With respect to the non-integro-fractional derivative, in previous studies, the non-integro-fractional derivative of non-negative real numbers can be calculated. However, by previous denitions, the non-integro-fractional de- rivative of negative values can not be calculated due to t; 2 (0; 1). For example, (2)12 =2 R for t = 2 and = 1 2 : So what should we do for the non-integro-fractional derivative of “negative” real numbers? The pur- pose of this paper is to introduce more general derivative denition and we claim that we will obtain non-integro-fractional derivative of “all” real num- bers. Classic derivative, q-derivative, (p; q)-derivative, comformable fractional derivative, Katugampola fractional derivative and backward-forward dierence operator in Time Scale are the special cases of these general derivative deni- tions. These new denitions of ours must give us derivatives on both discrete and continuous calculus.

Purpose: Tophi can cause several severe complications. However, the predictors of tophi formation are not intensively researched. The aim of the study is to develop and validate a new prediction model for tophi formation amongst patients with gout. Methods: A prediction model was developed using data collected from 158 gout patients treated in the inpatient department of The First Affiliated Hospital of Zhejiang Chinese Medical University from May 2018 to May 2020. For the establishment and validation of the prediction nomogram, the least absolute shrinkage and selection operator regression model and the multivariable logistic regression analysis were conducted to determine the predictors. C-index, calibration plot and decision curve analysis were utilised to evaluate discrimination, calibration and clinical effectiveness of the predicting nomogram. Then, the nomogram was internally validated using a bootstrap procedure. Results: Nine predictors – hospitalisation frequency, disease duration, number of joints involved in gouty arthritis, gout flares frequency, smoking, and whether combined with atherosclerosis, diabetes, hypertension and kidney dysfunction – were determined from the prediction nomogram. The C-index of the nomogram was 0.854 (95% confidence interval: 0.772-0.936), and was confirmed to be 0.810 when tested through a bootstrap validation, suggesting the model’s good discrimination and prediction capability. Conclusion: A new model with nine predictors was developed to predict the risks of tophi formation amongst gout patients. The included predictors were practical and easy to obtain, whilst the nomogram was proved to predict the risks of tophi formation effectively and accurately. Keywords：tophi formation, gout, predictors, nomogram

Objective: To assess whether folic acid supplementation ameliorates hot flushes. Design: Double-blind, placebo-controlled randomised trial. Setting: Nine hospitals in England. Population: Postmenopausal women experiencing ≥50 hot flushes weekly. Methods: Women (n=164) were randomly assigned in a 1:1 ratio to receive folic acid 5mg tablet or placebo daily for 12 weeks. Participants recorded frequency and severity of hot flushes in Sloan Diary daily and completed Greene Climacteric and Utian Quality of Life (UQoL) Scales at 4-weekly intervals. Main Outcome Measures: The change in daily Hot Flush Score at week-12 from randomisation based on Sloan Diary Composite Score B calculation. Results: Data of 143 (87%) women was available for the primary outcome. The mean change (SD) in Hot Flush Score at week-12 was -6.98 (10.30) and -4.57 (9.46) for folic acid and placebo group, respectively. The difference between groups in the mean change was -2.41 (95% CI: -5.68, 0.87), p=0.149 and in the adjusted mean change was -2.61 (95% CI: -5.72, 0.49) with p=0.098. There was an increased benefit in the folic acid group regarding changes in total and emotional UQoL scores at week-8 when compared with placebo. The difference in the mean change from baseline was 5.22 (95% CI: 1.16, 9.28) and 1.88 (95% CI: 0.23, 3.52) for total and emotional score, respectively. Conclusions: Folic acid had a greater benefit in reducing Hot Flush Score over 12 weeks in postmenopausal women when compared with placebo; however, the difference did not reach statistical significance. Definitive evidence of benefit requires a larger study.

Anthropogenic activities and climate change are the important factors adversely affecting water resources in Kucuk Menderes Watershed. The watershed is shown as a water-stressed watershed due to increasing population and uncontrolled groundwater use. Water resources management within the watershed has become a challenge and to overcome this challenge, modeling studies are necessary. In this study, a hydrologic model for the watershed was established using SWAT (Soil and Water Assessment Tool). The model calibration and sensitivity analysis were performed by SWAT-CUP (SWAT-Calibration Uncertainty Programs) using Sequential Uncertainty Fitting Version-2 (SUFI-2) method. The model was mostly sensitive to CN2 parameter. Soil and groundwater parameters were the parameter categories that the model was mostly sensitive. The performance of the model was evaluated with P- factor, R- factor and objective functions. P- factor values for the calibration were in the range of 42-75 % meaning that the monitoring data were matched by the model within this range. According to the objective functions, the model performance was evaluated as good and satisfactory based on gauge stations. As this study is one of the first watershed modeling studies for the watershed, it will contribute to different studies to be done in water resources management. The results of this study could serve as a basis for a wide range of studies in the watershed such as water budget determination and sectoral water allocation, impact of climate change, future water quality modeling studies and understanding the impact of best management practices applications to prevent further deterioration in water quantity and quality within the watershed.

