P. aeruginosa (PSA) coverage if locally validated risk factors are present. They further recommend obtaining local data on CAP pathogens to quantify risk factors and help guide clinical decision-making. To comply with the current guideline recommendations and to determine which patients may benefit from empiric anti-pseudomonal therapy, we aimed to characterize our institution’s local risk factors for CAP caused by PSA. The 2019 ATS/IDSA community-acquired pneumonia (CAP) guidelines recommend empiric This is a retrospective single-center matched cohort study of patients admitted to our institution with a CAP diagnosis and a positive respiratory culture who received antibiotic treatment in the past 19 years. Multivariate logistic regression was performed to assess the relationship between PSA and the following risk factors: severe or very severe COPD (FEV1 < 50% predicted), requiring invasive mechanical ventilation or vasopressor support in the first 24 hours of admission, history of PSA infection/colonization in the previous year, tracheostomy, bronchiectasis, long-term care facility residence and admission with receipt of IV antibiotics in the previous 90 days.A total of 343 patients were screened and 213 were included. Patients were mostly male (99%) with a median (IQR) age of 70 (63-76) years. Long-term care facility residence was removed from the model to prevent it from being over fit as it was related tracheostomy. In the multivariate analysis the only independently associated risk factor for PSA CAP was evidence during the prior year of PSA infection or colonization . Other risk factors that did not reach statistical significance but may be clinically significant included severe or very severe COPD  and tracheostomy .The results of this study provide valuable data to help guide empiric CAP treatment at our institution. Based on these results, patients with PSA infection or colonization in the past year are appropriate to provide empiric anti-pseudomonal therapy for CAP. Further evaluation of severe or very severe COPD and tracheostomy would be beneficial to better characterize their role in PSA CAP.All Authors: No reported disclosures


