Annonaceae contain important commercially grown tropical crops, but development of other promising species is hindered by a lack of genomic resources to build breeding programs. In addition, Annonaceae are part of the Magnoliids, an ancient lineage of angiosperms for which evolutionary relationships with other major clades have remained unclear. To provide resources to both breeders and evolutionary researchers, we report the chromosome-level genome assembly of the soursop (Annona muricata). We assembled the soursop genome using a total of 444.32 Gb of DNA sequences that were generated using PacBio and Illumina short-reads, in combination with 10XGenomics, Bionano data and Hi-C sequencing. 949 scaffolds were assembled to a final size of 656.77Mb, with a scaffold N50 of 3.43 Mb. Repeat sequences accounted for 54.87% of the genome, and 23,375 protein-coding genes with an average of 4.79 exons per gene were annotated using de novo, RNA-seq and homology-based approaches. Reconstruction of the historical population size of A. muricata showed a slow but regular contraction of the population, likely related to Cenozoic climate changes. The soursop is the first genome assembled in Annonaceae, supporting further studies of floral evolution in Magnoliids, and providing an essential resource for delineating relationships of major lineages at the base of the angiosperms. Both genome-assisted improvement and conservation efforts will be strengthened by the availability of the soursop genome. The genome assembly as a community resource will further strengthen the role of Annonaceae as model species for research on the ecology, evolution and domestication potential of tropical species in pomology and agroforestry.

Grazing exclusion (GE) has been applied as a suitable strategy to soil conservation worldwide, mainly in semiarid soils. However, it is unclear how GE management reduces the negative effects of overgrazing on the microbial community. In this study, we assessed the bacterial community in three different soil management belonged to a semiarid region from the Brazilian Caatinga biome, as follows: Native Caatinga (NC), Grazing exclusion (GE), and a highly degraded area by Overgrazing (OG). The bacterial community was assessed through the sequencing of the V4 region of the 16S rRNA gene. We also analyzed soil chemical and physical properties and correlated with bacterial community composition, and α- and β- diversities. Our results demonstrated that GE increases the content of soil C, N, and bacterial diversity. However, the changes in bacterial diversity were significant in a specific site (nº 1), suggesting that GE strategy could be a context-dependent and a complex approach to Caatinga soils. Moreover, overgrazing might restrain the potential of bacterial diversity to sustain ecosystem functions, since non-beneficial elements (e.g., Na+ and Al3+) increased in OG, which presented a negative correlation with the bacterial community. Our study provides novel evidence that high-intensity disturbance by overgrazing could not only reduce soil fertility, but it may also restrain bacterial composition, with implications on environmental functioning. Thus, the Caatinga soil microbiome may be unable to maintain ecosystem services such as plant and animals’ development under overgrazing management.

Objective: To define the prevalence of adverse outcomes according to the gestational age of maternal infection in a large cohort of ZIKV-infected Brazilian women and their infants. Design: Prospective, population-based cohort study. Setting: Ribeirão Preto’s region private and public health facilities. Population: All pregnant women with confirmed ZIKV-infection and their infants. Methods: Prenatal/early neonatal data were obtained for all pairs. A subgroup of infants had cranial ultrasonography, eye fundoscopy, hearing, neurological exam, and Bayley III screening test within 3 months of age. Main Outcome Measures: Prevalence of pregnancy losses, anomalies detected at birth or within 3 months according to the gestational age of infection. Results: 511 women with ZIKV were identified from a total of 1116 women with flavivirus-type symptoms. Pregnancy losses 24/511(4.7%) and/or ZIKV-related anomalies occurred in 43/511(8.4%) mothers. Microcephaly or other CNS malformations were diagnosed in 1/4(25.0%) of the stillbirths and 19/489[3.9%;CI95%:2.5-5.9] of the live-born infants, with 13/513[2.5%;CI95%:1.5-4.3] neonates presenting major signs of CZS. Fetal abnormalities were 14.0(CI95%:7.6-26.0) times more likely with gestational infection <11 weeks. Among 280 asymptomatic evaluated infants, 2/155(1.3%) had eye abnormalities, 1/207(0.5%) CNS imaging significant findings, and 16/199(8%) neurological alert signs. Conclusions: This prospective, population-based study represents the largest Brazilian cohort of ZIKV in pregnancy. Congenital anomalies potentially associated with CZS are less frequent than previously thought. There is a strong relationship between the gestational age of infection (<11 weeks) and worse early infant prognosis. A notable proportion of apparently asymptomatic newborns can present with subclinical findings within 3 months of age. Funding: FAEPA/SES-SP

Dr. PUYA DEHGANI-MOBARAKI (Orcid ID: : 0000-0001-8339-1868)Article type: Letter to the EditorTitle Page

SARS-CoV-2, appeared in winter 2019, in Wuhan State of Hubei Province in China, which has already marched more than 210 countries with 5,418,496 cases and 344,206 fatalities. Through an ongoing unprecedented global public health effort, the pandemic is now slowing down slightly after 6 months of its original occurrence. Until now, the media coverage is incredibly accurate and has been providing worldwide pictures to enrich scientific data. As of May 25, 2019, there are more than 21000 citations related to SARS-CoV-2 in the medical literature according to the WHO on global research on coronavirus disease 2019 (COVID-19). However, among these citations, only 5-10% are related to laboratory experimental data. This review is aimed to analyze the unique laboratory experiment aspects of SARS-CoV-2, to describe the epidemiology, threat to pediatric and women health, mutational intimidation, diagnostics and treatment of the SARS-CoV-2 in regard to future epidemics, and to use the SARS-CoV-2 experience as a model for future pandemics.

