Background. Atrial fibrillation (AF) is an important cause of embolic stroke of undetermined source (ESUS). Imaging-patterns like multiple infarcts, simultaneous involvement of different circulations, infarcts of different ages, and isolated cortical infarcts are likely to indicate cardioembolic stroke. The aim of our study was to evaluate the association between embolic stroke patterns, ESUS, and the new diagnosis of AF. Methods. Stroke etiology and imaging characteristics from patients included in the Find-AF study were obtained. Embolic stroke patterns in CT- or MR-imaging were correlated with the diagnosis of ESUS as well as the short- (on baseline ECG and during 7-day Holter) and long-term (12-month follow-up) diagnosis of AF. Results. From 281 patients included in the Find-AF study, 127 (45.2%) patients with ischemic lesions detected in CT or MRI were included. 26 (20.5%) of these patients had ESUS. At least one embolic stroke pattern was detected in 67 (52.7%) patients. Embolic stroke patterns were not associated with ESUS , the short-term  or long-term diagnosis of AF . Conclusions. This secondary data analysis of the Find-AF study could not provide evidence for an association between embolic stroke patterns, ESUS, and the new diagnosis of AF. Early diagnosis of stroke etiology is crucial for secondary prevention in patients with acute ischemic stroke. In cardioembolic stroke, risk of recurrence is highest in the first weeks after stroke around 10%) and drops to 5% in the following 12 months [0% and drAbout 25% of all ischemic strokes are classified as cryptogenic, of which the majority is likely to be of embolic origin, including major-  and minor-risk  cardiac sources –6. It haAim of our study is to identify imaging parameters which are associated with ESUS and the new diagnosis of AF in acute stroke patients to find another approach of identifying patients with embolic stroke which are likely to benefit from oral anticoagulation even in the absence of a definite diagnosis of an embolic source.ISRCTN 46104198). Details of the Find-AF trial have been published previously [In this secondary data analysis, we evaluated clinical and imaging data from the monocentric, observational Find-AF trial ISRCTN 464198. DetThe diagnosis of ESUS applied to patients with nonlacunar stroke , absence of extra- or intracranial ≥ 50% luminal stenosis proximal to the infarct, major-risk cardioembolic source of embolism , and other specific causes of stroke  . Exclusion of the following: Intra- or extracranial stenosis ≥50%  criteria) or occlusions supplying the area of ischemia Evidence of cardioembolic pathologies (major cardiac sources) Exclusion of atrial fibrillation: No history of atrial fibrillation, atrial fibrillation on baseline ECG or in the first 24 h of the 7 d HolterNo evidence for sick sinus syndrome, atrial asystole, cardiac thrombus, mechanic valve replacement, myxoma or cardiac tumor, mitral valve stenosis, recent myocardial infarction (<4 weeks) or heart failure (EF < 30%), and endocarditis Lacunar infarct pattern  caused by small vessel occlusion in white matter  No evidence for rare stroke etiologies like: migrainous infarction, vasculitis, or thrombophiliaIn the analysis for the association between stroke patterns and new diagnosis of AF and ESUS, only patients with a detection of acute or subacute stroke in CT or MRI attributable to initial clinical symptoms were included. Patients with a history of AF prior to index stroke have been excluded. Patients with new AF on baseline ECG or new AF in 7 d Holter were considered as short-term-AF-positive. Patients with the new diagnosis of AF between baseline ECG and 12-month follow-up were considered as long-term-AF-positive.Embolic stroke patterns were retrospectively evaluated on CT- and MR-imaging performed on admission or during inpatient stay after index ischemic stroke. Every patient received CT-imaging. In patients with additional MR-imaging, MR data were evaluated instead of CT-imaging. The senior neuroradiologist classifying the embolic stroke patterns was unaware of the clinical status of the included patients.Stroke patterns were defined as multiple acute infarcts, simultaneous involvement of different circulations, multiple infarcts of different ages, and isolated cortical ischemia (see the following list).Imaging Criteria for Embolic Stroke Patterns  Multiple acute infarcts: MRI: multiple noncontiguous lesions, which were hyperintense on DWI and hypointense on ADC maps; CT: multiple, noncontiguous, and hypodense lesions Simultaneous involvement of different circulations: MRI/CT: multiple acute ischemic lesions in both right and left anterior circulations or in both anterior and posterior circulations Multiple infarcts of different ages: MRI: ischemic lesions with hyperintense signals on DWI that meet 2 of the following 3 criteria: hypointense on ADC and isointense on FLAIR (hyperacute); hypointense on ADC and hyperintense on FLAIR (early acute); isointense on ADC and hyperintense on FLAIR (late acute or subacute); CT: simultaneous presence of acute, subacute, and/or old (liquorisodense) ischemic lesions Isolated cortical ischemia: MRI/CT: presence of multiple, isolated cortical ischemic lesionsThe presence of microangiopathy was defined as either punctual or confluent white matter T2w-hyperintensities in MRI or hypodensities on CT. The extent of microangiopathic changes in stroke imaging was quantified using the Fazekas scale for MRI and adapting it for CT by evaluating hypodense white matter lesions. The score ranged from 0 (no microangiopathic changes) to 3  .Baseline characteristics were assessed using relative frequencies and means (±standard deviations). Groups were compared using chi-squared tests and univariable logistic regression models. All data analyses were performed using Stata 12 .p = 0.019). Of the 127 patients included, 65 (51.2%) had baseline MRI. Of the 105 excluded patients, MR-imaging was performed in 32 (30.5%). At least one embolic stroke pattern was detected in 67 (52.6%) patients.From 281 patients included in the Find-AF study, 127 patients were eligible for this imaging substudy. As shown in in the flow-diagram in https://doi.org/10.1155/2017/1391843). 26 patients (20.5%) fulfilled the criteria for ESUS. There was a higher number of patients with multiple infarcts of different ages on the ESUS-group, which did not reach statistical significance . There was no association between other stroke patterns or the presence of at least one embolic stroke pattern and ESUS etiology  criteria  patients in baseline ECG and/or 7-day Holter and in additional 5 (3.9%) patients in the period between 7-day Holter and 12-month follow-up. Embolic stroke patterns in general as well as the prevalence of at least one embolic stroke pattern were neither associated with the short-term nor with the long-term diagnosis of AF Tables . Includip = 0.083) and isolated cortical infarctions  in the ESUS-group (Supplementary Table 2). As in the analysis of the whole study group, embolic stroke patterns were not predictive for the new diagnosis of AF on baseline ECG or 7-day Holter (Supplementary Table 3).As shown in Supplementary Tables 2 and 3, we performed an analysis in the subgroup of patients with MRI. This subanalysis revealed a trend towards a higher number of patients with multiple infarcts of different ages  and in 91% of patients with versus 77% without the new diagnosis of AF (p = 0.158). The extent of microangiopathic changes was not different in patients with and without ESUS or with and without the new diagnosis of AF ).Neither the presence nor the extent of microangiopathy was associated with ESUS or the new diagnosis of AF. Microangiopathy was present in 80% of patients with versus 79% of patients without ESUS  compared to our study (n = 127).A similar approach was made in a recent subgroup analysis of the CRYSTAL-AF study, in which infarct topography of patients with cryptogenic stroke and the new diagnosis of AF by an insertable cardiac monitor have been investigated . In thatIn our study, detection rates of AF after 12 months were higher compared to the detection rate of the CRYSTAL-AF study (Find-AF subgroup 28 (22.0%) patients; CRYSTAL-AF 12.4%). On the one hand, this higher detection rate would have made it more likely to find an association between stroke patterns and AF; on the other hand, 75.1% of patients included in the CRYSTAL-AF substudy had cMRI versus 51.2% of patients in our analysis. The higher proportion of CT-based assessment of stroke patterns makes it more likely to miss (embolic) infarcts.Despite the differences in study design, numbers of MRI, and included patients, our results go in line with the findings of the CRYSTAL-AF substudy and cast doubt of the clinical value of infarct topography in cryptogenic stroke and ESUS. The lack of an association between stroke patterns and embolic stroke etiologies in both our and the CRYSTAL-AF study contradicts mechanistic considerations, because it seems likely that underlying stroke etiology in a high proportion of patients with cryptogenic stroke or ESUS is AF and that these patients are likely to show embolic stroke patterns in brain imaging caused by embolization in different circulations or shattered emboli. Moreover, the subpopulation of stroke patients with cryptogenic stroke and AF has an increased risk of recurrence . The risAnother reason for a lack of association between stroke patterns and AF in both the Find-AF and the CRYSTAL-AF study could be the inclusion of patients with small strokes and low National Institutes of Health Stroke Scale (NIHSS) (median NIHSS in the CRYSTAL-AF was <2 and in our study 3), as there is a known association between large infarct volumes and high NIHSS in patients with cardioembolic strokes caused by AF . RecentlThe strength of our study is the high data quality and integrity of the prospectively designed Find-AF study and the blinded assessment of stroke imaging by an experienced senior neuroradiologist. The major limitation of our study is the low number of patients with detectable ischemic lesions attributed to the index stroke symptoms and the low number of patients with MRI, which is more likely to detect  embolic strokes compared to CT-imaging. It is likely that if more patients without ischemic lesions in the baseline CT would have received MRI, the statistical power of our subgroup analysis would have been higher, as the rate of TIA-patients with ischemic lesions on MRI has been described to be higher than 30% . MoreoveNeither our data nor the subgroup analysis of the CRYSTAL-AF study could find convincing evidence for an association between ischemic stroke patterns in acute brain imaging and the new diagnosis of AF. In addition, our study could not provide evidence for a predictive value of stroke imaging for the diagnosis of ESUS. It will be important for future studies to further investigate the link between ischemic stroke patterns with larger sample sizes including patients with major stroke and MR-based stroke imaging as well as investigating patients receiving more sensitive devices  or prolonged monitoring with Holter ECG, like in the Find-AF randomized study .The supplementary material includes: additional information about the ESUS-group (reasons for non-fulfillment of the ESUS-criteria) and findings in the subgroup with MR-imaging .