Fluorescence Tracker App downloadable via MATLAB® file exchange). Statistical analysis of FI-time plots compared tumours  against control during FI curve rise, peak and decline from apex. Early kinetic FI signal measurement delineated discriminative temporal signatures from tumours  offering rich data for analysis versus delayed spot measurement (n = 10 cancers). Malignant lesion dynamic curves peaked significantly later with a shallower gradient than normal tissue while benign lesions showed significantly greater and faster intensity drop from apex versus cancer. Automated tracker quantification efficiently expanded manual results and provided algorithmic KNN clustering. Photobleaching appeared clinically irrelevant. Analysis of a continuous stream of intraoperatively acquired early ICG fluorescence data can act as an in situ tumour-identifier with greater detail than later snapshot observation alone. Software quantification of such kinetic signatures may distinguish invasive from non-invasive neoplasia with potential for real-time in silico diagnosis.As indocyanine green (ICG) with near-infrared (NIR) endoscopy enhances real-time intraoperative tissue microperfusion appreciation, it may also dynamically reveal neoplasia distinctively from normal tissue especially with video software fluorescence analysis. Colorectal tumours of patients were imaged mucosally following ICG administration (0.25 mg/kg i.v.) using an endo-laparoscopic NIR system  including immediate, continuous in situ visualization of rectal lesions transanally for up to 20 min. Spot and dynamic temporal fluorescence intensities (FI) were quantified using ImageJ  and by a bespoke MATLAB® application that provided digitalized video tracking and signal logging at 30fps ( Improved intraprocedural tissue characterisation could allow better in situ primary tumour profiling and confirmation/exclusion of metastatic deposits acuminating cancer outcomes and healthcare efficiency2.Direct visualization by endoscopy is an early component of clinical pathways for many patients with visceral cancer that directs subsequent care. At operation, direct inspection assists quantification of overall cancer burden especially in areas poorly seen by non-invasive workup and impacts surgical strategy. However, determination of tissue nature by operator judgement alone or indeed by traditional biopsy  is imperfect3. Such capacity can help characterise tissue intraoperatively with most clinical application thus far for tissue perfusion assessment using the non-selective fluorophore indocyanine green (ICG)6. For this, the NIR-ICG visualization is dynamic, occurring within seconds of agent administration, fitting current surgical practice very well. In contrast, NIR cancer identification strategies have concentrated on advanced preprocedural fluorophore administration with visual interrogation planned for many hours or days later at a time when tissue agent concentrations are relatively static7.Surgical colorectal cancer care is ideally suited for digital advance with both endoscopy and laparoscopy embedded in its diagnosis and therapy. Its endolaparoscopic systems are capable of providing multispectral illumination including tissue-penetrating near-infrared (NIR) spectral vision9. Their irregular vascular architecture and lack of a lymphatic recovery system leads to the tumoritropic accumulation of macromolecules such as albumin in solid tumours 10. Such characteristics mean even a chemically non-selective perfusate, such as ICG, could functionally discriminate cancer at any site allowing in situ optical delineation. However, when applied simply by preoperative administration and later snapshot observation, high false positive rates pertain 11.Malignant tumours distinguish from normal tissue and benign neoplasia by hallmark metabolic behaviours including their neovascularization (angiogenesis) as well as cell–cell and host-tumour interstitial interactions12. As the processes being visualized are more complex than perfusion alone and non-tumour background noise may manifest, video-based analytics could de-risk image interpretation permitting greater interpretative clarity and even potentially a ‘digital tissue biopsy’ through software. Herein we pilot the use of systemic NIR-ICG as a licensed available-now agent for endoscopic colorectal neoplasia perfusion interrogation with the goal of identifying discriminant tissue characterisation features. The automated operative perfusion quantification methodology developed and used for this study is available for download so others may test and add to this exploratory work while we continue to expand our clinical series on a collaborative basis.We hypothesized that kinetic characterisation of the evolving dynamic fluorescence intensity (FI) signature at and within cancer deposits could provide discrimination of cancer versus non-cancer even with a passive, non-targeted fluorophore such as ICGThis clinical experience involved adult patients already undergoing endolaparoscopic diagnostic or therapeutic procedures for colorectal neoplasia under general anaesthesia. Informed consent was obtained from all participants in accordance with relevant guidelines and, regulations and with institutional  ethics approval . ICG is licensed internationally for tissue perfusion characterisation and has an excellent safety profile. NIR Endoscopic Systems are commercially available with the one used in this study  being capable simultaneous white light and NIR display. Therefore, no experimental agents or devices were used and no clinical care decisions changed based on NIR-ICG appearances.Patients with colorectal tumors were administered ICG intravenously at a dose of 0.25 mg/kg intraprocedurally. The endoscopic NIR system was used to directly visualise rectal tumours continuously transanally for up to 20 subsequent minutes and enabled a video recording to be made of endoscopic white light and NIR appearances simultaneously. Ex vivo resection specimens from a separate cohort also receiving the same dose of ICG systemically were opened and their mucosal surfaces examined post-operatively with the same camera for still image analysis. In addition, to examine for photobleaching effects in tissue, two opened specimens were examined continuously postoperatively for 20 min at the site of neoplasia and the recording analysed similarly to the in situ rectal recordings (see below).The videos along with similar high-resolution photographs of the opened mucosal surface of any resected specimens ex vivo underwent post-hoc fluorescence intensity (FI) analysis. All imagery contained both the neoplastic lesion and some adjacent normal tissue. Patient demographics and reactions possibly related to ICG usage were recorded prospectively along with the routine pre and postoperative pathological and radiological reports to capture cancer-relevant details.13 after annotation of regions of interest (ROI) on the endomucosal surface regions representing the tumour and adjacent normal tissue (control) avoiding obvious areas of surface blood by a surgeon. Spot mean FI in 25 × 25 pixel areas in the tumour were contrasted with normal mucosa ®, Galway, Ireland . This allowed in-app surgeon-ROI-annotation for tumour and control areas from the white-light (RGB) images prior to the onset of non-zero fluorescence intensities in the NIR images with automatic detection and frame-by-frame tracking of surface feature points in the white light images  to account for the changing pixel locations of these areas due to camera movement. By continuously tracking in the white-light image, the app maps FI in the corresponding pixels of the complimentary NIR image for the ROIs throughout the video duration. Also, following surgeon annotation of tumour versus control ROI, the software can group the dynamic intensity results using K-Nearest Neighbour (KNN) algorithm , a surgeon again postoperatively annotated ROIs as above also avoiding those areas only variably seen over time in the movies. Post-hoc kinetic plotting of FI dynamic patterns of in situ lesions over time, was initially performed using Image-J on grayscale still image stacks serially sampled at one frame per second (fps) from the time of fluorescence signal onset to video end. Thereafter fluorescence measurement was digitalized and automated through the creation of a bespoke, standalone Fluorescence Tracker App (FTA), developed in collaboration with MathWorkssee Fig. . For aut17. An intensity rise of 5 grey units was marked as the end of the latency period and the starting block for the incline. Following the rapid inflow period, the point of maximum fluorescence intensity (Fmax), time to achieve this summit (Tmax) and respective gradient (Fmax/Tmax) were calculated along with the time taken (T½max) to achieve half the maximum (F½max) intensity. Following peak intensity, fluorescence clearance from the target tissue was flagged at 100 s (T100) from the start of the descent  and SPSS Software  version 26 with statistical significance ascribed to p-values less than 0.05. Spot ex vivo FI measurements and dynamic mean values were compared from tumours versus control tissue using Mann–Whitney U. FI signals from in vivo videos were plotted against time and examined for distinctions regarding specific curve milestones and variables adapted from previously described methodologiesIn total, thirty-two patients were recruited into the study (see Table With respect to spot ex vivo intensity measurement (n = 10) late after ICG administration, mean (± standard deviation) cancer intensity was non-significantly raised 57.0 ± 61.3) compared with control (36.0 ± 28.3) (Mann–Whitney U) with considerable overlap of scores suggesting poor discrimination of cancer by single point in time analysis even some hours after ICG administration , were analysed manually by Image J (1 fps) and both these and the next twelve were analysed using the automated FTA. Both manual Image J analysis n = 8) and automated FTA analysis (n = 20) of lesions in situ being dynamically profiled displayed potentially discriminative statistical differences between cancers and benign tumours from their FI temporal signature kinematics. Figure  and automax comparisons showed that the cancer intensity curve zenith (Fmax 202 ± 35.68) was significantly higher than for both the benign tumours  and control tissue  (Mann–Whitney U). With respect to the FTA graphs, three-way analysis using Kruskal–Wallis comparison of cancer, benign and control regions showed significant differences in upslope (gradient from baseline to Fmax p = 0.039) and for both the downslope and fall between Fmax and T100 (p = 0.046 for each). Direct comparison with Mann–Whitney U between cancers and control regions showed that cancers peaked significantly later, took significantly longer to rise from