Circulatory shock is defined syndromically as hypotension associated with tissue hypoperfusion and often subcategorized according to hemodynamic profile  and etiology . These shock subgroups are generally considered homogeneous entities in research and clinical practice. This current definition fails to consider the complex pathophysiology of shock and the influence of patient heterogeneity. Recent translational evidence highlights previously under-appreciated heterogeneity regarding the underlying pathways with distinct host-response patterns in circulatory shock syndromes. This heterogeneity may confound the interpretation of trial results as a given treatment may preferentially impact distinct subgroups. Re-analyzing results of major ‘neutral’ treatment trials from the perspective of biological mechanisms  may reveal treatment effects in subgroups of patients that share treatable traits . In this review, we discuss the emerging literature suggesting the existence of distinct biomarker-based host-response patterns of circulatory shock syndrome independent of etiology or hemodynamic profile. We further review responses to newly prescribed treatments in the intensive care unit designed to personalize treatments . Circulatory shock incurs a high mortality, with minimal incremental improvements in survival demonstrated by clinical trials in the last two decades –4. For tThe initial step in the management of circulatory shock is generally to control the cause of shock . Medical therapy is provided in the form of volume replacement, transfusions, and vasopressors/inotropes to correct hypovolemia, anemia, hypotension and low cardiac output. In the case of severe organ dysfunction, patients receive supportive therapies, including renal replacement therapy, mechanical ventilation, and/or mechanical circulatory support  . The ‘miEmerging translational evidence demonstrates the existence of variability in the host response to circulatory shock syndromes and the existence of potential common ‘treatable traits’  within subgroups of patients across different forms of shock. Conserved biological signatures occurring across diverse shock subtypes include combinations of endothelial dysfunction, inflammatory cell activation, reactive oxygen species formation, immune dysregulation, neurohormonal dysregulation, activation of coagulation, and fibrinolysis –11.It has been hypothesized that heterogeneity in a given etiology or hemodynamic profile of circulatory shock may dilute a demonstrable benefit of specific interventions when applied broadly in clinical trials due to diverse individual treatment response profiles , 12. It (i) distinct and common biological patterns of host response in circulatory shock syndromes and (ii) their response to different established  or novel interventions . This paper is a narrative review from the 2022 Critical Care Clinical Trialists (3CT) Workshop expert panel for circulatory shock endotyping (https://www.3ctmeeting.com/). Our aim is to highlight the main studies in the field and not to provide an exhaustive review of the literature.In this narrative review, we overview the current literature related to Biomolecular heterogeneity is not reflected by non-specific clinical syndromic criteria for patients with critical illness, specifically those with shock. Even if standardized diagnostic criteria for sepsis/septic shock, cardiogenic shock and hemorrhagic shock have evolved over the years, yet substantial underlying heterogeneity exists within populations of patients meeting these definitions.Here, we summarize the main studies using readily available clinical and biological data and/or omics-based biomarkers  to unravel host response heterogeneity within distinct circulatory shock syndromes.. identified four distinct clinical phenotypes of sepsis using readily available clinical and biological data at hospital admission [In a retrospective analysis of sepsis/septic shock cohorts and clinical trials, Seymour et aldmission . The pheIn a prospective observational cohort of 288 sepsis/septic shock adult patients in Uganda, Cummings et al. used unsupervised clustering of 14 soluble host immune mediators, reflective of key domains of sepsis immunopathology , and to whole-blood RNA-sequencing data to identify immune and transcriptional subtypes . The autIn the study of Davenport et al. only ~ 60% of patients with pneumosepsis had “classic” immune activation (as many as 40% manifested an immunosuppressed response). In this study, the authors assayed peripheral blood leukocyte gene expression in septic shock patients. The authors used a clustering approach to identify two sepsis response signatures (SRS). SRS-1 had an immunosuppressed phenotype and worse outcome .k-means clustering (a non-model-based clustering technique) to identify three subclasses/phenotypes in a multicenter cardiogenic shock cohort [Zweck et al. recently used k cohort . The thrThese three clusters were replicated by Jentzer et al. with the same six admission laboratory variables in 1498 cardiogenic shock patients, finding differences in echocardiographic markers of cardiac function and long-term survival between groups .In an exploratory study of 107 patients with ST-segment-elevation myocardial infarction and acute heart failure , peripheral leukocyte gene expression patterns (mRNA expression data) were used to identify host-response endotypes. Hierarchical clustering grouped patients in two endotypes based on pathway variability in mediators of inflammation, immune function. Demographic and clinical characteristics did not significantly different across host-response endotypes, suggesting that molecular profiling might be incremental to clinical classifiers alone .Last and not least, Scolari et al. reported that cardiogenic shock patients have a higher frequency of clonal haematopoiesis  than in patients with ambulatory heart failure matched for age, sex, ejection fraction, and heart failure etiology . This co. used a clustering approach to identify distinct immunologic endotypes [In an analysis of a prospective cohort study including 102 severe trauma patients with hemorrhagic shock, Brakenridge et alndotypes . Multipl. used untargeted metabolomics and plasma immune circulating markers in 86 severely ill trauma patients to identify distinct host-response subclasses [Cyr et albclasses . Three hMore and more evidence suggests that the host response to many forms of injury is shared across distinct circulatory shock syndromes. The same biological signatures  were highlighted in circulatory shock with different etiologies using a single-biomarker or a multiple-biomarkers approach.It has been reported in both sepsis/septic shock and cardiogenic shock that levels and rapid changes in circulating bio-adrenomedullin  on admission are associated with worse hemodynamics and organ dysfunction independently from severity of chronic and acute illness and initial lactate level , 25.Similarly, high circulating levels of angiopoietin-2  were reported as associated with organ dysfunction and mortality in distinct populations with cardiogenic shock, septic shock, and traumatic hemorrhagic shock independently from age, comorbidities, and severity scores on admission –28.These results support the suggestion of Johansson et al. of a mechanistic link between sympatho-adrenal hyperactivation in circulatory shock independently from the insult and the endothelial phenotype. They defined a potential unifying pathophysiologic mechanism linked to poor outcome as shock-induced endotheliopathy .n = 167) with matched  healthy subjects and with 133 severely burned patients or 4 healthy adult subjects administered low-dose bacterial endotoxin. Despite different insults, the early genomic changes were highly comparable (> 80% of the cellular functions and pathways) between blunt trauma patients, burns, or stressors. These findings demonstrate a common host-response pattern reflective of the large overlap in upstream receptors and signaling intermediates activated by each condition , Toll-like receptor 4 (TLR4), alarmins).In the Inflammation and the Host Response to Injury large-scale collaborative research program (Glue Grant), the investigators described the circulating leukocyte transcriptome in critically injured patients with circulatory shock . They co. recently described common injury-induced immune profiles in a large cohort of critically ill patients with different etiologies  [Venet et alsurgery) . The aut. reported in the ShockOmics cohort (n = 37) a similar pattern of differential expression of genes coding for inflammatory and immunoglobulin proteins among patients with sepsis and cardiogenic shock. The overlap in biological patterns suggests shared mechanistic signatures between the two critical illness syndromes [Braga et alyndromes .. used an unsupervised clustering approach across three etiologies of critically ill patients  to identify distinct molecular subclasses based on single cell transcriptomic patterns in circulating leukocytes. The authors identified three clusters reflecting dysregulation in genes involved in DNA repair and RNA processing between the etiologies  with different associated clinical outcomes [Chen et aloutcomes .The U.S. Food and drug administration (FDA) defines predictive enrichment in clinical research as the prospective selection of a study population in which detection of a treatment effect (if one is in fact present) is more likely than it would be in an unselected population . The aimThe selection of patients could be based on a known pathway biomarker or be unsupervised  in case of unknown mechanisms  . This apHowever, as demonstrated in the IMPRESS trial of AMICS that specifically enrolled high-risk cardiogenic shock individuals (> 90% of whom were comatose after cardiac arrest), high-risk individuals may not be more likely to respond to a tested intervention if they have competing mortality risks that are not modified by the intervention .Re-analyzing results of major ‘neutral’ treatment trials in circulatory shock from the perspective of biological mechanisms may allow identification of salutary effects of treatments in subclasses of patients  –38. It s. assessed the use of high-affinity polymyxin B hemoperfusion in patients with septic shock to remove bacterial endotoxin from the circulation through selective adsorption [Predictive enrichment can be achieved by classifying patients using a biomarker linked to the tested intervention. In the EUPHRATES trial, Dellinger et alsorption .The authors randomized only patients with an endotoxin activity assay level of 0.60 or higher. Polymyxin B hemoperfusion compared with sham hemoperfusion did not significantly decrease 28-day mortality among the randomized patients. In a post hoc analysis of the EUPHRATES trial including high severity of illness (Multiple Organ Dysfunction Score (MODS) > 9) and an endotoxin activity level between 0.6 and 0.89, Polymyxin B hemoperfusion use was associated with an absolute mortality reduction compared