Early antiretroviral therapy (ART) initiation in patients diagnosed with HIV-associated tuberculosis (TB) reduces mortality among those with the lowest CD4 counts. At the same time, both early ART and a low CD4 count heighten the risk of paradoxical TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). TB is common in patients starting ART in sub-Saharan Africa. Safe interventions that reduce the incidence or severity of TB-IRIS are needed. Prednisone has been shown to reduce symptoms and markers of inflammation when used to treat TB-IRIS.To determine whether prophylactic prednisone in patients at high risk for paradoxical TB-IRIS initiating ART reduces the incidence of TB-IRIS.≤100/μL). The primary endpoint is development of TB-IRIS, defined using an international consensus case definition. Secondary endpoints include time to TB-IRIS event, severity of TB-IRIS, quality of life, mortality, hospitalization, other infections and malignancies, and adverse events including corticosteroid adverse effects.We are conducting a randomized, double-blind, placebo-controlled trial of prophylactic prednisone  initiated at the same time as ART in patients at high risk for TB-IRIS (starting ART within 30 days of TB treatment and CD4 count Enrollment for the trial began in August 2013. All 240 participants have been enrolled, and safety follow-up will be completed in March 2017.No preventive strategies for TB-IRIS currently exist. If results of this trial demonstrate the efficacy and safety of prednisone, this will provide clinicians with an evidence-based preventive strategy in patients at high risk for paradoxical TB-IRIS when initiating ART. Tuberculosis (TB) is the most common opportunistic disease affecting HIV-1-infected patients in low- and middle-income countries; up to 42% of patients starting antiretroviral therapy (ART) in sub-Saharan Africa are on treatment for active TB .≤50/μL improved survival compared with starting at around 8 weeks [Mycobacterium tuberculosis antigen at sites of disease. Attenuating this aberrant inflammatory response during early ART with corticosteroids may prevent TB-IRIS or at least reduce the severity of TB-IRIS clinical manifestations.Several clinical trials have evaluated the optimal timing of ART initiation in ART-naïve HIV-infected patients diagnosed with active TB. These were included in a recent meta-analysis which showed that early ART (around 2 weeks into TB treatment) in patients with CD4 counts  8 weeks . Thus, w 8 weeks , because 8 weeks . TherefoThe host immune response contributes to pathology caused by TB , and corA Cochrane systematic review of corticosteroids as an adjunct to TB treatment in TB meningitis showed that corticosteroids reduced the risk of death . The survival benefit occurred irrespective of the severity of TB meningitis . One of M indicus pranii in a factorial design) in 1400 patients with tuberculous pericarditis, of whom 67% were HIV-infected [The Investigation of the Management of Pericarditis (IMPI) trial was conducted in several African countries and evaluated prednisolone (and infected . ParticiP=.03). These were mainly HIV-related cancers, and most patients who developed HIV cancers were not taking ART at the time of enrollment to the trial . These findings added to concerns regarding the use of adjuvant corticosteroids in HIV-infected patients present from two prior trials conducted in Uganda evaluating prednisolone in HIV-associated TB, both conducted prior to ART availability. One showed that prednisolone was associated with more rapid clinical and radiological improvement but also with an excess of Kaposi sarcoma [M tuberculosis from sputum with prednisolone treatment but also a transient increase in HIV viral load  [In the IMPI trial, prednisolone was associated with an increase in cancers  . A thirdlycemia) .We previously conducted a randomized double-blind placebo-controlled trial of prednisone for the treatment of paradoxical TB-IRIS . A 4-weeIn HIV-infected patients with pneumocystis pneumonia, early adjunctive treatment with corticosteroids reduces mortality and the risk of mechanical ventilation. It is presumed that as organisms are killed, inflammation increases in the lungs, leading to a worsening of the patient’s clinical condition; corticosteroids possibly reduce or prevent this worsening by reducing inflammation .We are currently conducting a randomized controlled trial  in Khayelitsha, South Africa, with the primary objective to determine whether a 4-week course of prednisone in patients at high risk for TB-IRIS (starting ART within 30 days of starting treatment for TB and a CD4 count of ≤100/μL) reduces the incidence of TB-IRIS. This PredART trial is different to our prior treatment trial  in that Among the secondary objectives, we aim to determine whether prednisone reduces the severity of TB-IRIS and the risk of hypersensitivity drug reactions and consequent drug interruptions in this group of patients as well as to assess its safety and potential changes in health-related quality of life (HR-QOL).In summary, TB-IRIS is a common complication of ART in patients with HIV-associated TB. The risk of TB-IRIS is highest in patients with the lowest CD4 counts; rapid ART initiation in such patients  increases this risk even further. Immunological studies have shown elevation of a range of proinflammatory cytokines at the time of TB-IRIS onset ,24-26. CThis is a proof-of-concept, phase III, randomized, double-blind, placebo-controlled trial of prednisone to assess its efficacy and safety in preventing paradoxical TB-IRIS in high-risk patients starting ART. The intervention is oral prednisone 40 mg daily for 14 days started within 48 hours of initiating ART, followed by 20 mg daily for 14 days. Based on the average weight of participants, this is a lower dose than was used in our previous TB-IRIS prednisone treatment trial . Our reaThe incidence of paradoxical TB-IRIS in patients on TB treatment starting ART varies between 0% and 54% in the literature. In a recent meta-analysis, the pooled estimate was 18% (95% CI 16%-21%) . AssuminBlinded medication containers were packaged at an independent off-site pharmacy in a 1:1 randomization sequence with block sizes of 8. The sequence was prepared before the trial started by an independent statistician. The packages contain either prednisone 5 mg or identical placebo tablets. Each package has a number from 1 to 240. Participants are enrolled sequentially and receive the next study number from 1 to 240 with the corresponding medication package. Participants and all study staff remain blinded to the treatment allocation throughout the course of the trial. When deemed essential for ongoing clinical management by the attending clinician, unblinding of the randomization allocation can occur.Participants are recruited from four different TB clinics in Khayelitsha, a township 20 kilometers from Cape Town’s center with an estimated 500,000 inhabitants. An estimated 16% of the population is HIV infected ; TB caseInclusion and exclusion criteria are shown in Inclusion criteria:Age 18 years or olderHIV-infectedCD4 count ≤100/μL (in the past 3 months)ART-naïveConfirmed diagnosis of TB or strong clinical and radiological evidence of TB with symptomatic response to TB treatmentOn TB treatment for less than 30 days prior to study entryEligible for ART and patient consents to start ART within 30 days of starting TB treatmentWritten informed consentExclusion criteria:Kaposi sarcomaPregnantTB meningitis or tuberculoma at TB diagnosisClinical syndrome of pericardial TB at TB diagnosisRifampicin-resistant TBOn corticosteroids for another indication or on any other immunosuppressive medication within the past 7 daysUncontrolled diabetes mellitusAlanine aminotransferase >200 IU/LAbsolute neutrophil count <500/μLNot on standard intensive-phase TB treatmentPoor clinical response to TB treatment prior to ART as judged by the clinical investigatorsHepatitis B surface antigen positiveThe primary endpoint is the development of paradoxical TB-IRIS within 12 weeks of starting ART, defined using the International Network for the Study of HIV-associated IRIS (INSHI) consensus case definition . SecondaSecondary efficacy endpoints:Time to TB-IRIS event from start of ARTSeverity of TB-IRIS events Duration of TB-IRIS eventsMortality attributed to TB and TB-IRISAll-cause mortalityComposite endpoint of death, hospitalization, or hepatotoxicityOther (non-TB) IRIS eventsHealth-related quality of life assessments using the Patient-Reported Outcomes Quality of Life–HIV (PROQOL-HIV) , an adapAdverse events and severe adverse events ascribed to TB treatment, ART, or co-trimoxazoleDiscontinuation of ART or TB treatment for more than 5 days due to adverse eventsNumber of hospitalizations and total days hospitalizedSecondary safety and tolerability endpoints:Corticosteroid-associated adverse events Laboratory safety data: glucose, full blood count, and electrolytesOther infections and malignanciesAll grade 1, 2, 3, and 4 adverse events using the Division Of AIDS Table For Grading the Severity of Adult and Pediatric Adverse Events Study medication is prednisone tablets (5 mg) or identical placebo. The study medication was manufactured by the Gulf Drug Company in Durban, South Africa; this company supplies prednisone (Trolic) to the South African government hospital pharmacies, and the product is registered with the Medicines Control Council of South Africa. Participants receive 8 tablets daily (40 mg prednisone or placebo) for 14 days followed by 4 tablets daily (20 mg prednisone or placebo) for 14 days. Study medication is dispensed at week 0 (for the first 14 days) and at week 2 (for the next 14 days). During these first four weeks of the trial, concomitant treatment with nonsteroidal anti inflammatory drugs, any systemic corticosteroid medication, or any other immunosuppressive medication or chemotherapy is prohibited. The protocol requires that the study drug be stopped in the following situations: Kaposi sarcoma or new World Health Organization stage 4 opportunistic condition diagnosed, diagnosis of rifampicin-resistant TB, development of TB-IRIS requiring open label prednisone, requirement for prohibited concomitant medication, diagnosis of pregnancy, request by the participant, clinical reasons believed to be life threatening by the trial doctor, or interruption of ART or study drug for more than five days by the participant or by clinician .ART is provided according to the South African Department of Health guidelines . First-lTB treatment is prescribed according to South African Department of Health guidelines  by the pStudy visits occur at screening, enrollment, week 0 (the day the participant starts study drug and ART), week 1, week 2, week 4, week 8, and week 12. A window period of 4 days is allowed for each visit from week 1 to week 8; week 12 has a 7-day window. Assessments done at each visit are summarized in Outside the scheduled visits, participants can attend for unscheduled visits if they experience symptomatic deterioration or if deemed necessary by the attending clinician. For participants with ongoing TB-IRIS at week 12, follow-up is extended in order to ascertain the end date of TB-IRIS.In the initial protocol, participant follow-up ended at week 12 unless there was ongoing TB-IRIS at this visit. A year after the start of our trial, the results of the IMPI trial  became aM indicus pranii; this is relevant, as most of the cancers were diagnosed in participants receiving both prednisolone and M indicus pranii in the IMPI trial.As a study team we reviewed the implications of the IMPI findings for safety of participants in our trial. A number of considerations make the IMPI trial different from the PredART trial with respect to the risk of Kaposi sarcoma. The prednisone dose used in PredART is substantially lower and of shorter duration. All participants in the PredART trial are started on ART when they start study medication, and ART is known to reduce the risk of Kaposi sarcoma ; in contAt the time of the IMPI publication, 89 participants had been randomized in our trial and none had developed