Our study's motive was to recognize various immune-mediated inflammatory processes involved in the pathogenesis of depression and psoriasis and interlink between them based on inflammatory mediators.A careful and comprehensive literature search was done through various databases like PubMed, Google Scholar, and EBSCO. A total of 56 studies were included in our study after careful screening.+, CD4+, CD8+ T-lymphocytes were also found to be raised in both depression and psoriasis, validating their relationship. Hyperactivity of HPA-axis was also found another interlink between them along with reduced melatonin amount.The immune-mediated inflammatory process was significantly associated with the pathogenesis of both depression and psoriasis. Most of the inflammatory markers involved in Psoriasis , and increased serotonin transporters (5-HTT) were also found in the pathogenesis of depression, showing the immune-inflammatory linkage between psoriasis and major depression. Based on immune chemistry, the levels of CD2According to various studies, the neuro-dermatological association between psoriasis and depression is significant. Different immune markers involved in the pathogenesis of depression and psoriasis also show the bidirectional association between them. However, this association between psoriasis and depression is positively correlated, but more work is required to answer why all depressed patients fail to develop psoriasis and why all psoriatic patients fail to develop depression. However, it can involve whole body surfaces, as well 2.This is a systematic review for exploring the immune-mediated inflammatory association between psoriasis and significant depression. The literature was done using PubMed, Google Scholar, and EBSCO search engines using psoriasis's general keywords and significant depression. A total of 1470 studies were found using search terms of depression and psoriasis, but after searching the specific keywords related to our study aims and objectives, we found 94 studies of our interest with two studies from other sources. Some of these studies were duplications and were excluded from our study. A total of 56 studies were finally included. Throughout this process of selection of studies, PRISMA guidelines were followed and presented in the form of a PRISMA flow chart .3.The most common psychological factors associated with psoriasis are stress, anxiety, and depression, also known as major depression 3.1.Psoriasis is generally regarded as a multifactorial disease associated with various genetic and environmental factors that provoked immune-mediated inflammatory processes in various organs via Th 1 and Th 17 induced pathways Dendritic cells are considered antigen-presenting cells that have a paramount role in regulating the body's immune system through innate and adaptive immunity. Various types of dendritic cells are associated with psoriasis' pathogenesis, including Langerhans cells, plasmacytoid dendritic cells, and dermal myeloid DC 3.2.Major depression is considered a leading cause of disease burden worldwide, affecting almost 4.4% of the world population Patients with major depression have been repeatedly observed to have increased inflammatory cytokines, chemokines, and acute-phase proteins such as C-reactive proteins (CRP) in peripheral blood and cerebrospinal fluid (CSF) 3.3.After carefully describing the immune-inflammatory processes involved in the pathophysiology of depression and psoriasis, we concluded that major depression and psoriasis are significantly associated with each other validating their directionality evident from the presence of similar cytokines interleukins and other mediators involving pathologies as mentioned above. However, to strengthen this concept of bidirectionality, we believe that still more studies are required. Many other studies are still proving this bidirectional association, as evident from the published literature that the pro-inflammatory cytokines involved in Psoriasis' pathogenesis are likely to cause hyperactivation of the Hypothalamic-Pituitary-Adrenal axis leading to major depression. This hyperactivity of the Hypothalamic-Pituitary-Adrenal axis also leads to decreased serotonin levels, which is another causative factor in developing major depression +, CD4+, CD8+ cells were found to be high in both psoriasis and depression with a markedly increased ratio of CD4+/CD8+ cells The studies are also suggesting that major depression and psoriasis have a high impact on both genetic and immunological parameters, as evident from a study showing that levels of CD24.Though very little work has been done to find the association between depression and psoriasis to prove it through skin-brain axis theory, some studies clearly show this association of bidirectionality. This association of psoriasis and depression is not just a coincidental finding; in actual, an immune-mediated inflammatory process is involved in proving this bidirectional association. The most commonly involved inflammatory markers observed in the pathogenesis of both depression and Psoriasis are IL-6, IL-17, IL-13, IL-23, IL-10, IL-1β, and type A cytokines  through Th1 and Th17 lymphocytes mediated processes. This pro-inflammatory cytokine production was also associated with HPA-axis over-activation with serotonin transporters' upregulation (5-HTT) and reduced serotonergic neurotransmitters in the body's depression. However, melatonin level was also found to be on the lower side in both depression and psoriasis, validating the bidirectional association. However, why every depressed patient never develops psoriasis, and why every patient with psoriasis is not always depressed, this mastery still needs more discussion and debate.


In recent years, the adjuvant treatment of endometrial carcinoma has changed due to the integration of the molecular features in the clinical–pathological classification. The new ESGO/ESTRO/ESP guidelines (2021) proposed the evaluation of the adjuvant treatment of endometrial carcinoma using a prognostic-risk group stratification based on pathogenetic, clinical, and molecular features. Moreover, the adjuvant therapy of endometrial carcinoma is currently being re-defined in ongoing studies. This review provides a comprehensive overview of endometrial carcinoma adjuvant therapy, analyzing the “new standards” and “new perspectives”.Endometrial carcinoma is the most frequent cancer of the reproductive female organs. Most endometrial cancers are diagnosed at early stage (75%). Treatment options depend on pathogenetic, histopathologic and clinical characteristic at the diagnosis. To improve patient management in the near future, recent research has focused on new molecular features; evidence has shown that these give a better definition of patient prognosis and can help in tailoring adjuvant treatments by identifying specific subgroups of patients whose tumors may benefit from specific therapeutic approaches. In this review, we will focus on current knowledge of adjuvant treatment of endometrial carcinoma, using a prognostic-risk group stratification based on pathogenetic, clinical and molecular features, and will take a look at the ongoing trials that will further change the therapeutic approach in coming years. Endometrial carcinoma (EC) is the fourth most frequently diagnosed cancer in women with 130,051 estimated new cases and 29,963 deaths in Europe in 2020 [Over the years, EC has been classified using three different approaches: pathogenetic, histopathologic and molecular. The first was proposed by Bokhman in 1983. He classified two clinic-pathological types ; type I The Cancer Genome Atlas (TCGA) performed an integrated genomic and proteomic analysis of 373 endometrial cancers that provided insights into disease biology and diagnostic classification with immediate therapeutic application ,9,10 As The new European Society of Gynaecological Oncology/European Society for Radiotherapy & Oncology/European Society of Pathology (ESGO/ESTRO/ESP) guidelines for the management of patients with endometrial carcinoma, defined in 2021, give new recommendations for adjuvant treatments which are strongly dependent on the prognostic risk group, defined according to several elements: 1. histopathologic type, according to WHO Classification of tumors (5th edition) ; 2. gradIn this review we will focus on the adjuvant treatment proposed for each prognostic risk group of EC in the new ESGO/ESTRO/ESP Guidelines and review the literature supporting the final statements. Risk groups with and without molecular classification are described in The Low-risk group includes stage IA endometrioid carcinoma, low-grade and LVSI negative or focal (defined by the presence of a single focus around the tumor). A consensus has been found for managing these tumors: no adjuvant treatment is recommended. The data backing this conclusion are based mainly on multiple randomized trials reporting no improvement in prognosis when adjuvant RT is given, at the cost of an increased toxicity ,19,20,21The sub-group analysis of the PORTEC-3 trial showed that patients with POLEmut EC have an excellent prognosis independently of adjuvant treatment choice ,11,22. BThe vagina is the most frequent site of recurrence after surgery in intermediate risk EC patients. Many randomized trials have shown that vaginal brachytherapy (VBT) is effective in preventing vaginal relapse ,28,29,30Moreover, new standards suggest that in younger than 60-year-old IR patients the omission of adjuvant brachytherapy can be considered . This isWhen the molecular classification is known, into this category are placed stage IA p53abn and/or non-endometrioid  without myometrial invasion, and MMRd and NMSP EC with IR clinical and pathologic characteristics.In this setting, published data are very scarce; however, according to some case series, vaginal brachytherapy might be effective in preventing vaginal relapse in stage I type 2 endometrial cancer, while others have suggested that adjuvant chemotherapy could improve survival . Based oLastly, in the case of P53abn carcinoma restricted to a polyp or without myometrial invasion, there are no available randomized trials and new standards do not recommend adjuvant therapy due to the uncertainty of its effect .The long-term, 10-year follow up analysis of the PORTEC-2 trial reported that substantial LVSI and L1 Cell Adhesion Molecule (L1CAM) expressions are strong predictive risk factors for recurrence in intermediate risk EC patients. In the PORTEC-2 trial, women with these unfavorable risk factors showed a greater risk of locoregional recurrence: based on this new evidence another risk group has been defined (high-intermediate risk) for which EBRT is recommended .As for the management of this risk group we need to differentiate two different clinical situations: 1. when lympho-nodal status is known and negative (patients received lymphadenectomy or sentinel lymph node procedure): new guidelines recommend adjuvant brachytherapy to reduce vaginal recurrence; 2. when the lympho-nodal status is unknown because staging was not performed: EBRT is the treatment of choice. Chemotherapy can be considered especially for high grade and/or substantial LSVI .The first evidence of a possible role for adjuvant chemotherapy in HIR EC was reported by Maggi et al.  and SusuSusumu’s study is a multi-center randomized phase III trial comparing EBRT with 3 cycles of CAP in women with endometrioid adenocarcinoma with deeper than 50% myometrial invasion. The observed PFS and OS were not statistically different between the two regimens, but a subgroup analysis showed that CT significantly improved PFS and OS in HIR patients with respect to EBRT . Both thThe combined analysis of NSGO/EORTC-trials showed that the sequential combination of CT and EBRT was associated with a 36% reduction in the risk of relapse or death and a 49% reduction in the risk of cancer-related death . The NSGMore recently the results of the GOG 249 trial  were repWith a lower level of evidence, suggesting a general uncertainty about the best treatment for these patients, other options were reported by the panel, which stated that a “tailored” treatment may be the better choice for HIR EC patients: omission of any adjuvant treatment and adjuvant brachytherapy alone, particularly for high-grade LVSI negative and for stage II grade 1 ECs, are also reported options . When moThe molecular sub-group analysis of PORTEC-3 trial suggests that there is no benefit from CT in MMRd carcinomas ,38.For these patients the recommendations are represented by EBRT with concurrent and adjuvant CT, or in