benefit compared to any oral anticoagulants across the spectrum of COVID-19 patients.Any randomized controlled clinical trial might not show the benefit of anticoagulation, if the study subjects are critically ill and are not matched or randomized based on the patient’s BMI and the D-dimer level at the time of any enrollment. The study observed that the D-dimer level directly correlates with the critical versus noncritical stages of COVID-19 at the time of enrollment. Both factors (patient BMI and D-dimer) should be randomized among the treatment and control arms for a sound clinical trial to evaluate whether anticoagulation will show a survival benefit or not.A quick study with a similar impact can be done by evaluating the patient population who are already taking a therapeutic dose of Apixaban, Rivaroxaban, or Betrixaban for chronic medical conditions like atrial fibrillation, DVT, PE, or mechanical valve. We need to evaluate whether this subset of patients develops any ARDS, stroke, PE, DVT, or has a decreased death rate when diagnosed with COVID-19. A previous study on laboratory-confirmed COVID-19 analyzed across the New York City health system did not show any survival  benefit and time to mechanical ventilation effect on patients who were already taking therapeutic anticoagulation unrelated to their COVID-19 diagnosis . This st(1) If any patient get diagnosed with COVID-19 but does not meet the hospitalization criteria, then treat the patient with direct Xa inhibitors  for at least one month after considering bleeding risk related to therapeutic anticoagulation.(2) If the patient is diagnosed with hypoxia on presentation, admit the patient to a hospital, and titrate Enoxaparin dose based on serum D-dimer trends. Consider low dose of Enoxaparin (40 mg SubQ daily) or intermediate dose of anticoagulation (Enoxaparin 0.5 mg/kg SubQ twice a day), if patients with COVID-19 have high bleeding risk.(3) Consider starting Dexamethasone of 6 mg intravenous (IV) daily, concomitantly, if the patient requires oxygen.(4) Consider starting full dose of anticoagulation among patients with COVID-19 who present with concomitantly another hypercoagulable disease.(5) For the hospitalized patients, consider intermediate-dose of Enoxaparin (40 mg SubQ twice a day) among patients with high bleeding risk and titrate dose use based on D-dimer trends.(6) Adjust enoxaparin doses based on kidney function. Consider Heparin drip for for any patient with end-stage renal disease instead of Enoxaparin.(7) Increasing or decreasing trend of D-dimer accurately predicts changes in oxygen requirements within 24 h. D-dimer trends provide an early opportunity to titrate up or down Enoxaparin dose before the patient’s status changes. Patients with COVID-19 are less likely to die, if their D-dimer level is low.(8) Calculate bleeding risk before starting therapeutic anticoagulation. Request permissions from patients and family members, when they are started on high-dose of anticoagulation as there is a bleeding risk.(9) If patients on anticoagulation at home for an unrelated reason gets admitted to a hospital with COVID-19, start full dose of anticoagulation (Enoxaparin or heparin) instead of continuing home anticoagulation. In addition, start Dexamethasone of 6 mg (or 10 mg) IV daily, concomitantly.(10) When patients with COVID-19 are ready for discharge, send the patient home with direct Xa inhibitors  for at least one month to prevent DVT, PE, stroke, or post-COVID-19 syndrome.The study observed the following treatment strategies have the highest survival benefits among patients with COVID-19:5Serum inflammatory bio-marker D-dimer trends are associated with changes in oxygen requirement among patients with COVID-19, if patients present at an early stage and titration of Enoxaparin (anticoagulation) dose based on D-dimer trends leads to increased patient survival. Recently published clinical trial validates the fundamental principles of the study’s ten steps COVID-19 treatment strategies. Starting with high dose anticoagulation upon diagnosis of COVID-19 among noncritically ill COVID-19 patients showed improved survival benefit. This study recommends starting direct factor Xa inhibitors, among patients who do not meet hospitalization criteria, to reduce the need for hospitalization and improve survival rates. The study’s rest of the steps for COVID-19 treatment strategies need to be validated through rigorous, well-designed clinical trials to reduce mortality and morbidity related to COVID-19.