Kaposi sarcoma. We communicated these findings and considerations to the PredART trial data safety and monitoring board (DSMB), which advised that the PredART trial should continue but that we should add extra visits for safety assesments. We added one visit at week 28 and a telephonic follow-up at one year to ascertain HIV-related cancers. During the week 28 visit, patient history is taken and clinical examination is performed specifically to assess for any history, symptoms, or signs of cancer. One year after starting ART, participants are phoned by the study team and their clinical records are assessed to review if there has been a new diagnosis of cancer subsequent to the week 28 visit. The protocol was amended accordingly and the information given during the informed consent process was updated with approval by the relevant ethics committees. The additional assessments applied to all participants, including those who had already completed their 12-week follow-up at the time of this protocol change.TB-IRIS is a diagnosis of exclusion. When TB-IRIS is suspected, investigations are performed with the main aim to exclude alternative causes of clinical deterioration. For all participants with suspected TB-IRIS, these include the laboratory investigations listed in Mild drug rashes are closely monitored with symptomatic therapy. If more severe drug rashes occur, potential causative drugs  are stopped and rechallenge occurs following local guidelines. All other clinical management, including treatment of new opportunistic infections, malignancies, and comorbidities, is according to South African National Department of Health guidelines.Health-related quality of life (HR-QOL) is measured using three different questionnaires: the Patient-Reported Outcomes Quality of Life–HIV (PROQOL-HIV) , an adapAn endpoint review committee has been established to review all cases of suspected TB-IRIS and determine whether they fulfill the INSHI case definition. This committee is comprised of 3 expert clinical investigators not active at the clinical site. Reviewers will have access to all clinical and laboratory data entered in the database, including chest radiographs and TB-IRIS narrative summaries written by the attending clinician, and they will be blinded to treatment allocation. The review will take place after completion of the clinical trial. Each reviewer will independently review the summaries and data submitted to him or her, using the INSHI paradoxical TB-IRIS case definition . For thoThe statistical analysis of the trial will be performed according to a plan prespecified before the database is locked and allocation unblinded. The primary analysis and secondary efficacy analysis will be performed using an intention-to-treat approach; safety analysis will be performed using the all-patients-treated approach. The primary endpoint will be tested comparing the proportion of patients diagnosed with paradoxical TB-IRIS among treatment groups using a Fisher exact test. Secondary endpoints will be analyzed comparing study arms with the Fisher exact test  or Wilcoxon rank-sum test (for continuous data). Time to event analysis will be used to compare time from the start of ART to TB-IRIS between study arms. A prespecified subgroup analysis of those patients with a baseline CD4 count <50/μL will be performed. Adverse events will be coded following the Medical Dictionary for Regulatory Activities (MedDRA). Safety endpoints will be compared between both arms individually  as well as collectively .The identity and information of trial participants is kept confidential. All relevant clinical information to reconstruct and evaluate the trial is kept as source documents. Data from source documents are entered into a Web-based electronic database specifically developed for the trial. The database is access-controlled and data deidentified. Point-of-entry data validation and a double–data entry system with discrepancy reporting are key measures to ensure data integrity. After completion of the first 12 weeks of the study, the electronic record of each participant is reviewed against the case report form. After completion hereof, aggregate database entries are checked for outlying data, missing data, and systematic errors according to the prespecified data management plan.The trial is sponsored by the University of Cape Town. which has subcontracted an independent clinical trial monitor who conducts monitoring visits once every 1 to 2 months and reports to the sponsor. An independent DSMB reviewed study recruitment, data quality, and safety endpoints twice during the trial—after 80 participants had completed their week 12 visit and again after 160 participants had completed their week 12 visit. The DSMB was constituted and conducted its tasks according to the study-specific DSMB charter. It was required to advise the sponsor of any major safety and data quality issues. At both interim reviews, the DSMB advised that trial recruitment and follow-up should continue. All adverse study drug reactions, serious adverse events, and deaths are reported to the sponsor, the University of Cape Town Human Research Ethics Committee, the Institute for Tropical Medicine Institutional Review Board, and the Medicines Control Council according to their respective reporting guidelines.The protocol was approved by the University of Cape Town Human Research Ethics Committee (HREC 136/2013), Institute of Tropical Medicine Institutional Review Board (882/13), and the Antwerp University Hospital Ethical Committee (13/20/224). The same approval schedule is applicable to protocol amendments. The trial is conducted according to International Council for Harmonisation Good Clinical Practice standards , the SouThis trial is funded by the European and Developing Countries Clinical Trials Partnership through a Strategic Primer Grant (SP.2011.41304.074) that was awarded to the University of Cape Town, the Institute of Tropical Medicine, and Imperial College London. There is cofunding from the South African Government Department of Science and Technology, the Wellcome Trust , the Medical Research Council of South Africa, and a PhD fellowship from the Institute for Tropical Medicine.The trial started enrollment at the end of August 2013; 240 participants are currently enrolled according to plan. Follow-up for the first 12 weeks was completed in June 2016, and the final safety assessments for the trial will be completed by March 2017.With guidelines advising that ART be started with minimal delay during treatment for HIV-associated TB, and many patients still presenting with a low CD4 count, TB-IRIS will remain a major complicating factor in patients with HIV-associated TB starting ART in sub-Saharan Africa. If corticosteroids are shown to reduce the risk of TB-IRIS without safety concerns, clinicians will have an evidence-based preventive option in patients at high risk for TB-IRIS provided they do not have a contraindication for corticosteroids. Therefore, we anticipate that the findings of this clinical trial could inform clinical practice and guidelines in sub-Saharan Africa and internationally.


Thailand reported the first Middle East respiratory syndrome (MERS) case on 18 June 2015 (day 4) in an Omani patient with heart condition who was diagnosed with pneumonia on hospital admission on 15 June 2015 (day 1). Two false negative RT-PCR on upper respiratory tract samples on days 2 and 3 led to a 48-hour diagnosis delay and a decision to transfer the patient out of the negative pressure unit (NPU). Subsequent examination of sputum later on day 3 confirmed MERS coronavirus (MERS-CoV) infection. The patient was immediately moved back into the NPU and then transferred to Bamrasnaradura Infectious Disease Institute. Over 170 contacts were traced; 48 were quarantined and 122 self-monitored for symptoms. High-risk close contacts exhibiting no symptoms, and whose laboratory testing on the 12th day after exposure was negative, were released on the 14th day. The Omani Ministry of Health (MOH) was immediately notified using the International Health Regulation (IHR) mechanism. Outbreak investigation was conducted in Oman, and was both published on the World Health Organization (WHO) intranet and shared with Thailand’s IHR focal point. The key to successful infection control, with no secondary transmission, were the collaborative efforts among hospitals, laboratories and MOHs of both countries. From 2012 to 21 July 2017, there have been 2,040 reported laboratory-confirmed cases and 712 deaths from Middle East respiratory syndrome coronavirus (MERS-CoV) infection in 27 countries [The Thai Ministry of Public Health (MOPH) launched MERS surveillance and made MERS a notifiable disease in 2012, particularly targeting people travelling into Thailand from affected countries. It also initiated a nationwide public education campaign . In 2015There have been increasing numbers of incoming travellers from the Middle East seeking medical care in Thailand in the past decade. More than 1.3 million medical tourists travelled to Thailand in 2015, of which 14.2% were from United Arab Emirates (UAE) and Oman .This study shows that, in addition to needing collaboration among different organisations during an outbreak, diagnosis cannot rely only on laboratory examination alone, especially when the specimen was not suitable. A negative laboratory result in a patient from an endemic region with MERS-like clinical signs still demands cautious infection control measures in an isolation unit.On 15 June 2015 (day 1), A 75-year old Omani man travelled to Thailand, seeking treatment for his heart condition. Upon arriving at the airport, the patient took a taxi to a hotel and checked in before leaving to a private hospital in another taxi. Upon presentation at the emergency room at the private hospital, the patient was promptly diagnosed with heart failure and possible pneumonia. As the patient had travelled from the Middle East that day, MERS was suspected and he was isolated in a negative pressure room (NPU). On day 3, the private hospital notified the Bureau of Epidemiology, under the Thai MOPH, of the Omani patient. RT-PCR for MERS-CoV on upper respiratory tract samples  that were sent on days 2 and 3 resulted in false negatives, leading to a 48-hour delay in diagnosis and a decision to transfer the patient out of the negative pressure unit (NPU) on day 3. Subsequent examination of a sputum sample later on day 3 confirmed MERS-CoV infection in the patient. The patient was immediately transferred back into the NPU. On day 4, Thailand’s MOPH officially reported the first imported MERS case and the patient was transferred from the private hospital to Bamrasnaradura Infectious Disease Institute (BIDI).The Omani Ministry of Health (MOH) was immediately notified as per the International Health Regulation (IHR) mechanism (day 4). Outbreak investigation was conducted in Oman, and the Oman IHR focal point published the results of this investigation on the World Health Organization (WHO)’s intranet to which all IHR focal points worldwide, including the one in Thailand, have access. The following report provides a brief patient history and clinical report, detailed laboratory findings and the diagnostic challenges faced in the first imported case of MERS in Thailand.Over 170 individuals, including 48 with high-risk of exposure were traced. Thirty-six high-risk close contacts were quarantined in Thailand and 40 low-risk contacts were monitored in Oman. Another 12 high-risk close contacts (airline crew members) were quarantined in the country they were situated when traced. Medical records from the private hospital and BIDI under the Department of Disease Control, under the Thai MOPH, were reviewed [N-acetylcysteine) and via nasopharyngeal swab (when sputum was not available), using QIAamp viral RNA mini kit  for extraction. Two real-time RT-PCR assays targeting upstream of envelope (UpE) and open reading frame 1a (ORF-1a) genes [In accordance with WHO interim guidelines for laboratory testing for MERS-CoV , MERS-Coa) genes ,10, and Respiratory specimens  were collected daily from the