alternative sequential CT and radiotherapy. Chemotherapy alone is also an option .The role of combined adjuvant chemotherapy and concurrent chemo-radiotherapy is reported in the PORTEC 3 trial, which compared this strategy with EBRT alone in high-risk EC. Updated results of this trial, published in 2019 when the majority of the patients had reached 5 years of follow-up, showed improved 5-year OS  and failure-free survival . In subgroup analysis, women with stage III endometrial carcinomas and serous carcinomas reported the greatest advantage while, for women with stage I–II endometrial cancer, combined adjuvant treatment translated only to a small absolute improvement of 2% in 5-year OS and 4% in failure-free survival , thus suThe GOG-258 study was a randomized phase III trial evaluating six cycles of platinum-paclitaxel CT vs. tumor-directed RT followed by CT in patients with stage III-IVA endometrial cancer. This trial showed that the combined regimen was not superior to chemotherapy alone in prolonging relapse-free survival, although locoregional relapses were less frequent than with chemotherapy alone. .When the molecular classification is known, the subgroup analysis of the PORTEC-3 trial reported an improved OS from combined therapy for stage I-III p53abn carcinomas with myometrial infiltration; benefits of CT were, however, not clear for MMRd carcinomas, while stage III NSMP carcinomas seemed to see some benefit from the addition of chemotherapy.Despite the recent implementation of molecular features into clinical classification in order to better individualize the adjuvant treatment of endometrial cancer, there are still some limitations to be addressed and some settings for which the 2021 guideline does not provide strong recommendations, due to a lack of a high level of evidence . Table 3Next perspectives for the adjuvant therapy of endometrial carcinoma are currently being defined in ongoing studies.The RAINBO trial is an international program of personalized, molecular based, adjuvant treatment for high-risk EC patients. The objective of the program is to improve the management of endometrial carcinoma by approaching the cure with a molecular-driven strategy and to compare standard treatment to personalized treatment based on molecular features. After surgery, EC patients will be recruited in four independent and parallel trials based on their molecular profiling: P53abn, MMRd, NSMP and POLEmut. The p53abn-RED trial will investigate the role of 2-year maintenance therapy with Niraparib after chemo-radiotherapy in stage I-III p53abn ECs. The MMRd-GREEN trial will evaluate the role of adjuvant anti PD-L1 inhibitors in stage II-III MMRd EC with substantial LVSI. The NSMP-ORANGE trial will compare the addition of hormone adjuvant therapy to EBRT vs. the addition of CT to EBRT in stage II-III NSMP EC patients. The POLEmut-BLUE trial is a single arm prospective phase II trial of observation for all stages POLEmut EC; adjuvant treatment is not planned, with the exception of EBRT in advanced stage.The role of immunotherapy in combination with CT in the adjuvant setting of high-risk EC is being addressed in the ENGOT-EN11 ongoing trials. This is a randomized phase 3 trial evaluating the role of anti PD-1 Pembrolizumab in combination with platinum-paclitaxel chemotherapy vs. CT/placebo in newly diagnosed endometrial FIGO stage I/II non-endometrioid histology, FIGO Stage I/II any histology with known p53abn expression and FIGO Stage III/IVA any histology carcinoma or carcinosarcoma.Patient should have received curative intent surgery with no residual disease and no prior radiation or systemic therapy for endometrial cancer including neoadjuvant therapy. RT is optional in both arms. The primary end points of the trial are both disease-free-survival (DFS) and OS.It is expected that these trials, if positive, will change the adjuvant treatment strategy of EC and the molecular features will guide in the next future the choice of treatment, with a more targeted treatment approach.It has also to be noticed that, in the individualized therapies era, other targeted agents are under investigation. In the adjuvant setting, antibodies targeting HER2 over-expression within the p53abn group have shown promising results .The integration of molecular features in the clinical–pathological classification of EC represents an urgent step forward and definitive turning point in the general management of the disease. The possibility of identifying the molecular characteristics of patients will offer the opportunity to better define the prognosis of the disease and to individualize treatments according to well defined molecular profiling.


There have been multiple reports of patients with coronavirus disease (COVID-19) testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) after discharge; however, information on the characteristics of such cases is limited. In this case report, we aimed to identify clinical and epidemiological characteristics of patients who had a repeat positive polymerase chain reaction (PCR) test for SARS-CoV-2. We analyzed data of 22 COVID-19 patients who tested positive for SARS-CoV-2 on polymerase chain reaction (PCR) testing after two consecutive negative PCR results following discharge from hospitals. The interval between the two positive tests in the episodes of COVID-19 ranged from 4 to 117 days. More than one-third of the cases were healthcare workers (HCWs) and one-third of them had comorbidities. The main symptoms were cough and fever, and we noticed that males experienced more symptoms and signs of COVID-19 than females. Individuals with repeat SARS-CoV-2 positivity tend to experience milder illness during the second episode than the first episode. To confirm the reinfection of SARS-CoV-2, the results of other tests, such as viral culture and immunological assays of immunoglobulin G (IgG) and immunoglobulin M (IgM), need to be considered. Recovered COVID-19 patients should continue social distancing, using face masks, and practicing hand hygiene, especially HCWs who are more likely to be exposed to SARS-CoV-2. On 31 December 2019, the World Health Organization  Country Office in China reported a case of pneumonia of unknown cause in Wuhan, China. On 30 January 2020, the WHO declared the outbreak a Public Health Emergency of International Concern. The new disease was subsequently named coronavirus disease (COVID-19), and the causative virus was identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [In the Kingdom of Saudi Arabia (KSA), patients with COVID-19 who require admission to hospitals are discharged after they have been asymptomatic for more than three days and have at least two consecutive negative SARS-CoV-2 results on real-time polymerase chain reaction (RT-PCR) tests . SeveralIn this case report study, we included all admitted patients who tested positive for SARS-CoV-2 after recovering from COVID-19 . We exclIn this study, we used BGI’s Real-Time Fluorescent RT-PCR Kit for detecting SARS-CoV-2. It is one of the kits used characterized by a highly sensitive SARS-CoV-2 detection rate. Samples of the patients were collected from the throat  swabs and nasopharyngeal swabs by using the MGI automated sample preparation system. The laboratories run the test on the Roche LightCycler 480 Instrument as well as Applied Biosystems 7500 Fast, 7500, and QuantStudio 5 Real-Time PCR Systems. BGI’s Real-Time Fluorescent RT-PCR Kit deals with Taqman Reverse Transcription PCR and it targets the ORF1ab gene as the domain target. It is highly sensitive, detecting as low as 100 viral copies/mL for BALF samples, and highly specific, with no cross-reactivity with 54 human respiratory pathogens.p-values < 0.05 were considered statistically significant.Data analysis was performed using SPSS version 21 . Distributions were summarized using descriptive statistics and are presented as frequencies. Categorical variables are summarized as frequencies and proportions. The Shapiro–Wilk test was used to test for normality of the distribution of continuous variables . The values of the Shapiro–Wilk test were less than 0.05, indicating that the data were not normally distributed. Hence, we measured median values and corresponding interquartile ranges (IQRs) to summarize continuous variables. The comparisons between study groups were performed using the Chi-squared test and Fisher’s exact test, as appropriate. A total of 22 patients who were reinfected with SARS-CoV-2 were included in this study. The median age was 33.5 years (range: 23–57 years). The median durations from illness onset to cure in the first episodes were 12.5 days (range: 8–38 days), whereas the median interval between first and second episodes was 11.5 days (range: 4–117 days) . The onsCough and fever were the most common symptoms experienced by the patients. From the present findings, we noticed that males experienced more symptoms and signs of COVID-19 than females, and they had more chest X-ray abnormalities, as well as they needed antibiotic therapy and oxygen support more than females. Although, the differences between males and females were not statistically significant and this may be attributed to the small sample size .Fewer patients experienced fever during the second episode compared to the first episode. During the first episode, 36% (8/22) of patients required antiviral therapy, 41% (9/22) required antibiotic therapy, and 23% (5/22) required supplemental oxygen . GeneralIn this study, we reported about 22 patients who had repeat positive PCR tests for SARS-CoV-2 after 2 consecutive negative test results over a period of 8 months in Jeddah Health Affairs hospitals. The interval between the first negative result at the end of the first episode and the first positive result at the beginning of the second ranged from 4 to 117 days. More than one-third of the patients who had repeat positive tests were HCWs, and more than one-third of the patients had comorbidities. The second episode was either asymptomatic or milder than the first episode. The main symptoms were cough and fever.Viral reinfection is not uncommon, and it occurs with several respiratory viral infections. Moreover, reinfection with respiratory viruses may be explained by an insufficient immune response or infection with another genotype or species of virus as well as the diversity of viral serotyping . There hIn this study, the age of the participants ranged from 23 to 57 years, as reported by various studies ,13,14. WThe maximum duration of positivity during the first episode was 38 days, which reflects the burden that COVID-19 places on the healthcare system, as well as a possibility of an increased infection rate among contacts of positive patients. The maximum interval between the first and second episodes was 117 days, suggesting the possibility of reinfection. Cough and fever were the most common symptoms experienced by patients during the first episode. Additionally, the second episode of positivity was asymptomatic or milder than the first episode, and fewer patients required hospital admission during the second episode.Several patients were retested despite the absence of symptoms. Many patients requested retesting for reassurance and to avoid a false-negative result. RT-PCR tests may produce false-negative results owing to low sensitivity, inadequate diagnostic timing, or low viral load . In addiThe interval between the first and second episodes of COVID-19 extended up to 117 days. One study could not clarify whether the repeat positive PCR test result represented a new infection or long-term viral shedding . In our This study illustrates that many patients who have recovered from COVID-19 have repeat positive PCR tests for SARS-CoV-2 after having negative results with or without symptoms. The severity of the second episode is generally milder than the first episode. Many of the repeat positive cases occurred in HCWs and patients who had other comorbidities. It indicates that the policy of discharging patients with COVID-19 should be reconsidered, and RT-PCR test results should be combined with other tests such as viral culture and immunological assays of IgG and IgM, if possible. We recommend the continuation of social distancing, use of face masks, proper hand hygiene, and other preventive measures even in recovered patients, especially in HCWs who are at higher risk of reinfection as they are more likely to be exposed to SARS-CoV-2. Further studies should be conducted to explore the association between the repeat positive tests and the immunological status of patients in terms of the presence of IgG and IgM.