to sham patients of 10.7% at 28 days . These rIn a post hoc analysis of the ‘neutral’ Sepsis Coagulopathy Asahi Recombinant LE Thrombomodulin trial (SCARLET), the authors reported lower mortality in patients with septic shock associated coagulopathy and elevated coagulation markers  treated with thrombomodulin, suggesting this coagulation pattern could be used to select patients most likely to respond .In another retrospective analysis of the phase III randomized interleukin-1 receptor antagonist trial in Sepsis patients with multiorgan dysfunction syndrome and/or shock, the authors reported in the subclass of patients with macrophage activation syndrome  an association of IL-1 receptor blockade with significant improvement in survival at 28 days . This siA post hoc analysis of patients enrolled in the ATHOS-3 trial (Angiotensin (AT) II for the Treatment of High-Output Shock) , tested The authors reported that in vasodilatory shock patients with renin concentrations higher than the study population median, angiotensin II infusion significantly reduced 28-day mortality when compared with placebo  which waThe authors hypothesized that the inflammatory host response in circulatory shock may reduce angiotensin-converting enzyme activity, which may lead to decreased conversion of AT-I to AT-II and conversion of AT-I to vasodilatory AT degradation peptides causing persistent hypotension and high renin-levels . They copost hoc enrichment strategy based on circulating dipeptidyl peptidase 3 (cDPP3)  may indicate that therapeutic efficacy is most important  in patients with lower cDPP3 levels [.In the AdrenOSS-2 phase 2a biomarker-guided trial, Laterre et al. investigated a non-neutralizing adrenomedullin antibody (adrecizumab) in septic shock patients with high adrenomedullin . The pri3 levels . The sam3 levels .The pathways underlying different circulatory shock syndromes are complex and treatment responses are multifactorial, necessitating multiple biomarkers to identify a significant amount of the variability in response . Limiting ourselves to known biomarkers may not advance much-needed discovery which can instead be promoted using unsupervised clustering approaches .k-means clustering, latent class analysis) may allow the identification of distinct mechanistic signatures underlying the heterogeneous circulatory shock syndromes and the discovery of candidate biotargets  [Patients can be classified using multiple readily available clinical and biological data or more sophisticated high-dimensional biomarkers . The identification of subclasses/subphenotypes using clustering and unsupervised machine learning algorithms  –52.In Seymour et al. study, simulation models suggested that the four phenotypes  identified using unsupervised clustering demonstrated proof-of-concept in support for molecular endotypes underscoring treatment effects in septic shock patients . The estIn a post hoc analysis of the VANISH trial including patients with septic shock , genome-In a retrospective analysis of the PROPPR randomized trial including severe trauma patients with hemorrhagic shock which compared transfusion of plasma, platelets, and red blood cells in a 1:1:1 ratio to a 1:1:2 ratio regarding mortality, the investigators applied latent class analysis to identify two trauma subphenotypes (TS-1 and TS-2). They used 36 circulating markers of inflammation, endothelial dysfunction, and coagulation measured prior to patients’ randomization. In patients assigned to TS-2 (lower plasma concentrations of IL-8 and TNF-α), a 1:1:1 transfusion ratio was associated with significantly reduced risk for 30-day mortality compared to a 1:1:2 approach when adjusted for age, sex, injury severity, and injury mechanism. There was no difference in mortality by treatment assignment when the patients were stratified by severity of illness severity or injury mechanism .A summary of the aforesaid circulatory shock studies with predictive enrichment is represented in Table The identification of distinct host-response subclasses/subphenotypes may further inform mechanisms of persistent organ dysfunction and enable prognostic and predictive enrichment in circulatory shock regardless of the etiology or clinical classification. Secondary analyses of major critical care clinical trials and measurement of biomarkers in longitudinal biobanked samples to identify signals for benefit in a biologically defined subclass could evaluate whether the biological profiles are just capturing different points along patients’ trajectory towards a final common pathway, whether the biological signature is the same for all interventions studied or specific to a targeted intervention and whether the same heterogeneity of treatment effect is seen in other etiologies of circulatory shock.These analyses may support future randomized controlled trials of personalized therapies in circulatory shock patients in which patients are prospectively enrolled based on a biological signature rather than on a non-specific clinical syndrome, such as sepsis, cardiogenic shock, or major trauma that invites empiric therapy. This approach  may be a key step to improve translation of research findings to the bedside for a more personalized critical care medicine. As a result, for example, we could be talking about “renin and/or bio-adrenomedullin-driven shock”, etc., rather than clinically defined “syndrome/etiology” models. We believe that regardless of the triggering etiology, the development of refractory shock and organ failure likely occurs via multiple overlapping conserved pathophysiological mechanisms, and their persistence over time which might be targets for therapy.Identifying distinct biological patterns is promising, but it does not guarantee the distinction of specific pathophysiological processes with causal links to intervention effects that might ultimately allow a personalization of treatment in circulatory shock patients. Diverse influences on these biomarkers are present, and it is unproven how well these candidate markers integrate diverse clinical, genetic, pathophysiologic, and treatment influences. Nevertheless, there is a theoretical advantage that they may summarize these diverse, ‘upstream’ influences on some extent and represent biologic indicators closer to the patient phenotype.To minimize the risk of categorizing the studied population differently  without capturing the complexity of underlying biological mechanisms, we think it is important to consider the following points. The use of a multi-biomarker approach reflecting diverse pathways involved in circulatory shock in humans  may support comprehensive profiling. Ideally, this approach can be coupled with modeling the dynamic interplay between different actionable biomarkers using unsupervised machine learning  instead of a single-biomarker approach with a single cutoff.Without considering personalized host responses, dozens of promising targeted molecular therapies and efforts to individualize risk prediction have failed to reduce mortality. This parallels oncology clinical research with a high response rate of successful targeted therapies in biomarker-driven patient selection evaluated in early clinical trials –57.We suggest the following roadmap as a strategy to advance research in circulatory shock Fig. :Fig. 1A First to set up a collaborative, multicenter and interdisciplinary deep subphenotyping platform centered on the biological/molecular drivers of circulatory shock to identify and largely validate distinct mechanistic signatures in circulatory shock . The French and European Outcome Registry in Intensive Care Units (FROG-ICU) is an example of a cohort with a biobank and molecular trait mapping of circulatory shock patients with different etiologies, under one “roof” supporting feasibility  , 59.Second, coupling discovery research with clinical trials and develop an integrative subphenotyping approach using unsupervised machine learning and biomarker data to inform effective new therapies in future clinical trials. This may allow signal enrichment and noise reduction and help decrease neutral circulatory shock clinical trials. Developing a harmonized strategy is fundamental with minimal criteria of groups of candidate biomarkers such as inflammatory, immune dysfunction, endothelial injury, organ dysfunction , abnormal coagulation, cell damage and oxidative stress for circulatory shock endotyping. A suggestion of a panel of groups of biomarkers for circulatory shock endotyping is represented in Fig. Implementation of biomarker-stratified adaptive clinical trial designs is likely to be an important mechanism to facilitate this approach. Adaptive clinical trials may offer opportunities to better accommodate the possibility of heterogeneous treatment effects into the trial design prospectively—a tool which may better support individualization of clinical care based on host-response profile , 61. ThiMany obstacles need to be overcome to implement biological subclasses/subphenotypes into clinical trials design and daily practice at the bedside. First the important heterogeneity of studies using different clustering approaches and biomarkers. Second, the stability/evolution and overlap of the identified subphenotypes and the interaction between comorbid illnesses and acute subphenotypes which makes it difficult to understand the overlap between subclasses with a poor replicability. Third, the timely serial assignment of subphenotype at the bedside using a simplified clustering/classification algorithm and rapid real-time assays in the ICU . Last anEmerging translational evidence highlights existing heterogeneity regarding the underlying host response between and within circulatory shock syndromes on one hand and demonstrates the existence of potential common ‘treatable traits’ within subgroups of patients across different forms of shock on the other hand. Further research should focus on these host-response pathways to shift from a cause–consequence model towards a host-response subphenotype model. This could pave the way towards personalized critical care medicine.Traditional shock subgroups defined clinically on basis of etiology and hemodynamic features are incorrectly considered homogeneous entities. Emerging translational evidence highlights the existing heterogeneity regarding the underlying host response between and within circulatory shock syndromes.Accepting the results of neutral clinical trials without taking into consideration the heterogeneity of underlying biological mechanisms and the existence of distinct host-response patterns is a missed opportunity to discover subclasses of patients that may benefit from targeted treatments.Identifying host-response patterns may provide new insights regarding the pathophysiology of circulatory shock and pave the way towards the development of innovative biomarkers and targets of pharmacological therapies. This may allow predictive enrichment to define personalized treatments  and ultimately transform current research and care.