Objects: To evaluate the feasibility and effectiveness of in-bed wearable elbow robot training for motor recovery in patients with early and late subacute stroke.Methods: Eleven in-patient stroke survivors  received 15 sessions of training over about 4 weeks of hospital stay. During each hourly training, participants received passive stretching and active movement training with motivating games using a wearable elbow rehabilitation robot. Isometric maximum muscle strength (MVC) of elbow flexors and extensors was evaluated using the robot at the beginning and end of each training session. Clinical measures including Fugl-Meyer Assessment of upper extremity (FMA-UE), Motricity Index (MI) for upper extremities, Modified Ashworth Scale (MAS) were measured at baseline, after the 4-week training program, and at a 1-month follow-up. The muscle strength recovery curve over the training period was characterized as a logarithmic learning curve with three parameters .Results: At the baseline, participants had moderate to severe upper limb motor impairment {FMA-UE [median (interquartile range)]: 28 (18–45)} and mild spasticity in elbow flexors {MAS [median (interquartile range)]: 0 (0–1)}. After about 4 weeks of training, significant improvements were observed in FMA-UE (p = 0.003) and MI (p = 0.005), and the improvements were sustained at the follow-up. The elbow flexors MVC significantly increased by 1.93 Nm  and the elbow extensor MVC increased by 0.68 Nm . Muscle strength recovery curve showed that patients with severe upper limb motor impairment had a greater improvement rate in elbow flexor strength than those with moderate motor impairment.Conclusion: In-bed wearable elbow robotic rehabilitation is feasible and effective in improving biomechanical and clinical outcomes for early and late subacute stroke in-patients. Results from the pilot study suggested that patients with severe upper limb motor impairment may benefit more from the robot training compared to those with moderate impairment. Stroke is the leading cause of long-term disability among adults in the United States  evaluate the feasibility and effectiveness of a wearable elbow robotic device in subacute stroke in-bed training; and (2) investigate the active motor recovery patterns of stroke survivors with severe and moderate levels of motor impairments. It was assumed that: (1) a 4-week in-bed robot-guided training would improve elbow biomechanical properties and motor function; (2) patients with different motor impairment levels at the baseline would have different motor recovery patterns.Patients with early subacute (7 days to 3 months post-stroke) and late subacute (3–6 months) stroke were enrolled in this study  traumatic brain injury; (2) subarachnoid hemorrhage or lacunar infarct without apparent hemiplegia or hemiparesis; (3) previous upper limb amputation; (4) previous musculoskeletal problems on the impaired side including severe arthropathy, arthritis, or complicated orthopedic surgery on either side; (5) other degenerative neurologic problems such as Parkinsonism, Alzheimer’s dementia, or known other dementia; (6) skin lesion, acute infection on application site of the robotic arm; and (7) multiple stroke with neurological sequelae. The study was carried out in conformity with the Declaration of Helsinki; all patients gave their informed consent to participate in the study, which had been approved by the local scientific and ethics committees.A wearable elbow robot  with audiovisual feedback was used for the in-bed elbow movement training . The exoThe wearable robot was designed to provide passive stretching, game-based active movement training with the assist-as-needed scheme, and evaluation of biomechanical properties, including muscle strength and elbow range of motion. The wearable robot was interfaced through a touchscreen computer for display and user interface . The usePatients lay supine in bed and wore the wearable robot on the paretic arm, with the shoulder at about 30-degree flexion and 15-degree abduction. The elbow robot was carefully mounted on the affected elbow with the brace adjusted to align the elbow flexion axis along with the wearable robot output axis . The comThe training procedures are shown in During the passive intelligent stretching, the forearm was passively moved by the robot in the sagittal plane at 30–40°/s. As the resistance may increase near the extreme positions of the elbow joint, the robot gradually slowed down to stretch the muscle-tendon complex slowly and safely  of elbow flexors and extensors. During the measurement, the wearable robot was locked at the 90° elbow flexion and the participant was encouraged to extent and flex his or her elbow maximally. Each measure was done three times with a rest break of 30–60 s to minimize fatigue. The measured data were saved in the robot computer and the averaged value of the three assessments was taken as the corresponding outcome measure.Clinical outcome measures, including upper limb motor recovery, muscle strength, and spasticity, were made on all the participants before and after all the robot-aided training  and 4 weeks after the completion of the training.Fugl-Meyer Assessment of upper extremity (FMA-UE) was used to evaluate motor recovery (maximum score of 66) with a higher score indicating better motor recovery . Considering the 1+ score is not ordinal, the scores of 0, 1, 1+, 2, 3, and 4 were adjusted to 0–5 ordinal scores in further analysis, with a higher value indicating more severe muscle