baseline to maximum and exhibited a shallower gradient to the peak. This resulted in a significantly later T100. Skew for cancers was further to the right (− 1.69 ± 1.17 vs − 0.41 ± 1.37 p = 0.04). In comparing cancers with benign lesions, there were also significant differences by T100 in terms of both fall and downward gradient. There was no statistically significant difference in these measures between all lesions together and benign lesions alone compared with the controls.Tables time to rise’ demonstrated on neoplastic tissue (p = 0.041) versus control when these were manually grouped.Within the group analysed by FTA, six cancer cases underwent application of the KNN classification algorithm. With surgeon ROI (lesion and control) selection, the algorithm was able to cluster the data into two groups segregating cancer from normal tissue automatically, in a fashion not significantly different to the manually segregated data (Wilcoxon signed rank resting). However, the automated classification was unable to reproduce the significantly raised ‘3. Notably, it is already impacting decision-making and step-sequencing in reconstructive surgery both of the gastrointestinal tract18 and other tissues19. As well as a means to demarcate watersheds between perfused and non-perfused intestine, other uses include critical boundary identifications such as ureters21 and fascial planes22 by direct instillation. For cancer and draining lymph node identification, ICG has been placed peritumorally submucosally by endoscopic tattoo25. In situ revelation of cancer including tumour margination however requires labelling pathology rather than physiology. While cancerous tissue can retain fluorescent agents, there remains a significant issue with false positive findings27. Because of this lack of sensitivity, most research groups are now focusing on development of new cancer-selective agents although accuracy remains problematic30. Given that cancers likely act to accumulate agents in their vicinity differently to other areas that trap agents more passively, we thought to observe dynamically the processing of ICG by tumours under continuous direct observation different to others who have focused on single point in time observations.Fluorescence-guided surgery is proposed as the next progressive iteration in cancer surgery, especially endo-laparoscopic operations31 but one that seems less relevant in vivo due perhaps to protective effect of tissue and dynamic turnover of dye in the ROI in situ). This desktop post-hoc based assessment of the curve metadata has demonstrated possible discriminative flow milestones and timepoints related to the early phase behaviour of the dye in the peritumoral environment that preludes late stage appearances. While additional distinguishing parameters may also exist and could be identifiable via longer videos enabling analysis of dye processing and efflux patterns and/or by using more sophisticated analytical methods, this initial work is encouraging .In this experience, digital FI quantitative assessment of tumour perfusion angiograms has been demonstrated, controlling too for potential impact due to photobleaching . Such a distinct FI signature could be visually noticed in both grey-scale, composite and threshold modes and could be quantified with post-hoc image data analysis. Manual intensity quantification allowed mathematical comparisons of the FI time patterns although such data generation was labour-intensive while episodic sampling (even at 1fps) made smoothing of data difficult and background noise impaired statistical analysis. Automating feature detection, tracking and quantification enabled higher sampling rates (30fps) and so provided richer data for analysis with processing time being a function of computational ability rather than human labour.32. In lesions where biopsy is still indicated, the fluorescent signal profile could indicate the site of most relevant yield re cancer detection. With regard to visible lesions, the key issue to discriminate is cancer versus not cancer and so benign tumor behaviour being similar to normal tissue fits the clinical paradigm re lesion management.While further work needs to be done these findings are of great potential clinical relevance. The ability to optically characterize neoplasia through its biological hallmark behaviours could help optimize clinical diagnostic pathways by immediately indicating the nature of lesion and facilitate, in cases of benign aetiology, immediate local excision (or conversely caution such an approach in lesions with benign appearances but containing an invasive focus). Avoidance of biopsy is increasingly advocated in these cases as such an act can introduce architectural distortion in the samples and induce fibrosis in the residual lesion 33. Detailed region by region biopsy collated to continuous FI perfusion criteria may too yield digital tumour margin delineation and heterogeneity appreciation. Greater patient numbers is of course needed too and, with early proof of principle now provided, a larger clinical study is now ongoing to develop and validate these findings 32 while AI methods are also being developed to enable real-time deployment34.To be maximally useful however this work of course necessitates future effort translating our dataset into a classifier which would allow validation against a gold standard such as histopathology. In this regard, KNN clustering showed encouraging discriminative abilities and which may be refined with further artificial intelligence methodologies37. As ICG can be seen in this experience to passively concentrate in tumours, it seems likely that so too will, at least in part, a “cancer-specific” agent. Such internalisation mechanisms could prove advantageous in performance over cell-surface or ligand-specific agents which could be limited in applicability due to variance in intra and inter-tumour target expression. It is likely also that the ICG uptake mechanisms through cancer pathophysiology seen here are shared across other common cancers and could extend to sites of regional spread and metastatic disease.Cell-specific targeting remains of great interest for future advances in this area but a deep understanding of tumoural functional characteristics is necessary to best inform the purpose and level of probe engineering needed. ICG accumulates quickly and can be effectively imaged with a variety of commercial cameras and so there is much to be learned from this study for new agent development. Its non-specific tumour uptake mechanisms include enhanced permeability and retention (EPR), aberrant gap junctions and dysregulated pinocytosis38 or injury will equally be prone to incidental, unintended probe accumulation. This indicates that a relatively high rate of false positive findings may continue despite any additional tumour targeting features. Rigorous preclinical and clinical study controls are required to minimize heuristic mechanistic targeting assumptions. While long-in-advance (24–48 h) administration of the fluorophore has been proposed to offset non-cancer signalling , a significant downside exists with respect to the unpredictability of operative timing and patient-to-patient pharmacokinetic variances.While cancer cell selectivity can be engineered in cell culture, tumour imaging in vivo encompasses a variety of host:cancer interactions as well as additional cell signalling and response pathways. Furthermore, additional unrelated sites of inflammation39.An inbuilt synchronous and continuous dynamic quantification algorithm and screen display can be of use to all fluorescence imaging agents and could even enable synchronous use of multiple probes of different wavelength colours. Addition of cancer-specific targeting could still accelerate agent accumulation at the ROI following systemic distribution, enabling short-window observations with the greatest sensitivity and specificity possible within minutes. This would be of use for the operator more akin to episodic perfusion assessment with the added biochemical, biological and imaging complexity hidden. “Off–on” fluorogenic compounds are especially attractive for this purpose as their signalling only switches on when they arrive at the appropriate microenvironment40. Furthermore, while other surgical camera manufacturers offer similar systems for ICG visualization by NIR, camera design and performance investigation has shown previously significant inter-manufacturer variation between signal and ICG concentration (including the tendency of some systems to boost the images for human interpretation) which limits the generalizability of these findings until further (ongoing) validation is performed41. While selection of the specific timepoints for analysis (e.g. 100 s post-peak timepoint) is somewhat arbitrary, they do provide milestones for statistical analysis enabling comparisons between lesions and adjacent healthy tissue as control. Statistical curve analysis is currently not calculated in real time and is limited to one curve per ROI. Simultaneous synthesis and dissection of multiple curves may further discern tumour heterogeneity. Although the automatic classifier diminished the differentiation ability of our metrics when compared to surgeon-based classification, better classification algorithmic methods may to some extent replace operator input. Other tracking algorithms exist and further software development may address field of view interruptions.This study is of course limited by the small cohort studied although has the strength that patients were recruited into the study without arbitary preselection. Fluorescence data is also dependent on the recording of the detected fluorescence signal. Video stability, suctioning, instrumentation and tumour oozing/desloughing impaired continuous tracking and required further user interaction. The distance and angulation of the camera as well as the depth of ICG have been found to influence the signal and need consideration in further protocols42.This endeavour has nonetheless shown the feasibility of ICG with NIR-illumination for continuous quantitative FI assessment. Software assessment of these perfusion curves has yielded metadata which could potentially be used to identify cancer in human patients. The previous focus on spot readings may alleviate the need for concurrent injection and recording but has overlooked the potential for incorporating dynamic ICG flow patterns to improve confidence of interpretation. Equally incorporation of computer-assistance can help and even potentially replace the need for human observer visualization promising near real-time assessment of lesions during procedures with minimal user interaction as a ‘digital biopsy’ enabled through advances in computer processing, artificial intelligence and broad cloud-based datasets