Background: Survival following childhood cancer has increased considerably. We examined associations of specific types of cancer therapy with the presence of oral and dental abnormalities among childhood cancer survivors. Procedure: 131 children who were diagnosed with malignancies during childhood were referred to full oro-dental exams. Permanent teeth were examined clinically and radiographically to identify dental caries and anomalies in dental developmental: hypocalcification or hypoplasia, microdontia, root changes and absent tooth bud categorized hypodontia. Results: Dental developmental anomalies were observed in 56 (46%) of 121 children, in 309 teeth (9%). Hypocalcification or hypoplasia of enamel appeared in 21 (17%) patients. The mean decayed, missing and filled teeth (DMFT) score was 6.69 (SD 6.19). Altered root development appeared in 26 patients and hypodontia affected 13 (10%). Dental anomalies were observed in 36 (43%) individuals who received chemotherapy and not radiation, in 20 (52.63%) who received radiotherapy, and in 15 (60%) of those who received head & neck radiotherapy. Young age (under 6 years) was associated with a higher number of malformed teeth among patients who received only chemotherapy. Various chemotherapy agents associated similarly with dental anomalies and also with DMFT. Conclusions: Antineoplastic treatment that combines chemotherapy and radiotherapy appears to increase the risk of developing serious dental anomalies. Radiation to the head and neck area particularly increases the risk of dental developmental anomaly. No specific chemotherapy agent was found to be associated more than the others with dental side effects.

COVID-19 Outbreak: Current scenario and Future prospect in Bangladesh

Background: The addition of baked-milk products to the diet appears to markedly accelerate the development of tolerance to unheated-milk compared to a strict avoidance diet. Objective: The present study aims to investigate the predictors of baked milk tolerance in children with IgE-mediated cow’s milk allergy. Methods: The study included 80 cases who were diagnosed with IgE-mediated cow’s milk allergy upon oral food challenge (OFC) testing in our clinic. Cases who did and did not develop reactions during OFC with baked milk were compared regarding clinical and laboratory parameters. Results: The cases with cow’s milk allergy were 48 male and 32 female and the average age was 7.25 ± 2.45 (3-13) months. We found that 62.5% of cases showed tolerance to baked milk in the OFC test performed with cakes containing 2.6 g milk protein. When the patients who could and could not tolerate baked milk products were compared as for test results, we detected a statistically significant difference intergroup regarding diameter of wheal in skin prick test (SPT) performed with muffin slurry, levels of sIgE for cow’s milk (CM), sheep’s milk (SM), goat’s milk (GM), casein, and the amount of unheated milk consumed until a reaction developed in the OFC test performed with unheated milk (p <0.05). Conclusion: We defined novel decision points based on for CM, SM, GM, casein sIgE levels, wheal diameter in SPT with muffin slurry, and the amount of milk ingested during OFC performed with unheated milk that may be useful in predicting outcomes to baked milk challenges.

BACKGROUND: Severe Covid-19 is associated with a cytokine storm leading to the hyper-expression of cytokines such as IFN-gamma, TNF-alpha, and IL-6, which may be responsible for most severe symptoms and signs of the disease. The immune response of the atopic patient is mostly Th2-oriented, associated with the expression of cytokines such as IL-4, IL-5, and IL-13, and atopic patients express fewer ACE-2 receptors than non-atopic individuals do. We assessed whether atopic status may protect from the most severe consequences of Covid-19. METHODS: Atopic status along with co-factors such as diabetes, hypertension, coronary heart disease, and thrombosis was investigated in severe Covid-19 patients admitted to different Italian hospitals. Patients were classified as having a mild, severe, or very severe disease based on the need of respiratory assistance; severity was plotted against the different co-factors and underwent multivariate analysis. RESULTS: 531 adults aged 25 - 100 years were studied; 57 (11.7%) were atopic. Atopic status showed a significant association with a milder disease irrespective of all other co-factors considered (p <0.001); the protective effect of atopy was detectable throughout all age groups (p< 0.001). CONCLUSIONS: Atopic status appears to protect from the most severe consequences of Covid-19.