index case from the time of patient isolation on day 5 through to day 17. The respiratory samples were sent to three centres, the BIDI, the Thai National Institute of Health (NIH) and WHOCC, for parallel real-time PCR testing of MERS-CoV. Additional molecular sequencing was performed by WHOCC.The whole genome amplification of MERS-CoV was carried out from extracted viral RNA from collected sputum of the index case. Seventy sets of specific primer pairs were used to amplify the complete genome as previously described , followeFor the analysis, all MERS-CoV genomes with complete coding sequences available in GenBank as of 30 December 2016 (n = 233), were compared with the MERS-CoV genome obtained in this study. Sequences showing less than 35 divergent nt positions and two representatives of the five lineages defined by Sabir et al. , were seContact tracing was immediately implemented by the Thai MOPH. Contacts were divided into two categories; high-risk and low-risk. A high-risk close-contact was defined as any person who was within 1 m of contact with the index case while the patient was symptomatic, regardless of duration of contact. Airline passengers seated in the two rows surrounding the index case’s seat were also considered high-risk close contacts as per WHO guidelines . A low-rSeveral methods of contact tracing and active case finding were applied depending on the nature of contact, contact location, degree of symptoms at the time of contact, etc. At the hospital, attending physicians’ and nurses’ contact status was determined via interview and the hospital surveillance camera. At the hotel, potential contacts were identified by interviewing the personnel on-duty when the patient checked in and by using the hotel’s surveillance camera. The investigation team from the Department of Disease Control (DDC) at the Thai MOPH identified the airport-to-hotel taxi driver using the airport taxi booking slip and the hotel-to-hospital taxi driver by looking at the surveillance camera from the Traffic Control Department. The airline provided the investigation team with the passenger manifest and the Thai authorities identified passengers’ local address using immigration arrival cards. Local health authorities in relevant provinces were informed and asked by the investigation team to locate and contact the identified passengers in their jurisdiction. Some passengers voluntarily reported to a hospital or health authority in response to the MOPH’s announcement of first imported MERS case in Thailand. Central authorities were responsible for locating all high-risk close-contacts, while local authorities were responsible for low-risk contacts. The time lapse between the affirmed diagnosis and each contact-tracing varied. Contacts at the hospital were identified within a day, while other high-risk close contacts, such as passengers on the flight, were identified within 3 days. Other low-risk contacts were traced within 7 days.Patients who were in the same NPU ward as the index case at the private hospital on day 1 were monitored despite being considered non-contacts because: i) the room for each patient was separated, ii) they had no direct contact with the index case and iii) the known mode of transmission of MERS-CoV is respiratory droplet. Further, patients in the ICU, which is where the index case was moved after being taken out of the NPU 8 hours before diagnosis on day 3, were monitored, despite being non-contacts. In the event they developed a new episode of fever or respiratory symptoms, samples were collected and sent for testing to rule out MERS-CoV infection. Another concern was ICU healthcare workers’ simultaneous care of several patients. Prompt quarantine and monitoring of patients in the ICU was to be implemented if any ICU healthcare worker developed any symptoms or was diagnosed with MERS-CoV infection.Most high-risk close contacts were quarantined and all were continuously monitored for 14 days. Nasopharyngeal and throat swabs, stored in single viral transport media, from 36 high-risk close contacts were collected on two occasions as per the Bureau of Epidemiology guidelines : first uSera from three high-risk close contacts (the close relatives who travelled with the patient to Thailand) were sent to the Institute of Virology, University of Bonn Medical Centre, Bonn, Germany to test for anti-MERS IgG and IgM using MERS-CoV infected Vero cells for immunofluorescence assay .The real-time RT-PCR results on the patient’s nasopharyngeal swabs were negative for UpE and ORF-1a gene targets on days 2 and 3 , and theThe patient was referred to and isolated at BIDI on the morning day 4. The patient’s clinical presentation at that time was diffused bilateral pneumonia with pending acute respiratory distress syndrome . He did Later the same day, sputum was collected from the patient for reconfirmation, which tested positive for UpE and ORF-1a genes by four different laboratories: the NIH, Ramathibodi Hospital, BIDI and WHOCC. The Thai MOPH proceeded to publicly announce the first confirmed imported MERS case in the evening of 18 June 2015 (day 4). The patient was monitored for MERS until 1 July 2015 (day 17) and was discharged on 3 July 2015 (day 19).Upon laboratory confirmation on day 3, the case was immediately notified to the WHO. In order to support local handling of the outbreak, an epidemiologist and a risk communication expert were deployed from the WHO South-East Asia Regional Office and WHO Headquarters, respectively.The epidemiological investigation revealed retrospectively that on 4 June 2015, 11 days before the admission to the private hospital in Thailand, the patient was admitted to a regional hospital in Oman, with retrosternal and left-sided chest pain, which was radiating to his left arm . The conThe virus sequence (THA/CU/2015) obtained from the patient was submitted to GenBank (GenBank accession number KT225476). THA/CU/2015 showed closest relations (99.91% nt identity) to three human MERS-CoV strains isolated in Saudi Arabia in 2015 . Correspondences with a close relative of the patient and the Omani MOH revealed that the patient was a fisherman from Ghasil village, South Sharqiya Governorate, but spent June–August in Al Mintrib village of Bidiya Wilayat, North Sharqiyah Governorate. The patient neither had any history of travel outside Oman nor contact with anyone with a history of travel outside Oman within the 14 days preceding his travel to Thailand. Further, the patient had no contact with any person with acute respiratory infection or confirmed MERS before developing symptoms. The family used to own one camel but had not had contact with that camel for few months. A close relative who lived near the patient, but did not travel to Thailand with the patient, owned and cared for three camels. Samples collected from these camels tested negative in Oman for MERS-CoV by RT-PCR on day 15. It is also noteworthy that the patient and the patient’s close relatives never consumed raw camel milk or camel urine.A total of 211 contacts of the index case were identified after the patient was confirmed to have MERS. In Thailand, 170 contacts  travelled with the patient to Thailand and took care of the patient. They were also isolated at BIDI on the morning of 18 June 2015 (day 4) along with the patient. Their RT-PCR tests (each person tested four times) were negative for MERS-CoV. However, they were closely monitored for symptoms until 1 July 2015 (day 17). Sera from these three close relatives collected on 19 June and 1 July 2015 (days 5 and 17), were sent to the Institute of Virology at University of Bonn Medical Centre, Bonn, Germany, and all tested negative for anti-MERS IgG and IgM using MERS-CoV infected Vero cells for immunofluorescence assay  . The Thai outbreak investigation identified 45 other high-risk close contacts, including 14 airline passengers who sat in the two rows around the index case’s seat, 12 airline crew members, 17 healthcare workers at the private hospital  in Bangkok and two taxi drivers. All but the 12 airline crew members were quarantined as the crew members left the country for their return flight operation on 15 June 2015 (day 1). However, once the diagnosis was confirmed, the crew members were notified and self-quarantined for 14 days. Laboratory testing carried out on samples collected from 36 high-risk close contacts all tested negative at least twice for MERS-CoV by real-time PCR. Further, none of the high-risk close contacts, including the airline crew members and healthcare workers, reported to have developed symptoms compatible with MERS-CoV infection during the quarantine period.This study demonstrates the challenges faced by physicians and the cross-border threats that exist with increasing international medical tourism. Although precautions such as ThermoScan are in place at airports in light of the MERS-CoV outbreak in the Middle East and South Korea, cases can slip through checkpoints due to atypical presentations. The patient flew on a commercial airline despite his sickness and was not detected by the ThermoScan at the immigration checkpoint in Bangkok as he was afebrile. He only had a mild, non-productive cough. This case report also provides important lessons regarding clinical case identification. The clinical diagnosis was complicated due to the existence of congestive heart failure, a condition that predisposes to either community-acquired or nosocomial pneumonia of various aetiologies. Furthermore, initial chest radiographs did not show clear signs of interstitial pneumonia as expected with MERS-CoV infection. Various contact tracing methods involving the cooperation of several authorities and business institutes, such as the border control, airline, hotel management, traffic control, local authorities and hospitals, were used to track-down all potential contacts in order to prevent an outbreak. Phone calls, passenger manifests, surveillance videos and immigration cards were essential tools for the successful contact tracing.Upper respiratory tract samples, such as nasopharyngeal and oropharyngeal, are often used to detect upper respiratory tract illnesses during the acute phase. In MERS-CoV infection, however, higher viral loads have been found in specimens from the lower respiratory tract , with spThe algorithm for diagnosing MERS in the current WHO interim guidelines for laboratory testing indicates that two positive real-time PCR tests are sufficient in diagnosing MERS, i.e. ORF-1a and UpE. However, we found that performing three simultaneous assays and sequencing for UpE, ORF-1a and RdRp genes in parallel, allowed for swift in-country confirmation of the presence of MERS-CoV and reporting within 24 hours, facilitating prompt outbreak control measures. There was no secondary transmission, not even to close relatives or the healthcare workers at BIDI where the patient was transferred after the diagnosis was confirmed, despite 170 contacts, including 48 high-risk close contacts [Despite the successful outcome of infection control measures, the case provides an example of the risk of MERS-CoV infection importation. Aside from providing technical support through the MOPH Emergency Operations Centre, deployments of experts from the WHO South-East Asian Regional Office also greatly facilitated the exchange of information on possible modalities of MERS-CoV infection with the Omani MOH through the IHR (2005) mechanism . This st