Background: Minimally invasive mitral valve(MV) surgery(MIVT) is increasingly performed with excellent clinical outcome, despite longer procedural times. This study analyzes clinical outcome and secondary organ function effects in a propensity-matched comparison with conventional MV surgery. Methods and Results: Out of 439 patients undergoing MV surgery from January 2005 to May 2017, 345 patients were included after propensity-matching: 95 sternotomy patients and 250 MIVT patients. Endpoints focused on survival, quality of MV repair and organ function effects through analysis of biomarkers and functional parameters. Despite longer cardiopulmonary bypass(sternotomy: 96.0(IQR34)min – MIVT:134.0(IQR42)min, p<0.001) and cardioplegic arrest times(sternotomy: 61.0(IQR26)min – MIVT:87.0(IQR34)min, p<0.001), no differences in survival nor complication rate were found. Effect on renal function(creatinine, p=0.751 – ureum, p=0.538 - glomerular filtration, p=0.848), myocardial damage by troponine I level (sternotomy:1.8±3.9ng/ml – MIVT:1.2±1.3ng/ml, p=0.438) and ventilatory support > 24 hours(sternotomy:5.5% - MIVT:9.5%, p=0.240) were comparable. Systemic inflammatory reaction by postoperative CRP count was markedly lower for MIVT(p<0.001). Increased rhadomyolysis was found after MIVT surgery, based on significant elevation of creatinine-kinase levels(sternotomy: 431±237U/L – MIVT: 701±595U/L, p<0.001). Conclusion: Despite an inherent learning curve, minimally invasive MV surgery guarantees a clinical outcome and MV repair quality, at least non-inferior to those of MV surgery via sternotomy. Notwithstanding longer cardiopulmonary bypass and cardiac arrest times, the impact on secondary organ function is negligible, excepted for a lower systemic inflammatory response. The postoperative increase of CK-enzymes suggestive for enhanced rhabdomyolysis needs to be accounted when procedural times tend to exceed the critical time threshold for severe limb ischemia.

The need for sustainable livelihood is compelling many artisanal sand dredgers to engage in other economic activities to augment the income from sand dredging which is affected by the season. The study showed that most respondents (59.2%) were female while 82.6% of the respondents were married. The literacy level was low among the respondents with 43.9% had primary education. The study revealed that 86.2% of artisanal sand dredgers engaged in other economic activities. The averages of working day per week for sand dredging and other economic activities were 4.2 days and 3.0days respectively. The average income earned per month from sand dredging and other economic activities were ₦50229.27 and ₦31023.76 respectively. Sand dredging activity contributed 65.7% of the total income of respondent while other economic activities contributed 34.3%. There was fair income diversification (0.46) among respondents. Age of the respondents, household size, sand dredging income and family labour were the factors that influenced extent of livelihood diversification in the study area. The intervention of NGOs by encouraging the sand dredgers in their diversification efforts through training and retraining in small scale enterprises of their choice will help to reduce pressure on sand dredging and thus saving the aquatic habitats.

Despite the importance of headwater basins for western United States’ water supply, these regions are often poorly understood, particularly with respect to quantitative understanding of evapotranspiration (ET) fluxes. Heterogeneity of land cover, topography, and atmospheric patterns in these high-elevation regions lead to difficulty in developing spatially distributed characterization of ET. As a significant fraction of the water budget, ET contributes to overall water and energy availability in the basin. Using an eddy covariance tower in the East River Basin, a Colorado River headwaters basin, this study improves the quantification of water and energy fluxes in high-elevation, complex systems to better constrain ET estimates and calculate overall water and energy budgets. The eddy covariance method estimates ET from years 2017 through 2019 at a saturated, riparian end-member site. During the late spring, summer, and early fall months, due to strong variations in lower atmospheric stability and evidenced by a less than 30% energy balance closure error in these months (within the range of closure error reported at other riparian locations) we conclude that the eddy covariance method is useful in high-elevation, complex areas such as the East River Basin and helps bound regional ET estimates. We also compared East River ET magnitudes and seasonality to two other eddy covariance towers (Niwot Ridge, CO and Valles Caldera, NM), with similar site characteristics, located in the Rocky Mountains. East River ET estimations are useful for constraining water budget estimates at this energy-limited site, which uses groundwater for up to 76% of ET in the summer months. This data is useful for constraining ET estimates in similar end-member locations; however, to better constrain ET estimates across the entire East River basin, additional sampling is needed. This study helps constrain both the energy and water budgets in locations that are underrepresented by observations and where indirect estimates of ET may perform poorly.