spasticity  at pre-and post-training, and follow-up were calculated. For the clinical outcome measures, the Friedman test was used to test whether the change between pre-, post-, and follow-up was statistically significant. Paired comparisons using the Wilcoxon signed-rank test were made between pre-and post-training conditions and between pre-and follow-up with Bonferroni adjustment. All statistical analyses were performed using the SPSS statistical software . The statistical significance was set at Furthermore, for MVC of elbow flexors and extensors, measured before and after each of the treatment sessions, improvement curves over sessions based on a logarithmic fitting equation as below  was calculated to assess the goodness of fit.where Eleven patients (mean age ± SD: 50.7 ± 10.6 years) with moderate to severe upper limb motor impairment  at subacute stroke stage (post-stroke duration: 2.6 ± 1.9 months) completed the training during their hospital stay of 28 days on average (range: 24–30 days). We applied the robot training in accordance with their routine in-patient treatment schedule and there was no dropout in the patients. Mild skin compression due to robot fixation and muscle soreness were reported by six patients after the first session of training, but this symptom was relieved within 24 h after onset of the symptoms. In general, the in-bed elbow robot training was well-tolerated by the participants without other adverse events. Every participant was able to complete the 50-min training and reported satisfaction with passive stretching and occasionally mild fatigue following the active movement when asked by the researchers. Except one patient, who was discharged after 13-sessions of training, the other 10 patients completed 15 sessions of training. Due to the researcher applied assistance to patients during the muscle strength testing, the biomechanical measures for three patients were excluded from the analysis. Thus, in the following in-session and curve-fitting analysis, biomechanical data for eight patients over 13 sessions were included.p = 0.017) and the MVC of elbow extensors significantly increased by 0.68 Nm  and severe motor impairment . Overall, the improvement rate derived from the post-session measures was larger than the pre-session measures for both elbow flexion MVC  than those with moderate motor impairment , and the post-session improvement rate was larger in the severe motor impairment group (a = 0.865) compared to the moderate motor impairment group (a = 0.323).Each session of robot-guided training-induced changes in the MVC of elbow flexors and extensors, as indicated by the pre-and post-session dot plots over 13 sessions are shown in xion MVC  and extexion MVC , which wxion MVC , overallPatient No. 11 with very severe motor impairment (FMA-UE = 5) at baseline was unable to generate active elbow movement in the first five sessions of training. His recovery curve was discontinuous due to the important zero to non-zero motor output change and was modeled separately .p = 0.003) and Motricity Index . However, no significant differences were observed between the post-training and 4-week follow-up. In addition, subscale value of FMA are presented in The clinical measures were conducted before and after 15 sessions of training (except for one patient discharged after 13 sessions of training), and 4 weeks after the termination of training. After 4 weeks of training, significant improvements were observed in FMA-UE  for upper limb muscle strength at baseline, immediately after the intervention program, and 1-month after the termination of the program, which could serve as a self-control comparison . ImmediaThere are limitations to the study. First, patients in the study also received routine in-patient rehabilitation, which could contribute to their improvement. However, this study demonstrated the feasibility to incorporate the in-bed robot training with routine inpatient rehabilitation training, which may not focus on sensorimotor rehabilitation. Anecdotally, the patients enjoyed the robot training and were highly motivated. However, we did not have a treatment satisfaction rating using the Likert system to evaluate patients’ responses, which should be adopted in future studies. Second, patients in the present study had mild or absent elbow spasticity which may limit the generalizability of the study. The mild or absent elbow spasticity would be due to most of the patients being at the early subacute stage (7 days to 3 months post-stroke; Bernhardt et al., In conclusion, the above study demonstrated the feasibility of using in-bed wearable elbow robot-aided rehabilitation training in subacute stroke survivors with moderate to severe upper limb motor impairment. Furthermore, robotic therapy may result in significant improvement across biomechanical and clinical measures. The recovery curve generated from the robot biomechanical measures could provide useful information to guide the clinical applications of robot-aided training. Patients with severe motor impairment may benefit more from the robot training compared to those with less severe impairment.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the ethics committee of Presbyterian Medical Center, Jeonbuk, South Korea. The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.L-QZ has an ownership in Rehabtek LLC, which received U.S. federal fundings in developing the rehabilitation robot used in this study. 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.