Hepatocellular carcinoma (HCC) is a huge worldwide healthcare burden. The incidence of non-viral causes of hepatocellular carcinoma, such as non-alcoholic steatohepatitis (NASH), is rising. The introduction of immune checkpoint inhibitors (ICI) has led to a paradigm shift in the systemic treatment of HCC. However, not all patients can benefit from ICI. Recent studies have suggested that the response to ICI may allude to the underlying aetiology of HCC, such as NASH. Our review aims to summarise the latest evidence of ICI in advanced HCC, elaborates on the controversy surrounding the use of ICI in NASH-HCC, and discusses potential biomarkers that can be used to predict responses to ICI in advanced HCC.Immune checkpoint inhibitors have revolutionised the systemic treatment of advanced hepatocellular carcinoma. Although phase III trials, testing single agent nivolumab and pembrolizumab, failed to meet their primary endpoints, the combination of atezolizumab and bevacizumab has demonstrated a remarkable objective response and unprecedented survival benefits, replacing sorafenib as the standard first-line treatment for advanced hepatocellular carcinoma. Despite these successes observed in immune checkpoint inhibitors in the management of advanced hepatocellular carcinoma, not all patients responded to treatment, which has led to the search of risk factors and biomarkers that could predict the response to immune checkpoint inhibitors. Recent translational studies have begun to shed light on the impact of an underlying liver disease, namely NASH, which might affect the response to immune checkpoint inhibitors. In addition, antidrug-antibody and gene expression assays have demonstrated promises in predicting the response to immune checkpoint inhibitors. In this article, we will provide an overview of the use of ICI in the management of advanced HCC, review the evidence that surrounds the recent controversy regarding NASH-HCC, and discuss potential biomarkers that predict the response to immune checkpoint inhibitors. Hepatocellular carcinoma (HCC) is a global healthcare challenge with increasing incidence and mortality ,2. HCC in = 1074) evaluating sunitinib against sorafenib resulted in early termination due to futility and safety reasons. The median OS was significantly shorter with sunitinib compared with sorafenib  [n = 1155) evaluating brivanib against sorafenib also failed to reach its primary endpoint of non-inferiority OS. The median OS was 9.9 months for sorafenib and 9.5 months for brivanib (HR: 1.06) [n = 1035). This trial was also negative because it failed to meet its primary endpoint of non-inferiority OS  [n = 720) comparing sorafenib plus erlotinib with sorafenib alone in advanced HCC also reported negative result. The trial reported that the addition of erlotinib did not improve the median OS  [Although early HCC can be managed with curative surgery, ablation or liver transplantation, the majority of HCC patients present with unresectable or recurrent disease requiring systemic treatment. It is estimated that approximately 50–60% of HCC patients will eventually be treated with systemic therapy . ConventR: 0.93) . HoweverThe recent introduction of immune checkpoint inhibitors (ICI) has revolutionised the management in oncology across multiple cancer types, including HCC ,14,15,16n = 1656) included three large randomised trials of patients  with advanced HCC treated with ICI. In the overall population, ICI improved survival . Survival was also improved in the viral HCC subgroup  but not in the non-viral HCC subgroup .Recently, a paper indicated that the use of anti-PD-1 treatment in the context of NASH may potentially accelerate hepatocarcinogenesis . This fiWith this background, it is timely to review the current evidence of ICI in advanced HCC and the controversy that surrounds it in the management of NASH-HCC.The concept of immune surveillance can be traced back to more than a centennial ago. In 1909, Paul Ehrlich formulated the hypothesis that the human body constantly generated neoplastic cells that could be eradicated by the immune system . HoweverIt is important to understand that the pathogenesis of HCC, regardless of the underlying aetiology, stems from chronic inflammation. It is essential to recognise that the immune microenvironment in the liver is distinctive to other organs, in order to prioritise biomarkers for drug development and treatment strategies. The liver has a unique blood supply, with the hepatic arterial blood joining the portal venous blood and draining into the hepatic veins, within a structure called the liver sinusoid. A large spectrum of microbes, microbe-associated molecular patterns (MAMPs) and damage-associated molecular patterns (DAMPs) continuously shower the liver sinusoids from the gut through the portal blood . While tUnder conditions of chronic inflammation, this balance is lost and tips towards the pro-inflammatory state, resulting in increased hepatocytes turnover, compensatory proliferation, acquisition of mutations and malignant changes . EventuaComprehensive multiomics and single-cell analyses of human HCC tissues provided support of the presence of immunosuppressive cell populations in the tumour microenvironment, which fostered the growth of HCC ,40. AmonAmongst the most studied immune checkpoints to date are CTLA-4 and PD-1 ,43. ThesAs opposed to CTLA-4, PD-1 is a negative regulator at the effector phase of T-cell activity at the tumour site . It is aThe first evidence of ICI in advanced HCC came in 2017 in the phase I/II trial dose escalation and expansion trial, CheckMate-040, evaluating the anti-PD-1 antibody nivolumab . TherefoUnfortunately, the initial hype for these two ICI was hampered by the negative results from their respective phase III trials . In the n = 157), there was a trend of greater benefit with pembrolizumab compared to the overall cohort [Interestingly, in a subgroup analysis of the Asian population of the KEYNOTE-240 trial  or sorafenib (n = 165). The study was stopped early at the first interim analysis due to the demonstration of significant improvements in median PFS  and median OS . Notably, the study demonstrated an unprecedented ORR in the advanced HCC of 30%, including 8% of complete responder, and a median OS of 19.2 months. There were no alarming safety events observed with the atezolizumab–bevacizumab combination. Serious adverse events occurred more frequently with atezolizumab–bevacizumab (38%) than with sorafenib (30.8%), but no specific events were responsible for the increased incidence of serious adverse events in the atezolizumab–bevacizumab group. The most common grade 3/4 treatment-related adverse event was hypertension (15.2%), consistent with the previous known safety profile of bevacizumab. Grade 3/4, increased in aminotransferase, occurred in 7% of the treatment group vs. 5% in the sorafenib group. As a result of IMbrave150, atezolizumab–bevacizumab became the new standard of treatment for advanced HCC, as recommended by international HCC guidelines [IMbrave150 was the first phase III randomised trial testing the ICI-based combination regimen  that yielded a positive finding over a sorafenib-controlled arm ,24. In Iidelines . Other sAnother ICI combination strategy is to target two immune checkpoints simultaneously. This can be achieved by blocking both PD-1/PD-L1 and CTLA-4. This strategy releases the “brake” from T-cell activation in both the priming phase and effector phase. The addition of CTLA-4 inhibitor restores the costimulatory signal triggered by CD80/86-CD28 binding on T-cells and eliminates Tregs via antibody-dependent cytotoxicity to enhance the T-cells activation .CheckMate-040 cohort 4 was a phase I/II study that evaluated the efficacy and safety of ipilimumab (anti-CTLA-4) and nivolumab (anti-PD-1). This combination is the only dual ICI combination that has been approved by the FDA so far for sorafenib-treated advanced HCC . There wTremelimumab (anti-CTLA-4) and durvalumab (anti-PD-L1) were another combination being tested in the management of advanced HCC. In a randomised expansion phase I/II study reported recently, 332 patients who progressed on, were intolerant to, or refused sorafenib were assigned to four arms. Arm A: tremelimumab 300 mg plus durvalumab 1500 mg for one dose followed by durvalumab 1500 mg every four weeks; arm B: durvalumab monotherapy 1500 mg once every four weeks; arm C: tremelimumab monotherapy 750 mg once every four weeks for seven doses, then once every 12 weeks; arm D: tremelimumab 75 mg once every four weeks plus durvalumab 1500 mg once every four weeks for four doses, followed by durvalumab 1500 mg once every four weeks . AmongstIn the corresponding phase III trial HIMALAYA, which was presented in ASCO GI 2022, the combination of tremelimumab and durvalumab demonstrated a superior OS benefit, compared to sorafenib in the first-line setting for advanced HCC . In the Taken together, the addition of anti-CTLA-4 with anti-PD-1 immunotherapy produces a statistically significant improvement in OS with a manageable safety profile, providing an alternative option for advanced HCC patients who are not suitable for multi-kinase inhibitors or anti-VEGF, such as in the context of increased bleeding risks commonly found in advanced HCC patients.Nature titled ‘NASH Limits Antitumour Surveillance in Immunotherapy’, has provided shocking evidence of the potential detrimental effect of ICI in NASH-HCC [While the extraordinary ORR and OS offered by ICI have been heralded as the game changer in the management of advanced HCC, a recent paper published in NASH-HCC . The stun = 130), the median OS was 5.4 months for NAFLD-HCC vs. 11.0 months for HCC of non-NAFLD aetiology; in the second validation cohort (n = 118), the median OS was 8.8 months vs. 17.7 months. Collectively, this study signalled a proposition that immunotherapy might not confer beneficial effects in NAFLD/NASH-HCC.The group took their study further to examine if similar findings could be extrapolated to human-NASH. Using single-cell RNA sequencing, they demonstrated that the CD8+PD1+ T-cells in patients with NASH shared similar gene expression patterns with those in NASH-mice. Subsequently, the group conducted a meta-analysis of three published phase III trials  comprising a total of 1656 patients to study the effect of immunotherapy in HCC according to the underlying aetiologies. The meta-analysis revealed that immunotherapy did not improve OS in non-viral HCC , whereas those with viral HCC derived survival benefits from immunotherapy . To isolate the effect of anti-PD-L1 immunotherapy with respect to the underlying aetiology of liver damage, the