Xenopus tropicalis as a model organism, the approach should be applicable to genotyping of any organisms.Targeted genome editing is a powerful tool for studying gene function in almost every aspect of biological and pathological processes. The most widely used genome editing approach is to introduce engineered endonucleases or CRISPR/Cas system into cells or fertilized eggs to generate double-strand DNA breaks within the targeted region, leading to DNA repair through homologous recombination or non-homologous end joining (NHEJ). DNA repair through NHEJ mechanism is an error-prone process that often results in point mutations or stretches of indels (insertions and deletions) within the targeted region. Such mutations in embryos are germline transmissible, thus providing an easy means to generate organisms with gene mutations. However, point mutations and short indels present difficulty for genotyping, often requiring labor intensive sequencing to obtain reliable results. Here, we developed a single-tube competitive PCR assay with dual fluorescent primers that allowed simple and reliable genotyping. While we used The online version contains supplementary material available at 10.1186/s13578-023-01042-2. Dear Editor,Xenopus tropicalis as an example.We would like to report a simple and faithful dual color assay for genotyping organisms generated from genome editing. Targeted genome editing is a powerful tool for studying the gene function and underlying molecular mechanisms of almost every aspect of biological and pathological processes. The most popular methods for targeted genome editing are engineered endonucleases, including Zinc Finger Nuclease (ZFN), Transcription Activator-Like Effector Nucleases (TALENs), and Clustered Regularly Interspaced Short Palindromic Repeats/Cas (CRISPR/Cas) system, the prevailing genome editing tool originating from the adaptive immunity system of prokaryotes . The comWe have been studying frog metamorphosis as a model for mammalian postembryonic development and organ regeneration, a period when plasma thyroid hormone (T3) level peaks and adult organ development and maturation occur –6. AnuraTo overcome this problem, we hypothesized that a perfectly matched primer  would compete more effectively against a primer with mismatches  when present in the same PCR reaction. Thus, we labelled the mutant-allele specific reverse primer Rm and the wild type allele-specific reverse primer Rwt for HAL2 gene with fluorescent dye IR700 and IR800, respectively. We mixed both primers together in a single tube PCR assay in the presence of the common forward primer F428 (Additional file To test whether primer competition enhanced the PCR specificity in the single tube PCR assay with dual fluorescent primers, we first carried out parallel PCR reactions to genotype HAL2 and MBD3 animals using a single pair of non-fluorescent primers per reaction on serially diluted target DNA templates. We observed significant non-specific amplifications (Additional file Genome editing is a powerful tool used to introduce mutations in targeted genes to study their function and underlying molecular mechanisms. Faithful and simple genotyping is key for the widespread use of such technology and to ensure correct interpretation of the experimental findings. PCR-based detection is an appealing approach as it works reliably on mutations with large indels that lead to significant size differences in the PCR products from wild type and mutant alleles. Additionally, it has the ability to amplify specific alleles with allele-specific primers. However, it is very difficult to design allele-specific primers with high specificity for organisms with small indels or point mutations, which are common mutant types from genome editing. In such cases, PCR often has non-specific amplifications, making this approach unreliable for genotyping. Targeting a region harboring a restriction enzyme recognition site that can be disrupted via genome editing expands the application of PCR-based detection on small indels but requires additional steps to purify and digest the PCR products prior to resolving them through electrophoresis. In recent years, a number of strategies have been developed to genotype organisms with such small indels with limited practical use due to complex designs and/or lengthy assays –10. Our These are shown in the supplemental information.Additional file 1. Comparative analysis of regular PCR and competitive single-tube dual fluorescent PCR for genotyping small deletion mutant X. tropicalis animals generated via CRISPR/Cas9-mediated genome editing. Regular PCR with a single genotype-specific primer set in a PCR reaction often leads to non-specific amplification and inconclusive or false genotyping results. On the other hand, competitive single-tube PCR with a mixture of two genotype-specific fluorescent primers and a common primer inhibits non-specific amplification to allow accurate genotyping.