Abstract Lockdown, quarantine, self-isolation, personal protection equipment, social distancing have become words of daily usage ever since the world health organisation declared COVID-19 as a pandemic. The impact of COVID 19 extends over the medical field, economy, education and politics. Though the knowledge of the virus is evolving, we are yet to find a solution. India, country with the 2nd largest population, went into a phase of lockdown from 25th March 2020 to 31st May 2020. There was phased measure to “Unlock” starting from1st June 2020. This has affected the clinical practise and training of the resident. The challenges faced during this unprecedented time are multi-faceted which includes overcrowding, health care system, educational background. Indian Association of Cardiovascular-Thoracic Surgeons kept continuing the educational program through a series of “Masterclass”.

Microorganisms often live in environments that fluctuate between mild and harsh conditions. Although such fluctuations are bound to cause local extinctions and affect species diversity, it is unknown how diversity changes at different fluctuation rates and how this relates to changes in species interactions. Here, we use a mathematical model describing the dynamics of resources, toxins, and microbial species in a chemostat where resource supplies switch. Over most of the explored parameter space, species competed, but the strength of competition peaked at either low, high or intermediate switching rates depending on the species' sensitivity to toxins. Importantly, however, the strength of competition in species pairs was a good predictor for how community diversity changed over the switching rate. In sum, predicting the effect of environmental switching on competition and community diversity is difficult, as species' properties matter. This may explain contradicting results of earlier studies on the intermediate disturbance hypothesis.

Objective: Little is known about the demographic and clinical factors associated with SARS-CoV-2 infection in pregnant women in the United States. The objective of this study was to evaluate the factors associated with SARS-CoV-2 infection in women admitted for labor and delivery, in the context of universal screening. Design: Prospective cohort study. Setting: Four Boston-area hospitals. Population: Convenience sample of all women admitted for delivery (n= 1,153). Methods: We reviewed the health records of all women admitted for delivery at the largest health system in Massachusetts between April 19-May 16, 2020. Factors evaluated for potential association with SARS-CoV-2 infection included age, BMI, race, co-morbidities, zip code, infection in a household member, number of children in the household, occupation, and insurance type. Main Outcome Measures: Risk of SARS-CoV-2 infection and associations between SARS-CoV-2 infection and clinical characteristics. Results: A total of 32 patients (2.8%, 95% confidence interval 1.9-3.9) tested positive for SARS-CoV-2 infection on admission for delivery; 24 (75.0%) of the patients who tested positive were asymptomatic. Factors associated with SARS-CoV-2 infection included: younger age, obesity, African-American or Hispanic race/ethnicity, residence in heavily affected communities, household member with known infection, essential worker occupation, and Medicaid insurance. 93.5% of patients testing positive for SARS-CoV-2 had one or more factors associated with disease acquisition. Conclusions: In this large sample of deliveries, SARS-CoV-2 infection was largely concentrated in patients with distinct demographic characteristics. Understanding factors associated with infection may inform public health efforts directed towards at risk populations and serve in counseling pregnant women.

Introduction: The significance of high precordial electrocardiograms in idiopathic ventricular fibrillation (IVF) is unknown. Method: This study included 50 consecutive patients (48 men; age, 42±18 years) who had spontaneous ventricular fibrillation not linked to structural heart disease and received implantable cardiac defibrillator therapy. IVF was diagnosed in 35 patients and Brugada syndrome was diagnosed in other 15 patients. Electrocardiograms in high intercostal space were compared between 35 patients with IVF and 105 age- and sex-matched healthy controls (patient: control ratio, 1:3). Results: The frequency of J point elevation ≥ 0.1mV in the 4th intercostal spaces was similar between patients with IVF (14%) and healthy controls (7%). However, the frequency of J point elevation ≥ 0.1mV in the 3rd intercostal space was higher in patients with IVF (40%) than controls (11%) (P < 0.01). J point elevation was present only in the 3rd intercostal space but not in the 4th intercostal space in 30% of patients with IVF but only in 6% of controls (P < 0.01). During follow up, the recurrence of ventricular fibrillation was higher in patients with IVF who had J point elevation in the 3rd intercostal space (36%) and Brugada syndrome(40%) than those with IVF who did not have J point elevation in the 3rd intercostal space.(11%) (P < 0.05 for both). Conclusion: J point elevation in the 3rd intercostal space was associated with IVF and recurrences of ventricular fibrillation. Electrocardiogram recordings in the high intercostal space may be useful to identify risk of sudden death.