A recent meta-analysis of published clinical trials conducted over the past 50 years has confirmed that the administration of fibrates to a broad range of high-risk patients lowers the risk of cardiovascular events.1The 10 to 13% relative risk reduction (RRR) found in this meta-analysis could be regarded as modest, but in high-risk patients, this contribution to the prevention of cardiovascular events is significant. Fibrates showed no benefit in this meta-analysis on stroke, all-cause mortality or sudden death.The cardiovascular event reduction was highest in patients with a higher mean baseline triglyceride concentration > 2 mmol/l), a finding that agrees with subgroup analyses done in several clinical trials, including the ACCORD trial. mmol/l, Data from the ACCORD trial available in published form to the authors of the meta-analysis did not allow the low-HDL subgroup to be separated from the hightriglyceride subgroup. So currently, the role of fibrates in reducing cardiovascular events in a subgroup of patients with low HDL levels and triglycerides below 2 mmol/l should be the subject of further investigation.This extensive meta-analysis included 45 000 individuals with a broad range of baseline characteristics. With regard to other cardiovascular conditions, the risk of heart failure was reported in three trials of 8 581 participants who had 584 heart failure events. Overall, there was no benefit of fibrates on heart failure. However, when the VA CO-OP Atherosclerosis trial,Three trials including more than 15 000 patients showed that fibrates reduced the risk of albuminuria by 14%. A very significant reduction of 37% was seen in the relative risk of diabetic retinopathy in two trials, which included more than 10 000 patients.5


The Statin-Associated Muscle Symptom Clinical Index (SAMS-CI) is a method for assessing the likelihood that a patient’s muscle symptoms  were caused or worsened by statin use. The objectives of this study were to prepare the SAMS-CI for clinical use, estimate its inter-rater reliability, and collect feedback from physicians on its practical application.For content validity, we conducted structured in-depth interviews with its original authors as well as with a panel of independent physicians. Estimation of inter-rater reliability involved an analysis of 30 written clinical cases which were scored by a sample of physicians. A separate group of physicians provided feedback on the clinical use of the SAMS-CI and its potential utility in practice.Qualitative interviews with providers supported the content validity of the SAMS-CI. Feedback on the clinical use of the SAMS-CI included several perceived benefits  and some possible concerns (workflow issues and applicability in primary care). The inter-rater reliability of the SAMS-CI was estimated to be 0.77 , indicating high concordance between raters. With additional provider feedback, a revised SAMS-CI instrument was created suitable for further testing, both in the clinical setting and in prospective validation studies.With standardized questions, vetted language, easily interpreted scores, and demonstrated reliability, the SAMS aims to estimate the likelihood that a patient’s muscle symptoms were attributable to statins. The SAMS-CI may support better detection of statin-associated muscle symptoms in clinical practice, optimize treatment for patients experiencing muscle symptoms, and provide a useful tool for further clinical research.The online version of this article (doi:10.1007/s10557-017-6723-4) contains supplementary material, which is available to authorized users. Statins are among the most widely prescribed drugs in the USA , and staWhile no gold standard measure exists for the identification of statin-associated muscle symptoms, progress toward a clear definition came in a 2014 publication from the Statin Muscle Safety Task Force of the National Lipid Association (NLA). In this work, Rosenson et al. , and raters completed the SAMS-CI for all the cases at their convenience within a 2-week period between May 18 and June 1, 2015. The order of presentation of cases was randomized by rater and they were required to provide a rating for every case.n = 10) and inter-rater reliability (n = 10) studies also gave input on the feasibility of using the SAMS-CI in their practice , and must be interpreted in the context of other clinical information, such as recent physical exertion or hypothyroidism.Need for information from two previous episodes of muscle symptoms to calculate a score.Clinicians also cited some possible concerns about routine use:Clinicians also expressed interest in embedding the SAMS-CI into electronic medical record systems, which would streamline the administration of the tool and centralize the results for access by clinical staff.The SAMS-CI offers a framework for attributing muscle symptoms to statin use. The initial form of the instrument, the SMCI, had not been previously optimized for routine clinical use. This mixed-method study revised the SMCI to produce a new version (the SAMS-CI) ready for use and further testing, both in clinical practice and in research on its predictive validity with real patients. Methods in this study included qualitative research on content validation and a quantitative study of inter-rater reliability. Qualitative results supported the content of the SAMS-CI, and the inter-rater reliability of the SAMS-CI was estimated to be 0.77 (above the customary minimum ICC threshold of 0.7 ), indicaAlthough muscle symptoms often co-occur with statin use, statins are not necessarily their cause. Both the ODYSSEY ALTERNATIVE and GAUSS-3 studies , 14 recrThese two examples demonstrate that reported muscle symptoms are not always related to statin use and illustrate how difficult it is to properly identify the statin intolerance population. These rechallenge studies provide further evidence that the predominant cause of statin intolerance may be the “nocebo” effect, which is totally dependent on patient awareness of a treatment and its potential adverse effects , 15. TheThe need for tools to identify statin intolerance is rapidly growing. Recently, two manuscripts were published which created an algorithm to identify statin-associated muscle symptoms from claims databases and/or electronic medical records , 17. FurA next step in this process will be to collect evidence about the performance of the SAMS-CI with actual statin patients in practice. Further research can establish the positive and negative predictive values of the SAMS-CI to proactively identify cases of statin-associated muscle symptoms, thereby averting unnecessary rechallenges. While the SAMS-CI has not yet been used in research contexts, it was developed in part from muscle symptom assessment protocols used in two recent clinical trials. The Effect of Statins on Skeletal Muscle Function study  used a dAttributing muscle symptoms to statin use has long been identified in the literature as a difficult problem to measure, standardize, and quantify. The SAMS-CI resolves some of these issues through the use of standard questions with vetted language, easily interpreted scores, and proven inter-rater reliability. As revised for clinical use, the SAMS-CI may support better detection of statin-associated muscle symptoms in clinical practice, better-optimized treatment for patients experiencing muscle symptoms, and stronger measurement in clinical research. Forthcoming research will seek to validate the SAMS-CI in a larger population and establish its predictive validity.Online Resource 1(PDF 15.5 kb)Online Resource 2(PDF 40.5 kb)Online Resource 3(PDF 208 kb)


Chemogenomic profiling is a powerful and unbiased approach to elucidate pharmacological targets and the mechanism of bioactive compounds. Until recently, genome-wide, high-resolution experiments of this nature have been limited to fungal systems due to lack of mammalian genome-wide deletion collections. With the example of a novel nicotinamide phosphoribosyltransferase (NAMPT) inhibitor, we demonstrate that the CRISPR/Cas9 system enables the generation of transient homo- and heterozygous deletion libraries and allows for the identification of efficacy targets and pathways mediating hypersensitivity and resistance relevant to the compound mechanism of action. However, one of the major challenges associated with compounds identified in such phenotypic screens still remains the elucidation of their binding target(s) and mechanism of action.The recent increase in the number of new drug approvals can in part be explained by a shift in the pharmaceutical industry towards phenotypic assays as the basis for new programs. Patient-derived iPS cells, 3-D organoid cultures, tissue printing (just to name a few) allow for increasingly complex phenotypic assays with much higher physiological and disease relevance compared to experiments on isolated protein targets S. cerevisiae. This report shows that chemogenomic profiling, including haploinsufficiency profiling of essential targets, may be deployed in a mammalian cellular context by taking advantage of the CRISPR/Cas9 system. Described here is a protocol that allows for the identification of the primary, efficacy target of bioactive compounds.Chemogenomic profiling by haploinsufficiency (HIP) and homozygous profiling (HOP) has demonstrated to be a powerful and unbiased approach to gain insight into the biology modulated by bioactive probes23To generate targeted loss-of-function alleles with genome-wide coverage we deployed a lentiviral, guide RNA (sgRNA) library with a redundancy of 5 sgRNAs per gene following published design principlesIn contrast to the specifically designed deletions in yeast, the CRISPR/Cas9 system does not allow for the controlled generation of heterozygous loss of function alleles. Nevertheless, heterozygous alleles are a prerequisite for a HIP assay that in yeast displays direct effects and thus is the relevant assay for target identification. We hypothesized that at least during the initial phase of editing, a given percentage of cells would be either heterozygous for a given gene or if homozygous, with some residual protein still present. Therefore, by conducting target identification during the phase of incomplete editing such an experiment would mimic the compound-induced hypersensitivity observed in the fungal HIP assay.50 around 30 nM as measured in a 384 well format. For chemogenomic profiling compounds need to be carefully dosed at sub lethal concentrations thus we repeated the potency determination in 6 well plates and identified the IC30 to be 10 nM and the IC50 to be approximately 15 nM under these conditions. These concentrations were used in the genome-wide experiment that was conducted according to the scheme depicted in In this proof-of-concept study, we aimed at identification of the mechanism of action of a hit identified in a medium throughput phenotypic cancer screen. LB-60-OF61, a pyrrolopyrimidine compound from the Novartis archive without previous annotation was identified to potently inhibit proliferation of several cancer cell lines displaying high levels of expression and dependency on the MYC oncogene with certain selectivity against other cells. . ExtendeWe also computed RSA  for enrichment, representing sgRNA editing results in resistance to LB-60-OF61 treatment. It was apparent that duration and/or higher doses yielded more hits. This fits with the idea of homozygous profiling (HOP) where complete inactivation of genes reveals synthetic genetic interactions. Obvious hits at multiple time-points and doses include PARG (poly ADP-ribose glycohydrolase), Sirtuin 1 (SIRT1), phosphofructokinase (PFKP), aconitase (ACO2), and the E1A binding protein EP300. Inhibition of NAMPT has been previously shown to lead to NAD and energy depletionWhen considering the underlying mechanisms potentially leading to the observed profiles, it became apparent that behavior of the top hit NAMPT was in agreement with the concept of haploinsufficiency profiling: i) as LB-60-OF61 was cytotoxic the target was expected to be essential; a characteristic reported for complete NAMPT inactivation in HCT116 cellsTo experimentally investigate if HIP was the underlying mechanism leading to separation of NAMPT from the other genes in the pool we transduced HCT116-Cas9 cells with the best scoring single sgRNA against NAMPT and harvested samples at the time points used to calculate the profiles shown in Both, hypersensitive and resistant candidate genes of our chemogenomic profiling experiments supported NAMPT as the primary target of LB-60-OF61. We decided to validate this finding by three orthogonal methods: First, to enable competition-based chemoproteomics LB-60-OF61 was modified to ZA-87-IW08 to allow immobilization on NHS activated sepharose beads. Importantly, the N-acylated linker surrogate ND-37-YO30 retained the same cellular activity of LB-60-OF61, indicating that a ZA-87-IW08-based affinity matrix should be suitable for functional target enrichment. Quantitative mass spectrometry-based analysis, using iTRAQ isobaric mass tags, identified and robustly quantified 2327 proteins common to both experiments, with NAMPT showing strong enrichment as well as the strongest dose-responsive competition .50 concentration of LB-60-OF61 by more than 150-fold but had no effect on the potency of the non-NAMPT inhibitor doxorubicin  supporting broad applicability of this approach. As depicted in Recent work suggested that CRISPR was not a suitable tool for chemogenomic profiling of compounds that modulate essential targetsHow to cite this article: Estoppey, D. et al. Identification of a novel NAMPT inhibitor by CRISPR/Cas9 chemogenomic profiling in mammalian cells. Sci. Rep.7, 42728; doi: 10.1038/srep42728 (2017).