Background: Activation of the mTOR signaling pathway is ubiquitous in cancers and a favourable therapeutic target. However, presently approved mTOR inhibitor monotherapies have modest benefits in labeled indications while poor outcomes have been reported for mTOR inhibitor monotherapy when administered in a label-agnostic setting based on univariate molecular indications. The present study aimed to determine whether patient-specific combination regimens with mTOR inhibitors and other anticancer agents selected based on multi-analyte molecular and functional tumor interrogation  yields significant treatment response and survival benefits in advanced or refractory solid organ cancers.Methods: We evaluated treatment outcomes in 49 patients diagnosed with unresectable or metastatic solid organ cancers, of whom 3 were therapy naïve and 46 were pre-treated in whom the cancer had progressed on 2 or more prior systemic lines. All patients received mTOR inhibitor in combination with other targeted, endocrine or cytotoxic agents as guided by ETA. Patients were followed-up to determine Objective Response Rate (ORR), Progression Free Survival (PFS) and Overall Survival (OS).Results: The Objective Response Rate (ORR) was 57.1%, the disease Control rate (DCR) was 91.8%, median Progression Free Survival (mPFS) was 4.9 months and median Overall Survival (mOS) was 9.4 months. There were no Grade IV treatment related adverse events (AEs) or any treatment related deaths.Conclusion: Patient-specific combination regimens with mTOR inhibition and other anti-neoplastic agents, when selected based on multi-analyte molecular and functional profiling of the tumor can yield meaningful outcomes in advanced or refractory solid organ cancers.Trial Registration: Details of all trials are available at WHO-ICTRP: https://apps.who.int/trialsearch/. RESILIENT ID CTRI/2018/02/011808. ACTPRO ID CTRI/2018/05/014178. LIQUID IMPACT ID CTRI/2019/02/017548. Since at cancer . Likewist cancer  owing tot cancer .It is accepted that tandem therapeutic targeting of multiple signaling pathways can lead to improved outcomes in cancer . The mTOAlthough the potential benefits of Everolimus in combination with chemotherapy agents have been hypothesized in various cancers, the benefits of such regimens in a refractory setting has not yet been demonstrated. Further, selection of chemotherapy agents for such combination regimens have been largely derived from Randomized Clinical Trials (RCT) or Standard of Care (SoC) guidelines rather than via patient-specific evaluation of drug resistance or sensitivity in respective tumors. The benefits of the latter approach lie not only in identifying relevant drugs with higher antitumor activity  but alsode novo combination treatment regimens has been previously demonstrated  for identifying vulnerabilities in advanced refractory cancers (ARC) and their targeting with personalized nstrated . Here, wThis manuscript reports data from a subset of patients from three prospective interventional phase II/III trials, including RESILIENT (CTRI/2018/02/011808), ACTPRO (CTRI/2018/05/014178) and LIQUID IMPACT (CTRI/2019/02/017548) who received mTOR inhibitor-based treatments. The primary outcome data for the RESILIENT Trial has already been published . The outBetween Jan 2018 and Jun 2019, 37 patients with advanced solid organ cancers received treatments with mTOR inhibitors in combination with other systemic anticancer agents as part of various prospective interventional clinical trials conducted by the study sponsor. All study participants were previously counseled regarding study objectives, potential benefits and potential risks and provided signed written informed consent for participation in the trial and for publication of deidentified data. Between Jan 2018 and Dec 2018, 12 patients underwent ETA as a commercial service to inform precision systemic therapy options for advanced broadly refractory solid organ tumors and received treatments with mTOR inhibitors in combination with other systemic anticancer agents. Treatment outcomes were available in these patients and were hence considered for analysis. All patients consented for analysis and publication of deidentified data. Outcome data for these patients are reported.in vitro chemoresponse profiling (CRP) of viable tumor tissue derived cells (TDCs) or Circulating Tumor Associated Cells (CTACs) from peripheral blood. Both cytotoxic anticancer agents as well as mTOR inhibitors were evaluated by CRP where viable TDCs/CTACs were treated in vitro with standardized concentrations of anti tumor agents and the proportion of cell death was measured. Next Generation Sequencing (NGS) analysis of tumor tissue DNA or peripheral blood circulating tumor DNA (ctDNA) using a targeted gene panel (452 or 411 genes) was performed to identify molecular alterations in the mTOR pathway genes that are known to be indicative for selection of mTOR inhibitor as well as molecular alterations to select appropriate targeted and endocrine agents. Finally, Immunohistochemistry (IHC) profiling of tumor tissue was used to determine expression of Estrogen Receptor (ER) and Androgen Receptor (AR) for selection of Endocrine agents. ETA findings were integrated to generate patient specific treatment recommendations which were shared with the treating oncologist.The process of ETA and generation of patient specific therapy recommendations have been described previously  and is aAll patients received individualized combination regimens with mTOR inhibitors and other targeted, endocrine or cytotoxic drugs which were informed by ETA findings. Among 39 patients where the combination regimen included ≥1 cytotoxic agents, the choice of single or multiple cytotoxic agents was based on reported safety information (AE profiles) of each individual cytotoxic agent (labeled toxicity), as well as phase I trial data of safety and toxicity of combinations. This safety information was used to anticipate/predict patient-wize expected AEs which was referred to while determining the appropriate starting dose as well as dose escalation in each patient. In all patients, the treatment agents were initially administered at lower (≤50%) doses, and were escalated based on an individualized dose escalation schedule. Other factors which guided patient-specific dosage and schedule included institutional guidelines and protocols as well as clinical assessment of the patients’ health. As per the treatment plan in the trials, patients were to be administered treatments until progression or death or dose limiting toxicity. Patients who showed durable response were maintained with suitable dose reduction as decided by the treating clinician. For non-trial patients, schedule and duration were determined by the treating clinician based on clinical assessment of patients’ health.Treatment response was assessed in all patients based on a baseline and follow-up radiological imaging (CT/PET-CT) as per RECIST 1.1 criteria  to deterPatients were followed up until study termination or patient exclusion  or until December 2020, to determine Progression Free Survival (PFS) as well as Overall Survival (OS). Post completion of study, patients were followed-up every 6 months for OS only. Patients who were not part of the clinical trials underwent follow-up imaging scans at intervals specified by the treating clinicians.Treatment related AEs were prospectively obtained for trial patients during the trial. Treatment-related AEs for non-trial patients were obtained from patients’ clinical records which were provided by the treating clinician. All AEs were graded according to NCI-CTCAE v5  and repoThe present manuscript reports outcomes in 49 patients  who received mTOR inhibitor-based treatment regimens informed by ETA . This con = 20), cytotoxic and other targeted/endocrine agents (n = 19), or ≥1 targeted or endocrine agents (n = 10). In this cohort, seven patients were AR+, three patients were ER+ and two patients were AR+, ER + by IHC. All anticancer drugs in the combination treatments were approved by the United States FDA for use as antineoplastic agents. Selection of all treatment agents (including mTOR inhibitors) was agnostic to the respective labeled indications. Patient-wize drugs and regimens are provided in All patients were administered mTOR inhibitors as part of multi-drug regimens where the combinations included either ≥1 cytotoxic agent  showed Complete Response (CR), 27 (55.1%) showed Partial Response (PR), 17 (34.7%) showed SD and 4 (8.1%) patients showed PD. The Objective Response Rate (ORR) in this sub-cohort was 57.1% and disease Control Rate (DCR) was 91.8%. Patient outcomes are summarized in Among 20 patients who received mTOR inhibitors in combination with cytotoxic agents (mTOR_C), PR was observed in 10 patients (50%). Among 29 patients, the combination regimen included an additional targeted or endocrine agent  for tandem blockade of other signaling pathways; 18 of these patients (62.1%) showed PR. Within these 29 patients, PR was observed in 6/10 (60%) patients where AR/ER was targeted in tandem with mTOR, 5/9 (55.5%) patients where the VEGF signaling pathway was a tandem target and in 6/9 (66.7%) patients where the EGFR/ERBB2 pathway was targeted along with mTOR.n = 49) reported median PFS (mPFS) and median OS (mOS) of 4.9 months (95% CI: 3.6–6.2) and 9.4 months (95% CI: 6.6–12.2) respectively. The PFS rate and OS rate at 12 and 24 months were ∼60 and ∼35% respectively. The mPFS, PFS rates, mOS and OS rates in the various regimen subtypes are summarized in The study patients (The molecular landscape of mTOR pathway associated genes in the study cohort as determined by NGS is depicted in There were no grade IV treatment related Adverse Events (AEs) or any treatment related deaths. Grade III treatment related AEs were seen in 34 patients. The most common grade III treatment related AEs were Fatigue (27%), Anorexia (11%) and Oral Mucositis (8%) which were managed by administration of standard treatment modalities Hyperglycemia which has been previously reported in mTOR regimens was observed in one patient. Patient-wize AEs are provided in The study outcomes support the hypotheses of the study that ETA-guided combination regimens of mTOR inhibitors with other anti-neoplastic agents can achieve meaningful response in advanced refractory cancers especially when such combinations include other targeted/endocrine agents for tandem blockade of other tumor-associated signaling pathways. While PFS rates were higher in combination regimens that included another targeted agent , the OS rates were similar across all therapy regimen subtypes indicating that mTOR inhibitors in combination regimens offer OS benefits while tandem targeting of additional tumor pathways yields PFS benefits as well apart from to OS benefits. It is generally accepted that subsequent lines of anticancer treatments are associated with decreasing probability of success. However. among patients who received ETA-guided combination regimens, there was an almost doubling of the PFS (PFS2:PFS1 ratio) indicating significant therapeutic benefit to patients. The authors acknowledge that the instances of censored PFS may underrepresent the actual extent of benefit. However, the recorded data indicate a significant median advantage despite censored observations; since therapy was ongoing in several patients, eventual improvements to these ratios are anticipated. We hence conclude that ETA guided combination regimens can provide significant PFS improvements even in heavily pre-treated populations. The response and survival benefits indicate the ability of ETA guided combination treatments to exploit known targetable vulnerabilities as well as to overcome known resistance variants. The present outcomes are remarkable in context of the PFS and ORR reported for the mTOR arm in the SHIVA trial , as welln = 24, 48.9%), loss of PTEN gene function via SNV or CNA . Deleterious SNV/CNA in multiple mTOR pathway genes were also observed in some patients . The present study does not aim to establish the predictive efficacy of these mTOR pathway variations for mTOR inhibitor selection or treatment response; the profile of (detected and undetectable) molecular variants in the known mTOR pathway genes suggests the role of additional hitherto unidentified genes and gene-variants linked to resistance or response toward mTOR inhibitors. Molecular alterations (SNV and CNV) of unknown significance in mTOR pathway genes were detected in 9 cases. These variations are speculated to be probable indications, which may be confirmed based on future insight into the phenotypic consequence (gain/loss of function) of these variations.Presently, apart from Alpelisib, selection of other mTOR inhibitors is not based on molecular indications. Prior attempts to match variations in mTOR pathway genes with label-agnostic mTOR blockade  have reported largely discouraging outcomes. Several variations are associated with mTOR activation such as alterations in the AKT (1/2/3), PIK3CA and PTEN genes besides the mTOR gene itself . Among tin vitro CRP of cell lines or primary tumor cellsy  with in vitro and largely in vivo response to mTOR inhibition, but where the tumor harbored no known alterations indicative of mTOR activation.Prior attempts to identify potentially synergistic and safe anticancer drug combinations  as well r cellsy  reflect de novo drug combinations. The safety profile of multi-drug anticancer regimens especially those with combinations of targeted and cytotoxic agents has been discussed at length in prior meta analyses (de novo (targeted and cytotoxic) drug combinations in most patients with manageable profiles of adverse events (AEs). It is generally agreed that although the actual profile of Adverse Events (AEs) in any given patient cannot be accurately predicted, the commonly occurring AEs associated with each drug or combinations can be anticipated. The profile of AEs shows that even though this heavily pretreated cohort was at an inherently higher risk of AEs due to cumulative toxicities from prior treatments, ETA guided therapies were generally well tolerated with a manageable toxicity profile  heavily pretreated cohort of patients with acceptable toxicity profile.We demonstrate that patient-specific combination regimens which achieve mTOR blockade and tandem targeting of other tumor vulnerabilities not only lead to favourable outcomes in advanced refractory cancers but also had manageable toxicity profiles. While prior attempts to expand the scope of mTOR inhibitor monotherapy in an organ agnostic setting based on univariate molecular profiling have been largely successful, we show that personalized combination regimens based on multi-analyte tumor profiling can yield significant and meaningful treatment benefits in various solid organ cancers. This is a viable pan-cancer treatment strategy since it overcomes the limited efficacy of mTOR inhibitors as well as the drug-resistance associated with activation of mTOR.