However, humans spend virtually all their awake hours in a fully light-adapted state. Here we review the evidence for a narrow blue circadian sensitivity curve for light-adapted humans derived from experiments using spectral filtering of light sources, and comparisons of light sources with diverse spectral power distributions. This light-adapted Circadian Potency function permits the development of circadian-protective light for nocturnal use and circadian-entraining light for daytime use.Light exposure at night can disrupt the circadian timing of cellular processes and is associated with a broad range of health disorders. To spectrally engineer lighting which minimizes circadian disruption at night it is necessary to define the precise spectral sensitivity of the human circadian system. Prior attempts have used short monochromatic light exposures in dark-adapted human subjects, or  These studies used dark-adapted subjects with induced pupil dilation [Previous assessments of the spectral sensitivity of the circadian system, based on dilation –3, dark-g violet 00–429 nmnd green 00–560 nmdilation , 90 min However, the test conditions of the ‘dark-adapted’ light-exposure studies are very different than the typically much longer (up to 16+ hours), continuous and fully-adapted exposure of humans to polychromatic white light in everyday life. Because of the initial dark adaptation, the previously reported circadian spectral sensitivity curves may include, in addition to 430–499 nm (blue) wavelength sensitivity, transient 400–429 nm (violet) and 500–560 nm (green) components resulting from cone- and rod-mediated extrinsic inputs to Intrinsically-Photoreceptive Retinal Ganglion Cells (ipRGCs) which decay over the first two hours of extended light exposure.In experiments with longer 6-hour) exposure to monochromatic blue or green light , conducted with initially dark-adapted subjects [-hour expTransient effects may be also seen with violet light exposure, resulting from transitory extrinsic input to ipRGCs from S-cones. Experiments on previously dark-adapted subjects showed that melatonin suppression by monochromatic violet light (420–424 nm) was much larger after 30 minutes (95% suppression)  than aftThe light-adapted human circadian spectral sensitivity curve under normal workplace lighting conditions has now been defined using a) light exposure times of greater than 12 hours instead of brief ≤90 minute light exposures of the dark-adapted eye; b) polychromatic overhead ceiling white light sources, instead of monochromatic lights; c) exposures to illumination levels recommended by the IES Lighting Handbook for work surfaces  ; and d) The first indication that the light-adapted circadian sensitivity curve was narrower than the published dark-adapted curve came from studies using eyeglasses with dichroic cut-off filters . In humaWe explored the spectral boundaries of light-adapted human circadian sensitivity by comparing human subjects illuminated from 20:00 h to 08:00 h overnight by an unfiltered LED overhead light source providing 540 lux illumination at tabletop, and with the same subjects under the light source with dichroic notch filters which either removed all wavelengths between a) 450–490 nm or b) 430–500 nm. The nocturnal pattern of salivary melatonin was suppressed under the unfiltered light source and partially suppressed by the light source with 450–490 nm filter, but the melatonin curve was unsuppressed with the 430–500 nm filter , indicatTo measure the spectral sensitivity of light-adapted human subjects more precisely, we ran a similar 12-hour overnight protocol, using, instead of filtered light, six spectrally diverse polychromatic white LED light sources (A-F). Based on the resulting nocturnal salivary melatonin patterns, a steady-state human spectral sensitivity curve was derived. This Circadian Potency spectral sensitivity curve with a Full Width at Half Maximum (FWHM) of 438–493 nm and peaking at 477 nm  is much in vitro peak sensitivity (479 nm) of human melanopsin [2) monochromatic blue light (480 nm) near that Circadian Potency peak wavelength generates an amplitude of the circadian phase response curve that is comparable to that of a polychromatic light source with much higher irradiance level (3000 μW/cm2).The Circadian Potency peak wavelength of 477 nm, obtained from light-adapted subjects under extended polychromatic light exposure, is close to the lanopsin , indicatlanopsin  that shoThe human circadian timing system can be disrupted by non-optimal light exposure such as insufficient day light or excessive evening or night light. Light at night is associated with detrimental health effects including compromised mood, sleep and immunity, higher obesity and diabetes risks and higher rates of neuroendocrine sensitive cancers such as breast and prostate cancer –17. ConsThe Circadian Potency curve is applicable to real-world situations as it was obtained under typical workplace conditions with light-adapted subjects and extended exposure to polychromatic light.The Circadian Potency spectral sensitivity curve spans a narrower wavelength range (FWHM 438–493 nm) than the rather broad (400–560 nm) range of the ‘dark-adapted’ spectral sensitivity curves that spread across violet, blue and green wavelengths. Removing this wide wavelength range from the polychromatic (380–780 nm) white light spectrum for the purpose of healthy nocturnal lighting is not practical for manufacturing attractive white or near-white light desired for most human purposes.Further, the narrower Circadian Potency spectral sensitivity curve makes it feasible to engineer energy-efficient nocturnal lighting using energy efficient violet LED dies which would not be feasible according to the ‘dark-adapted’ sensitivity curve.Defining the specific spectral characteristics of harmful and helpful electric lighting by means of spectral sensitivity curves is important to help spectrally engineer appropriate lighting solutions. The Circadian Potency spectral sensitivity curve  has seveIt allows the use of violet (410–425 nm) LED dies to engineer calorimetrically-balanced white light for nocturnal lighting instead of the conventionally used blue LEDs with ~450 nm peak emissions.The replacement of blue wavelengths by violet wavelengths reduces the negative health impacts of blue-rich nocturnal lighting, while maintaining the positive effects of short wavelength light on alertness and performance ,21, and The fact that the Circadian Potency spectral sensitivity curve suggests relative insensitivity at spectral wavelength below 425 nm is of particular interest:Besides using the Circadian Potency spectral sensitivity curve for spectrally designing healthy nocturnal white lighting, it can be also used for applications to phase shift the circadian clock for purposes of adjusting to shift work or jetlag, or for treating circadian sleep disorders. While specific Phase Response Curves (PRCs), that describe how wavelengths with high Circadian Potency can produce phase delays or phase advances, are not determined, the closest approximation currently available is the type 1 PRC that was developed for monochromatic blue (480 nm) light . The queUnder normal light-adapted conditions with polychromatic white light, the spectral sensitivity of the human circadian system appears to be limited to a narrow band of blue wavelengths with a peak at 477 nm and a FWHM of 438–493 nm. This Circadian Potency function has a narrower sensitivity range than the spectral sensitivity curves previously derived from short exposures to monochromatic lights under dark-adapted conditions. This appears to be because violet and green light effects seen in dark-adapted subjects are transient components that decay with extended exposure to light. The light-adapted Circadian Potency spectral sensitivity function has enabled the development of sensors and spectrally-engineered LED light sources to minimize circadian disruption. It also makes it possible to address the health risks of light exposure at night in our 24/7 society, by alternating between daytime circadian-entraining white light spectra and nocturnal circadian-protective white light spectra without loss of visual acuity.