Globally, tuberculosis (TB) was the deadliest infectious disease before the COVID-19 pandemic, with ca 10 million cases and around 1.5 million deaths worldwide each year . InitialIn this issue, Maurer et al. report on a survey of National TB Reference Laboratories in the WHO European Region, documenting the impact of COVID-19 on TB laboratory services, including countries with high TB multidrug resistance . The autDara et al. analyse the public health aspects of TB care during the COVID-19 pandemic, also in this issue . Based oWith successful COVID-19 vaccination programmes now well underway in many countries, it will be important to conduct further scientific analyses to gain reliable estimates of the benefits, harms and costs of the various COVID-19 pandemic measures. These estimates need to be considered alongside the impact of the disease itself as well as in the context of other diseases and wider aspects of health and wellbeing to inform public health decision-making. Now is also the right time to renew our commitment to ‘end TB’  and stre


COVID-19 associated severe respiratory failure frequently requires admission to an intensive care unit, tracheal intubation, and mechanical ventilation. Among the risks of prolonged mechanical ventilation under these conditions, there is the development of tracheoesophageal fistula. We describe a case of a severe COVID-19 associated respiratory failure, who developed a tracheoesophageal fistula. We hypothesized that one of the mechanisms for tracheoesophageal fistula, along with other local and general risk factors, is the local infection due to the location of the virus itself in the tracheobronchial tree. The patient was managed successfully with surgical intervention. This case highlights the increased risk of this potentially life-threatening complication among the COVID-19 patient cohort and suggests a management strategy. The COVID-19 pandemic caused by the SARS-CoV-2 virus has dramatically and rapidly spread around the world in recent months. A wide spectrum of clinical manifestations with different degrees of severity may occur, including those associated with the virus' predominant symptom of severe respiratory distress.Patients who require intensive care for respiratory failure are critical due to the severity of the illness and to the risks associated with prolonged mechanical ventilation and intensive care unit (ICU) stay; among them, pulmonary barotrauma due to positive ventilation and high positive end-expiratory pressure (PEEP) has to be considered . In addiWe present the case of a patient with severe COVID-19-associated pneumonia who underwent orotracheal intubation and prolonged mechanical ventilation. The patient developed a tracheoesophageal fistula (TEF) successfully repaired. The decisional algorithm should balance between an early effective surgical repair and the need of maintaining ventilation for a long-lasting respiratory failure. Different therapeutic options are available and discussed.On March 13, 2020, a 52-year-old man with obesity (BMI = 34) and with new-onset diabetes was admitted for fever and cough for six days. He tested positive for SARS- CoV-2 virus. After 2 days, he developed increasing dyspnea, fatigue, and decreasing oxygen saturation despite treatment with noninvasive ventilation (NIV), and he was transferred to the ICU. Intensive respiratory treatments was started including prone position, 20% of the day on average during the first week, due to obesity of the patient and high risk of developing pressure sores. The patient was placed on pressure-regulated volume control with the following settings: tidal volume 500 mL; respiratory rate 24; inspiratory/expiratory ratio 1/1,3; static compliance: 24; PEEPi: 0. Nevertheless, the PaO2/FiO2 ratio was <120.On hospital day 25, the patient developed thoracic subcutaneous emphysema and increased troponin-T and NT-proBNP levels. A chest X-ray showed bilateral pneumothorax and subcutaneous emphysema. A chest CT scan confirmed the radiological findings and revealed the presence of a large pneumomediastinum Figures  and 2 anThe repair was checked on postoperative day 10 via a CT scan  and on p2O.Acquired, nonmalignant TEF is one of the fearful complications of prolonged intubation for mechanical ventilation. Several factors could facilitate its development such as cuff overinflation of the tracheal or tracheostomy tube , high aiA recent consensus statement suggested to perform tracheostomy in COVID-19 patients expected to require prolonged intubation; however, a specific timing was not recommended . Timing