As a milestone in soft and hard tissue engineering, a precise control over the micropatterns of scaffolds have lightened new opportunities for the recapitulation of native body organs through 3D bioprinting approaches. Well-printable bioinks are pre-requisites for the bioprinting of tissues/organs where hydrogels play a critical role. Despite the outstanding developments in 3D engineered microstructures, current printer devices, suffer from the risk of exposing loaded living agents to mechanical (nozzle-based) and thermal (nozzle-free) stresses. Thus, tuning the rheological, physical, and mechanical properties of hydrogels are promising solutions to address these issues. The relationship between the mechanical characteristics of hydrogels and their printability is important to control printing quality and fidelity. Recent developments in defining this relationship have highlighted the decisive role of main additive manufacturing strategies. These strategies are applied to enhance the printing quality of scaffolds and determine the nurture of cellular morphology. In this regard, it is beneficial to use external and internal stabilization, photo curable biopolymers, and cooling substrates containing the printed scaffolds. The objective of this study was to review cutting-edge developments in hydrogel-type bioinks and discuss the optimum simulation of the zonal stratification in osteochondral and cartilage units.

Osteopetrosis (OP) is rare metabolic bone disease characterized by impaired osteoclastic bone resorption. It is inherited by autosomal dominant or recessive mode, with variable penetrance, resulting in variable severity. It can present with cytopenia’s, extramedullary hematopoiesis and neurological features like nerve compression. Hematopoietic stem cell transplant (HSCT) is the curative treatment for severe cases (Malignant Infantile Osteopetrosis- MIOT variant) however literature to support the same is very sparse. We report 3 patients with OP, two of which were successfully treated with HSCT using TTF (Thiotepa Treosulfan Fludarabine) conditioning. HSCT is curative in these patients with better outcome when done early.

Background: Socioeconomic and health care coverage disparities are established as poor prognostic markers in adults with sarcoma, but few studies examine these differences among pediatric, adolescent and young adults (AYA). This study examines the association between socioeconomic status (SES), insurance status, and disease presentation among children and AYA patients with sarcoma. Methods: This is a retrospective cohort study of patients aged 0-25 years with bone or soft tissue sarcoma from the National Cancer Database. SES assignments were based on estimated median income and education-level. Patient demographics and clinical factors were compared by SES and insurance status. Multivariate logistic regression models were fitted to determine adjusted odds ratios of SES and insurance status on metastatic disease or tumor size ≥5cm at time of presentation. Results: In a cohort of 9112 patients, 2932 (32.1%) had low, 2084 (22.8%) middle, and 4096 (44.9%) high SES. For insurance status, 5864 (64.3%) had private, 2737 (30.0%) public, and 511 (5.6%) were uninsured. Compared to high SES, patients with low SES were more likely to have metastatic disease (OR=1.16, p=0.03) and tumors ≥5cm (OR=1.29, p<0.01). Compared to private insurance, public and no insurance were associated with metastatic disease (OR=1.35, p<0.01 and OR=1.32, p=0.02) and increased tumors ≥5cm (OR=1.28, p<0.01 and OR=1.67, p<0.01). Conclusions: SES disparities exist among children and AYA patients with sarcoma. Low SES and public or no insurance are associated with advanced disease at presentation. Further studies are needed to identify interventions to improve earlier detection of sarcomas in at-risk children and young adults.