A 61-year-old man who had previously undergone pancreaticoduodenectomy underwent subsequent endoscopic ultrasound (EUS)-guided stent placement to bridge the jejunum, pancreatic duct, and stomach as treatment for pancreaticojejunal anastomosis stricture . Stent Video 1 Previous endoscopic ultrasound-guided pancreatic duct drainage and stent exchange using the lariat method.A lariat was prepared to facilitate safe removal of the stent during endoscopic intervention from the jejunum where the pancreatic duct had been anastomosed. The wire tip of a snare catheter was grasped using forceps inserted through a single-balloon enteroscope , and thThe scope was subsequently advanced into the jejunum . Then, Endoscopic observation during scope withdrawal confirmed that a few centimeters of the stent were located in the stomach.If the lariat method is not used, there are few strategies by which the previous stent can be safely removed while retaining guidewire routesEndoscopy_UCTN_Code_TTT_1AS_2AD


The approval of immune-checkpoint inhibitors (CPI) and mitogen activated protein kinase inhibitors (MAPKi) in recent years significantly improved the treatment management and survival of patients with advanced malignant melanoma. CPI aim to counter-act receptor-mediated inhibitory effects of tumor cells and immunomodulatory cell types on effector T cells, whereas MAPKi are intended to inhibit tumor cell survival. In agreement with these complementary modes of action preclinical data indicated that the combined application of CPI and MAPKi or their optimal sequencing might provide additional clinical benefit. In this review the rationale and preclinical evidence that support the combined application of MAPKi and CPI either in concurrent or consecutive regimens are presented. Further, we will discuss the results from clinical trials investigating the sequential or combined application of MAPKi and CPI for advanced melanoma patients and their implications for clinical practice. Finally, we outline mechanisms of MAPKi and CPI cross-resistance which limit the efficacy of currently available treatments, as well as combination regimens. Malignant melanoma is among the most aggressive solid tumors of the skin that displayed a fast-growing incidence in the last decades , 2. OnceV600) . . V600-mu9 months .Triple combination therapy has not only been investigated in the metastatic, but also in the neoadjuvant setting. In this setting, CPI or MAPKi are administered prior to definitive surgery. Neoadjuvant treatment regimens for resectable advanced stage III and stage IV melanoma are increasingly coming into focus of clinical investigations given the promising results of the recent OpACIN  and OpACResults from recently presented trials in patients with resectable stage III or oligometastatic stage IV melanoma confirmed these promising results for neoadjuvant Nivo plus relatlimab . The neoDespite the strong efficacy data for neoadjuvant treatment regimens, there remains a need to enhance treatment response for those patients that did not initially show pathological response. Due to the complementary effects of MAPKi and CPI and the high pRR among patients given neoadjuvant DT it has been reasoned that neoadjuvant triple combination therapies might enhance treatment responses in these patients. However, preliminary results have yet only been reported for the NeoTrio trial NCT02858921), a randomized trial that compared the neoadjuvant single-agent pembrolizumab with the sequential application of pembrolizumab with DT or the concurrent application of DT plus pembrolizumab in patients with resectable BRAF-mutant stage III melanoma. In particular it has been reported that pRR and pCR were highest in the triple combination arm as compared to the sequential arm or the single-agent arm . However858921, aAs higher toxicity levels of triple therapies may limit their applicability it has been reasoned that a sequential treatment of CPI and MAPKi may reduce overall toxicity but exert similar efficacy rates. However, initial investigations testing sequential regimens with vemurafenib followed by IPI, provided disappointing results in terms of efficacy with ORR of only 32.6%, although tolerability was substantially improved . In addiV600 mutant metastatic melanoma, recent evidence rather showed that the up-front use of CPI before MAPKi results in better survival outcomes [Optimal treatment sequencing strategies have first been evaluated in retrospective studies demonstrating that responses to second line therapy were typically worse than responses to first-line treatment, regardless of treatment modality , 114. Whoutcomes –123.V600-metastatic melanoma patients [V600-mutated melanoma responsiveness to MAPKi [These favorable outcomes for the upfront use of CPI have also been confirmed by two pivotal randomized-controlled phase II/III trials  confirmed superior 2-year OS rates (73% vs. 65%) for the sequential regimen with upfront IPI plus Nivo as compared to upfront encorafenib plus binimetinib in a cohort of 209 patients with advanced BRAFmelanoma . Howevermelanoma .V600-mutant melanoma patients. In accordance with previous results reported in the SECOMBIT trial, preliminary data indicate that an early switch from vemurafenib and cobimetinib to atezolizumab is feasible and safe, although tumor-control achieved during run-in was maintained only in a subset of patients on subsequent CPI monotherapy [As compared to the aforementioned trials evaluating optimal treatment sequencing upon disease progression, trials using the technique of planned switch from MAPKi to CPI rather evaluated overall treatment efficacy regardless of disease progression. Here, a single-arm phase II trial comprising 46 patients with advanced melanoma reported that an initial 6 week lead-in phase of vemurafenib before starting IPI 10 mg/kg was associated with a lower rate of severe liver enzyme elevations, but yet promising response rates and median OS of 18.5 months . In addiotherapy   and an increase in immunosuppressive myeloid cells that could be overcome by direct modulation of the TME via DC maturation and expansion as well as inhibition of the MAPK pathway [The relevance of the immunosuppressive myeloid cell compartment for melanoma cross-resistance was further explored by Steinberg and coworkers who reported that BRAFi resistance was associated with an increasing influx of MDSC into TME that relied on MAPK pathway reactivation and downstream production of myeloid-cell derived CCL2 that could be reversed by the addition of an MDSC blocking C–C chemokine receptor type 2 antagonist . These d pathway .Last, Peng and coworkers showed that the loss of the tumor-suppressor PTEN and subsequent activation of the phosphoinositide 3-kinase (PI3K)/protein kinase B pathway promoted immune resistance in melanoma patients via reduction of T cell infiltration of the tumor and an increase of immunosuppressive cytokines such as VEGF that attract tolerogenic DC, MDSC and Treg . ImportaV600-mutant melanoma patients. Nonetheless, subgroup analyses and preliminary results from trials evaluating triple combination regimens in patients with MBM suggested that patients with higher disease burden and rapidly progressing disease might derive a greater benefit from these treatment regimens. Emerging biomarker analyses might help to better identify this patient population, i.e., it has been reported that particularly patients with a high CD4/CD8 T cell ratio at baseline and a higher circulating tumor (ct)DNA shedding derived a significant benefit from triple combination therapy with spartalizumab, dabrafenib plus trametinib as compared to the DT comparator group [V600-mutant melanoma. However, prospective clinical trials evaluating triple combination regimens compared to combined checkpoint blockade with IPI plus Nivo as an active comparator are required to adequately address this issue and might particularly delineate their efficacy in specific cohorts of patients including those with more aggressive disease, MBM or those that are refractory towards CPI. Also, these trials might yield more comprehensive data on the efficacy of a short-term run-in of BRAFi/MEKi on the premise of inducing rapid responses before adding CPI in patients with rapidly progressive disease. Regardless of the recent advances in the field of MAPKi/CPI combination therapies an urgent need remains to establish additional treatment options as secondary acquired resistance towards these agents will affect approximately 50% of patients in the long-term and thus poses a vital issue for both treatment options as responses to second-line treatments remain low [The introduction of CPI and MAPK-targeted therapeutics has considerably improved the treatment options for melanoma patients , 140. Thor group . Meanwhior group , 124. Whmain low .


Vaginal mesh exposures and infections are recognized complications of open and laparoscopic sacrocolpopexy performed for vault prolapse. In severe cases, complete sacrocolpopexy mesh removal may be necessary. This case report presents a 72-year-old woman with previous mesh sacrocolpopexy who presented with infected mesh and recurrent vaginal bleeding despite multiple attempts at surgical transvaginal mesh excision. A life-threatening massive hemorrhage occurred intra-operatively. After several failed attempts to control bleeding, hemorrhage Occluder™ Pins were successfully placed by vascular surgery to control presacral veins. Although an exceedingly rare complication, anticipation and rapid management of life-threatening bleeding are critical to save life during complicated mesh removals. •Mesh infections are rare but serious complications of abdominal sacrocolpopexy.•Complete removal of infected mesh may be necessary and carries high risks of complications.•Sudden bleeding during infected mesh removal may require a multi-disciplinary approach for treatment.•Hemorrhage Occluder™ Pin placement may be necessary to control presacral bleeding. Re-oper studies ,4. For t studies . A new t studies . DependiThis case report presents a completely infected SCP mesh requiring open removal. A sudden and cataclysmic bleed occurred from large presacral veins during surgery, prompting an emergency massive transfusion protocol and a vascular surgery consultation. Hemorrhage Occluder™ Pins were placed to control this bleeding and save the patient's life.2A 72-year-old woman, gravida 4 para 3, presented to the emergency department with increased vaginal bleeding and worsening abdominal and back pain. The patient had a history of gastroesophageal reflux (GERD), chronic back pain, and recurrent urinary tract infections (UTI) as well as a past surgical history relevant for a cholecystectomy, total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO) for endometriosis in her late thirties, and a mesh sacrocolpopexy (SCP) with midurethral sling placement (MUS) at the age of 56. She underwent subsequent transvaginal mesh excision surgeries for recurrent vaginal bleeding at ages 57 and 59.). The original procedure was resumed once hemostasis was achieved and the patient was stabilized. The infected mesh was completely removed down to the vaginal cuff exposure. The removed specimen showed an abscess pocket with a thick capsule and copious amounts of purulent material  may havDuring pelvic trauma or colo-rectal surgery (proctectomy), bleeding can arise from important veins coursing on the surface of the sacrum or from the foramina of sacral basivertebral veins. A multidisciplinary approach requiring seven surgeons was necessary to stop presacral bleeding in the case of one colo-rectal surgery . This tyA review of the literature indicates rare prior reports especially in the past decade due to the rapid acceptance of robotic surgery for SCP during which venous bleeding can be easier to control. However, robotic technology is not yet available everywhere and certain re-operations are not amenable to a robotic approach.Z-suture along with a warm sponge compression were enough to stop the bleeding. The patient did not require a blood transfusion. The last abdominal sacrocolpopexy case report to date with intra-operative hemorrhage that required the use of pins was in 1991 by Timmons et al. [In prior literature, Nygaard et al. reported a 4.4% rate of hemorrhage, blood transfusion, or both during abdominal sacrocolpopexy, while Rondini et al. found a 3.7% rate of overall intra-operative complications but did not differentiate between types of complications ,12. In as et al.  Several s et al. ,16.4The teaching point of this case report is to alert pelvic reconstructive surgeons to the availability of these Hemorrhage Occluder™ Pins designed to handle massive bleeding from sacral venous plexuses and to reinforce the importance of a multi-modality approach to achieve hemostasis and save life.