group investigated two additional small cohorts of NAFLD-HCC patients. Consistent with their hypothesis, NAFLD-HCC patients had a shortened OS after immunotherapy, as compared to patients with other aetiologies. In the first validation cohort  demonstrated that the use of aspirin was associated with significantly lower HCC risk  [In the past few years, new knowledge has been added to our understanding on the molecular mechanisms that drive the transition from NAFLD/NASH to NASH-HCC. These findings support a parallel and multiple-hits paradigm of immune cell-hepatocyte interactions that contribute to the development NASH-HCC ,57,58. F51–0.73) . ThirdlyThe meta-analysis conducted by Pfister et al. raised some important key questions . ContrarTo date, no robust biomarkers predicting responses to ICI in patients with HCC have been found. Unlike the non-small cell carcinoma of lung (NSCLC) ,69, wherAntidrug antibodies (ADA) have been studied as biomarkers to predict responses to ICI. Administration of any biologic agents to humans is likely to be recognised by the immune system and trigger a humoral response, resulting in ADA formation . The preRenewed interest in the gene expression assay has grown to predict ICI response. Recently, Haber et al. performed a transcriptomic analysis on 111 tumour samples from patients with HCC treated with the single-agent anti-PD1 . They noImmunotherapy has opened a new era of management in advanced HCC. In comparison with other approved treatment options, immunotherapy has offered an unprecedented ORR up to 35% . The IMbIt is still too early for a change in clinical practice in HCC based on the underlying aetiology of HCC. The undeniable improvement in OS derived from the combination of atezolizumab–bevacizumab in the IMbrave150 study and tremlimumab–durvalumab in the HIMALAYA study, coupled with the limitations of the meta-analysis described above, provided support in maintaining ICI combination strategy as the first-line standard treatment of HCC. However, it is important to keep in mind the underlying aetiology of HCC and that immunotherapy may not be effective for NASH-HCC. As soon as progressive disease is observed, a quick switch to second-line treatment is warranted.Looking into the future, NASH is fast becoming the most common cause of cirrhosis in most regions of the world and is a rapidly increasing cause of HCC in the West . Approprn = 249) with advanced NSCLC, renal cell carcinoma and urothelial carcinoma who received ICI, patients who received antibiotics had a significantly shortened PFS and OS than those who did not receive antibiotics [Akkermansia muciniphila correlated with poor response to ICI. Oral supplementation of A. muciniphila in mice who received faecal microbiota transplantation from non-responding patients restored the efficacy of ICI [Furthermore, there has been some evidence to suggest that epidemiological factors, such as ethnicity, lifestyle, and diet may influence the response to ICI . Of noteibiotics . Metageny of ICI . A phaseThe introduction of ICI has changed the treatment landscape of advanced HCC. Combination strategies with an anti-VEGF or an ICI offer unprecedented ORR and survival benefits. Recent studies have begun to shed light on our understanding of the impact of the underlying aetiology of chronic liver disease, such as NASH, on the response to ICI. In addition, biomarkers and gene signatures are being explored to predict responders to ICI. Further studies incorporating these factors are needed to address the optimal treatment strategies for the different subgroups of HCC patients.


To produce statements based on the available evidence and an expert consensus  on the use of lung ultrasound for the management of patients with COVID-19 admitted to the intensive care unit.A modified Delphi method was applied by a panel of anesthesiologists and intensive care physicians expert in the use of lung ultrasound in COVID-19 intensive critically ill patients to reach a consensus on ten clinical questions concerning the role of lung ultrasound in the following: COVID-19 diagnosis and monitoring , positive end expiratory pressure titration, the use of prone position, the early diagnosis of pneumothorax- or ventilator-associated pneumonia, the process of weaning from invasive mechanical ventilation, and the need for radiologic chest imaging.A total of 20 statements were produced by the panel. Agreement was reached on 18 out of 20 statements  in the first round of voting, while 2 statements required a second round for agreement to be reached. At the end of the two Delphi rounds, the median score for the 20 statements was 8.5 [IQR 8.9], and the agreement percentage was 100%.The Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care produced 20 consensus statements on the use of lung ultrasound in COVID-19 patients admitted to the ICU. This expert consensus strongly suggests integrating lung ultrasound findings in the clinical management of critically ill COVID-19 patients.The online version contains supplementary material available at 10.1186/s44158-021-00015-6. The use of lung ultrasound (LUS) in the intensive care setting has increased during the coronavirus disease 2019 (COVID-19) pandemic. It is being employed as a diagnostic and monitoring tool in patients with COVID-19-related pneumonia—a condition which in some cases evolves into acute respiratory distress syndrome (ARDS) . The senThis project was conducted according to a modified Delphi method to reach consensus on key aspects of the use of LUS in critically ill patients with COVID-19. Discussions were based on the available scientific evidence as well as the panel of experts’ own clinical experience. The experts were selected by the project coordinators (LV and FM) based not only on their clinical and scientific interest in the topic  but alsoA systematic review of MEDLINE, PubMed, EMBASE, and pre-print depositories (medRxiv and bioRxiv) was performed by the evidence review team with the added input of AC. The full search strategy can be found in Additional file Two rounds of voting were held between March and June 2021. The respondents were blinded to each other’s responses. In the first round, expert panelists responded to the online questionnaire and were offered the possibility of adding their opinions using an open text box. The research assistance team , with the input of the methodologist (AC), assessed and presented the results from round 1 in the form of bar graphs to facilitate the comments and clarifications offered by each participant during an online meeting. During this meeting, the panel openly discussed the statements/rationales on which agreement had not been reached. In some circumstances the discussion led the panelists to reconsider their initial opinions, whereas in others it resulted in the working group modifying the statements. A second round of blind online voting was then held. The results of the consensus process were tabulated and presented both descriptively and graphically. The process was closed on 16 June 2021.The group’s opinion on each statement and rationale was studied in terms of the score and the level of consensus reached by the panelists. The same criteria were applied to each of the statements and rationales. Opinions were expressed using a unique nine-point ordinal Likert-type scale, according to the model developed by UCLA-RAND Corporation  . This scThe panel was composed of a total of 18 experts, 4 methodologists, and 2 senior heads. The panel produced a total of 20 statements. The criteria for a consensus of agreement  were met for 18 out of 20 statements in the first round of voting. Consensus was not achieved in relation to statements no. 5 and no. 17 Does LUS have a role to play in the diagnosis of COVID-19?Statement 1: LUS should be integrated in the clinical workup to diagnose COVID-19 pneumonia.Statement 2: In patients with high clinical suspicion of COVID-19 and LUS findings compatible with ultrasonographic interstitial pneumonia, a negative nasal/oropharyngeal RT-PCR should not be used alone to exclude COVID-19.Statement 3: LUS should not be used alone to rule in and rule out SARS-CoV-2 pneumonia in suspected COVID-19.B)Can LUS help in the early assessment of COVID-19 severity in the Emergency Department and/or at ICU admission?Statement 4: Sonographic multifocal and bilateral pleural and lung abnormalities, a high overall LUS score, and/or a high score in the gravity dependent areas can be used for the early assessment of COVID-19 severity in the Emergency Department and at ICU admission since all correlate with worsening patient outcomes—intended as the need for ICU admission, non-invasive ventilation (NIV), intubation, and a higher mortality rate—although ICU admission still remains a clinical decision based on clinical assessment and some related exams.Lung ultrasound has been shown to improve the diagnostic accuracy in patients who present with acute respiratory symptoms . The relC)Can LUS be used as a lung monitoring tool in COVID-19 patients undergoing non-invasive respiratory support ?Statement 5: In COVID-19 patients undergoing non-invasive respiratory support , LUS integrated with clinical and physiological parameters may contribute to predict non-invasive respiratory support outcome and early detect complications.Several observational prospective cohort studies of COVID-19 patients have found a significant correlation between LUS findings and poor outcome, defined as ICU admission, increased likelihood of acute respiratory failure, the need for non-invasive or invasive mechanical ventilation, and a higher hospital mortality rate , 35. In Although robust evidence in COVID-19 patients has yet to be gathered, apart from some interesting case series , 57 and Statement 6: LUS should be integrated into the multimodal assessment of disease progression and the response to treatments in mechanically ventilated COVID-19 patients.Statement 7: LUS should be integrated into the clinical decision-making process and monitoring of procedures, such as fibrobronchoscopy, in mechanically ventilated COVID-19 patients.Statement 8: LUS should be integrated into the clinical decision-making process and monitoring of treatments, such as antibiotics, in mechanically ventilated COVID-19 patients.Statement 9: LUS should be integrated into the clinical decision-making process and monitoring of fluid removal in mechanically ventilated COVID-19 patients.D) Can LUS be used as a lung monitoring tool in COVID-19 patients undergoing invasive mechanical ventilation?E)Can LUS guide the titration of positive end expiratory pressure in severe COVID-19 patients receiving invasive