Scientific reports 10.1038/s41598-021-97868-2, published online 15 September 2021Correction to: The original version of this Article erroneously included preview URL in Data availability section.http://proteomecentral.proteomexchange.org) via the jPOST partner repository (https://jpostdb.org) with the data set identifier PXD021851 . The other datasets generated during or analyzed during this study are available from the corresponding author on reasonable request.""The MS raw data and analysis files have been deposited in the ProteomeXchange Consortium  via the jPOST partner repository (https://jpostdb.org) with the data set identifier PXD021851. The other datasets generated during or analyzed during this study are available from the corresponding author on reasonable request.""The MS raw data and analysis files have been deposited in the ProteomeXchange Consortium (The original Article has been corrected.


Repetitive transcranial magnetic stimulation (rTMS) is a promising approach for post-stroke rehabilitation but there lacks a rationale strategy to plan, execute, and monitor treatment. We present a case of targeted rTMS using the Omniscient Infinitome software to devise targets for treatment in a post-stroke patient and describe the functional connectomic changes after treatment. A 19-year-old female with no medical history presented 19 months after suffering a left middle cerebral artery (MCA) superior division ischemic stroke, resulting in language impairment and diminished right upper extremity motor function. She underwent a resting-state MRI (rsMRI) with tractography and images were processed using the Omniscient Infinitome software. Analysis using the anomaly detection within the software enabled us to identify three targets for rTMS . These areas were treated with 25 sessions of intermittent Theta Burst Stimulation (iTBS) over five days at 80% of motor threshold concomitantly with targeted physical therapy and speech therapy. At five months follow-up, her language and right upper extremity functions significantly improved. Her connectomic analysis revealed substantial neural changes, including normalization of the sensorimotor network, substantially thicker callosal fiber bundle connecting the two hemispheres, and increased cortical recruitment in her language network. We present the first description of robust connectomic alterations in a post-stroke patient following targeted rTMS treatment. Further studies on the use of rTMS with an emphasis on functional connectomics are warranted. Ischemic strokes are a leading cause of disability in the world . The socRepetitive transcranial magnetic stimulation (rTMS) has been investigated as a treatment adjunct to hasten neurorehabilition ,4. It isWe report a case of rTMS used for post-stroke neurorehabilitation in a young female in conjunction with a novel, cloud-based software (Omniscient Infinitome) that provides detailed network maps of her functional connectomes. We demonstrate the utility of this software in selecting rationale rTMS targets and demonstrating changes in fiber tracts after intervention.The patient was a 19-year-old right-handed female without any past medical history who suffered an ischemic stroke, resulting in extensive cystic encephalomalacia and gliosis in the territory of the cortical branches of the superior division of the left middle cerebral artery (MCA)  chosen as targets in the same fashion using the abnormality detector with the goal to further improve her right upper extremity dexterity (functional outcome in Figure Repetitive TMS has shown promise in improving functional outcomes in patients struggling to recover from ischemic strokes over conventional therapy alone . In the Neuroplasticity associated with the recovery and associated changes in tractography have been previously demonstrated in post-stroke patients . Tract iOutside of the confines of a single case report, we acknowledge the fact that this patient had several advantages that may have positively influenced her outcome. Aside from her young age and presumably more robust neuroplasticity, her relative independence allowed her to participate in therapy . FurtherWe report a case of robust connectomic alterations in a chronic post-stroke patient following rTMS treatment. It suggests that individualised iTBS treatment guided by anomaly detection algorithms could be a successful modality to improve speech and motor outcomes long-term, even in stroke patients who have seen no improvement in their condition for over a year. Further studies on the use of rTMS with an emphasis on functional connectomics are warranted.


Angiographically confirmed complete surgical excision of brain arteriovenous malformations (bAVMs) is conventionally considered curative. Recurrence in adults is rarely encountered; only 18 cases have been reported in the English literature over the past 30 years. The potential for recurrence and consequent need for routine long-term follow-up are important considerations in the management of these lesions. We report a case of a 23-year-old female with a recurrent bAVM discovered incidentally on routine imaging three years after complete surgical excision. We review the existing literature and discuss the options for surveillance and management. Brain arteriovenous malformations (bAVMs) are congenital anomalies of dysplastic blood vessels with direct connections between arteries and veins without intervening capillaries which form a tangle of abnormal dilated channels called a nidus. Most of these lesions are discovered incidentally during imaging for other indications; symptomatic bAVMs most commonly present with haemorrhage and seizures -3. bAVM A 23-year-old right-handed lady with no medical history presented in April 2017 to a district general hospital with acute onset left brachiofacial hemiparesis. A computed tomography (CT) scan of the brain showed a right frontal intraparenchymal haematoma Figure  and CT aShe was taken to theatre emergently for decompressive craniectomy, evacuation of the haematoma and excision of the bAVM. Intra-operative indocyanine green (ICG) angiography revealed two main arterial feeders on the cortical surface and one main draining vein to the superior sagittal sinus. The bAVM was excised en-bloc and post-excision ICG showed no remnant which was confirmed on immediate post-operative DSA Figure .She was transferred to our rehabilitation centre 19 days after surgery. While undergoing rehabilitation she had a generalised seizure attributed to scar epilepsy which was controlled with levetiracetam. She recovered well; her Functional Independence Measure (FIM) score improved from 28 to 108, and she had a cranioplasty implant four months later. She remained clinically well on six-monthly follow-up apart from another seizure in June 2018. A non-enhanced CT showed no haemorrhage and she had no further seizures after the dose of levetiracetam was increased. A routine CTA in August 2020 showed partial recanalization of the same bAVM nidus, now supplied via tiny right middle cerebral artery (MCA)  cortical branch(es) with venous drainage towards the superior sagittal sinus Figure .In light of her age and good functional status, repeat surgical resection was recommended although the option of stereotactic radiosurgery was also offered. After consulting with a radiosurgeon, she decided to proceed with surgical resection. A stereotactic CTA repeated in February 2021 showed stable size of the bAVM. She underwent resection of the recurrent AVM in March 2021 with stereotactic navigation via CTA. Intra-operatively, small cortical feeders were seen which were taken circumferentially; no large draining vein was identified. Post-operative day 1 CTA showed no remnant bAVM Figure . She hadbAVM recurrence in adults after angiographically demonstrated complete excision is a rare phenomenon. Only sporadic case reports/series exist; just 18 cases have been reported in the English literature over the last 30 years  have been found in adult samples , and higThere is little evidence to guide the duration, schedule and modality of follow-up imaging in adult patients after complete surgical resection; there is no consensus even in the paediatric literature ,31. BaseThe appropriate treatment strategy is similarly poorly established, and the risk of re-rupture of these recurrent bAVMs is unknown. Just over half the adult recurrences were treated by surgical excision, stereotactic radiosurgery (SRS) was the next most common option. A systematic review in 2018 that included paediatric cases found that surgery (59%) and SRS (37%) were the most common methods of treatment  and a rebAVM recurrence in adults after complete surgical resection is a rare but potentially important phenomenon. Routine follow-up imaging over an extended duration may be warranted, especially in cases with one or more risk factors for recurrence. New or progressive clinical manifestations should similarly trigger vascular imaging. Non-invasive imaging modalities may be a viable alternative to DSA for surveillance. Repeat surgical excision and SRS were the most common methods of treatment.