A 66-year-old woman presented with a right femoral false aneurysm following an aortobifemoral bypass for lifestyle-limiting claudication. A computed tomography (CT) angiogram revealed features of complete aortobifemoral graft infection. A two-stage procedure was performed. The first hybrid stage involved the excision of only the femoral components and covered stenting of the aortic stump, along with recanalization of bilateral native iliac systems. The second stage, six weeks later, involved aortic stent and graft explant via midline laparotomy with aortic bovine pericardium patch repair . Follow-up imaging demonstrated no residual infection, and the patient remained without complication at the 12-month follow-up. This novel approach utilizes hybrid surgical techniques and modern bioprosthetic material to safely manage an infected aortobifemoral bypass graft. Prosthetic material infection following aortoiliac or aortofemoral reconstruction is one of the most challenging complications in vascular surgery . Extra-aWe present a previously undescribed technique that utilizes modern bioprosthetic material and hybrid surgical techniques to provide low morbidity lower limb revascularisation and removal of infected prostheses. A 66-year-old woman presented with fevers and a painful indurated right femoral mass following elective aortobifemoral bypass grafting for lifestyle-limiting claudication performed 18 months prior. At the time of presentation, she was free from claudication. A computed tomography (CT) angiogram demonstrated a large right femoral false aneurysm as well as fluid collection along the entire length of the graft  to prevent potential aortic stump "blow out" at a later stage. Two large bore corrugated drains were placed in each groin and removed one week post-operatively following no further drain output. Repeat CT angiography performed one week post-operatively demonstrated no infective recollection surrounding both common femoral arteries and no aortic false aneurysm. A moderate aortic collection was still present; however, its appearance was unchanged from the initial pre-operative CT. The patient was discharged on postoperative day six.Six weeks following the initial procedure, the patient underwent removal of the final infected aortic graft. This was performed via a midline laparotomy. A moderate amount of suppuration was identified surrounding the remaining aortic graft component. The graft was excised in its entirety, and following an explant of the aortic V12 stent, the aortic anastomotic defect was closed with a Xenosure® bovine pericardium patch . Completion of digital subtraction angiography (DSA) demonstrated a patent aortoiliac system with no complications (Figure The management of an infected aortobifemoral prosthetic graft is one of the most challenging problems facing vascular surgeons. Traditional management of infected aortobifemoral grafts requires graft explant and extra-anatomic bypass, typically by axillobifemoral bypass grafting . High moThe method described in this case report represents a novel use of hybrid techniques to maintain lower limb perfusion while negating the need for an extra-anatomic bypass. In the case of our immunosuppressed patient, avoiding axillobifemoral bypasses was ideal for minimizing the use of further prosthetic material, while our staged approach also allowed time for drainage and resolution of infection prior to the insertion of the bovine pericardium patch. It should be noted that native racanalization may not be technically possible in all scenarios, which limits the generalizability of our approach.The use of a bovine pericardium patch to repair aortic anastomosis has also not been previously described. Although the patient has demonstrated no recurrent infection at 12 months, the success of this case report is limited as it is unclear if the bovine pericardium patch will remain infection-free in the longer term.Infected aortofemoral grafts are one of the most feared complications facing vascular surgeons today. The advent of hybrid vascular surgery has presented new solutions to this challenging problem. Our case describes a novel approach of staged infected graft explant followed by interval in-situ endovascular reconstruction, which may be a safer alternative to traditional extra-anatomical bypass grafting. Our technique should be considered in immunosuppressed patients, where the use of further prosthetic material should be avoided. The XenoSure® bovine pericardium patch is also emerging as a biological alternative to prosthetic grafts for arterial reconstruction in infected fields. Further randomized control trials comparing bovine pericardium to an autologous vein or other prosthetic material are needed to prove their role in vascular infection.


The impact of providing cognitive pharmacy services following hospital discharge has been studied with various results. This study is specifically focused on comprehensive medication management services delivered postdischarge in an interprofessional team environment to patients aged greater than 65 years.To determine if delivery of comprehensive medication management services postdischarge will prevent hospital readmissions or emergency department visits within 6 months following discharge in patients aged greater than 65 years. Secondary endpoints included 30-day and 60-day postdischarge events.This was a prospective group matched-controlled study of patients aged greater than 65 years with selected diagnoses identified as high risk for readmission. The intervention group received comprehensive medication management that was provided face-to-face in the patient’s primary care clinic within 2 weeks of discharge.No statistically significant difference was found between intervention and control groups in hospital readmissions or emergency department visits at 30 days, 60 days, or 6 months after discharge. No statistically significant difference was seen in mortality between groups.Provision of comprehensive medication management services did not reduce emergency department visits or readmissions in this study. This study was limited by multiple other changes occurring in the health system during the time of this study that potentially confounded results. In addition, the study may have been too small to detect a difference.


Tardigrades are known for their remarkable ability to withstand extreme stresses . HoweverRamazzottius varieornatus using a previously established specific antibody (TardiVec are vectors designed to express exogenous proteins, such as GFP, under the control of the ~1-kbp upstream sequence of the target genes. As demonstrated, this 1-kbp segment drives distinct tissue-selective expressions depending on the target genes . Corresp4antibody  in Fig. antibody B–E. Thisantibody . The TarUsing TardiVec provides another notable advantage to enable live imaging the in vivo distribution changes of target proteins in desiccating tardigrades. An earlier study has shown that RvCAHS3 form numerous filaments in both human and insect cells under water-deficient stress . Using TIn conclusion, the expression system using TardiVec provides valuable opportunities for tardigrade research. It is also recommended to consider the limitations in recapitulating the endogenous expression pattern and the difficulty in observing fine structures in desiccated tardigrades. Confirmation using alternative methods will solidify the findings about these aspects.


Ocular lymphatic vessels play major physiological role in eye homeostasis and their dysfunction can contribute to the progression of several eye diseases. In this study, we characterized their spatiotemporal development and the cellular mechanisms occurring during their ontogenesis in the mouse eye.Whole mount immunofluorescent staining and imaging by standard or lightsheet fluorescence microscopy were performed on late embryonic and early postnatal eye mouse samples.We observed that the ocular surface lymphatic vascular network develops at the early postnatal stages (between P0 and P5) from two nascent trunks arising at the nasal side on both sides of the nictitating membrane. These nascent vessels further branch and encircle the whole eye surface by sprouting lymphangiogenesis. In addition, we got evidence for the existence of a transient lymphvasculogenesis process generating lymphatic vessel fragments that will mostly formed the corneolimbal lymphatic vasculature which further connect to the conjunctival lymphatic network. Our results also support that CD206-positive macrophages can transdifferentiate and then integrate into the lymphatic neovessels.Several complementary cellular processes participate in the development of the lymphatic ocular surface vasculature. This knowledge paves the way for the design of new therapeutic strategies to interfere with ocular lymphatic vessel formation when needed. The formation of a lymphatic trunk that further branches and encircles the entire ocular corneolimbal and conjunctival surface was described.C57BL6/J wild type mice were used, in accordance with the statements of the ARVO  for the animal use guidelines in ophthalmology and vision research. The project was ethically approved by the French Ministry for Research and Education (agreement no. APAFIS 13689-2018022110161501 v2). Whole eyeballs from late embryos (E18.5), early postnatal neonates (P0 to P5), 11- and 30-day-old mice were collected by careful dissection, taking care to preserve the conjunctival and ocular surface tissues.Indirect immunofluorescence experiments were performed essentially as previously described.Light sheet fluorescence microscopy (LSFM) imaging was performed using a light Sheet ZEISS Z1 microscope  and ZEN Black software. The whole eyeballs were placed in the sample chamber either after embedding into 1% agarose or after fixation with superglue to a home-made sample holder. The LSFM images shown are two-dimensional reconstructions (maximum intensity projections) of series of acquired Z-stack images.The imaging of whole mount immunostainings of the anterior eye were performed after cutting into four quadrants and flat mounting of the eye anterior segment with Fluorsave reagent .–,,The spatiotemporal ocular surface lymphatic vessel formation was observed by LSFM imaging of the lymphatic vessel endothelial hyaluronan receptor 1 (LYVE-1) immunofluorescent staining. LYVE-1 represent a powerful antigenic marker to visualize the ocular surface lymphatic vasculature.,The quantitative analysis confirms that the development of the LYVE-1-positive ocular surface lymphatic vessel network is achieved at early postnatal steps (from E18.5/P0 to P4/P5), and the delayed formation of the ventral network compared to the dorsal one . AlthougLymphangiogenesis, which corresponds to the sprouting and the formation of new vessels from preexisting ones, appears to constitute an important cellular mechanism involved in the expansion of the nascent LYVE-1–positive trunks that emerge adjacent to the nictitating membrane from P0 A. IndeedAlthough sprouting lymphangiogenesis appears to be a major process for corneolimbal and conjunctival lymphatic network expansion, a lymphvasculogenesis process could also be involved. One can observed the independent formation of LYVE-1–positive isolated cell clusters that develop cord-like structures. These cell clusters, which are also Prox-1 positive, which establishes their lymphatic identity, are mainly seen at the surface of the cornea above the corneolimbus. Such LYVE-1–positive and Prox-1-positive lymphatic cell clusters are illustrated in ,,Several macrophage subtypes expressed LYVE-1 at different expression levels.The presence, at early developmental stages, of many single LYVE-1 and CD206-positive cells in close proximity with the sprouting lymphatic neovessels A, 8B, isTo know whether these macrophages can transdifferentiate into ocular lymphatic endothelial cells, we looked at the potential existence of cells expressing a mixed macrophage-lymphatic phenotype at P0/P1, during the early steps of lymphatic vessel formation. Some cells constituting the sprout were found to highly express LYVE-1 and concomitantly some remaining CD206 expression, whereas scattered macrophage at the vicinity display high CD206 and low LYVE-1 expressions A–9C. DouIn this study, we characterize the spatiotemporal and cellular mechanisms of development of the ocular surface lymphatic vascular system in the mouse. We confirmed that the timing of the ocular surface lymphatic vessel organogenesis occurs mostly during early postnatal steps, between P0 and P5, as previously described.,Actually, we provide novel insights in the characterization of the cellular mechanisms involved in the generation of the ocular surface lymphatic network. In addition to sprouting lymphangiogenesis, our results bring the evidence for the involvement of lymphvasculogenesis. This process appears to be mainly responsible for the formation of the corneolimbal lymphatic vascular plexus. Several lymphatic vessel segments arise at the surface of the cornea. They will migrate and connect with the conjunctival developing network and further encircle the ocular globe at the basis of the cornea. These two different morphogenetic cellular mechanisms are in accordance with the cellular mechanisms known to be involved in lymphatic vessel development in other mouse organs.,–,,,,We analyzed whether a third cellular mechanism for ocular lymphatic vessel formation could involve cells of the myeloid/macrophage lineage. Indeed, macrophages are key modulators of both angiogenesis and lymphangiogenesis processes either during tissue repair and remodeling or in pathological situations, including eye diseases. This is mainly achieved by the secretion of angioactive or lymphangioactive growth factors such as VEGF-A and FGF2Our results also provide some evidence that during early developmental processes, resident M2-like macrophage could contribute to the formation of new lymphatic vessel of the ocular surface by direct incorporation into the lymphatic neovessel. The question to know whether it corresponds to true macrophage transdifferentiation and/or to lymphatic endothelial mimicry awaits further investigation. Nevertheless, a lymphatic reprograming of macrophages does not appear before their physical integration into a lymphatic sprout. Indeed, in contrast to what was described by Maruyama et al.,In conclusion, the ontogenesis of the ocular surface lymphatic vessel network formation appears to be more complex than previously reported. Our results indicate that the ocular surface lymphatic network develops by several different but complementary morphogenetic processes: sprouting from a lymphatic trunk originating behind the nictitating membrane but also differentiation of isolated lymphatic progenitors to develop lymphatic-committed cell clusters. Our results also support that macrophages can contribute by their direct integration in the expanding lymphatic vessels. Our results strongly suggest that M2-polarized tissue-resident LYVE-1–positive macrophages could transdifferentiate into lymphatic endothelial cells to constitute new lymphatic vessels. This is in accordance with the existence of myeloid-lymphatic progenitors which have been postulated to express M2-macrophage specific markers.