mechanical ventilation?Statement 10: LUS should be considered as an additional tool for PEEP titration in COVID-19.Specific ultrasound findings provide useful information for the monitoring of mechanically ventilated patients , 67. A cF)Can LUS guide the use of prone positioning in patients with severe COVID-19?Statement 11: LUS should be integrated into the assessment of patients considered potential responders to prone positioning, according to the focal and non-focal pattern of lung aeration loss.Statement 12: LUS can be used to monitor variations in lung aeration during prone positioning.The limitations of LUS as a tool for titrating PEEP levels in COVID-19 patients are the same as those applying to ARDS patients, namely, the limited capability to quantify recruitment and detect hyperinflation. PEEP-induced recruitment in COVID-19 is heterogeneous and limited in most patients . LUS shoG)Can LUS help early diagnosis of pneumothorax in severe COVID-19 patients undergoing invasive mechanical ventilation?Statement 13: LUS should be used in COVID-19 patients, in line with its clinical appropriateness as ascertained by studies in non-COVID-19 patients.In conventional ARDS patients, lung ultrasound has been used to monitor the effects of prone positioning on lung reaeration , 83. HadH)Can LUS help the early diagnosis of ventilator-associated pneumonia in severe COVID-19 patients undergoing invasive mechanical ventilation?Statement 14: LUS should be used in COVID-19 patients, in line with its clinical appropriateness as ascertained by studies in non-COVID-19 patients.Analysis of the current literature failed to reveal the presence of studies specifically addressing LUS accuracy in pneumothorax diagnosis in COVID-19 patients. A single observational study by Li et al. , involviI)Can LUS help the process of weaning severe COVID-19 patients from invasive mechanical ventilation?Statement 15: We are unable to create any statement on the use of LUS in the assessment of patient readiness to sustain a spontaneous breathing trial (SBT). No study has evaluated the potential of LUS for this purpose in COVID-19 patients, and data in non-COVID-19 patients are conflicting.Statement 16: In association with standard clinical and physiological indexes, LUS can improve the prediction of SBT outcome in COVID-19 patients.Statement 17: In association with standard clinical and physiological indexes, LUS can improve the prediction of extubation failure in COVID-19 patients.Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection occurring in the ICU; it is associated with increased mortality, a greater use of antimicrobials, longer mechanical ventilation, and higher healthcare costs. VAP is suspected in patients under mechanical ventilation presenting fever/hypothermia, leukocytosis/leukopenia, purulent tracheal secretions, and impaired oxygenation . No specThe term weaning refers to the whole process leading to the liberation from mechanical ventilation and removal of the endotracheal tube . The proReadiness for SBT is commonly assessed by means of a composite evaluation, including clinical and physiological variables . LUS ima2O of inspiratory pressure support and 5 cmH2O of positive end-expiratory pressure, the discriminative power of LUS for successful weaning was 0.8 with a sensitivity and specificity of 0.76 and 0.73, respectively [The outcomes of SBTs and extubation depend on a variety of factors, such as cardiovascular dysfunction, inability of the respiratory muscles to sustain an excessive work of breathing, neuromuscular disorders, severe anemia, altered metabolic, nutritional, or neuropsychological conditions, and the inability to clear secretions . While Lectively . An increctively . In eldeectively .Combining LUS with cardiac and diaphragmatic ultrasound assessment has the potential to improve weaning failure prediction, providing insights into the origin of reduced pulmonary aeration , 114. A In non-COVID-19 patients, LUS was successfully applied to predict extubation outcome. Regardless of the primary cause of the weaning failure, LUS performed in 100 ICU patients during successful SBTs in T-tube mode was able to predict the occurrence of post-extubation distress . A LUS sChanges in the LUS score during SBTs in COVID-19 patients could add some information concerning the loss of aeration. Cardiac and diaphragm ultrasound assessments might also be able to enhance SBT outcome prediction.L) Can LUS decrease the need for radiologic chest imaging in severe COVID-19 patients?Statement 18: In patients with known COVID-19 and severe symptoms, LUS should be performed instead of radiologic chest imaging as the first-line imaging test to monitor disease progression.Statement 19: LUS findings suggestive of pneumonia can render additional imaging techniques unnecessary, especially when the likelihood of an alternative diagnosis is low.Statement 20: In COVID-19 patients with severe symptoms, a negative LUS exam should prompt an additional radiologic chest imaging work-up.Monitoring critically ill patients by serial chest X-ray is not advisable due to the technique’s low sensitivity and long execution time; moreover, it represents a suboptimal allocation of available resources .Conversely, LUS demonstrates high agreement with chest computer tomography (CT), closely mirrors the longitudinal changes found by CT without exposing the personnel to infection risks, and is quick to perform . If inteIf a patient presents LUS findings suggestive of pneumonia together with a low pre-test probability of an alternative or secondary diagnosis, an additional imaging modality may not be necessary –120; howIn patients with severe symptoms, the probability of entirely normal radiologic findings is low. Thus, in patients with severe symptoms, a negative LUS should prompt additional radiologic chest imaging work-up by chest CT owing to its higher accuracy in imaging centrally based abnormalities and diagnosis of pulmonary embolism –124.The panel produced 20 statements in relation to 10 clinical questions on the bedside use of LUS in COVID-19 critically ill patients, summarizing the latest available literature and the direct experience of the expert panelists. As the use of LUS became ineluctable during this pandemic, anesthesiologists and intensive care physicians have been quick to incorporate this important tool into their armamentarium –6, 9. ThIn conclusion, our expert consensus is the first detailing the use of LUS for diagnosis, management, and monitoring of COVID-19 pneumonia in the critically ill patient. We hope that the statements produced will help ICU physicians in their daily clinical practice while facing the ongoing pandemic.Additional file 1. Search strategyAdditional file 2: Table S1. PICO question and criteria for inclusion/exclusion of articles. Fig. S1. PRISMA Flow Diagram. Fig. S2. Report of the first round of voting. For each statement, median score, interquartile range and proportion (percentage) of agreement are reported. Green circle (or red) represents the median score while the horizontal bar represents the interquartile-range. CPAP: Continuous positive airway pressure; COVID-19: Coronavirus diseases 2019; LUS: Lung ultrasound; HFNC: high flow nasal canula; IQR: interquartile range; ICU: Intensive care unit; NIRS: Noninvasive respiratory support; NIV: Noninvasive ventilation; PEEP: Positive end expiratory pressure; RT-PCR: Real-time polymerase chain reaction; SBT: Spontaneous breathing trialAdditional file 3. Full output of the search and the selection of potentially relevant articles


The features discovered such as ultrahigh sensitivity may prompt the presented technologies to be applied for early diagnosis of cTnI in blood, particularly for emergency medical centers overloaded with patients with acute myocardial infarction who would suffer from time-delayed diagnosis due to insufficient assay device sensitivity.This work demonstrates the quantitative assay of cardiac Troponin I (cTnI), one of the key biomarkers for acute cardiovascular diseases (the leading cause of death worldwide) using the fluorescence-based sandwich immune reaction. Surface plasmon coupled emission (SPCE) produced by non-radiative coupling of dye molecules with surface plasmons being excitable via the reverse Kretschmann format is exploited for fluorescence-based sandwich immunoassay for quantitative detection of cTnI. The SPCE fluorescence chip utilizes the gold (2 nm)-silver (50 nm) bimetallic thin film, with which molecules of the dye Alexa 488 (conjugated with detection antibodies) make a near field coupling with the plasmonic film for SPCE. The experimental results find that the SPCE greatly improves the sensitivity via enhancing the fluorescence signal (up to 50-fold) while suppressing the photo-bleaching, permitting markedly enhanced signal-to-noise ratio. The limit of detection of 21.2 ag mL Thus, te onset) ,16, trane onset) ,18, cheme onset) , fluorese onset) , colorime onset) , surfacee onset) ,23, and e onset) .em). This near field coupling produces the directional emission at wavelengths identical to λem, into an adjacent medium of a high refractive index through the metal film. The directional emission has the angles determined by the photon momentum conservation [em in a Kretschmann configuration, reflecting the SPCE as the time-reversal operation of the SPR [The fluorescence technique that lab-on-chip assays would adopt as the primary workhorse is known to suffer from difficulties in efficient light collection and dye photo-bleaching. These challenges, however, may be resolved by surface plasmon coupled emission (SPCE) that produces the metal enhanced fluorescence due to dye–surface plasmon near field interaction. This nano-photonics technology has been explored to amplify the fluorescence signal via applying near field plasmonic technologies to the fluorescence assay without influencing analytes ,26. The ervation ,28. Thes the SPR ,30.The SPCE that occurs via the non-radiative decay channel of excited dye molecules would increase both the fluorescence power detected and the light collection efficiency owing to the feature of directional emission. It has also been unfolded that the SPCE would reduce the photo-bleaching effects into the enhanced dye stability.