Background: Surgical staging including lymph node dissection (LND) is considered the gold standard method of evaluating LN status and guiding adjuvant therapy in endometrial cancer (EC). The standard surgical treatment of EC includes systematic LND, which is associated with morbidity. Consequently, there is debate weighing the risks and benefits of LND. Objectives: To evaluate the role of LND in all stages of EC. Search Strategy: Systematic search of MEDLINE up to 9th January 2020 including references of relevant studies. Selection Criteria: Published literature in English describing LND in EC. Data Collection and Analysis: 176 articles were screened by title and abstract to select those describing roles of LND in EC. Main Results: We confirmed the diagnostic role of LND and the benefits of risk stratifying early-stage EC patients, despite variations in stratification systems. Low and high-risk groups have well-established guidelines. The role of LND remains controversial in intermediate and high-intermediate risk groups. Sentinel lymph node dissection seems promising to prevent under-/over-treatment. In all risk groups, the prognostic role of LND is well-understood however therapeutic use is debatable. In most stages of advanced EC, LND is beneficial, except for non-bulky nodal disease. Variation exists in what constitutes adequate LN counts, targets and surgical methods. Conclusions: International standardisation of the definition of LND and further adoption of sentinel lymph node algorithms is required. Future research should investigate the need to stratify for bulky and non-bulky nodal disease in advanced EC. New RCTs are needed to guide revaluation of the ESMO-ESGO-ESTRO 2016 guidelines.

Objective To assess background rates of adverse pregnancy outcomes before implementation of a maternal pertussis immunisation programme in the Netherlands, to put into perspective the safety concerns about such outcomes following immunisation. Design Retrospective cross-sectional study. Setting and population Dutch pregnant women and their infants who were registered in the Dutch Perinatal Registry in the 2006-2018 period. Births of ≥500g birth weight and ≥24+0w gestational age were included. Methods Annual numbers of adverse outcomes were used to calculate incidence rates per 10,000. Trends with moving-average-lines over the past 3 years were plotted, with 95% confidence interval. Main Outcome Measures Adverse outcomes at maternal and neonatal level. Results From 2006 through 2018, yearly numbers of pregnancies ranged between 158,868-175,710. Numbers of newborns ranged between 161,307-178,874, of whom 160,838-178,177 were live-born. Most outcomes were stable over time. Between 2006-2011, occurrence of labour induction increased by 68%, and postpartum hemorrhage increased by 25%. Both stabilised from 2011 onwards. Perinatal mortality up to day 7 or 28 postpartum decreased by 38% and 37%, respectively. Occurrence of low Apgar score among preterm infants born before 37+0w gestational age and among term infants increased by 19% and 27%, respectively. Conclusions Our study on background incidences showed notable increases over time in occurrence of labour induction, postpartum hemorrhage and low Apgar score, while showing a considerable decrease in overall perinatal mortality. These findings should be considered when interpreting data on adverse events occurring since Tdap vaccination was implemented.