The acute presentation of TEF in this patient is typical in patients undergoing mechanical ventilation, with a drop in oxygen saturation (in spite of adequate ventilation), positive cuff leaks, and gastric distension. The diagnosis of TEF is confirmed with a CT scan, endoscopy, or barium esophagography .As the spontaneous closure of a TEF is rare, surgical repair is generally required. However, the timing of fistula closure in ventilator-dependent patients is a matter of debate. The majority of the authors advocate to postpone the repair until the patient is fully stable and weaned from mechanical ventilation, to reduce the risk of anastomotic dehiscence . We consOur surgical approach was through a left lateral cervicotomy. Although either a transverse anterior collar or a U-shaped cervical incision might be preferred by some authors , a left Despite high-related morbidity and mortality of TEF, even higher in patients with COVID-19 , surgicaAs described, a tracheal stenosis was observed in the postoperative period. We hypothesized that the combination of tracheostomy and infection led to the formation of secondary scar tissue healing with shrinkage of the. The trachea stenosis was treated with the temporary placement of a Montgomery T-Tube. A vocal rehabilitation program was required due to temporary palsy of the vocal cords that, however, did not impair swallowing and the resuming of oral intake.In summary, a COVID-19 patient with respiratory failure developed a precocious TEF. Due to an expected long-term respiratory dysfunction, immediate surgical repair was carried out, prior to weaning from mechanical ventilation. Repair of TEF was successful without life-threatening complications or major surgical sequelae. Surgical repair of TEF in COVID-19 patients is feasible and should probably be done earlier than later.


ABSTRACT IMPACT: Despite its importance in systemic diseases such as diabetes, the eye is notably difficult to examine for non-specialists; this study introduces a fully automated approach for eye disease screening, coupling a deep learning algorithm with a robotically-aligned optical coherence tomography system to improve eye care in non-ophthalmology settings. OBJECTIVES/GOALS: This study aims to develop and test a deep learning (DL) method to classify images acquired from a robotically-aligned optical coherence tomography (OCT) system as normal vs. abnormal. The long-term goal of our study is to integrate artificial intelligence and robotic eye imaging to fully automate eye disease screening in diverse clinical settings. METHODS/STUDY POPULATION: Between August and October 2020, patients seen at the Duke Eye Center and healthy volunteers (age ≥18) were imaged with a custom, robotically-aligned OCT (RAOCT) system following routine eye exam. Using transfer learning, we adapted a preexisting convolutional neural network to train a DL algorithm to classify OCT images as normal vs. abnormal. The model was trained and validated on two publicly available OCT datasets and two of our own RAOCT volumes. For external testing, the top-performing model based on validation was applied to a representative averaged B-scan from each of the remaining RAOCT volumes. The model’s performance was evaluated against a reference standard of clinical diagnoses by retina specialists. Saliency maps were created to visualize the areas contributing most to the model predictions. RESULTS/ANTICIPATED RESULTS: The training and validation datasets included 87,697 OCT images, of which 59,743 were abnormal. The top-performing DL model had a training accuracy of 96% and a validation accuracy of 99%. For external testing, 43 eyes of 27 subjects were imaged with the robotically-aligned OCT system. Compared to clinical diagnoses, the model correctly labeled 18 out of 22 normal averaged B-scans and 18 out of 21 abnormal averaged B-scans. Overall, in the testing set, the model had an AUC for the detection of pathology of 0.92, an accuracy of 84%, a sensitivity of 86%, and a specificity of 82%. For the correctly predicted scans, saliency maps identified the areas contributing most to the DL algorithm’s predictions, which matched the regions of greatest clinical importance. DISCUSSION/SIGNIFICANCE OF FINDINGS: This is the first study to develop and apply a DL model to images acquired from a self-aligning OCT system, demonstrating the potential of integrating DL and robotic eye imaging to automate eye disease screening. We are working to translate this technology for use in emergency departments and primary care, where it will have the greatest impact.