−1 via the SPCE-enhanced fluorescence at the wavelength centered at 522 nm. This detection limit is lowest ever achieved to date amid those relying on optical technologies such as luminescence and label-free optical biosensor techniques. We also discuss how SPCE enhances the fluorescence signal from the sandwich assay that imposes the geometrical characteristics of molecules on the metal surface, such as the dye molecule-metal surface spacing.In this paper, we present the fluorescence-based sandwich immunoassay of cTnI with the SPCE technique employed for signal amplification of 50-fold at maximum. The SPCE chip fabricated includes the cTnI-specific capture antibodies on the bimetallic thin films of 2 nm-thick gold (Au)/50 nm-thick silver (Ag) layers on a glass substrate. The bimetallic SPCE based sandwich immunoassay that greatly suppresses the photo-bleaching demonstrated the ultrahigh sensitivity, with the limit of detection (LOD) of ~21.2 atto-gram (ag) mLThe technologies presented also remove the need of using a dichroic beam splitter commonly used in a typical lab-on-chip fluorescence assay to separate emitted fluorescence from excitation source. Its simpler form potentially better suits a mini-sized assay device. The ultra-high sensitivity achievable with the SPCE chip can thus find a suitable application in biomedical assays using a simpler format of lab-on-chip based fluorescence technologies. In particular, the technologies presented for ultrahigh sensitivity assay of cTnI can open up possibility of errorless early diagnosis of cTnI in blood for effectively managing an emergency medical center, with its entry frequently overloaded with a large number of patients with acute cardiovascular diseases due to insufficient sensitivity of the current diagnostic devices.2H7NS.HCl, 98%), N-hydroxysuccinimide , N-(3-dimethylaminoproyl)-N′-ethylcarbodiimide hydrochloride , (3-amininpropyl)triethoxysilance , and propanol  were purchased from Sigma-Aldrich Co., . Phosphate buffered saline , ultra-pure filtered water, albumin  were bought from Biosesang Co. . Pellets of Au (99.99%), Ag (99.99%) and Cr (99.99%) used for plasmonic metal coating via thermal evaporation were purchased from Taewon Scientific Co., Ltd. . Polydimethylsiloxane (PDMS) was purchased from Dow Corning Co., .We purchased the two types of cTnI antibodies used for the sandwich immunoassay, i.e., capture antibody  and detection antibody conjugated with the dye  from Novus Co., . Recombination Human cTnI was bought from Abcam Co., . Cysteamine hydro-chloride ), at the pressure ≤ 7 × 10−6 Torr. We made the PDMS structure, which has a thick-walled hollow inner space with its open top looking like an equilateral hexagon (side length of 1 cm) as shown in The Cr layer acts as an adhesive layer for coating the Ag layer on a glass substrate . The 2 nCare has to be taken to ensure that the illumination area by the dye excitation light source did not exceed the hexagonal area of the chamber bottom to avoid unwanted scattering of light with chamber wall.−1 concentration is introduced to the amine-modified surface. The C-Ab binding amine group is taken in 90 min at 4 °C. Prior to immobilizing the C-Ab, we activate its carboxylic groups in 15 min by immersing it in the solution of 1,4-dioxane, toluene, 1-ethyl-3-(3-(dimethylamino)propyl) carbodiimide (EDC) and N-hydroxysuccinimide (NHS) with phosphate buffered saline (PBS) solvent. The bovine serum albumin (BSA) of 2 mg mL−1 is in turn injected to the surface and incubated in 15min as the blocking agents to avoid non-specific binding of cTnI with the Au surface. Then the target molecules and cTnI of various concentrations are injected to the C-Ab modified surface in 30 min. Next, the D-Ab@Alexa 488 of 1 µg mL−1 is injected in 1 h at 37 °C to complete the sandwich immune reaction, with the chip surface being ready for the SPCE-enhanced fluorescence. It is noted that the concentrations of the C-Ab and D-Ab@Alexa 488 all need to exceed that of cTnI injected to avoid unwanted saturation of cTnI assayed. All bio-agents are diluted in PBS solvent. The surface is rinsed with PBS solvent immediately after every immobilization procedure mentioned above. Finally, the SPCE chip is dried in an oven at 37 °C for 30 min to make an air ambient that determines the SPCE directional angle, before being installed in the optical setup for fluorescence detection.We also prepare the control chip to detect the fluorescence without SPCE enhancement, reflecting the fluorescence signal similar to that obtainable by a conventional fluorescence technique. Its signal magnitude is used as a reference to estimate the amplification factor of the SPCE-enhanced fluorescence. The control chip is designed to have the same layers as the SPCE chip, i.e., C-Ab with blocking agent, cTnI, and D-Ab@Alexa 488, except those of the bimetallic film. Therefore, for control chip fabrication, the slide glass surface undergoes the oxygen plasma treatment prior to being incubated in the APTES (volume concentration of 2% in propanol) to generate the amine-modified surface. We use the procedures for immobilizing, on the control chip, C-Ab, BSA (blocking agents), cTnI, and D-Ab@Alexa 488, exactly in the same ways as those mentioned above for the SPCE chip.−1). Under illumination of blue excitation light, green fluorescence is clearly visible while its inset shows an image under white light illumination. Observation of the green fluorescence verifies the successful immobilization of D-Ab@Alexa 488 through the sandwich immune reaction described above.As shown in em while blocking light at λex for detection. It is worth noting that the extremely low levels of the cTnI concentrations ranging from 0.01 pg mL−1 to 0.5 pg mL−1 (PBS buffer) cannot serve for the visual check of the dye green color when using the fluorescence microscope. It is noted that, for a given excitation power, at each concentration (including zero concentration), three independent measurements are conducted to obtain an error bar. Each measurement includes recording the signal for 10 s with the data sampling frequency of 1 Hz.em (not λex). The incident angle at the reflectance minimum being calculated as 43.7° is considered the same as the angle of the SPCE light at λem [t at λem . The depThe light collection optics comprises a plano-convex lens of a 30 mm focal length, the emission filter (EMF)  with its pass band of 525 ± 25 nm, and a neutral density (ND) filter. The collected light is then detected by a photomultiplier tube (PMT)  connected with a multi-meter  which is interfaced with a data acquisition computer. We set the PMT gain voltage as 0.3 V and the ND filter optical density (OD) as 0.6, both to avoid signal saturation and to enable noise floor to be detectable as the minimum possible value. We then keep these parameters fixed during measurement for all concentrations of cTnI used.It should, however, be mentioned that the fact that the SPCE produces the 3-dimensional conical direction of light rays must generate the complex internal reflections, given the asymmetrical inner structure of the prism, such as reflections azimuthally slanted and skew from those shown in It is found that use of the control chips hardly distinguish the signals from the different concentrations of cTnI while use of the SPCE chips do. This is primarily due to the photo-bleaching and the saturation effects of the excited dye molecules on the control chip, which began to be significant already at the low concentrations used. −1 for excitation powers of 2, 5.8, 10, and 17 mW with coefficient of variation (CV) < 5.2%, respectively. For LOD estimation, we use linear regression of the data at small concentration close to zero, being considered a good approximation as seen in In contrast, the SPCE chip produces much higher signal-to-noise (S/N) ratio than the control chip at each concentration of cTnI for all incident excitation powers. This enables the signals from different concentrations to be markedly distinguishable, especially at the low concentration range as shown in em. The non-radiative coupling of the excited dye molecules into surface plasmons at the dielectric–metal interface, a sort of non-radiative decay of a dye molecule, occurs only for those spaced close to the metal film, i.e., those within the evanescent field depth from the outermost metal (Au) surface of the SPCE chip. This non-radiative decay rate (γsp) that can be boosted by the enhanced density of local photonic modes of surface plasmons [t) of a dye emitter as given byse is the radiative decay rate due to the spontaneous emission while we group the other possible non-radiative decay processes with the single rate constant γnr. Eventually, the presence of non-radiative decay channel, γsp, would produce the directional emission of light at a specific angle into the prism  for the sandwich immune reaction. The excited states of dye molecules make a near-field coupling with the bimetallic film for surface plasmons at λplasmons ,47 can crism see d at the Moreover, this non-radiative decay channel driven by −1) only for higher excitation powers used. It is not clear for this behavior but the presence of elastic scattering of excitation light with cTnI/D-Ab@Alexa 488, which can in turn leak through the emission filter, may be one of the reasons. This noise cannot be ruled out by the process of subtracting the background noise from the measured signal. It is interesting to note that, though signal suffers from severe saturation, it still rises with concentration increasing to the highest one  obtained with the SPCE-chip while the Scontrol is that obtained with the control chip at each concentration as seen in We here define the enhancement factor (η) of the detected fluorescence as given byThe fitting curves to the measured data for quantitative detection of cTnI are also shown in ex. The quasi-straight geometry of optical components aligned for detecting SPCE (with no beam splitter) from an excitation light source to a detector . This attenuation effect can eliminate the need of using optical component that separates the excitation light from fluorescence signal, such as a dichroic beam splitter commonly found in a typical fluorescence-based lab-on-chip to suppress the noise power at λctor see a) would It is also worth noting that the SPCE quenching would occur for the dye molecules spaced less than 10 nm from the metal surface due to the non-radiative energy transfer to the metal similar to the Förster resonance energy transfer (FRET) . The layMeanwhile, the fact that the excited dye molecules cannot produce the s-polarized SPCE limits the further enhancement of S/N ratio in fluorescence detection. The waveguide layer containing the dye-molecules, instead, might be added on the bimetallic film for the s-polarized SPCE coupling into the direction emission , though The time taken for procedures of sandwich reaction after having C-Ab immobilized on the surface, e.g., the bond between C-Ab and cTnI (~30 min), and that between cTnI and D-Ab@Alexa 488 (~60 min) is ~90 min. This