Main text:“Misfortune might be a blessing in disguise.”~ Tao-Te-Ching (Book of the Way) by Lao-Tzu, 350 B.C.ESince its first report in Wuhan, China, in December 2019, the novel pandemic COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2 virus), has rampaged throughout the world. Approximately 80% of the COVID-19 patients manifest with only mild upper respiratory symptoms, 10-15% develop bilateral infiltrated pneumonia, and 5 to 10% of the severe cases progress to develop Acute Respiratory Disease Syndrome (ARDS) and multiple organs failure by the ‘cytokine releasing storm’ (CRS).1 Older age, male gender, chronic cardiovascular diseases and metabolic syndrome, such as obesity, hyperlipidemia, and diabetes are among the risk factors associated with severe COVID-19.2 Asthmatics are known to be more frequently infected and at a greater risk of developing more severe outcomes with respiratory/common cold viral infections, particularly in those with poorly controlled asthma.3Moreover, there is a deficiency and delay of the production of type I and type III interferons in the lung cells of asthmatic patients, potentially more favorable for SARS-CoV2 infection that depends on a hampered innate anti-virus immune response in the respiratory tract.3 However, recent reports have accumulated evidences that the prevalence of allergic diseases and asthma in patients with COVID-19 is lower than expected and underrepresented among other comorbidities and risk factors of the severe form of COVID-19.4-6 Li et al.5 reported that the prevalence of asthma in patients with severe COVID-19 (n= 269, 49.1% of total 548 patients) was 0.9%, markedly lower than that in the adult population of Wuhan. Moreover, none of the children (below 12 years of age) infected with SARS-CoV2 at the Wuhan Children’s Hospital had underlying asthma.6 These findings on the low prevalence of asthma may be confounded by a sampling bias (all hospitalized patients) in the reported cases, underdiagnoses, or lack of recognition of asthma in those with COVID-19. In fact, lack of surveys of the confirmed COVID-19 cases in the general population is a major limiting factor in answering the question whether chronic respiratory diseases, such as asthma, are key risk factors of SARS-CoV2 infection.4However, the interesting question to ask is why asthmatic patients did not have an increased exacerbation of asthma or became more prone to the severe form of COVID-19 after being infected with SARS-CoV2? We, therefore, propose the following plausible mechanisms in asthmatic patients that may have effects in the determination of the susceptibility and severity regarding SARS-CoV2 infection. Firstly, coronavirus recognition and infection is dependent on the cellular receptors, the angiotensin converting enzyme 2 (ACE2) for ducking spike protein of SARS-Cov2, and transmembrane protease serine 2 (TMPRSS2) to cleave the ducked spike protein for virus entry by membrane fusion.7 Lung cells that co-express these two molecules include nasal goblet secretory cells, bronchial transient secretory cells, and alveolar type II pneumocytes.8The gene expression levels of ACE2 and TMPRSS2 are influenced by the genetic variants of the host, microbial infections, and induced by innate immune response, such as the production of interferons and mucins.8 It has been found that SARS-COv2 virus can hijack and enhance this innate anti-virus defense interferon production to induce ACE2, a human interferon stimulated gene (ISG), expression in the other uninfected cells, and promote its potential transmission and spread.8 While in asthma patients, the expression of these two molecules in the respiratory epithelial cells for SARS-CoV2 infection are determined by the age, gender, comorbidity and type 2 allergic inflammation. Jackson et al. found asthma and respiratory allergy are associated with reduced ACE2 expression in airway cells based on their patient cohorts.9 Moreover, ACE2 expression in the lower airway epithelium was lower in the post–allergen challenge samples, and its levels of expression was also significantly inversely associated with type 2 immune inflammation biomarkers. 9 In contrast, in an analysis of the nasal airway epithelial transcriptome in 695 children, Sajuthi et al.10 demonstrated that TMPRSS2 is part of a mucus secretory network, highly upregulated by type 2 allergic inflammation mainly by interleukin-13. Peters et al.11 from the same group, found the gene expression for ACE2 and TMPRSS2 in the cells obtained from induced sputum did not differ between healthy and asthmatics. Instead, a higher expression of ACE2 and TMPRSS2 in males, African Americans, and patients with diabetes mellitus provides rationale for monitoring these asthmatic subgroups for poor COVID19 outcomes.11 Therefore, these reports did not describe convincing information as to whether the asthmatic patients had a lower expression of ACE2 and serine protease TMPRSS2 for SARS-CoV2 based on their allergic status and/or chronic lung inflammation. Particularly, these studies lacked information on the effect of SARS- CoV-2- specific analysis and observations in asthmatic patients to be able to reach a conclusion in the real world.Secondly, viral load and immune response of the host determines the final outcome and/or the severity of ARDS and multiple organ failures in COVID-19 patients. At the initial phase, antivirus innate immune response determine the clearance of virus by the production of Type I/III interferons of infected cells. Lack of or lowered production of IFNα2 and IFNλ, and high viral loads are frequently found in the severe cases that deteriorated into needing ICU care.12 At the second phase of COVID-19 infection, aberrant host immune response by infected macrophages that lead to cytokines releasing storm, and T lymphocytes depletion due to the prolonged viral infection are the two major determining factors for a final clinical outcome.12 For asthmatic patients, the innate immune response to COVID-19 infection may be impaired due to lower levels of IFNγ in their bronchial epithelial cells, but it may also turn into favor for reducing ACE2 expression, which is depended on IFNγ production.8 In addition to IFNs, there are other molecules of innate immunity in the respiratory tract that may also have anti-viral functions, such as mannose binding lectin (MBL), and surfactant protein A (SP-A) and D (SP-D) that are produced by alveolar type 2 cells in the lung, which are also the largely infected by SARS coronavirus. These molecules, MBL and SP-D, found in higher concentrations in the Broncho-alveolar lavage fluids (BALF) of patients with asthma and respiratory allergy and are increased due to chronic inflammation, have been identified to bind spike protein of SARS coronavirus, and inhibit its binding to ACE2 cellular receptor, and thereby able to protect the alveolar macrophages from virus-induced activation.13, 14Recently, it is found that long-term boosting of the innate immune responses, also termed ‘trained immunity’, by prior microbial infection or certain live vaccines, induces heterologous protection against infections, through epigenetic, transcriptional and functional reprogramming of innate immune cells.15 Experimental studies have demonstrated that alveolar or lung macrophages can also undergo long-term reprogramming after infections. For example, gamma herpes virus infection can protect against an allergic response in experimental asthma,16 while adenovirus infection-induced remodeling in alveolar macrophages and subsequently induced more pronounced anti-bacterial immunity.17This trained immunity in the myeloid cells and alveolar macrophages of asthmatics may provide anti-viral immunity in specific organs such as the lungs. Although this hypothesis has not been validated in patients with COVID-19, clinical trials to booster trained innate immunity by BCG vaccination to protect against COVID-19 have been initiated in several countries.18Finally, we highlight that therapeutic medications and biologics used for asthma control may have some beneficial pharmacological effects in COVID-19 infections. From in-vitro models, inhaled corticosteroids alone or in combination with bronchodilators have been shown to suppress coronavirus replication and cytokine production.19 Asthmatic patients using inhaled corticosteroids (ICS) demonstrated lower expression of ACE2 and TMPRSS2 in their bronchial epithelial cells.11 There is a clinical report of the improvement in three COVID-19 patients after using inhaled ciclesonide, although this study did not have proper controls.20 Before the outbreak of COVID-19, clinical observation in children with severe asthma who received anti-IgE monoclonal antibody (omalizumab) have shown decreased duration of human rhinovirus (HRV) infections, viral shedding, and risk of HRV-related illnesses compared with guideline-driven care alone.21In vitro, omalizumab attenuated plasmacytoid dendritic cell (pDC) FcεRIα protein expression while simultaneously augmenting pDC IFN-α responses to HRV and influenza virus.22 Together, these findings provide direct evidence that blocking IgE decreases susceptibility to respiratory viral illnesses through enhanced IFN-α responses in pDCs. Whether this anti-virus effect by anti-IgE treatment also includes infection with coronavirus and SARS-CoV2 is an open question that remains to be verified. More interestingly, azithromycin combined with hydroxychloroquine in an open-label non-randomized clinical trial for COVID-19 patients, has significant decreased the viral load after six days of treatment compared to untreated controls.23Azithromycin has been demonstrated to reduce the frequency of asthma exacerbation and improve the quality of life of asthmatic adults and preschool children with asthma that was not adequately controlled on standard inhaler therapy.24 Although the mechanisms of this anti-inflammatory effect in asthma is still not well defined, some studies presented a reduction of IL-6 levels after azithromycin treatment.25 Moreover, a relevant study from Gielen and co-workers demonstrated that azithromycin augments IFN-β and IFN-λ production and decreasing rhinovirus replication and release from rhinovirus-infected human bronchial epithelial cells in vitro.26 Hence, it is suggested that azithromycin may have protective effects in reducing SARS-CoV-2 invasion by interfering with ligand/CD147 receptor interactions, a novel SARS-CoV2 cellular receptors beside ACE2, and decreasing the expression of some metalloproteinase (downstream to CD147) in primary human bronchial epithelial infected with rhinovirus.27 However, controlled clinical trials using azithromycin to treat patients with COVID-19 (not involving asthmatic subjects) are now registered in several countries with results still pending.In summary, we have seen a new zoonotic coronavirus, SARS-CoV2, infection that has had a devastating effect on the host immunity via the inhibition of interferons leading to aberrant innate immune response, macrophages inflammation in cytokine releasing storm, and exhaustion of the cellular immunity of T lymphocytes.28 In contrast, due to chronic and sustained type 2 immune inflammation in the lungs of asthmatic patients, or fortunately by the medications they use for asthma control, it seems asthma may not be a major confounding disease in COVID-19 infection, and this unexpected phenomenon may throw a new light in finding therapies or preventative strategies for SARS-CoV2 (Figure 1 ). We still need a more comprehensive and in-depth immune analysis of SARS-CoV2 infection in the coming days to explore this hypothesis. However, all standard asthma therapies, whether inhaled steroids, combination of inhaled steroid plus long acting bronchodilator therapies, or monoclonal antibodies like omalizumab and azithromycin, should be continued to be used to optimize asthma control as recommended by all medical societies, for they can not only substantially reduce the risk of asthma exacerbation, but also will reduce risks and severe outcomes of COVID-19.