CASE PRESENTATION: A 70-year-old man with drug refractory symptomatic paroxysmal atrial fibrillation (AF) was referred for pulmonary vein isolation (PVI). After completing anatomical PV encirclement, interrogation of the PVs with a circular mapping catheter (CMC) showed that left superior PV (LSPV) remained electrically connected (entrance block into left inferior PV was confirmed). Body surface ECG and intracardiac electrograms during sinus rhythm [sinus cycle length (CL), 1000 ms] (figure 1-A) and during pacing from distal coronary sinus (CS) at a CL of 600 ms are shown (figure 1-B). When the pacing CL was lengthened to 750 ms, atrial trigeminy appeared with a fixed coupling interval (figure 2). The trigeminy vanished when pacing CL was 700, 800, and 900 ms (data not shown), however, it was reproducibly induced only when pacing CL was 750 ms.What is the mechanism of the atrial trigeminy induced only at the specific pacing CL?COMMENTARIES:During sinus rhythm, the 2 distinct PV potentials (P1 and P2) were recorded on the CMC placed within the LSPV ostium (figure 1-A). The interval between P1 and P2 was 210 ms during sinus. When pacing at the CL of 600 ms from the distal CS, however, the P2 disappeared (figure 1-B). When the pacing CL is increased up to 750 ms, not only the P2 appeared again, but also the P1-P2 interval presented a Wenckebach periodicity increasing slightly from 235 to 245 ms (figure 3-A). Moreover, the third PV potential (P3) appeared every third beat and was conducted to the left atrium (LA), resulting in the atrial trigeminy. The P1-P3 interval was constant (245+135 ms), which led to the fixed coupling interval. The third pacing impulse did not capture the LA which remained refractory (figures 2 and 3-A).Then, what is the mechanism of the double or triple PV responses to a single atrial impulse? The P1 and P3 were recorded on the all bipoles of the CMC but they were different in activation sequence [note the site of earliest PV spike of each PV potential (arrows in figure 3-A)]. Whereas, the P2 was recorded only on limited bipoles of the CMC, suggesting far-field signals from the distal LSPV. These findings indicated that the P3 was an “echo” from the distal LSPV. The reproducible induction of the PV echo by atrial stimulation at the specific pacing CL indirectly suggested reentry as its mechanism.Proposed mechanism of the intra-PV reentry causing the echoes is demonstrated in Figure 3-B. Two PV myocardial sleeves which meet the following criteria are assumed: 1) each of the 2 sleeves remains connected to the left atrium (LA); 2) one of the 2 sleeves has a slower conduction velocity and a slightly longer refractory period than the other (“faster” and “slower” sleeves); and 3) the 2 sleeves are connected at the site distal to the slow conduction zone existing between the proximal and distal PVs. When the pacing CL was 600-700 ms, P2 (represents depolarization of distal PV sleeve) was not produced since the slow conduction zone was refractory (figure 3-B1). When the pacing CL was 750-1000 ms, the P2 was produced via the faster sleeve. P3 was not present since retrograde impulse from the faster sleeve was blocked within the slower sleeve due to refractoriness or collision with impulse via the slower sleeve (figure 3-B2). When the pacing CL was 750 ms, both the P2 and P3 appeared since unidirectional block occurred in the slower sleeve, and the P3 was conducted to the LA (figure 3-B3). Almost no difference in length of refractory period of the two PV sleeves may have resulted in the very narrow echo zone.After the radiofrequency application at the anterior carina of the LSPV, which resulted in entrance block into the LSPV, the PV echo was no longer inducible despite pacing within the PV or provocative isoproterenol and adenosine. The patient is currently asymptomatic 1 year after the procedure, with no evidence of AF recurrence.In the present case, an uncommon cause of atrial trigeminy; atrial impulse-triggered PV echo associated with conduction gaps in PV encircling lesions, has been described. Moreover, the PV echo was induced only at the specific pacing CL. Atrial impulse-triggered PV echo has not been reported at the present moment. Bun and colleagues observed double PV response to a single PV stimulus within the electrically isolated PV1. In our patient, however, PV echo was not inducible after the LSPV was electrically isolated from the LA. Recently we reported sinus impulse-triggered echoes within superior vena cava (SVC) resulting in atrial bigeminy, although response of the SVC to programed atrial stimulation was not evaluated2. In conclusion, the atrial rate-specific repetitive PV response resulting in atrial premature beat is a newly observed phenomenon that may provide insights into the arrhythmogenesis of the incompletely ablated PV muscular sleeves.

Background: Laninamivir octanoate hydrate (laninamivir) is a commonly used drug for influenza virus. This study is part of our long-term, systematic surveillance to monitor its effectiveness. Methods: We investigated the duration of fever and other symptoms after laninamivir inhalation for the outpatients in the Japanese 2017/18 and 2018/19 influenza seasons, then compared the results with those of the previous six seasons. Results: The number of laboratory confirmed patients analyzed was 111 in the 2017/18 season and 84 in 2018/19. The median duration of fever for B was significantly longer than for A in the 2017/18 season (p = 0.0182). In the 2018/19 season, when we could compare only between A subtypes, the median duration of fever was significantly longer for A (H3N2) (p = 0.0290). In contrast, the differences in the median duration of other symptoms were not significant. With the previous six seasons added, we evaluated the data of 1,473 patients over eight sequential influenza seasons. Seasonal differences were observed in the prevailing types/subtypes. The median duration of fever among the types/subtypes was significantly different in some seasons, and it was generally longer for B than for A. The difference in the duration of fever among the eight seasons was all within 24 hrs, and it was statistically significant only for A (H3N2). Conclusions: These results indicate the continuing clinical effectiveness of laninamivir against all types/subtypes of influenza virus, despite its broad use in Japan. Longer duration of fever for B than for A was observed after laninamivir inhalation.