leads to the possibility that, given the dynamic antibodies developed to shorten the immune reaction time, the ultrahigh sensitivity available by the presented SPCE technologies would make it plausible to diagnose the cTnI level in blood in amuch earlier stage.It is also worthwhile to note that the LOD, however, may be likely to be worse than the current one when using human sera that contain various kinds of proteins. This is because they can induce unwanted non-specific binding  that would increase the background signal noise. Use of surface rinsing and blocking medium included in the surface treatment of the present work may reduce such unwanted noise and thus prevent the very high sensitivity demonstrated in the present device from being tarnished. em, collected by a prism without a dichroic beam splitter commonly used in a typical lab-on-chip fluorescence device. Signal fluctuations of zero concentration turns out to be much smaller than the differential change that occurs as concentration rises to the minimum concentration used. This leads us to estimate the detection limit of 21.2 ag mL−1 being the lowest ever reported to date amid those obtained by optical technologies, such as label-free optical bio-sensing and luminescence-based assay where cTnI in PBS buffer is used (not in human sera).This work demonstrates the SPCE based fluorescence detection for quantitative assay of cTnI using the sandwich immune reaction. With greatly suppressed photo-bleaching, remarkably enhanced fluorescence is detected with the enhancement factor of up to 50-fold. The dye–bimetallic film near-field coupling produces the SPCE induced directional emission at λIt is also noted that the fact that the near field coupling cannot occur for the s-polarized SPCE limits further enhancement in detecting fluorescence. However, further enhancement may be accomplished by adding a waveguide layer on top of the bimetallic film to simultaneously obtain the s-polarized directional emission in addition to the p-polarized one for even higher sensitivity ,48,49,50This work presented does not use human sera that would contain many other kinds of proteins, while focusing on adaptability of the SPCE technologies to cTnI sandwich assay using pure cTnI in PBS buffer. The protocol of the sensing surface treatment that includes the sandwich immunoassay with DI water rinsing and use of blocking solution, however, would be able to detect cTnI specifically together with minimizing non-specific adsorption under presence of other substances such as in human sera. This can strengthen utility of the ultrahigh sensitivity of the sensor transduction demonstrated in the present work.−1 level at worst. However, this level still would be very low (still good sensitivity), deserving further investigation with the surface treatment to remove unwanted non-specific bonding. In addition, use of dynamic antibodies may shorten the detection time considerably, being more favorable for early diagnosis of cTnI.Future works shall cover the clinical application of the presented SPCE technologies for cTnI detection in human sera, expecting the LOD to be about an order-of-magnitude higher than the atto-g mLThe technologies presented for the ultrahigh sensitivity of cTnI assay can also potentially open up an opportunity of removing the need that patients with emergent cardiovascular diseases, such as acute coronary syndromes, should wait several hours until their level in blood rises to the level detectable by the assay devices and kits currently available in the emergency medical center.


The risk of hospitalization and death from Coronavirus disease-19 (COVID-19) increases with age. The extreme elderly have been particularly vulnerable, with those above the age of 80 having a case-fatality rate as high as 15%. Aging of the immune system can lead to impaired inflammatory responses where eradication of an organism such as Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV2) is inadequate but is exaggerated in such a way as to enhance pneumonia and acute respiratory distress syndrome. Frailty and comorbidity are both more common in the elderly, and these can enhance the morbidity and mortality from COVID-19. Studies from Northern California and Italy suggest that elderly persons with inflammatory bowel disease (IBD) were more likely to acquire SARS-CoV-2 infection than youths with IBD. While the specific impact of age-related comorbidity is less well established among people with IBD who acquire COVID-19, data from the Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD) database reported that having two or more chronic illnesses was independently associated with developing severe COVID-19 among people with IBD. Despite having exaggerated auto-inflammatory responses, people with IBD do not appear to have an overall increased risk of developing severe COVID-19 than the general population. However, whether seniors with IBD do worse once they acquire COVID-19 compared with seniors without IBD is not known. The advent of telehealth care has posed an information technology challenge for many seniors with and without IBD. Most persons with IBD have expressed satisfaction with virtual IBD health care (phone or video-based visits). While the elderly may have less robust immune responses to vaccinations, learning from experiences with other vaccination programs, especially influenza, have shown that vaccinating seniors decreases both morbidity and mortality and, in turn, healthcare resources.  Seniors have the highest risk of severe COVID-19 in the general population and among those with IBD.Senescence of the immune system and comorbidities both enhance the morbidity and mortality from COVID-19 among the elderly.Seniors with IBD do not have an increased risk of acquiring SARS-CoV-2 and share a similar risk of complications from COVID-19 as compared to seniors without IBD.Telehealth care has been an important mechanism for seniors with and without IBD to maintain contact with their healthcare providers and ensure their care unrelated to COVID-19 is minimally compromised by the pandemic.While seniors may have less robust immune responses to vaccinations, experiences with other vaccination programs, especially influenza, have shown that vaccinating seniors decreases both morbidity and mortality and, in turn, healthcare resources.Seniors represent the Fastest-growing demographic with IBD in Canada with nearly 1 in 160 Canadians above the age of 65 affected . Every dThe risk of hospitalization and death from COVID-19 increases with age . In the Immune aging (immunosenescence) refers to age-related changes that tip the balance of immunity in favour of pro-inflammatory pathways. The expression of angiotensin-converting enzyme 2 (ACE2), which converts angiotensin II to angiotensin, decreases with age and with CVD . AngioteAging is also characterized by chronic, low-grade inflammation with a relative increase in the production of pro-inflammatory cytokines, such as interleukin (IL)-6 and tumor necrosis factor-α (TNF-α) ,14. SeveFrailty, as reflected by reduced physiologic reserve due to comorbidities, bone and muscle atrophy, decreased physical activity and reduced cognition, is more prominent in seniors. Greater frailty is associated with increased mortality and morbidity, particularly in the setting of systemic infection . FrailtyPre-existing CVD, chronic lung disease, hypertension, diabetes and obesity, which are observed more often in seniors, have all been associated with more severe COVID-19 ,27–29. WA growing proportion of people with IBD are elderly, and this already vulnerable group may shoulder the brunt of the risk from COVID-19. Despite physical isolation, seniors with IBD seemed to have managed relatively well with respect to mental health compared with younger persons with IBD. The brave new realm of virtual medicine that evolved during the COVID-19 pandemic has also introduced new challenges for the elderly as well as opportunities.SECURE-IBD) registry suggest that having two or more chronic illnesses was independently associated with developing severe COVID-19 among people with IBD   . Studies others) ,41. Nota others) ,42–44. H others) . Another others) . Seniors others) . Data fr others) . OverallThe COVID-19 pandemic has also had a substantial impact on the mental health of people with IBD in general, with the majority citing negative impact on mood, anxiety and sleep. Interestingly, in a survey from the United Kingdom, individuals with IBD aged above 55 years were more likely to experience a positive psychosocial impact . In anotBeyond the immediate risk posed by COVID-19 to seniors with IBD, another challenge has been accessing continued medical care during lockdowns and business occupancy limits. Throughout the course of the COVID-19 pandemic, IBD health services have transitioned to virtual care throughout most of Canada. Most of the persons with IBD have expressed satisfaction with virtual IBD health care (phone or video-based visits) ,51. For Similar to COVID-19, the vast majority of seasonal influenza infections and related deaths from the disease occur among the elderly. A Dutch study between 1967 and 1989 reported that 95% of influenza-related mortality occurred among people above 60 years of age . Hence, Some studies have suggested that influenza vaccination may be less effective among subgroups of senior populations. For example, a multicentre study suggested that influenza vaccine effectiveness is lessened among frail older adults . InfluenOn the one hand, similar results of lower efficacy among individuals above 80 years have been reported for pneumococcal vaccination . On the Extrapolating from these findings, the effectiveness of COVID-19 vaccination among the elderly with IBD may be lower than among younger individuals, particularly compared with those without IBD. However, substantial benefits are likely to occur. A necessary strategy to improve benefits among elderly individuals with IBD is going to be avoiding delays in receiving the second dosage.The COVID-19 pandemic has disproportionately impacted the senior population. Those with IBD who are elderly may be at increased risk of acquiring SARS-CoV-2 infection and, like the general population, have similarly higher risk of more severe disease and mortality. Despite these risks, seniors with IBD seemed to have fared no worse—if not better—than their younger IBD counterparts from a mental health perspective. Most have adapted reasonably well to virtual care, and there is an opportunity to continue some aspects of these transformative models of healthcare delivery to address the specific needs of this population post pandemic.