METHODS/STUDY POPULATION: Lysates were prepared from BAL cells isolated from horses with no, mild/moderate and severe EAS. Relative MARCKS protein levels were determined using equine specific MARCKS ELISA (MyBioSource). Cultured BAL cells were pretreated with a MARCKS inhibitor peptide (MANS), control peptide (RNS) or vehicle control and stimulated with zymosan for 5 hours. Reactive oxygen species levels were determined by luminescence to evaluate respiratory burst. Data were analyzed by One-way ANOVA (p<0.05). RESULTS/ANTICIPATED RESULTS: We determined that normalized MARCKS protein expression is significantly increased in BAL cell lysates from horses with mild/moderate or severe EAS, compared to horses with normal BAL cytology. Preliminary findings also suggest that MANS treatment of zymosan-stimulated equine BAL cells ex vivo attenuates levels respiratory burst. DISCUSSION/SIGNIFICANCE OF IMPACT: These findings point to a possible role for MARCKS protein in the pathophysiology of EAS and support MARCKS inhibition as a potential therapeutic strategy.OBJECTIVES/GOALS: Asthma is a significant health concern that affects people of all ages worldwide. EAS demonstrates many of the pathophysiological characteristics of nonatopic human asthma, which has led EAS to be used as naturally occurring model. Previous work from our lab determined that MARCKS (Myristoylated Alanine Rich C Kinase Substrate) protein is an essential regulator of cellular inflammatory functions. In the current study, we hypothesized that MARCKS levels would be increased in BAL cell lysates from horses with EAS, and that inhibition of MARCKS in zymosan-stimulated BAL cells (


We demonstrate a 31% reduction in the RMS error for the predicted 17O Cq values relative to standard plane-wave methods using a carefully constructed test set comprised of 22 oxygen-containing molecular crystals. We show comparable improvements in accuracy using five different hybrid density functionals and find predicted Cq values to be relatively insensitive to the choice of basis set used in the single molecule calculation. Finally, the utility of high-accuracy 17O Cq predictions is demonstrated by examining the disordered 4-Nitrobenzaldehyde crystal structure.Modern approaches for calculating electric field gradient (EFF) tensors in molecular solids rely upon plane-wave calculations employing periodic boundary conditions (PBC). In practice, models employing PBCs are limited to generalized gradient approximation (GGA) density functionals. Hybrid density functionals applied in the context of gauge-including atomic orbital (GIAO) calculations have been shown to substantially improve the accuracy of predicted NMR parameters. Here we propose an efficient method that effectively combines the benefits of both periodic calculations and single-molecule techniques for predicting electric field gradient tensors in molecular solids. Periodic calculations using plane-wave basis sets were used to model the crystalline environment. We then introduce a molecular correction to the periodic result obtained from a single-molecule calculation performed with a hybrid density functional. Single-molecule calculations performed using hybrid density functionals were found to significantly improve the agreement of predicted  Solid-state nuclear magnetic resonance (SSNMR) spectroscopy has proven highly effective at characterizing molecular crystals. Advances in NMR hardware and the development of novel pulse sequences continue to improve the accuracy and availability of experimental data. However, mapping relationships between NMR observables and structural features remains a formidable challenge. SSNMR investigations are often coupled with X-ray diffraction and first-principals calculations to form the interdisciplinary field of NMR crystallography. The success of NMR crystallography has been greatly facilitated by the availability of accurate computational methods for predicting NMR parameters which typically employ density functional theory (DFT) .There are two broad classifications for DFT-based methods commonly applied to molecular crystals. First, the gauge-including projected augmented wave (GIPAW) method  employs 1H, 13C, 15N and 51V nuclei have shown fragment methods with hybrid density functionals improve the accuracy of predicted isotropic chemical shifts . Numerous studies have shown that using hybrid density functionals improves the accuracy of predicted NMR parameters . Previoul shifts . Fragmenl shifts  and pred for 14N .Recently, a novel approach involving GIPAW with a molecular correction (GIPAW + MC) was put forward for modeling the chemical shift tensor . This sc17O nucleus  to CS tensors has proven particularly effective in modeling NMR parameters for the quadrupolar  nucleus . Specifito GIPAW . Improvito GIPAW .17O environments. We demonstrate a 31% improvement in the accuracy of predicted Cq values relative to traditional plane-wave methods with a negligible increase in computational cost. These findings are particularly promising for NMR crystallography applications given the crucial role EFG tensor predictions have come to play in crystal structure refinement  series of basis sets. The performance of six commonly used density functionals are compared to demonstrate uniform improvement in accuracy through the application of a range of hybrid density functionals in the molecular calculation. We examine the relative improvement in EFG and CS tensor GIPAW calculations through the application of a molecular correction. Finally, GIPAW + MC EFG calculations are shown to accurately predict Cq values for the disordered oxygen atoms in the 4-Nitrobenzaldehyde crystal structure.In the following, benchmark data are employed to examine basis set convergence and the accuracy of the predicted V resulting from the charge distribution surrounding the nucleus.The EFG tensor is obtained from the second spatial derivative of the electrostatic potential V33|≥|V22|≥|V11|. The principal components of the EFG tensor are used to derive two NMR observables. First, the nuclear quadrupolar coupling constant Cq is obtained from V33 according to,e is the elementary charge, Q = −25.58 mb  is constructed from three separate calculations as follows,Minor structural changes can have a pronounced impact on both ly local , and theFirst, the EFG tensor is computed using a full plane-wave GIPAW calculation at the lower level of theory  to obtain Vmol terms rely on isolated gas-phase molecule calculations. Finally, the corrected EFG tensor is then subject to diagonalization to obtain the principal components which are used along with According to Cq values  chemical shielding calculations were performed using the optimized geometries. Calculations were performed using CASTEP  with ther nuclei . Full spωB97XD (n (n = 1–4) basis sets were used to determine if the accuracy of predicted Cq values could be improved using basis sets optimized for predicting NMR parameters. The Dunning-type and pcs-n basis sets where obtained from the basis set exchange   .17O EFG tensor parameters with those obtained experimentally from NMR and NQR spectroscopy. We have selected the quadrupolar 17O nucleus for two reasons. First, 17O has tremendous biological and pharmaceutical importance. Second, previous GIPAW + MC studies involving the CS tensor showed the largest magnitude improvement in predicted isotropic shieldings for 17O relative to other second-row nuclei  and those obtained from the GIPAW + MC calculations. In most cases, the sign of Cq cannot be determined from the NMR experiment therefore we provide the magnitudes of the predicted Cq values and report the absolute error (in MHz) relative to experiment.We have selected 22 crystal structures with 46 unique Cq values obtained from GIPAW + MC calculations relative to traditional GIPAW. Specifically, introducing a molecular correction carried out at the PBE0/cc-pCVTZ level reduces the RMS error by 31% and reduced the maximum absolute error by 26%. The choice of density functional and basis set used in the preliminary analysis was motivated by previous studies . To ensure convergence extends to all principal components we examine the deviation in all three principal components obtained from PBE0/pcs-n EFG tensor predictions for n = 1–3 relative to pcs-4. V33| (red), |V22| (blue), and |V11| (green) relative to pcs-4 calculations applied to the benchmark set. The largest RMS deviations were observed for the largest EFG tensor component, V33, followed by V22, and V11 yields the smallest deviation. Together, ζ basis sets. These findings are in agreement with previous work involving Dunning-type basis sets  uniformly improve the accuracy of predicted dictions . Extendidictions  yields tto TPSSh . Minor dto TPSSh .17O NMR parameters are highly sensitive to crystalline lattice effects  level and standard linear regression methods were used to map the predicted absolute shieldings to experiment. The details of the 17O regression models along with the experimental and calculated CS tensor data are provided in the supporting information.Based on the success in predicting 17O Cq values, isotropic shieldings (σiso) and the CSA tensor elements (σii). The RMS error for the 17O isotropic chemical shift predictions is 11.53 and 9.35 ppm for GIPAW and GIPAW + MC, respectively. This corresponds to a 19% relative improvement for GIPAW + MC which is in agreement with previous work (17O CSA tensor elements by 4% (19.88 ppm for GIPAW compared to 18.99 ppm for GIPAW + MC). These results are influenced by the larger variation in experimental uncertainties for isotropic shifts and CSA tensor elements . However, the GIPAW Cq predictions in Cq predictions which bracket the experimental value. This results in a weighted average of the GIPAW + MC predicted Cq values which more closely matches experiment relative to either structure examined in isolation.The predicted Cq values, we have shown the molecular correction improves the accuracy of predicted 17O CSA tensor elements. Comparing the relative improvement obtained through introducing a molecular correction to both EFG and CS tensor predictions we find a larger improvement in the accuracy of predicted EFG tensors. Finally, we apply GIPAW + MC EFG tensor calculations to the disordered crystal structure of 4-Nitrobenzaldehyde and show the molecular correction improves resolution between the different crystal geometries present in the disordered crystal (In summary, the present work establishes the GIPAW + MC method as a simple yet powerful approach for improving the accuracy of traditional plane-wave EFG tensor calculations. Introducing a correction based on the EFG tensor computed on an isolated monomer using a hybrid density functional substantially improves the accuracy of GIPAW calculations. The molecular correction is relatively insensitive to the choice of basis set, ensuring the cost of the molecular correction is a small fraction of the corresponding GIPAW calculation. In addition to improving the accuracy of predicted  crystal .