The global threat of COVID-19 is still continued with no commercially available vaccine or drug yet. While the application of convalescent therapy is mostly beneficial, for critically ill patients, the detrimental effect associated with some antibodies is also reported. The immunoglobulin G (IgG) antibody in response to severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) infection is described, albeit the lack of defining whether the difference in subclasses has a beneficial or detrimental role. IgG2 has limited ability to activate innate immune cells and complement-mediated inflammation, which has been described inversely in SARS-COV-2 pathogenesis. The expansion of IgG2 is promoted by interferon γ (IFN-γ), whereas there is a low level of IFN-γ in COVID-19 patients. Therefore, this review describes the importance of targeting IgG2, with IFN-γ in minimizing the SARS-COV-2 associated inflammation, and may provide insight in the design of vaccine to COVID-19.

Cardiopulmonary bypass and extracorporeal membrane oxygenation are commonly used adjuncts to lung transplantation. These techniques are not without associated morbidity and mortality, and the surgeon must be aware of the possibility of aberrant anatomy that could lead to vascular injury during cannulation. In this report, we describe a patient with congenital absence of the inferior vena cava undergoing lung transplantation who required perioperative cardiopulmonary support. A percutaneous dual lumen cannula, Protek Duo, was connected in an Oxy-RVAD configuration to provide right ventricular and oxygenation support both intraoperatively and postoperatively to this patient.

Cardiac injury presents a great challenge to the emergency doctors because these injuries require urgent intervention to prevent death. Sometimes serious cardiac injury may manifest only subtle or occult symptoms or signs. Cardiac foreign bodies induced cardiac penetrating injury infrequently and may lead to unpredictable complications, especially for those with sharp nature. However, we know little about the migrating paths or the foreign bodies location changes of such cases. As there is a rarely reported case of cardiac penetrating injury caused by a self-inflicted needle that migrated from the neck to the heart, we herein present a review of such injury on dynamic monitoring using perioperative echocardiography showed the needle shuttled through the ventricular wall along with increasing pericardial effusion.

Report on the relevance of the stress echocardiography after mild COVID-19 illness; this is significant for targeting specific therapies and addressing progression or regression of abnormalities in the cardiovascular system.

Aim: The current management of advanced gastric or gastro-oesophageal junction adenocarcinoma remains unsatisfactory. We investigated the efficacy and safety of the combination therapy of apatinib and S-1, considering the potential advantage of home-based treatment without hospital admission, in patients with platinum-refractory gastric or gastro-oesophageal junction adenocarcinoma. Methods：Between April 2015 and May 2019, we included 37 patients with advanced gastric or gastro-oesophageal junction adenocarcinoma refractory to first-line platinum-containing therapy, who were treated with apatinib at an initial dose of 500 mg once daily continuously and S-1 at a dose of 40-60 mg twice daily on days 1-14 of a 21-day cycle. The primary endpoints were progression-free survival (PFS) and overall survival (OS). The secondary endpoints were objective response rates, disease control rates, and safety. Results：At the data cutoff, the median PFS and OS were 4.2 months and 8.2 months, respectively. Of 37 eligible patients, 8 (21.6%) patients reached objective responses, 31 (83.8%) patients reached disease control. Grade 3 or 4 adverse events occurred in 8 (21.6%) patients, including hand-foot syndrome, hypertension, and diarrhea, etc. Conclusions: The combination of Apatinib and S-1 showed promising efficacy and manageable toxicity as a home-based, second-line therapy in patients with advanced gastric or gastro-oesophageal junction adenocarcinoma refractory to platinum-containing therapy.

Background The prevalence of allergy to cat is expanding worldwide. Allergen-specific immunotherapy (AIT) has advantages over symptomatic pharmacotherapy and promises long lasting disease control in allergic patients. However, there is still a need to improve cat AIT regarding efficacy, safety and adherence to the treatment. Here we aim to boost immune tolerance to the major cat allergen Fel d 1 by increasing the anti-inflammatory activity of AIT with the established immunomodulatory adjuvant CpG, but at a higher dose than previously used in AIT. Methods Together with CpG, we used endotoxin-free Fel d 1 as therapeutic allergen throughout the study in a BALB/c model of allergy to Fel d 1, thus mimicking the conditions of human AIT trials. Multidimensional immune phenotyping including mass cytometry was applied to analyze AIT-specific immune signatures. Results We show that AIT with high-dose CpG in combination with endotoxin-free Fel d 1 reverts all major hallmarks of allergy. High dimensional CyTOF analysis of the immune cell signatures initiating and sustaining the AIT effect indicates the simultaneous engagement of both, the pDC-Treg and -B cell axis, with the emergence of a systemic GATA3+ FoxP3hi biTreg population. The regulatory immune signature also suggests the involvement of the anti-inflammatory TNF/TNFR2 signaling cascade in NK and B cells at an early stage and in Tregs later during AIT. Conclusion Our results highlight the potential of CpG adjuvant in a novel formulation to be further exploited for inducing allergen-specific tolerance in patients with cat allergy or other allergic diseases in the future.