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Alzheimer's disease (AD) represents a major public health problem and it istherefore crucial that modifiable risk factors be known prior to onset ofdementia in late-life. The "Australian National University - Alzheimer's DiseaseRisk Index" (ANU-ADRI) is one of the potential tools for primary prevention ofthe disease.The aim of this study was to devise an adapted version of the ANU-ADRI foruse in Brazil.The instrument was translated from its original language of English intoPortuguese and then back-translated into English by bilingual translators.It was subsequently reviewed and evaluated as to the degree of translationissues and equivalence. In this study, the ANU-ADRI was applied usingindividual (face-to-face) interviews in a public hospital, unlike theoriginal version which is applied online by self-report. The final version(pretest) was evaluated in a sample of 10 participants with a mean age of 60years (±11.46) and mean education of 11 years (±6.32).The intraclass correlation coefficient (ICC) (inter-rater) was 0.954 of 95%=). Culturalequivalence was performed without the need for a second instrumentapplication step.After cross-cultural adaptation, the language of the resultant questionnairewas deemed easily understandable by the Brazilian population. Around 8million new cases of dementia are diagnosed each year, with AD being the mostprevalent type.4 The lifetime risk factors for AD mayvary, with middle age representing a critical period for changes in some of thesefactors.5 While a number ofclinical or lifestyle-related factors such as a low educational level (less than 12years), diabetes, hypertension in middle age, obesity in middle age, depression,dyslipidemia, and smoking are modifiable, biological or genetic factors such as age,gender, and apolipoprotein (APOE) ε4 genotypes are not.6Multiple factors are associated with the risk of developing AD.7Known protective factors are: Mediterranean diet (high in Omega-3 fatty acids) andmoderate alcohol consumption, both lifestyle-related.8The protective factors with stronger evidence are cognitive activities or reserve,physical activity, and engaging in other leisure activities that can stimulatesocial and cognitive aspects.Australian NationalUniversity - Alzheimer's Disease Risk Index (ANU-ADRI) could be used asone of several primary prevention strategies.9 The original items of the ANU-ADRI were developed inEnglish, precluding their use in other countries such as Brazil. Thus, theliterature recommends the process of translation and cross-cultural adaptation usingrigorous and widely used methods.12Focusing on the risk of AD as opposed to diagnosis, the Finally, there are no papers published on cross-cultural adaptation of the ANU-ADRIfor the Portuguese language. The instrument has not yet been used in specializedNeurology, Geriatrics or Psychiatry outpatient services or primary care , and its applicability in Brazil has notyet been adequately assessed.Our objective in this study to devise an adaptedversion of the ANU-ADRI for use in Brazil.Ethical considerations. Permission to translate and adapt the instrumentwas granted by the researchers at the Centre for Research on Ageing, Health andWellbeing (CRAHW) of the Australian National University (ANU) and by Dr. Kaarin J.Anstey (Email: kaarin.anstey@anu.edu.au). This research project wasreviewed and approved by the institutional review boards of the"Universidade Federal de São Paulo" - UNIFESP and"Escola Paulista de Medicina" - EPM (applying institution).Subsequently, the "Centro de Educação emSaúde" Research Ethics Committee of theHealth Department of Curitiba approved the project regarding the feasibility ofaccess to the research venue. The approved research project is available on the"Plataforma Brasil" database (CAAE registry No.38185614.5.1001.5505).Design: cross-cultural adaptation studyInstruments. A questionnaire was administered for sociodemographic andclinical data collection, after which the MMSE was applied for patient screening.The 84-item ANU-ADRI was the principal questionnaire. The Australian NationalUniversity Alzheimer's Disease Risk Index (ANU-ADRI) is a self-report instrument toassess: 11 risk factors and 4 protective factors for Alzheimer's disease. Thesefactors are shown in The total score was obtained by summing the scores assigned by category to the riskor protective factors in Participants. A convenience sample comprised 10 patients selected from apublic hospital in Curitiba, Brazil, between July and August 2015. All participantswere aged >40 years with no evidence of severe or disabling disease at theoutpatient service of "Hospital do Idoso Zilda Arns" (HIZA).11 Nopatients were excluded from the study. All patients were instructed as to the studygoals and provided written informed consent prior to instrument evaluation.The exclusion criteria were a history of any severe visual or hearing impairment ormarked psychomotor disability (e.g. parkinsonism); a history of severe psychiatricor neurological disorders; severe clinical or psychiatric disorders; dementia and/orbelow expected score on the Mini-Mental State Examination (MMSE) adjusted for levelof education .Procedures. The translation and cross-cultural adaptation werestandardized.12 The firststep was a forward translation of the English version of the ANU-ADRI instrumentinto Brazilian Portuguese by two bilingual health professionals (DI and RNS), bothof whom were Brazilian, independent, and aware of the main goal of the study.Translation focused on conceptual rather than linguistic equivalence of the items.The translations were compared by an expert review committee  and a consensus version was formulated fromthese two translations.In the next step, the consensus translation was back-translated into English by athird bilingual translator - a native English speaker with proficiency in thePortuguese language (ACD). Subsequently, this version was compared with the originalEnglish language instrument. The back-translation showed semantic equivalence andconsistency in the translated items.The final step consisted of ensuring cultural equivalence and involved the sameexpert panel who participated in the semantic equivalence process. This step isjustified by the fact that a word or statement used with a given intent in theoriginal context may not convey the same meaning to the target population of the newversion. The expert committee reviewed the questions with regard to content validityand prepared a summary version for pretesting in order to assess the acceptabilityand understanding of the instrument by the target population. The aim of this stepwas to identify the questions that were not understood or not answered by the targetpopulation. To that end, a "not applicable" answer choice was included alongsideeach question. The ANU-ADRI instrument was administered by five trained interviewersyielding data in the pretest phase.Statistical analysis. When evaluating screening instruments, testindices may be inaccurate if samples are too small. The aim of testingreproducibility is to assess the random fluctuations noted for the same individualinterviewed on multiple occasions. Each patient was assessed by a differentinterviewer in a random manner (inter-rater).13 ICC is definedas "the proportion of variance of an observation due to between-subject variabilityin true scores" and in order to offset potential errors, a 95% confidence intervalor standard error should be adopted.14 The data were analyzed using the SPSS version 20.0 statisticalpackage.Intraclass correlation coefficient (ICC) was the specific method used to estimateinter-rater reliability, with values around 1 indicating good agreement betweenanswers.p<0.001, 95% CI=).Cross-cultural equivalence was achieved with no need for a second step in theinstrument evaluation process. The intra-class correlation coefficient (inter-rater)of the ANU-ADRI was 0.954  needed the interviewer's assistance to readthe items concerning "Physical Activity" and "Depression" domains, yet had nodifficulty choosing the answers. None of the 84 questions were deemed "notapplicable" by the respondents.Supplementarymaterial).The mean time for administering the ANU-ADRI was 25 (±5) minutes. The finaladapted Portuguese version can be found as  scale adapted for older Brazilian individualsCultural equivalence presupposes a literal match between the original and adaptedversions, and should address the impact a term would have in the cultural setting ofthe target population sample. The expressions used in item 50 ("shoveling snow") anditem 60 ("doubles tennis") of the source questionnaire were excluded followingcultural adaptation as they would not be as meaningful in the adapted version forthe Brazilian population. To allow the use of IPAQ-based questions for olderindividuals, examples were included of activities that are common for persons inthis age group.16 were includedwithout changing the original structure of the questionnaire - for example, in items52 ("limpar a garagem"), 54 ,58 , and 60 .Other expressions from the Brazilian version of the IPAQ validated for oldermen18compared to adults with a higher level of education.It is important to know the particularities of the sample considering the fact thatrespondents' gender, age group, and level of education could have influenced theperformance of the instrument. Older adults with a low educational level had moredifficulty understanding the items related to the "Depression" domain based on theCES-D scale validated in Brazil19 The author of the cited studynoted that the ANU-ADRI should be tested in "target samples with lower levels ofeducation and higher ANU-ADRI risk scores".A randomized, controlled study including a sample of middle-aged adults (mean age=55years) with a high educational level (mean=18 years of education) revealed a lowermean ANU-ADRI score (-1.38) than that found in our sample (6.3).20 Theassessment of older people via questionnaires (either self-administered or in theform of interviews) is a particularly difficult task due to the inaccuracy of theinformation given and susceptibility to recording or recall bias. In the presentstudy, the ANU-ADRI was administered using individual interviews as opposed to theself-report approach of the original online version. The original version, the shortform and the Portuguese version are available for printout from theinternet.21In the present study, the mean administration time was longer (25±5 minutes)than that of the original ANU-ADRI, reported to be around 15±5 minutes. Theshort version of the ANU-ADRI can be considered an alternative whenever the originalversion is deemed too lengthy or "not applicable" due to limitations inadministration time.In conclusion, after the cross-cultural adaptation of the ANU-ADRI, the wording ofthe instrument was found to be easily understandable by the Brazilianpopulation.Furthermore, the final adapted version can facilitate international cooperationprojects that employ this instrument.In the near future, the authors of the present study intend to publish the validityand test-retest reliability of the ANU-ADRI with a larger sample (n=100) ofparticipants from the same institution in Brazil.