The HIV Organ Policy Equity (HOPE) Act allows persons living with human immunodeficiency virus (HIV) infection to accept HIV-positive donor organs. Risk of superinfection or viral recombination resulting from the transmission of a genetically distinct donor HIV-1 strain may be a concern. It is unknown if transplantation from acutely infected donors pose additional risk. Analysis of viral quasispecies from donor and recipient samples provides an opportunity to evaluate the transplanted kidney as a viral reservoir and explore the potential for viral superinfection or recombination in the recipient.(Table 1). Single genome amplification of the HIV-1 env gene was performed with viral RNA extracted from recipient urine and plasma and viral DNA from donor kidney cells, recipient PBMC and renal cells. We constructed phylogenetic trees assessed recombination probabilities.A 63-year-old HIV-positive recipient with focal segmental glomerulosclerosis and suppressed viral load (< 20 copies/mL) on antiretroviral therapy (ART) with dolutegravir and lamivudine, received a kidney from an acutely infected deceased HIV-positive donor env sequence was amplified from the recipient’s urine 30 hours post-transplant suggesting transfer of donor virus to recipient. Donor virus became undetectable on subsequent visits while recipient was maintained on ART. Notably, a third virus was detected 1.5 months post-transplant in urine-derived renal tubular epithelial cells and 5 months post-transplant in urine which was genetically distinct from previously detected donor and recipient strains . This third strain did not have genetic features suggestive of recombination. Our findings suggest potential superinfection in the donor or recipient.A new, genetically distinct We documented presence of three unrelated HIV strains within a transplanted recipient and within different viral reservoirs. Donor and recipient recombination did not occur. In acutely infected donors, when the transfer of virus within the kidney occurs, ongoing virologic suppression can be achieved if appropriate ART is maintained. Additional long-term monitoring of viral populations in the recipient is important to fully assess any clinical and virologic implications of this finding.All Authors: No reported disclosures


Investigate the effect on visitors' greenspace engagement by retro-fitting wayfinding, to create a looped walking route, within an urban park.rd March – 3rd May 2021) to determine public perceptions of wayfinding's role for recreational physical activity within the urban park and explore what information should be included on wayfinding. 1. An online-survey was distributed (23th March – 26th August 2021) and follow-up (29th August 2021 – 29th August 2022). A QR code accessed intercept survey was provided on the wayfinding to understand route-user visitation habits. 2. Automated and manual counts were monitored on footpaths where the new wayfinding was installed at baseline  valued the detachment from the urban environment that the park provided, which gave positive experiences to wellbeing, mental health, and social connections. Wayfinding was valued by irregular park users to help them confidently explore the park.Phase 3: Interviewees (Retro-fitting wayfinding in an urban park helps irregular users engage in the greenspace and wayfinding design needs to integrate with the natural environment to keep contrast with urban environments. The project illustrated the value of qualitative methods within natural experimental studies to capture intervention impacts.University of Northampton


Centers for Disease Control and Prevention (CDC) guidance recommends coordinated multifacility interventions to contain selected MDRO, such as carbapenem-resistant Enterobacterales (CRE). A mathematical model using data from a northeastern state estimated these interventions would lead to 76% relative reduction in CRE prevalence in a hospital network connected through patient transfers, but whether results would be similar using data from another state is unclear.We used Tennessee (TN) surveillance and hospital discharge data to estimate CRE transmissibility and patient transfers in a deterministic compartmental model to simulate regional spread of CRE. Simulations were initialized with the first clinical detection of CRE in the hospital with the most outgoing transfers. Interventions were initiated in facilities that detected CRE and those sending or receiving the largest numbers of patients to/from these facilities, including: 1) biweekly point prevalence surveys; and 2) enhanced infection control implemented immediately on CRE detection. We assumed interventions reduced intrafacility transmission by 20%. Surveys stopped after 2 consecutive negative rounds in a facility . We ran simulations using 2 patient transfer networks: 1) all hospitalized patients; and 2) CRE surrogates  .https://www.dartmouthatlas.org) connected by direct and indirect patient transfers with up to 365 days of intervening community stays. Patient transfer data were sourced from the 2018-2019 TN Hospital Discharge Database. Patients who were not admitted to another facility after being discharged in 2018 were attributed to transfers into the HRR corresponding to the hospital’s address. Each circle represents a short-term acute care hospital (STACH), each square represents a long-term acute care hospital (LTACH), and each triangle represents an HRR. The arrow represents the direction of transfers between hospitals. Node sizes correspond to the number of registered beds, and color represents the Emergency Medical Services (EMS) regions where the facility is located.In the multi-facility SIS model, we assume hospitals are at constant occupancy. Each bed was occupied by either an infectious (I) or susceptible patient (S). (b) Interventions outlined in the simulations followed the recommendations of the Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs). Initial detection at the facility with the highest number of outgoing transfers followed by immediate containment efforts and reduced transmissibility in intervened hospitals by 20% by day 30. Simulations were run 35 times. Each run randomly selected a transmissibility value derived from the distribution in our estimates derived from CRE surveillance data in TN.CRE case counts 3 years after importation and interventions were 21% lower (interquartile range [IQR]: 20–23%) than without interventions using the transfer network of all hospitalized patients; interventions were required in 52 (36%) of 144 hospitals. Simulations in the CRE surrogate network resulted in a 26% (IQR: 20–38%) CRE case reduction and interventions in 32 (24%) hospitals.The estimated CRE prevalence reduction achieved through simulating CDC guidance-recommended interventions in TN was lower than estimates using data from a different state, likely due to state-specific differences in patient transfer network structure and transmission parameters. Containment guided by transfer patterns of patients clinically similar to CRE-infected patients rather than all hospitalized patients requires interventions in fewer hospitals to achieve a comparable impact.Peter F. Rebeiro, PhD, MS, Gilead: Advisor/Consultant|Janssen Pharmaceuticals: Advisor/Consultant|National Institutes of Health: Grant/Research Support