Objective: To investigate a high-pitch spiral first (HPSF) approach for coronary computed tomography angiography (CCTA) in an unselected patient cohort and compare diagnostic yield and radiation exposure to CCTAs acquired via conventional, non-high-pitch spiral first (NHPSF) scan regimes. Materials and Methods: All consecutive patients from 1 January 2015 to 31 December 2017 were included. Two investigation protocols (HPSF/NHPSF) were used with the aim to achieve diagnostic image quality of all coronary segments. Low-pitch secondary scans followed the initial examination if image quality was unsatisfactory. Dosage and image quality were compared between both regimes. Results: 1410 patients were subject to a HPSF and 236 patients to a NHPSF approach. While the HPSF approach led to a higher fraction of re-scans , the fraction of aggregate scans that remained non-diagnostic after considering the initial and secondary scan was comparably low for the HPSF and NHPSF approach . Aggregate radiation exposure in the HPSF protocol was significantly lower  vs. 3.96 mSv  p < 0.001). Conclusions: In spite of a higher number of re-scans, a HPSF approach leads to a reduction in overall radiation exposure with diagnostic yields similar to a NHPSF approach. The excellent negative predictive value of coronary computed tomography angiography (CCTA) has put it in the spotlight as a non-invasive test for coronary artery disease (CAD). More widespread implementation of this method underlines the importance to continuously reduce radiation to exposed patients, a quest in part resolved by a combination of hardware adaptions and prospective ECG-gating ,2.While the improvements in dose-reduction are certainly paramount, one should nonetheless stress that clinical decision making based on CCTA results calls for reliable image quality and that a non-diagnostic scan may lead to further radiation exposure by alternative modalities such as invasive coronary angiography or Sesta-MIBI myocardial perfusion scan. In this setting, the potentially artefact-compromised data in high-pitch scans especially in patients with extrasystoles or elevated heart rates has often raised concerns about its robustness in a broad patient collective. One has to note, that CCTA can only be a reliable go-to method for non-invasive cardiac imaging if the coronary tree can be evaluated with diagnostic certainty. Ideally, such is the case after the first scan. Otherwise re-scans are necessary until the aggregate interpretation of all acquired data allows for the valid interpretation of each coronary segment. Rapidly moving coronary arteries make it difficult to achieve this goal; a common concept to improve image quality is to widen the acquisition window in order to allow for multiple reconstructions at different timepoints of the heart cycle. This of course increases radiation exposure. With the particularly low radiation exposure of the high pitch spiral scan another strategy of acquiring a low dose scan at a single timepoint first and repeating the scan in case of limited image quality is feasible. As long as the fraction of repeat scans is low, this strategy would translate to an overall radiation dose reduction.The PROTECTION IV study performed a groundwork multicenter exploration of high-pitch spiral CCTA, demonstrating the robust image quality and significant dose reduction when using this technique. Yet, inclusion was restricted to patients with a low and stable heart rate rendering assumptions of a high-pitch approach in an unselected patient cohort highly speculative .To clarify the potential of high-pitch scanning as a go-to method in a broader patient collective, i.e., including those with elevated heart rates and extrasystoles, we investigated radiation exposure and image quality among two examination algorithms that ultimately aimed to achieve CCTAs of diagnostic quality for each patient, namely a high-pitch spiral first (HPSF) approach and non-high-pitch spiral first (NHPSF) approach.Eligible for retrospective analysis were all consecutive patients referred for CCTA at our institution from 1 January 2015 to 31 December 2017. To investigate cardiac-specific radiation exposure, all scans extending beyond the aortic root or diaphragm were excluded. As patients presenting with atrial fibrillation are routinely not investigated via high-pitch spiral scan at our institution, these were not eligible for comparative analysis and excluded. Informed consent was received before scan acquisition.All patients were investigated using a dual-source Siemens SOMATOM FORCE  scanner. Scan preparation was done by administering up to four doses of 5 mg metoprolol i.v. in patients with a heart rate >60 beats per minute (bpm) as well as 0.8 mg of nitroglycerin sublingually for patients with a systolic blood pressure of at least 100 mmHg. An initial topogram was acquired, the scan area was defined as between the level of the carina and diaphragmatic surface of the heart. After a bolus timing single-slice scan, contrast application  followed by a 50 cc saline chaser was performed at an injection rate of 4–6 cc/s for CCTA. Tube voltage and tube current were determined automatically based on the body habitus of the patient . CT acquisition