To the Editor.The beneficial effects of Allergen Specific Immunotherapy (AIT) relies on the induction of allergen-specific Regulatory T-cells (Tregs) (1). Tregs, a subpopulation of CD4+CD25+T-cells expressing the specific transcription factor Foxp3, are not functionally homogeneous and their detection is complex and uncertain due to FoxP3 intracellular localization. Furthermore, FoxP3+ Tregs might become unstable and halt the production of their functional suppressive cytokines in inflammatory conditions (2) (1). In its place, the surface antigen CD127, whose expression inversely correlates with FoxP3, conveniently identifies Tregs as CD4+CD25+CD127negcells (3) (2), so surmounting the problems of FoxP3 stability and intracellular detection. Tregs also constitutively express the inhibitory antigen CD39, enhanced in highly suppressive memory Tregs (4) (3). Furthermore, HLA-DR expression is a monitor of Treg differentiation status and identifies a functionally and greatly suppressive population (1,5) (1,5). Lack of CD45RA characterizes memory T cells enabled to survive for long periods, even in absence of specific antigen, showing increased activity upon re-exposure and able to induce apoptosis in target cells (6) (3). CD4+CD25highCD39+CD127negcells are subtyped as Resting (CD45RA+/HLA-DRneg: rTreg), Activated (CD45RAnegHLA-DRneg: aTreg) and Effector (CD45RAnegHLA-DRlow/high: eTreg) Tregs (6) (6). This latter subtype includes terminally differentiated Tregs, the most highly suppressive (5) (7) (Supplementary Figure 1). They are different from secreting or type III Tregs expressing CD127 that represent a short-lived terminally differentiated population (5,6,8) . In order verify possible correlations between specific subsets of Treg and the effectiveness of AIT, we applied this analytical approach to study Treg profile in adolescents suffering from mite allergic rhinitis, pre and 12 months post Sublingual Immunotherapy (SLIT) with mite monomeric allergoid, an acid-resistant allergen known to elicit early T reg-activation (7,8). The study was approved by the Ethical Committee of University “G. d’Annunzio”, Chieti-Pescara. All patients and parents signed a written informed consent after having been informed about the procedures of the study.Twenty patients diagnosed with mite-allergic persistent rhinitis with or without asthma were enrolled. Allergic rhinitis (AR) was graded according to ARIA guidelines in 1) intermittent mild, 2) intermittent moderate/severe, 3) persistent mild and 4) persistent moderate/severe. At the enrollment, each patient marked in a 100 mm visual analogic scale (VAS) the level of its health status related to allergy with 0 the best status and 100 the worst.All patients were treated by SLIT with mite monomeric allergoid (LAIS - Lofarma, Milan, Italy) at 1000 UA four times/week every other day, for 12-months. No adverse local and systemic reactions were detected. The effectiveness of SLIT was established comparing VAS, ARIA grading and ACT questionnaire performed after 12-months of treatment with their basal values. Two blood samples were drawn pre/post SLIT to be analyzed for Regulatory T-cells. Clinical and demographic details of the studied population, analytical methods, statistical approach and the outline of the study are detailed in the online supplementary material .Rhinitis scores VAS and ARIA significantly decreased after SLIT (Table 1), with the same statistical significance (Wilcoxon z -3.7236; p = 0.0002). Improvement was evidenced also in the subgroup of asthmatic patients (n=7) since ACT scores significantly increased from the baseline value of 18 (16-19) up to 24 (20-25) after 12 months of treatment (the low number of patients does not allow application of efficient statistics).Tregs were analyzed as frequency of total Treg cells and their three subsets, namely Resting (rTregs), Activated (aTregs) and Effector (eTregs), within the parental population of CD4+cells. Total Tregs did not change significantly; rTreg significantly decreased (Wilcoxon z-3.6214, p<0.0003), while, the abundance of aTregs and eTregs significantly incremented (Wilcoxon z-2.9011, p<0.05 and z-3.077, p=0.002, respectively) (Table 1). A significant negative correlation has been observed between the decrease in rTreg and the increase in aTreg (Spearman’s ρ-0.69391, p<0.02) and increase in eTreg cells (Spearman’s ρ-0.56845, p<0.02) (Figure 3 in supplementary material).HLA-DR resulted significantly up-regulated in all Tregs from 4.93±3.1 to 6.92±5.1 MFI (Wilcoxon z-4.2026, p <0.00001). HLA-DR increased on aTregs from 3.4±3.03 to 4.91±3.2 MFI (Wilcoxon z-3.2479, p=0.001) and on eTregs from 1.54±0.66 to 2.0±1.45 MFI (Wilcoxon z-2.9664, p=0.005). CD39 was found differently expressed in the three subsets of Tregs at baseline, with Resting<Activated<Effector. After 12 months of SLIT, CD39 surface expression was found significantly increased in all Tregs from 6.9±4 to 8.02±5 MFI (Wilcoxon z-3.1049, p=0.001) (HLA-DR and CD39 changes are reported in Table 1). We found some interesting correlations between laboratory data and clinical parameters. Changes in eTregs significantly correlated with both ARIA (Spearman’s ρ=0.58728, p=0.013) (Figure 1A) and VAS (Spearman’s ρ=0.49172, p=0.044) (Figure 1B) variations after SLIT. While a significant negative correlation was found between rTregs and clinical parameter changes after treatment (Spearman’s ρ-0.48482, p=0.0491). Changes in HLA-DR expression on all Treg cells significantly correlated with variation in VAS pre-/post-SLIT (Spearman’s ρ=0.54104, p= 0.01376) (Figure 1C). No other correlations were found except for the lowest increase (< 8%) of memory Tregs (CD45RAneg) detected in patients with the lowest levels of mite-specific serum IgE (not shown).To our knowledge this is the first report on successful SLIT being associated with re-patterning of the differentiation status of Tregs, with high rates of the most suppressive Treg subtypes: activated and effector, characterized by higher expression of HLA-DR and CD39 both playing inhibitory function in Tregs. Moreover, effective SLIT seems to be associated with the generation of cells lacking CD45RA that characterizes memory T cells with increased activity upon re-exposure to the antigen. Our results suggest that SLIT also induced empowerment of Treg inhibitory function, likely compensating the under-representation of Tregs observed in allergic patients (9) (9). In AR children, there are evidences that Tregs have defect in suppressing IgE production and that they can be incremented by mite SLIT.Next step of our study will be to evidence if such relationship between effective SLIT and Treg re-patterning is present in the first months of SLIT, with a view to profiling Tregs for the early identification of SLIT responders/non-responders by mean of a straightforward and non-invasive blood test.