Left ventricular (LV) thrombus is a complication of acute myocardial infarction and is associated with systemic thromboembolism. We describe a trans-aortic endoscopic approach to the removal of an LV thrombus in a patient undergoing concurrent coronary artery bypass grafting and aortic valve replacement.A 47 year old male presented following an embolic middle cerebral artery stroke and underwent transthoracic echocardiography demonstrating a mobile LV thrombus. Additional investigation revealed a moderately stenosed bicispid aortic valve, two vessel coronary artery disease and ischemic cardiomyopathy. The patient underwent early surgery to reduce the risk of further embolic episodes. A trans-aortic approach was utilized with videoscopy and single shafted instrumentation to aide in removal of the thrombus. The patient then underwent aortic valve replacement and coronary artery bypass grafting.We report an alternative technique for the removal of a left ventricular thrombus in a patient undergoing concurrent coronary and aortic valve surgery. The transaortic video-assisted approach provided excellent visualisation of the apex and near complete removal of the thrombus without damaging the surrounding trabeculae. The main benefit of this technique is sparing of LV tissue, thereby preserving left ventricular function. Left ventricular (LV) thrombus is a complication of acute myocardial infarction (MI) and is associated with systemic thromboembolism , 2. It oWe describe a patient with severe two vessel disease, ischemic cardiomyopathy and moderate bicuspid aortic stenosis diagnosed after an admission with a left middle cerebral artery (MCA) stroke. Transthoracic echocardiography demonstrated a mobile thrombus. Given the high risk of further embolic sequalae, the patient underwent surgical removal at the time of aortic valve replacement and coronary artery bypass grafting to reduce the patients risk of further stroke.A 47-year-old male presented following acute onset right upper limb weakness and expressive dysphasia. The past medical history included well controlled epilepsy and hypertension. There was no history of diabetes mellitus, hypertension or previous smoking. Urgent CT angiography of the head and neck demonstrated a distal left MCA embolic stroke. Transthoracic echocardiography demonstrated left ventricular dilatation with severe systolic dysfunction (left ventricular ejection fraction [LVEF] 25%). Mobile thrombus was noted at the apex of the left ventricle, measuring 14 × 12 mm , demonstrated the frontal lobe infarct with no evidence of further haemorrhagic transformation. Apixaban was discontinued and the patient commenced on intravenous heparin in preparation for surgery.The patient underwent surgery via median sternotomy and the left internal mammary artery (LIMA) was harvested as an in-situ pedicle graft. The left radial was harvested as a free graft. Systemic heparinisation commenced and cardiopulmonary bypass was instituted with bi-caval and distal ascending aortic cannulation. The left ventricle was vented via the right superior pulmonary vein. The aorta was cross clamped and the heart arrested via anterograde and retrograde cold blood cardioplegia. This was repeated at regular intervals to provide myocardial protection.Intra operative transesophageal echocardiography confirmed a bicuspid aortic valve with moderate aortic stenosis, severe left ventricular dysfunction and apical left ventricular thrombus with a mobile component Fig. . The aorOn review six weeks following surgery there was no evidence of left ventricular thrombus. The aortic valve appeared well seated and there was mild paravalvular aortic regurgitation. There was no residual sequelae from his previous stroke.Left ventricular thrombus is a recognised complication following acute MI, and can occur as frequently as in 25% of patients following an anterior MI . TransthRemoval of these thrombi via a left ventriculotomy is feasible, however cases of this approach have been reserved for patients with a concurrent ventricular aneurysm requiring repair . The conCase studies report the use of videoscopy to visualise intra-cardiac structures and to assist in excision of left ventricular lesions as a viable alternative to a ventriculotomy. A systematic review by Soylu et al. summarises a total of 34 studies incorporating 54 patients where left ventricular cardiac tumours were removed with the use of videoscopic devices . The majWe report an alternative technique for the removal of a left ventricular thrombus in a patient undergoing concurrent coronary and aortic valve surgery. The transaortic video-assisted approach provided excellent visualisation of the apex and near complete removal of the thrombus without damaging the surrounding trabeculae. The main benefit of this technique is sparing of LV tissue, thereby preserving left ventricular function.


A 54-year-old man presented with severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) positivity after experiencing flu-like symptoms. His condition progressed to acute respiratory failure, and he was placed on mechanical ventilation. Chest computed tomography (CT) showed bilateral ground-glass opacities with mild reticulation A. The pa-Diffuse pulmonary ossification is a rare chronic process characterized by the formation of small mature bone fragments in the pulmonary parenchyma. It is classified as nodular or dendriform, with the former usually occurring in the context of chronic congestion. DPO is an interstitial process that occurs in the setting of fibrosing interstitial lung disease. It may evolve with osseous metaplasia, which is seen as nodular and branching calcifications in imaging studies. This pattern has been observed mainly in areas of reticulation rather than in honeycombingAnother condition recently related to DPO is cicatricial organizing pneumonia. This distinctive form of organizing pneumonia may manifest as persistent linear opacities that mimic fibrosing interstitial pneumonia. It may also be displayed as ossification foci in imaging and pathology studies


During aging, alterations of hematopoietic stem cells are associated with functional decline of the blood system. Caloric restriction (CR) interventions have been reported to improve adult stem cells in other tissue types during aging so we sought to evaluate the effects of CR on the aged HSC compartment. We find significant epigenetic alterations in HSCs isolated from aged mice after life-long CR compared to ad libitum fed aged mice. We further evaluated the epigenetic landscapes and functional potential of aged HSCs shortly after allowing life-long CR mice access to ad libitum food. We uncover epigenetic modification associated with functional alterations of the HSCs, defining potential mechanisms by which restrictions in food consumption affect the aging hematopoietic compartment.


A 49-year-old woman presented to our dermatology department with a 1-year-long history of asymptomatic nail discoloration affecting the thumb of her right hand. She referred that she was treated with oral fluconazole by her general practitioner with no clinical improvement.Dermatological examination showed dark green discoloration of the nail plate . DermoscGreen nail syndrome is caused by the accumulation of pyocyanin that is produced by Pseudomonas aeruginosa bacterium . Althoug


It was declared a global pandemic by the World Health Organisation (WHO) on 11A Quality Management System (QMS) can be defined as a coordinated set of activities to direct and control an organisation regarding quality. A laboratory QMS is cardinal for achieving desirable laboratory performance and assurance of good laboratory results . ClinicaLaboratory mentorship has been known to be a pivotal factor to the successful implementation of laboratory QMS. In Zambia, this model has mainly been supported by external cooperating partners . HoweverMany countries depend on international trade for goods and services. The COVID-19 pandemic and the resulting global restrictions in air travel has negatively impacted the global supply chain . MedicalThe COVID-19 pandemic has greatly impacted health-care workers . Staff iThe COVID-19 pandemic has resulted in a global recession with a severe impact on the economy of Zambia including funding challenges to the health sector . Most la1) Increase local mentorship capabilities by training mentors drawn from accredited laboratories. Remote (offsite) mentorship using video conferencing tools such as Zoom, Microsoft Teams and similar applications should be explored. 2) Strengthen in-country training and certification of biomedical engineers to handle equipment maintenance and calibration needs of clinical laboratories. Traceability can be provided through training certification and externally calibrated reference equipment. 3) Laboratories should ensure the strict monitoring of reagent and consumable consumption data in order to have enough stock to sustain testing during unforeseen circumstances while procurement arrangements are being made. 4) In-country interlaboratory comparison should be encouraged through peer-to-peer assessments following the evaluation of possible referral laboratories. 5) Integrate COVID-19 testing in the QMS of laboratories to ensure quality. When changes in response to COVID-19 are planned and implemented, laboratories should ensure that the integrity of their QMS is maintained and that all applicable accreditation requirements are met. 6) Employment of medical laboratory personnel should be prioritised to meet the increased demand in testing. 7) There should be enough local funding for laboratory operations to cushion the impact of changing priorities by donors.The COVID-19 pandemic may affect QMS and ultimately healthcare in Zambia. There is need for targeted mitigation measures to ensure continual implementation of QMS and laboratory improvement.