We present the case of a 38-year-old woman with previous bilateral breast augmentation, who underwent wide local excision for Dermatofibrosarcoma protuberans, and reconstruction of the abdominal wall without shifting the inframammary fold.

Background and Purpose: Esophageal squamous cell carcinoma (ESCC) is the sixth leading cause of cancer-related deaths worldwide and there is no clinically effective targeted therapeutic drugs. OTSSP167, an orally administrated inhibitor targeting maternal embryonic leucine zipper kinase (MELK), is currently in several clinical trials in patients with hematological or solid malignancies. The objective of the study is to determine the antitumor activity of OTSSP167 against ESCC and elucidate its underlying mechanism. Experimental Approach: Effects of OTSSP167 on ESCC cell viability, colony formation, apoptosis, migration, invasion and the related signaling molecules were determined. the anti-neoplastic activity of OTSSP167 against tumor growth and metastasis was evaluated in the ESCC xenograft model and lung metastasis mouse model, respectively. Key Results: OTSSP167 effectively inhibited ESCC cell proliferation and colony formation. In addition, OTSSP167 induced cell apoptosis in a mitochondrial-dependent pathway via downregulation of Survivin. OTSSP167 also exhibited strong synergism with 5-fluorouracil and cisplatin in inducing cell growth inhibition and apoptosis. Furthermore, OTSSP167 remarkably suppressed migration and invasion of ESCC cells with MMP-2 decreased. Importantly, OTSSP167 potently hampered the growth and lung metastasis of ESCC in nude mice. Mechanistically, we demonstrated that MELK/FOXM1 signaling was fundamental for the OTSSP167-mediated tumor growth inhibition as well as metastasis blockage in ESCC. Conclusion and Implications: OTSSP167 exhibits a strong anti-neoplastic activity against ESCC growth and metastasis through targeting MELK/FOXM1 signaling. These data suggests that OTSSP167 is a promising therapeutic agent and warrants clinical trials to further investigate its efficacy in ESCC patients.