Increasing availability of genomic testing poses new challenges to clinicians, particularly where variant interpretation from commercial sources may be equivocal. We report a patient with recurrent rhabdomyosarcoma and subsequent bilateral breast cancer who was found to harbor a previously undescribed germline TP53 sequence alteration annotated by the commercial laboratory as a variant of uncertain significance (VUS). By investigating publically available databases of aggregated normal germline and malignant somatic genomic sequences, we conclude that this missense variant, c.476C>T (p.A159V), is a novel, pathogenic Li-Fraumeni syndrome mutation, and illustrate the utility of these resources in clinical pediatric hematology and oncology practice.

Objective: Sickle cell disease (SCD) is associated with neurocognitive and academic impairment. Routine screening is recommended to evaluate for possible concerns. This paper describes results from a neurocognitive screening battery and evaluates relationships with psychosocial and medical variables. Methods: Participants included 61 patients stratified among three age groups, including ages 6-7, ages 11-12, and ages 15-16. Patients completed a screening assessing cognitive performance, academic functioning, and attention (older subjects completed a task of executive function) and a measure assessing HRQL. Caregivers completed a clinical interview and forms evaluating HRQL, executive functioning, and attention. The impact of relevant medical variables and socio-economic status (SES) was also considered. Results: Between 20% and 33% of participants scored ≤ 1 SD below age-based means on intellectual subtests, and between 31 and 48% scored ≤ 1 SD below grade-based means on academic subtests. Attention concerns were noted in 25% of patients, while 20-31% of parents reported executive function concerns. Neither disease subtype nor hemoglobin were associated with cognitive or academic functioning. There was an association between mean corpuscular volume (MCV) and both cognitive abilities and psychosocial health. Cognitive scores were correlated with SES, suggesting an impact of socioeconomic disparities on performance. Conclusions: Sickle Cell Disease negatively impacts cognitive and academic functioning both directly and indirectly due to pain, missed school, and through socioeconomic and racial disparities. These concerns may increase over time as disease processes and medication compliance often worsen. Longitudinal research is needed to further explore these trends.