parameters were as follows: slice collimation 3 mm × 192 mm × 0.6 mm, pitch of 3.4. ECG-gated reconstruction algorithms led to a temporal resolution up to 66 ms. For analysis, multiplanar reconstructions (MPR), maximum intensity projections (MIP) and 3D volume rendered (VR) techniques were used. Heart rate and presence of sinus rhythm or extrasystoles was documented during the acquisition.Two investigation protocols were used in this study with the aim to ultimately achieve diagnostic image quality of all coronary segments. The HPSF protocol consisted of a prospectively ECG-triggered high-pitch spiral CCTA in mid-diastole, followed by a low-pitch method (prospective step-and-shoot (SAS) scan, spiral scan with retrospective gating) or prospective high-pitch spiral with double acquisition in the case of non-diagnostic initial image quality. The NHPSF approach firstly used SAS, retrospectively gated spiral scans or prospective high-pitch scans with double acquisition, followed by a second low-pitch scan method if image quality was deemed unsatisfactory. Repeat scanning was performed in both protocols either holo-cardiac or segment-specific depending on which segments of the coronary tree were initially non-diagnostic. For calcium scoring a low dose native acquisition was performed prior to the selected protocol on every patient. The choice of scan method was nonrandomized at the discretion of the examining senior radiologist depending on patient characteristics, such as heart rate, weight, extrasystoles and pre-existent patient conditions. If obstructive CAD was diagnosed on the first scan, no repeat imaging was performed even if other coronary segments were of non-diagnostic quality and patients were immediately referred for further work-up.Each coronary segment was evaluated for the presence of plaques, defined as any structure within and/or adjacent to the coronary artery lumen >1 mm that could be clearly distinguished from the vessel lumen . Images Segmental evaluation of coronary arteries was performed on the basis of the classification of the American Heart Association, using the first 15 of the proposed coronary segments . The CT volume dose index  version 2.10.1 including the package rms was used for statistical analysis [Categorical variables are expressed as frequencies and percentages. Continuous variables are described as means ± standard deviation or as median and interquartile range in the case of non-normal distribution. Student’s analysis .In total, 1797 patients were investigated via CCTA during the study period. Of these, 121 were excluded because the scan extended beyond the cardiac region. Thirty patients were investigated with a double high pitch spiral scan on the ground of atrial fibrillation and therefore excluded. The study population of 1646 patients consisted of 1410 patients with a HPSF and 236 patients with a NHPSF approach.Due to the nonrandomized nature of this study, there were significant differences in patient characteristics of the HPSF and NHPSF cohort, including a higher heart rate, BMI and more frequent intra-procedural recordings of extrasystoles for the latter. Furthermore, due to the “allcomer” design, there was some missing patient data concerning heart rate, heart rhythm and BMI. Patients with missing data were subsequently excluded from subgroup analysis . Detailep < 0.001). In detail, significantly more patients in the HPSF-group had an excellent  but also non-diagnostic  image quality on initial scanning. In total, 17 patients in the HPSF-group and 9 patients in the NHPSF-group had initial scans with non-diagnostic quality of some coronary segments but did not get repeat scans due to a relevant stenosis that was evident in the diagnostic coronary segments. A flow-chart illustrating the methods of scan acquisitions is given in In the 1410 patients with a HPSF protocol, analysis on a per-patient basis revealed that image quality in the first scan was excellent or diagnostic in 899 (63.8%) patients, compared to 202 (85.6%) patients with a NHPSF approach (p < 0.001).Both protocols allowed for similar fractions of excellent initial scans in patients with heart rates below 60 bpm. Higher rates of excellent image quality could yet be obtained when using the HPSF vs. NHPSF approach in patients with sinus rhythm and no extrasystoles during scan acquisition. This advantage faded however if extrasystoles occurred as both protocols then had similar fractions of excellent scans and the HPSF protocol led to more scans of non-diagnostic quality. Further, the occurrence of primary successful CCTAs was significantly reduced in patients examined with the HPSF approach if heart rates were beyond 60 bpm. Refer to Taken together, 1976, respectively 100 coronary arteries were characterized for artefacts in the 494 HPSF and 25 NHPSF patients that needed repeat scans . There was a trend for more artefact-ridden coronary arteries in the NHPSF than HPSF group mainly due to a higher rate of coronary arteries that were affected by motion artefacts. Artefact analysis for non-diagnostic scans is given in The HPSF-cohort had a significantly lower radiation exposure than the NHPSF-cohort for the first scan. In the 494 (HPSF-cohort) and 25 patients (NHPSF-cohort) with