Multimodal treatment of children with sacrococcygeal yolk sac tumor: retrospective analysis of clinicopathology characteristics and relapse-free survivalJia Zhu,1∗Huadong Chen,2∗ Tingting Chen,1∗Zijun Zhen,1* Juan Wang,1 Feifei Sun,1 Suying Lu,1 Junting Huang,1 Yizhuo Zhang,1 Xiaofei Sun1△1 Department of Pediatric Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P.R.China2 Department of Pediatric Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Zhongshan Er Lu, Guangzhou, 510080, P.R.China.Running title: Relapse-free survival of sacrococcygeal yolk sac tumor△Corresponding author: Xiaofei Sun MD, Department of Pediatric Oncology, Sun Yat-sen University Cancer Center, 651 Dongfengdong Road, Guangzhou, China, 510060; Tel: +86-20-87342468; Fax: +86-20-87342468; Email:sunxf@sysucc.org.cn∗Jia Zhu, Huadong Chen and Tingting Chen contributed equally to the article.List of Abbreviations

More than 1.2 million people died from chronic kidney damage (CKD) globally, in 2017. Anemia is a common complication of CKD. Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor that stimulates erythropoiesis and regulates iron metabolism. Roxadustat is often used to treat anemia caused by renal diseases. Its adverse effects include high blood pressure, myocardial infarction, heart failure, high potassium, and dizziness; however, there are no reports about rhabdomyolysis associated with roxadustat. One of our patients developed rhabdomyolysis after he was administered roxadustat to treat anemia caused by chronic renal failure. Physicians should be alert about the occurrence of rhabdomyolysis when roxadustat is used.

Hydrogen sulfide (H2S) together with polysulfides (H2Sn, n>2) are signaling molecules like nitric oxide (NO) with various physiological roles including regulation of neuronal transmission, vascular tone, inflammation, oxygen sensing etc. H2S and H2Sn diffuse to the target proteins to S-sulfurate their cysteine residues to induce the conformational changes to alter the activity. On the other hand, 3-mercaptopyruvate sulfurtransferase transfers sulfur from a substrate 3-mercaptopyruvate to the cysteine residues of acceptor proteins. A similar mechanism has also been identified in S-nitrosylation. S-sulfuration and S-nitrosylation by enzymes proceed only inside the cell, while reactions induced by H2S, H2Sn and NO even extend to the surrounding cells. Disturbance of signaling by these molecules as well as S-sulfuration and S-nitrosylation causes many neuronal diseases. This review focuses on the signaling by H2S and H2Sn with S-sulfuration compared with those of NO and S-nitrosynation, and discuss on their roles in physiology and pathophysiology.

Background: Hepatoblastoma (HB) is a rare embryonal liver tumor occurring in the pediatric population, and although intrinsic biological differences between tumors can impact HBs prognosis, few groups have studied this aspect. Given the crescent relevance of epigenetic mechanisms in the genesis and progression of these tumors, we aim to classify HB samples according to the different stages of liver development as well as DNA methylation machinery. Procedures: Using bioinformatics tools, we evaluate the expression of 24 genes associated with epigenetics and stages of hepatocyte differentiation as well as global DNA methylation to propose a stratification model for HB. Results: Based on the gene expression profiles of DNA methylation machinery and hepatocyte differentiation markers, HBs were clustered into three groups. Besides reinforcing the molecular heterogeneity of these embryonal tumors, our data propose that a panel of 13 genes can be used for HB stratification (TET1, TET2, TET3, DNMT1, DNMT3A, UHRF1, ALB, CYP3A4, TDO2, UGT1A1, AFP, HNF4A, and FOXA2). DNA methylation machinery exerts a key role in the characterization of HBs, directly reflected in diverse DNA methylation content. Moreover, we suggest that the group of HBs presenting similarity with differentiated livers, such as upregulation of mature hepatocyte markers, decreased expression of DNA methylation enzymes and higher global methylation levels are associated with a worse prognosis. Conclusions: HBs are heterogeneous tumors and our findings point out the role of the epigenetic machinery in the samples characterization, suggesting the need of new stratification system for patients with HBs.