The Parsis are one of the smallest religious communities in the world. To understand the population structure and demographic history of this group in detail, we analyzed Indian and Pakistani Parsi populations using high-resolution genetic variation data on autosomal and uniparental loci . Additionally, we also assayed mitochondrial DNA polymorphisms among ancient Parsi DNA samples excavated from Sanjan, in present day Gujarat, the place of their original settlement in India.Among present-day populations, the Parsis are genetically closest to Iranian and the Caucasus populations rather than their South Asian neighbors. They also share the highest number of haplotypes with present-day Iranians and we estimate that the admixture of the Parsis with Indian populations occurred ~1,200 years ago. Enriched homozygosity in the Parsi reflects their recent isolation and inbreeding. We also observed 48% South-Asian-specific mitochondrial lineages among the ancient samples, which might have resulted from the assimilation of local females during the initial settlement. Finally, we show that Parsis are genetically closer to Neolithic Iranians than to modern Iranians, who have witnessed a more recent wave of admixture from the Near East.Our results are consistent with the historically-recorded migration of the Parsi populations to South Asia in the 7th century and in agreement with their assimilation into the Indian sub-continent's population and cultural milieu "like sugar in milk". Moreover, in a wider context our results support a major demographic transition in West Asia due to the Islamic conquest.The online version of this article (doi:10.1186/s13059-017-1244-9) contains supplementary material, which is available to authorized users. The Parsi (or Parsee) community of the Indian sub-continent are a group of Indo-European speakers and adherents of the Zoroastrian faith, one of the earliest monotheisms that flourished in pre-Islamic Persia (present-day Iran) , 2. ZoroQissa-e-Sanjaan is that an Indian ruler called Jadi Rana sent a glass full of milk to the Parsi group seeking asylum [The Parsi trace their ancestry to the ancestors of the Zoroastrians of modern Iran, who are followers of the Prophet Zoroaster or Zarathushtra . In the g asylum , 18. Hisg asylum , 18. In g asylum , 19–21.Previous genetic analyses of the Parsis have focussed mainly on low-resolution uni-parental markers, which have suggested their affinity with both West Eurasian and Indian populations –24. Autodokhama (tower of silence) District Valsad, Gujarat, were excavated in 2004. The accelerator mass spectrometry dating of human remains suggest that the dokhama belongs to the 14th to 15th century A.D. [These early studies of the Parsi populations relied mainly on low-resolution markers, limiting the power of the analyses , 23–25, ury A.D. .We investigated whether the current Parsi people living in India and Pakistan are genetically related amongst themselves and with the present-day Iranian population, and if their genetic composition has been affected by the neighboring Indian and Pakistani populations. We also examined runs of homozygosity (RoH) to study consanguinity. To address the extent to which the current Parsi populations assimilated local females during their long formation history, we compared their mtDNA haplogroup composition with ancient remains excavated in Sanjan, the initial settlement established by these migrants from Persia .FST Indian and Pakistani Parsi = 0.00033 ± 0.000025), followed by the differentiation of each from the Iranian population , suggesting a common stock for both the Indian and Pakistani Parsis with the closest interpopulation affinity with populations from their putative homeland, Iran .For autosomal analyses, we used Illumina HumanHap 650 K genotyping chips on 19 Indian Parsi samples collected from Mumbai, and Illumina 2.5 M genotyping chips for 24 Pakistani Parsi individuals from Karachi  ancestry component was significantly higher (two-tailed P < 0.0001) in the Parsis than in any other populations residing in South Asia that were examined. The present-day Iranian population exhibited a striking difference from the Parsis, mainly in carrying an additional European component (light blue) and substantially lower South Asian ancestry (dark green)   had significant levels of gene flow with each other, as well as with both of the Parsi populations when evaluated with respect to the present-day Iranian population . However, the number of these chunks were significantly lower than the chunk counts shared between any pair of South Asian populations (two-tailed P < 0.0001)  . The max . The maWe used ALDER, a method based on linkage disequilibrium , to estiTo investigate further the parental relatedness among Parsis , we analIQBC1, an IQ-motif-containing B1 gene that is highly expressed in Epstein–Barr virus-transformed B lymphocytes [To investigate how random genetic drift has shaped the functional genetic variation after admixture in the Parsis, we implemented the population branch statistic  using thphocytes .To obtain a detailed understanding of the sex-specific South Asian and Iranian ancestries, we examined maternally inherited mtDNA and paternally inherited Y chromosome biallelic polymorphisms in a larger sample in both the Indian and Pakistani Parsi populations Additional file 2: Table S3.FST values based on an autosomal data set for all the populations included in this study. (XLSX 120 kb)The population-wise


Diseases are developed by abnormal behavior of genes in biological events such as gene regulation, mutation, phosphorylation, and epigenetics and post-translational modification. Many studies of text mining attempted to identify the relationship between gene and disease by mining the literature, but they did not consider the biological events in which genes show abnormal behaviour in response to diseases. In this study, we propose to identify disease-related genes that are involved in the development of disease through biological events from Medline abstracts. We identified associations between 13,054 genes and 4,494 disease types, which cover more disease-related genes than manually curated databases for all disease types  and also than those for specific diseases . We show that the text mining findings are reliable, as per the PubMed scale, in that the disease-disease relationships inferred from the literature-wide findings are similar to those inferred from manually curated databases in a well-known study. In addition, literature-wide distribution of biological events across disease types reveals different characteristics of disease types. Identification of the genes involved in diseases is an important tool for revealing the molecular mechanisms of disease development and for the development of new drugs. Although existing web services, such as Online Mendelian Inheritance in Man (OMIM)http://gcancer.org/digsee.While the previous version of DigSeeet al.We compared the identified disease-related genes with those from the OMIMThe extended DigSee search engine  crawled We investigated which genes were involved in multiple disease types across the most general 25 categories in the MeSH ontology . With thet al.We compared genes from the OMIMp-value < 0.05. DigSee had significant overlaps of genes for 99% of diseases (283/285) from OMIM and for 85% of diseases (198/232) from GWAS. Specifically, DigSee identified 75–100% of disease-related genes in OMIM for a majority of disease types , whereas it identified 50–75% of genes in GWAS for 49% (114/232) of diseases  is calculated based on the most specific GO term i among those shared by the two genes. SGO ≡ 2/min(ni), where ni is the total number of genes annotated for the GO term i. Then, the similarity of two diseases A and B is determined by the average of GO similarity of all gene pairs in diseases A and B. We also tested whether the disease-related genes identified by DigSee could be used to reveal functional relationships between diseases. We calculated the functional similarity of disease-related genes by gene ontology (GO) annotations, in the same manner as Menche In summary, for uncovering disease-disease relationships and functional relationships between diseases, the disease-related genes text-mined by DigSee present similar results as those identified from OMIM and GWAS, which supports reliabilities of the identified disease-related genes.μ + 1σ) of evidence sentences were related to mutations, referred to as mutation-enriched diseases. For 198 disease types, >41% (=μ + 1σ) of evidence sentences were related to expression, referred to as gene expression-enriched diseases . Similarly, it was observed that the ratio of transcription factors among genes related to mutation-enriched diseases was less than that of genes related to the gene expression-enriched diseases, with a p-value of 6.23E-13 The previous cancer version of DigSee introduced a Bayesian model for identifying evidence sentences, based on linguistically motivated features, and used the confidence scores of evidence sentences estimated by the model for ranking disease-related genes. Among the features, two features of “cancer keywords count” and “hallmark keywords count” were based on hand-crafted cancer-related terms and thus disease-dependent. To apply the two features for all diseases, we develop a novel disease-independent method of collecting disease-related terms by using Word2VecWe also tested whether the feature weights of the Bayesian model trained with the cancer dataWe compared five measures for ranking genes for each disease, including 1) the number of abstracts supporting disease-gene relations, 2) the number of evidence sentences, 3) the highest score of evidence sentences, and 4) the summation and 5) the average of normalized scores of evidence sentences. The first measure counts the number of abstracts containing the evidence sentences with disease-gene-biological events for each gene. The second measure counts the number of evidence sentences for each gene. Note that when calculating the first two measures, the scores of evidence sentences were not considered. The third measure selects the highest among the scores of the evidence sentences of a gene. For the fourth and fifth measures, genes are ranked by the summation and the average of normalized scores of the evidence sentences of the genes, respectively. We normalized scores using a sigmoid function.DigSee’s query consists of the following elements: (i) disease of interest .Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