repeat scans, the effective dose was also lower if HSPF was used. Hence, on aggregate, a significantly lower overall radiation exposure was noted for the HPSF-protocol. Detailed results on radiation exposure are given in Dichotomization for heart rate revealed that the HPSF approach had significantly lower radiation doses for both, patients with heart rates below and above 60 bpm. Similarly, utilizing the HPSF approach reduced radiation exposure irrespective if patients had extrasystoles or not . SubgrouIn patients with elevated BMI (≥25), a marked increase in radiation exposure could be noted for both, the HPSF and NHPSF protocol. On the other hand, rise of overall radiation exposure as a function of elevated heart rates (>60 bpm) or lacking extrasystole-free sinus rhythm could be noted in the HPSF approach only.In an effort to elucidate the potential of high-pitch prospective CCTA acquisition in a broad patient collective, our study suggests that (i) the implementation of a HPSF approach is inching towards sub-millisievert scanning and can significantly reduce radiation exposure and (ii) albeit a higher rate of repeat scans is necessary in a HPSF-concept, the amount of scans that remain non-diagnostic after repeat scanning is not significantly different from a conventional CCTA approach.X-ray based medical imaging is consistently challenged by an effort to lower radiation exposure while maintaining or even improving diagnostic quality.Multicenter evaluation of the dose-saving potential of high-pitch spiral vs. conventional scan methods has demonstrated the non-inferior image quality, impressive dose reduction and more frequent re-scanning in selected patients . While tNoteworthy works in this domain also reported low radiation exposures of around 1.3 mSv and good, yet heart-rate dependent image quality in 256 patients investigated with this method [Another working group was able to report comparable image quality with notably lower radiation exposure (0.53 ± 0.14 vs. 1.33 ± 0.17 mSv) in patients scanned with a high-pitch spiral compared to lower-pitch sequential scans .Further studies regarding other aspects of high-pitch spiral CCTA, be it its applicability for free-breathing acquisition, the rate of scans that were of non-diagnostic quality, or its robust image quality after tube voltage reduction, confirm the actuality of this matter ,10,11. RUp to date, one area of concern has been that beyond a certain detector pitch, susceptibility to artefacts rises exponentially, potentially leading to a higher rate of repeat scanning. This is confirmed by our observation of a significantly higher rate of re-scans in the HPSF approach, affecting around one-third of the patients. Previous studies reported notably lower rates of non-diagnostic high-pitch spiral scans, a discrepancy potentially explained by the broad patient cohort in the underlying study ,12,15,16In the vast majority of initially non-diagnostic cases only one or a few coronary segments needed repeat imaging and therefore the repeat scan only partly covered the coronary tree. Hence, the aggregate ED was around two-thirds lower if a high-pitch spiral was used ad initio. In detail, the “scan-to-diagnosis” ED was 1.12 vs. 3.96 mSv in favor of the HPSF protocol. In spite of the notable rise in ED, that difference remained significant when analyzing subpopulations with extrasystoles or elevated heart rates. Furthermore, and in agreement to established data, a higher BMI went in-hand with a rise in radiation exposure as dose modulation techniques counterbalanced the expected fall in contrast-to-noise . It needThe here-stated recommendation for HPSF as a go-to approach in CCTA holds true especially in patients with heart rates below 60 bpm and lacking extrasystoles. While we provide data on reduced radiation exposure in patients with higher heart rates or extrasystoles, more evidence in this regard is needed to conclusively validate the utility of a HPSF approach.Concerns on the robustness of HPSF imaging can be mitigated by our finding that the image quality of this approach is comparable to conventional scan regimes, in-line with results from other working groups that validated the image quality of high-pitch spiral scans ,21,22,23A limitation of this study is the observational, nonrandomized design. Hence, decisions regarding the scan protocol were taken by the investigator and presumably taken conservatively if difficult examination conditions were expected. Consequently, the NHPSF-cohort presented with higher heart rates, more extrasystoles and a higher BMI, all known factors to impair the image quality of a CCTA. Hence, a selection bias of the chosen scan protocol might have contributed to the superior image quality in the HPSF cohort. Furthermore, the NHPSF cohort had higher calcium score levels and a higher per-patient number of calcified plaques as patients with more protruded coronary artery disease were less likely to have sinus rhythm and might therefore have been more readily examined with a NHPSF approach.This study demonstrates that a HPSF approach for CCTA in an unselected patient collective allows for significant reductions in radiation exposure with similar diagnostic yields to conventional CCTA protocols.