Expanding Clinical Spectrum of Female X-linked Lymphoproliferative Syndrome 2Shruthi Suryaprakash, MD1, Mohammad El-Baba2, MD, Kelly J. Walkovich, MD3, Süreyya Savaşan, MD41Children’s Hospital of Michigan2Division of Gastroenterology, Children’s Hospital of Michigan3Division of Hematology/Oncology, Immuno-Hematology Comprehensive Program, C.S. Mott Children’s Hospital, University of Michigan4Division of Hematology/Oncology and Blood and Marrow Transplant Program, Children’s Hospital of Michigan, Carman and Ann Adams Department of Pediatrics, Barbara Ann Karmanos Cancer Center, Central Michigan University College of MedicineCorrespondence: Süreyya Savaşan, MD3901 Beaubien Blvd.Division of Hematology/OncologyBlood and Marrow Transplant ProgramChildren’s Hospital of MichiganDetroit, Michigan 48201E-mail: savas1s@cmich.eduPhone: 313-745-5516 Fax: 313-745-5237Text word count: 495Reference count: 4Tables and figures: 1Short running title: Spectrum of Symptomatic Female XLP2Key words: Female XLP2, EBV reactivation, Vitamin B12 deficiency, B-cell lymphopenia, clonal T-LGL proliferationDear Editor:X-linked lymphoproliferative syndrome type 2 (XLP2) due to pathogenic variants in the X-linked inhibitor of apoptosis (XIAP) gene is a rare cause of primary immunodeficiency. Symptomatic patients, primarily males, present with hemophagocytic lymphohistiocytosis (HLH), inflammatory bowel disease (IBD) and/or transient hypogammaglobinaemia.1 However, XLP2 in female patients is complicated with the rarity of symptomatic cases and clinical heterogeneity.2 We report a female affected by XLP2 with previously unreported findings.A currently 18-year-old female presented with fever, abdominal pain, diffuse lymphadenopathy, splenomegaly, and pancytopenia three years ago. She was diagnosed with HLH, treated with steroids and found to have low B-cells and borderline hypogammaglobinemia. Additionally, a single pathogenic variant in XIAP (c.389_392delACAG [p.Asp130Glyfs*11]) was identified. Further workup showed presence of EBV IgG, and normal expression of XIAP protein in only 8-19% of various white blood cell types by flow cytometry indicating skewed X chromosome inactivation. She had intermittent infections, one resulting in an additional HLH flare with elevated IL-18 and CXCL9 levels that was treated with steroids and intravenous immunoglobulin (IVIG). Repeated EBV PCR testing had been negative.However, she was found to have EBV reactivation with positive EBV VCA-IgM, high titer VCA-IgG and EA-IgG levels while EBV-PCR was negative when she presented to our clinic with diarrhea. There was ongoing history of headaches, abdominal pain, joint pain, and ADHD at that time. Later, she underwent work up for recurrent abdominal pain, diarrhea, urgency and elevated fecal calprotectin. MRI-enterography and capsule endoscopy were negative. Endoscopy was remarkable for chronic active proctitis. She was prescribed mesalamine with significant improvement in abdominal pain and resolution of mucuosy stools.Due to persistent knee/ankle pain, she was investigated for peripheral neuropathy and was found to have low vitamin B12 levels (112-145pg/mL; N:180-914) without dietary restrictions, absent anti-intrinsic factor antibodies and negative family history. Her pain improved significantly on vitamin B12 injections and gabapentin with normalization of vitamin B12 levels.She continued to have fluctuating and borderline low levels of serum immunoglobulins with persistently low B-cells. She was given IVIG supplementation when serum IgG levels were low. No additional HLH flares have occurred. Mild increase in CD5-dim T-cells (9%) representing T-large granular lymphocytes (T-LGL) and clonal T-cell receptor (TCR) rearrangement pattern were identified in peripheral blood. She continues to have migraine episodes and very high EA-IgG at >150U/mL (N <9).Female carriers are at risk for extra hematopoietic manifestations, if they have an extremely skewed X chromosome inactivation.3 She was EBV-PCR negative, but EBV VCA-IgM positive repeatedly suggesting a recent reactivation at presentation to our institution. Persistent high EBV EA-IgG titers is suggestive of ongoing EBV challenge due to immune deficiency and emphasizes the significance of EBV serology testing. Clonal T-LGL expansion may be related to EBV and/or immune deficiency.4 Low vitamin B12 raises the possibility of impairment in absorption; the presence of proctitis raises possible subclinical inflammation in the distal ileum. Observed conditions in this case add to the spectrum of this rare entity (Table1).

Aim: To describe the pattern of paediatric soft tissue sarcomas with emphasis on the grade and stage at the first surgical or medical oncologic intervention. Methods: We retrospectively reviewed all cases of histologically confirmed paediatric Soft Tissue Sarcomas in the Department of Pathology, University College Hospital (UCH), Ibadan, Nigeria in children age 0-14 years. The study period was January 1991 to December 2016. Information obtained included age, gender, morphology and site of the tumours. The tumour grade and pathologic/clinical staging of all cases that had surgical biopsy or surgical resection were also obtained and verified from the clinical records. Tumour grading was carried out using the Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) Sarcoma group grading system and staging was done using TNM. Results: One hundred and twelve cases were seen with an almost equal male-to-female ratio and age range from 5 months to 14 years (median 8.5 years). The peak age group was 5-9 years. Rhabdomyosarcoma was by far the most common histological type (73.2%). Other types were undifferentiated sarcomas (6.3%), fibrosarcoma (5.4%), Kaposi sarcoma (4.5%), and 2.7% each for synovial sarcoma, dermatofibrosarcoma protuberans. The common primary sites were the head and neck (including the orbit) 51(45.5%), and the abdominopelvic 27(24.1%) regions. Other sites included the lower limb 13(11.6%), trunk 12(10.7%), upper limb 6(5.4%). Majority (67.9%) had histologic grade 3 at presentation based on the FNCLCC grading system. About 48.2% had Stage T2b while 9.8% were stage T2a based on American Joint Committee on Cancer Staging (AJCC) system. Conclusion: Rhabdomyosarcoma, undifferentiated sarcomas and Kaposi sarcoma are the commonest paediatric malignant soft tissue tumours in our practice. Majority of our patients present with late stage tumour and with high histologic grade thereby conferring poor prognosis at presentation/first surgical or medical oncologic intervention.