Bipolar Disorder (BD) has been suggested to be a risk factor for development of Parkinson Disease. Psychiatric drugs used as standard treatment of BD includes many drugs that are known to induce drug-induced parkinsonism (DIP).Clinical differentiation between PD and DIP is a clinical and scientific crucial result. It might be aided by functional neuroimaging of the dopaminergic nigrostriatal pathway.123I-ioflupane dopamine transporter SPECT. Imaging data of BD patients with pathological nigrostriatal pathway were further compared to a population of de-novo PD patients.Twenty consecutive BD patients with parkinsonism were clinically assessed and underwent Four BD patients had abnormal scans; they had higher putaminal binding ratio and putamen-to-caudate ratios than PD patients, despite similar motor symptom burden.in our initial results, up to 20% of BD patients with parkinsonism might have an underlying dopaminergic deficit, which is higher than excepted in the general population. This evidences supports that BD represents a risk factor for subsequent development of neurodegenerative parkinsonism.None Declared


Over-the-scope clip to the rescue: solution for duodenal perforation from migrated biliary stent. Iatrogenic perforation of the duodenum caused by biliary stents is a rare adverse event of ERCP.A 66-year-old man was referred to our institution to resume management of choledocholithiasis and indeterminate biliary stricture. Eighteen months prior, he had jaundice secondary to bile duct stones and mid-distal common bile duct stricture for which he underwent ERCP and plastic stent placement. The COVID-19 pandemic led to delay in the necessary follow-up.www.giejournal.org). The fluoroscopic image confirmed the perforation and approximately 1 cm of the stent extended outside the duodenal lumen. The defect measured 4 mm in diameter  (diameter ; Video 1diameter ; Video 1diameter ; Video 1diameter ; Video 1diameter ; Video 1A postprocedural CT scan showed no evidence of drainable fluid collection or extraluminal gas ; Video 1A 71-year-old woman presented to an outside hospital with painless jaundice requiring ERCP and bilateral plastic biliary stent placement. Five days later, she was referred to our hospital for duodenal perforation from a migrated biliary stent with retroperitoneal fluid collection seen on a CT scan. She underwent a similar approach with removal of the stent via rat-tooth forceps and primary endoscopic closure of the duodenal defect with tissue ablation with argon plasma coagulation and OTSC closure ; Video 1A 71-year-old woman with metastatic pancreatic adenocarcinoma presented with septic shock and encephalopathy, and she was found to have a migrated biliary stent with duodenal perforation. Her course was complicated by multiple intra-abdominal abscesses, extensive pneumoperitoneum ; Video 1She underwent an ERCP that showed a migrated biliary stent causing opposing duodenal wall perforation. The defect site was ablated and an OTSC mended the perforation. Antibiotics were continued and she underwent percutaneous drain placement with radiology. There were no immediate adverse events and she had improvement in pain and mentation.Duodenal perforations from migrating plastic biliary stents are rare; however, they can be significantly morbid when they occur. While the presentations and time intervals between original stent placement to identification of duodenal perforation differed among the 3 cases ; Video 1Dr Phan is a consultant for Boston Scientific, Olympus, and Noah Medical. All other authors disclosed no financial relationships.


Congenital cytomegalovirus infection (cCMV) is the leading cause of non-hereditary sensorineural hearing loss and can cause other long-term neurodevelopmental disabilities. To consider antiviral treatment, it is important to differentiate between symptomatic and asymptomatic patients by early infancy. However, it is difficult to identify neurological complications in some cases. This study aimed to identify candidate plasma biomarkers for neurological complications of cCMV during the neonatal period using proteome analysis.This study retrospectively enrolled five patients with asymptomatic cCMV and nine patients with symptomatic cCMV, including those with hearing loss and/or abnormal brain imaging. Plasma samples were obtained during the neonatal period. After extraction of 14 high-abundant proteins from the plasma, proteins were digested by trypsin. The peptides were analyzed by liquid chromatography–mass spectrometry using an Orbitrap Fusion mass spectrometer. Protein quantification was performed using Proteome Discoverer. Levels of differently expressed proteins were validated by enzyme-linked immunosorbent assay.In total, 456 proteins were identified and quantified. Levels of 65 proteins were significantly higher in patients with symptomatic cCMV than in those with asymptomatic cCMV. The top two enriched categories for these proteins according to pathway enrichment analysis were “complement and coagulation cascade” and “inflammatory response.” In contrast, levels of 30 proteins were significantly higher in patients with abnormal brain imaging. Plasma levels of fms-related receptor tyrosine kinase 4 (FLT4) were significantly higher in patients with symptomatic cCMV than in those with asymptomatic cCMV. Moreover, levels of plasma peptidylprolyl isomerase A (PPIA) were significantly higher in patients with abnormal brain imaging than in those without.Proteome analysis showed that the proteins related to inflammatory response pathways were upregulated in patients with symptomatic cCMV. FLT4 and PPIA can be used as novel diagnostic biomarkers for neurological complications of cCMV to enable early therapeutic intervention with antiviral agents.All Authors: No reported disclosures


A 39-year-old woman presented with localized urticaria following N95 respirator use in a COVID-19 unit. After approximately 15 minutes of wear, she developed pruritus on her face, without associated angioedema or dyspnea. She had no history of cutaneous reactions to N95 respirators. Physical examination revealed several wheals with surrounding erythema limited to the area occluded by the N95 respirator . On eval1 Symptoms typically self-resolve within an hour. Antihistamines can be used in symptomatic dermatographism. The pathogenesis is likely related to vasoactive mediators released by mast cells as elevated serum levels of histamine have been associated.2 Differential diagnoses including pressure urticaria and contact dermatitis can be ruled out based on inciting factor, timing of onset and resolution with antihistamines.Dermatographism is characterised by the development of a wheal and flare reaction after pressure is applied to the skin by stroking or scratching, typically within minutes and persisting up to an hour.3 The recent pandemic has led to increased and extended respirator use. While evidence supports these respirators as offering substantial protection against COVID-19, this case highlights that occupational health departments should be alert for adverse cutaneous reactions that may affect HCWs.4N95 respirators are recommended for healthcare workers (HCWs) who provide care for patients with suspected or confirmed COVID-19 infection.


The detection of driver gene mutations has become essential for lung cancer; however, insufficient sample sizes make gene panel tests difficult to use. We previously reported that the lung cancer compact panel TM (LCCP) could detect EGFR and MET gene mutations with sputum cytology. To date, the detection of gene mutation using RNA from sputum samples is considered practically difficult. We report a case in which the EML4-ALK fusion gene was successfully detected from a sputum sample using the LCCP that was just released in Japan as a new next-generation sequencing lung cancer panel, CDx.


An 18-year-old male reported chief complaints of inability to close his right eye. He is a known case of oro-facial plexiform neurofibromatosis for the past 12 years. The patient had undergone a debulking surgery in the right eyelid 2 days back. The patient's left eye had been enucleated 10 years ago. On ocular examination, the right upper eyelid showed upper eyelid mass with 6 sutures post debulking on the upper eyelid with scleral show. The left eye had been enucleated and tarsorrhaphy sutures were present. The patient was managed with topical lubricating eye drops and gel as well as lid patching.