The study aims to evaluate the mid-term effects of carotid endarterectomy (CEA) on cognition and resting-state functional magnetic resonance imaging (rs-fMRI) using the Amplitude of Low Frequency Fluctuations (ALFF) technique.t-tests, adopting a p-value < 0.05 as statistical threshold. The ALFF technique was used for analyzing the differences between pre-CEA and post-CEA rs-fMRI scans in terms of regional neural activation. This was accomplished by applying non-parametric statistics based on randomization/permutation for cluster-level inferences, adopting a cluster-mass p-value corrected for false discovery < 0.05 for cluster threshold, and a p-uncorrected < 0.01 for the voxel threshold.In this observational study, patients eligible for CEA were prospectively included. On the same day, within 1 week of the CEA procedure performed and 12 months after the CEA procedure, all patients underwent (i) an MRI examination for rs-fMRI analysis and (ii) a cognitive evaluation using the Italian version of the Mini-Mental State Examination (MMSE) corrected for age and schooling. Pre-CEA and post-CEA MMSE scores were evaluated using paired sample p-value = 0.001). The ALFF analysis identified a single cluster of 6260 voxels of increased regional neural activity following CEA, and no cluster of reduced activity. The majority of voxels covered the right precentral gyrus, the right middle frontal gyrus, and the anterior division of the cingulate gyrus.Twenty asymptomatic patients were enrolled. The mean MMSE score resulted improved following CEA procedure (Mid-term cognitive improvements observed after CEA are associated to increased regional neural activity of several cerebral regions.The online version contains supplementary material available at 10.1007/s00234-021-02815-7. Ischemic stroke represents one of the main causes of morbidity and mortality worldwide. Approximately 800,000 strokes occur each year in the United States, and 87% of the cases are due to ischemic pathogenesis , 2. ExtrAccording to the current ESC guidelines , carotidRs-fMRI represent a useful tool for the analysis of neural activity and brain networking . Using tBased on these previous studies, we hypothesized that the cognitive improvements observed following CEA procedure are accompanied by changes of neural activity in analogy to what observed for CAS. We tested this hypothesis by designing an observational prospective study in which we analyzed the mid-term (12 months) effects of CEA on cognitive performances and on neural activity through the ALFF technique in a cohort of asymptomatic patients eligible for CEA.Institutional review board approval was approved by local ethical committee.The institutional review board approved the study, in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consecutive patients with asymptomatic mono-lateral ICA stenosis eligible for CEA according to the European Society of Cardiology (ESC) guidelines . In analAll the patients gave their written informed consent before enrollment.The week before the CEA procedure, in the same day, all the patients performed the Italian version of the Mini-Mental State Examination (MMSE) corrected for age and schooling , 23 in oIn analogy to previous studies , 19, a bThe follow-up (post-CEA) cognitive assessment and MRI examination, with the same MRI scanner and with the same modalities, were performed on the same day 12 months after CEA procedure.p-value = 0.2 as lower bound of the true significance. Once the normal distribution was verified, the pre-CEA and post-CEA MMSE scores were compared with a paired sample t-test, adopting a p-value < 0.05 as statistical significance threshold. Both the Kolmogorov–Smirnov test and the paired sample t-test were calculated by using the SPSS 24 statistical package .A Kolmogorov–Smirnov normality test (with Lilliefors correction) was performed for verifying the normal distribution of pre-CEA and post-CEA MMSE scores, assuming a http://www.fil.ion.ucl.ac.uk/spm/).The fMRI analysis was made on the Matlab platform vR2020b  with the CONN-fMRI fc toolbox v20b  based onz-value threshold = 5 standard deviations; subject-motion threshold = 0.9 mm);(c) functional and structural direct segmentation of grey matter, white matter and cerebrospinal fluid, and subsequent normalization to Montreal Neurological Institute (MNI) exploiting the default tissue probability maps , and (d) functional smoothing with 8-mm full width half maximum Gaussian kernel filter.Similarly to previous studies , 19, strThe first 5 volumes of T2-weighted EPI sequence were excluded from analysis in order to limit the potential bias derived by the attainment of the steady state magnetization . Subsequt-test, using pre-CEA and post-CEA scans for between-condition contrast. Non-parametric statistics based on randomization/permutation was used for cluster-level inferences using 1000 permutation iterations of the original data, adopting a cluster-mass p-value corrected for false discovery (cluster-mass p-FDR) < 0.05 for cluster threshold and a p-uncorrected (p-unc) < 0.01 for voxel threshold [ALFF maps were created by computing for each individual voxel the root mean square of BOLD signal in the low frequency range (0.008 to 0.09 Hz) , 28. Thehreshold .The mapping of brain regions was made by using the CONN’s default atlas; in particular the Harvard–Oxford atlas  was adopThe final study population consisted of 20 asymptomatic patients, 14 males and 6 females . CEA procedures were performed in the right side in 11 patients, whereas on the left side in 9 cases. None of the patients met the exclusion criteria above mentioned; in particular no incidental pathologic findings were detected during the execution of the baseline MRI scan. No procedural or peri-procedural complications following CEA, and the clinical course between the baseline and the follow-up assessment was uneventful. The demographic data are reported in Table p-value for pre-CEA MMSE scores = 0.111; p-value for post-CEA MMSE scores = 0.109). The paired sample t-test revealed statistically significant differences between the pre-CEA and the post-CEA MMSE scores : in particular, the mean pre-CEA MMSE score was 19.62  and the mean post-CEA MMSE score was 24.17 . The full statistics of the paired sample t-test are reported in Tables Kolmogorov–Smirnov normality test (with Lilliefors correction) confirmed the normal distribution of both pre-CEA and post-CEA MMSE scores  cognitive performances and on regional neural activity changes with the ALFF method. Regarding the cognitive performances, we demonstrated that CEA was associated with statistically significant improvements in MMSE score, and the ALFF analysis evidenced increased ALFF signal in several areas of the brain, in particular in the right precentral gyrus, right middle frontal gyrus, and the anterior cingulate cortex (ACC). To the best of our knowledge, this is the first longitudinal study that used ALFF to investigate the mid-term arrangements in regional neural activity after CEA treatment. The ALFF technique is a functional segregation method of analysis of rs-fMRI data that allows to evaluate the regional neural activity, and this technique of analysis was considered fit for the aim of prospective research because of its high temporal stability and test–retest reliability , 15, 16,For better understanding these findings, it is useful to resume the principal scientific evidences derived from literature regarding the association between extracranial ICA stenosis, cognitive impairment, and anatomical and functional rearrangements of the brain, as well as the effects of CEA on cognition and brain activity evaluated by using the rs-fMRI technique.Regarding the first point, the literature tends to confirm that extracranial ICA stenosis is associated with cognitive impairment . The cogRegarding the second point, both the carotid revascularization treatments, CEA and the CAS, are linked to long-term cognitive improvements . Some stIn our research we observed that asymptomatic patients following CEA showed significant improvement of the cognitive performances measured by MMSE. The statistically significant improvement in MMSE scores in the mid-term analysis (12 months) supports the hypothesis that the improvements in cerebral perfusion following the CEA procedure led to better cognitive performances and are in line with the findings from literature –10. RegaAmong the other areas that showed to be more activated following CEA procedure, it is noteworthy to mention the right middle frontal gyrus, which has been proposed to have a role in reorienting attention, working as a circuit-breaker in order to interrupt ongoing endogenous attention processes , and botUnderstanding cingulate cortex function is likely to be of clinical importance, despite the fact that to the best of our knowledge few neuropsychological researches have analyzed the cognitive consequences of focal lesions on ACC and PCC; however, it has been demonstrated that strokes around the posteromedial cortex produce an amnestic syndrome, which may result in part from damage to both the retrosplenial cortex and PCC . It is aAlthough the partial knowledge of the mechanisms underlying neurocognition limits the interpretation of our results, it is reasonable to conclude that the cognitive improvements observed after CEA, in analogy to what seen for CAS , are parFinally, we also speculate that CEA could influence not only cognition, but also other cerebral functions, such as motor and visual functions. For example, in 2019 Yan J et al.  producedIn conclusion, these data could enlighten new opportunity for patient affected by carotid stenosis and cognitive impairment, and might suggest new indication for surgical and endovascular treatment of carotid stenosis. Nonetheless, this was beyond the goal of our study, and future researches are needed to test this hypothesis.We acknowledge significant limitations in our current study. The first one is the small cohort size; in particular, with this small number of cases we were not allowed to evaluate whether and how confounding factors such as the laterality of the CEA procedure or the variations in the configuration of the circle of Willis influence the ALFF signal. However, our aim was to explore the potential role of ALFF evaluation technique in the study of brain responses after CEA in patient with severe ICA stenosis. The second limitation is the use of MMSE as the only test for the evaluation of the patients’ cognitive function and impairment. However, similar to Grunald IQ et al. , even ifThis prospective observational study analyzed the mid-term effects of CEA on neurocognitive status and regional neural activity on rs-fMRI using the ALFF technique in asymptomatic patients with severe ICA stenosis. The results support the hypothesis that the cognitive improvement observed after CEA could be related to increased regional neural activity of several brain area. Our results could represent a starting point to re-think the role of carotid revascularization not only for stroke prevention, but also for treatment of cognitive deficits in selected patients.Supplementary file1 (PDF 115 KB)Below is the link to the electronic supplementary material.