One-stop center for functional polycyclic aromatic hydrocarbons — a dichlorodiazaperylene intermediate has been synthesized and employed for the synthesis of highly functionalized coronene derivatives. Combining core annulation and peripheral group modification, we have demonstrated a divergent synthesis of a family of highly functionalized coronene derivatives from a readily accessible dichlorodiazaperylene intermediate. Various reactions, such as aromatic nucleophilic substitution, Kumada coupling and Suzuki coupling proceed effectively on α-positions of the pyridine sites, giving rise to alkoxy, thioalkyl, alkyl or aryl substituted polycyclic aromatic hydrocarbons. In addition to peripheral group modulation, the aromatic core structures can be altered by annulation with thiophene or benzene ring systems. Corresponding single crystal X-ray diffraction and optical studies indicate that the heteroatom linkages not only impact the solid state packing, but also significantly influence the optoelectronic properties. Moreover, these azacoronene derivatives display significant acid-induced spectroscopic changes, suggesting their great potential as colorimetric and fluorescence proton sensors. The former feature affects tuning of frontier molecular orbital energies and the related optoelectronic properties, while the latter is essential for intermolecular charge transport via a hopping mechanism.3 The combined structural features render PAHs excellent candidates for organic semiconductors. Structural tuning of these molecular systems can be realized either on the aromatic core, typically through ring annulation or by introducing different heteroatoms, or by changing the peripheral groups. Two major types of PAHs are linear acenes4 and radially expanded benzenoids such as coronenes and annulated coroenes.5 Different heteroatoms, such as B,6 N,7 O,8 P,9 and S,10 have also been incorporated to the core. On the other hand, the peripheral groups are known to affect the solubility, the intermolecular packing in the solid states, and the electronic structures, all relating to the anchoring atom between the aromatic core and the solubilizing alkyl chains. Commonly used peripheral substituents for PAHs are alkyl and alkoxy groups.7 Other peripheral substituents, such as thioalkyl11 and aryl groups,12 although less studied, have been shown to affect the energy levels as well as the packing in the solid state, all of which are very relevant for tuning optoelectronic properties.Polycyclic aromatic hydrocarbons (PAHs) and heterocyclic PAHs containing multiple benzenoid aromatic units, which can be considered as a small segment of graphene sheet,TAC) derivatives are one of the very few PAH monomers that have recently been employed in high performance conjugated polymers.13 The structure of TAC features (Voc) of 0.89 V in organic solar cells. Considering that the electron donating alkoxy group often leads to a reduction of the ionization potential, it is imperative to explore structural tuning of this multi-functional aromatic core by changing the peripheral groups. Herein we report a divergent synthetic route that involves a versatile and readily accessible intermediate, 1,7-diaryl-2,8-dichloro-3,9-diazaperylene (DAP). The 2,8-dichloro-substitution allows the introduction of peripheral groups with different heteroatom linkage via various routes, such as nucleophilic aromatic substitution (SNAr), Kumada coupling and Suzuki coupling reactions. The scope is further expanded when different aryl groups are introduced to the 1,7-position of the azaperylene, leading to diverse aromatic systems after simple transformations. The combined modifications of peripheral group and core structure have a great impact on properties of the PAHs, such as the solution optical properties and the solid state packing, as characterized by UV-vis/photoluminescence spectroscopies and single crystal X-ray analysis. Moreover, the PAHs form adducts with acids due to the presence of nitrogen heteroatoms in the azacoronenes. Significant colour and fluorescence changes are observed upon mixing the azacoronenes with acids, suggesting their great potential as dual-mode pH sensors.Thienoazacoronene (features  two nitrDAPs) are depicted in 1) and 2-arylacetyl chloride gave the diamides 3a and 3b, which underwent double intramolecular Knoevenagel condensation to afford the fused diamides 4a and 4b. The subsequent treatment with POCl3 gave the aromatized DAP5a and 5b. Aryl substituents, such as phenyl and thienyl groups were readily introduced to the bay positions of DAPs via this reaction sequence.The syntheses of dichloroazaperylenes  series when the precursors solutions were irradiated under UV light in the presence of catalytic amount of I2. Similar reaction sequences were applied to the thiophene derived DAP5b to give the thienoazacoronene (TAC) series  series . It is nDAPs to give alkyl or aryl substituted PAHs. As shown in DAP5a went smoothly in the presence of Ni(ii) catalyst to yield the carbon linked CEH-BAC (11). Under Suzuki coupling reaction conditions, aryl substituent was introduced to the 2,8-positions of the BAC core  and SEH-BAC (9) share great similarity to the reported OEH-TAC (13) analogue  reveals that the nearly flat aromatic surfaces stack into columns similar to these observed in OEH-TAC, with an inter-plane spacing and centroid-to-centroid distance of 3.36 Å and 5.06 Å, respectively. The intermolecular packing is however very different from OEH-TAC. As shown in SEH-TAC, as opposed to the parallel arrangement of columns in BACs and OEH-TAC.13 Such structural differences illustrate that the heteroatom linkage between the PAH core and the alkyl group could have a profound impact on the solid-state packing.Single crystal X-ray structure analysis of the azacoronenes provides direct information about the molecular structure and packing. The solid-state structures of analogue . The aroBAC and TAC derivatives shows the following features: (a) well-separated vibronic peaks at low energies are present in both TACs and BACs; (b) the lowest energy transitions of BAC are blue-shifted compared to these of the TACs by ∼7 nm; (c) the thioalkyl substitution shifts the transitions to the longer wavelength when compared to the alkoxy substituted ones by ∼20 nm, while the alkyl substitution shifts the transitions to the shorter wavelength; in addition, the absorption of the phenyl-substituted BAC is in between the thioalkyl and alkoxy substituted ones and exhibits broadened peaks, suggestive of extended conjugation and increased number of vibrations upon the attachment of the phenyl substituents.14 Cyclic voltammetric measurements revealed electrochemically irreversible oxidation and reduction peaks for all the azacoronene derivatives  indicates  was added into the toluene solution of ODP-BAC at 10 μM )16 is applied for the calculated HOMO and LUMO eigenenergies including toluene solvent17 on account of the systematic overestimation by B3LYP functional.18Density functional theory (DFT) calculations on the nature of the molecular orbitals and the frontier orbital energies are carried out on BAC and TAC derivatives are highly delocalized over the core, while the contribution from the peripheral groups is negligible. According to the ligand field theory, the more electron-withdrawing a functional group is, the more the HOMO is stabilized and the LUMO is destabilized. Since localization of LUMO orbitals is very similar for all BAC molecules, the order of LUMO energies (ODP-BAC is delocalized over the core unit as well as the peripheral phenyl rings, resulting in increased HOMO energy. Alkylsulfide and alkoxy destabilizes the HOMO to a very similar extent, while the alkyl group gives the lowest HOMO energy levels.As illustrated in energies  reflectsBAC and TAC derivatives bearing the same peripheral groups, the calculated bandgaps are slightly smaller for TAC derivatives, which are consistent with the experimental observations. The TAC core is more electron rich than the BAC one due to the introduction of more electron rich thiophene unit, as reflected by the higher HOMO and LUMO energy levels for both alkoxy and alkylsulfide substitutions. It is worth noting that in both BAC and TAC cases, the alkylsulfide and alkoxy groups possess the same HOMO but different LUMO energy levels. The lower LUMO energy level of alkylsulfide again confirms that it is more electron withdrawing than the alkoxy group. Such findings should be very valuable in guiding the fine tuning of optoelectronic properties of organic semiconductors.For SEH-TAC, SEH-BAC, ODP-BAC, OEH-TAC, OEH-BAC and CEH-BAC, respectively.The absorption spectra of these azacoronenes were also calculated  using toDAP intermediates, which facilitate the alteration of both the core structure and peripheral heteroatoms of a versatile azacoronene PAH system. The α-chloropyridine moiety is compatible with aromatic substitution reactions, Kumada coupling or Suzuki coupling reactions, from which thioalkyl, alkoxy, alkyl, or aryl substituents are readily introduced to the benzo- or thienoazacoronene cores. Such a family of PAHs allows a structure–property relationship study as verified by both experiments and theoretical calculations. The heteroatom linkages not only impact the intercolumnar arrangement, but also greatly change the optoelectronic properties. The thin films of these azacoronenes show strong fluorescence, implying their great potential for use in solid-state light emitting applications. In addition, the azacoronenes display significant spectroscopic responses when protonated, clearly suggesting that they can function as “naked-eye”dual-mode probes for protons. The synthetic methodology thus represents a concise route to an array of novel colorimetric and fluorescence pH sensors with tunable spectroscopic ranges.We have reported a modular synthetic approach of bisaryl-annulated azacoronene series using Supplementary informationClick here for additional data file.Crystal structure dataClick here for additional data file.