BACKGROUND AND PURPOSE: Immune response hyperactivation is critical in the progression of coronavirus disease (COVID-19). We studied the effect of the pre-exposure to disease-modifying antirheumatic drugs (DMARDs) that decrease immunological responses on the incidence of COVID-19 symptoms to explore therapeutic approaches in its early stages. EXPERIMENTAL APPROACH: Multicentre retrospective cohort study including 2,494 patients with inflammatory diseases recruited from 14 primary care centres in Barcelona (Spain). The primary outcome was the presence of confirmed or highly suspected COVID-19 (hsCOVID-19) symptoms reported during March 2020 at primary care or hospital emergency department. Multivariable Poisson regression models were fitted to estimate hsCOVID-19 symptoms relative risk (RR) adjusted by comorbidities. KEY RESULTS: Biological (RR=0.46, CI95%=0.31-0.67) and synthetic (RR=0.62, CI95%=0.43-0.91) DMARDs used in immunomediated inflammatory diseases diminished the incidence of symptomatic cases of hsCOVID-19. Striking sex differences were revealed. Protective effects of anti-TNFα pre-exposure (RR=0.50, CI95%=0.33-0.75) were higher in women (RR=0.33, CI95%=0.17-0.647), whereas anti-IL6/12/17/23 compounds pre-exposure (RR=0.47, CI95%=0.24-0.92) produced slightly higher protective effects in men (RR=0.44, CI95%=0.15-1.68). Pre-exposure to low glucocorticoid doses also revealed sex differences decreasing the incidence of hsCOVID-19 symptoms predominantly in women (RR=0.72, CI95%=0.42-1.22). A merely protective effect of pre-exposure to chloroquine/hydroxychloroquine (RR 0.76, CI95%=0.36-1.62) was observed. CONCLUSIONS AND IMPLICATIONS: We identified specific DMARDs with different immune-depressor mechanisms that decrease hsCOVID-19 symptoms with striking sex differences. These results underline the potential interest of starting clinical trials with anti-TNFα compounds in women to evaluate their efficacy in minimizing disease progression in the early stages of COVID-19.

Thoracic outlet syndrome (TOS) is caused by neurovascular bundle compression in the thoracic outlet space. Three pertinent structures may be compressed: brachial plexus, subclavian artery, and subclavian vein. Clinical presentation may be variable depending on the anatomical structure involved. We report a 36-year-old man with chronic recurrent pressure-quality left chest discomfort. Comprehensive cardiac investigations were nonrevealing. A venous and arterial duplex ultimately revealed dynamic venous and arterial compression. Our paper is to illustrate the sonographic approach to evaluate vascular compression in the thoracic outlet. We review the mechanisms of compression, and examination maneuvers to facilitate a Doppler-based diagnosis.

Aim Doppler echocardiography has become the standard imaging modality for diastolic function and provide pathophysiological insight into systolic and diastolic heart failure. In this study we aimed to obtain normal echocardiographic Doppler parameters of healthy Turkish population. Methods Among 31 collaborating institutions from all regions of Turkey, 1154 healthy volunteers were enrolled in this study. Predefined protocols were used for all participants during echocardiographic examination and The American Society of Echocardiography and European Association of Cardiovascular Imaging recommendations were used for echocardiographic Doppler measurements. Results A total of 967 healthy participants were enrolled in this study after applying exclusion criteria. Echocardiographic examination was obtained from all subjects following predefined protocols. Mitral E wave velocity and E/A ratio were higher in females and decreased progressively in advancing ages. E wave deceleration time and A wave velocity were increased with aging. Assessment of tissue Doppler velocities showed that left ventricular lateral e’, septal e’ and septal s’ were higher in younger subjects and in females. E/e’ ratio was increased progressively with advancing decades. Right ventricular e’and s’ were decreased but a’ was increased with increasing age. Septal e’ lower than 8 cm/s was 1.9% in the fifth decade and 13.7% in ages older than 50-years. The E/e’ ratio greater than 15 (and also 13) was not found. Conclusion This study, for the first time, provides echocardiographic reference ranges for normal cardiac Doppler data in healthy Turkish population which will be useful in routine clinical practice as well as in future clinical trials.