Anastomotic stenosis following esophagojejunostomy reconstruction by the overlap method with absorbable barbed sutures occurs only rarely in patients who have undergone laparoscopic surgery. We report anastomotic stenosis by the overlap method that we attributed to the lack of tactile sensation during robot-assisted surgery.An 83-year-old man underwent robot-assisted laparoscopic proximal gastrectomy and lymph node dissection at our hospital for treatment of gastric cancer. Double tract reconstruction followed with side-to-side esophagojejunostomy (overlap method) performed with an endoscopic linear stapler. On completion of the anastomosis, the enterotomy was closed under robotic assistance with absorbable barbed suture. Once solid foods were introduced, the patient had difficulty swallowing and felt as though his digestive tract was stopped up. When upper gastrointestinal endoscopy was performed, we found the anastomotic lumen to be coated with food residue. After rinsing off the residue with water, we could see barbed suture protruding into the anastomotic lumen that had become entangled upon itself, which explained how the food residue had accumulated. We cut the entangled suture under endoscopic visualization using a loop cutter.This case highlights a stricture caused by insufficiently tensioning barbed suture, which subsequently protruded into the anastomotic lumen and became entangled upon itself. We believe this occurrence was associated with the lack of tactile sensation in robot-assisted surgery. Esophagojejunostomy reconstruction by the overlap method is commonly performed in laparoscopic proximal or total gastrectomy, and enterotomy closure is often performed using absorbable barbed suture. Reported cases of stenosis are extremely rare –5. AbsorAn 83-year-old man underwent radical gastrectomy at our hospital for treatment of gastric cancer. Because the tumor was located just below the gastric cardia and clinical staged as cT2N0M0 and stage I according to the American Joint Committee on Cancer 8th edition, robot-assisted laparoscopic proximal gastrectomy and lymph node dissection were performed. Double-tract reconstruction followed, with side-to-side esophagojejunostomy (overlap method) performed with an endoscopic linear stapler . On compUnder endoscopic visualization, we cut the entangled suture using a loop cutter Fig. . Over thAnastomotic stenosis following overlap reconstruction occurs only rarely in patients who have undergone laparoscopic surgery –5. The sRobot-assisted surgery has not only restored the surgeon’s natural 3-dimensional vision but has also improved the surgeon’s skills by allowing fluid movements while eliminating the inevitable tremors and shaking of the surgeon’s hand and permitting increased reproducibility of movements , 8. AddiWe believe that this case should cause surgeons to realize the importance of overcoming the lack of tactile sensation, which is the present situation in robot-assisted surgery.


A 60-year-old man with a background of resected clear cell renal cancer and resected colorectal adenocarcinoma presented with a pulmonary mass lesion in the left upper lobe which was avid on 18-F FDG PET/CT. Needle biopsy confirmed metastatic renal cell cancer, which was surgically excised with wedge resection. Follow-up imaging 6 months later demonstrated a second slowly enlarging subcentimeter nodule in the contralateral lung with increasing FDG avidity, suspicious of further small volume oligometastatic disease. Following surgical resection of the second pulmonary lesion, histopathological examination demonstrated nodular pulmonary amyloidosis and no evidence of malignancy. Amyloidosis encapsulates a group of diseases which involve the deposition of misfolded, insoluble, polymeric protein fibrils which ultimately result in damage to the surrounding tissue or organ. Solitary pulmonary amyloidomas are great mimickers of malignancy and should be considered in a patient with a pulmonary nodule even in the setting of metastatic disease. We present a case of a solitary pulmonary amyloidoma mimicking metastases in a patient with previous proven pulmonary metastatic disease from renal cell cancer.A 60-year-old man with history of left nephrectomy for clear cell renal cancer (stage I) and resected colorectal adenocarcinoma (stage II) presented with a pulmonary mass lesion in the left upper lobe on surveillance imaging. Transaxial CT B revealeHistopathology of CT-guided core needle biopsy showed tumour cells with relatively uniform nuclear and clear cell cytoplasm with positive staining for PAX8 and renal cell antigen, consistent with metastatic renal cell carcinoma. The patient underwent wedge resection of the left upper lobe metastasis with clear excisional margins.6 months later, follow-up imaging with 18-F FDG PET/CT and diagnostic CT was performed. Transaxial CT B demonstHistopathology of the second pulmonary nodule demonstrated no evidence of malignancy. Instead, there was amorphous hyaline acellular amyloid-like material associated with a rim of multinucleated inflammatory cells . The chrAmyloidosis encapsulates a group of diseases which involve the deposition of misfolded, rigid, polymeric protein fibrils which ultimately result in damage to the surrounding tissue or organ Although misfolded amyloid proteins are not metabolically active, plasma cells producing amyloid proteins and the resultant inflammatory response are metabolically active. This results in variable FDG avidity within the pulmonary nodule, acting as a mimicker of primary pulmonary malignancy Delineation between malignancy and amyloidosis with evaluation of morphological appearance and metabolic activity on imaging is often difficult. Dual phase FDG PET/CT has been described as a technique to delineate between malignancy and amyloidosis This case study demonstrates that localised nodular amyloidosis is uncommon but may act as a great mimicker of malignancy. Amyloidosis should be a consideration in patients with enlarging FDG avid pulmonary nodules even in the setting of previous pulmonary metastatic disease.


Successful health outcomes in older patients are linked to the quality of the patient-provider relationship. Our study objective was to further understand the role of this relationship specific to pain management through perspectives from older adults and healthcare providers. Semi-structured interviews and focus groups were conducted with 9 older adults and 11 multidisciplinary healthcare providers. Transcripts were analyzed using a thematic analysis. Three main concepts emerged: (1) defining pain management goals — differences in providers and patients’ goals for pain and function, with sub-themes of realistic goal setting and a shift in pain treatment to minimize opioids as a first-line medication; (2) communication — perceived gap in providers communicating and coordinating across disciplines and with patients, with sub-themes of improving positive communication and inconsistent messaging among providers; and (3) therapeutic alliance — all parties feel that developing a relationship is built on consistent trust and open dialogue. Although providers and older adults often expressed similar perspectives, there were several areas of misalignment identified within each concept, representing areas of disconnect within the patient-provider pain management relationship. Our findings indicate providers could benefit from education on improving communication around realistic goals and patient-centered outcomes and incorporation of more holistic pain management approaches when working with older adult patients. Further study should focus on developing educational interventions to address the identified shortcomings.


We performed mesoscopic whole brain calcium imaging on awake animal to assess the MENs effects. Furthermore, we investigated the temporal profile of MENs in the vasculatures post-treatment and its toxicities to CNS. RESULTS/ANTICIPATED RESULTS: MENs were successfully localized to target cortical regions within 30 minutes of magnetic application. After wirelessly applying ~450 G magnetic field between 10-20 Hz, we observed a dramatic increase of calcium signals  both in vitro cultured neurons and in vivo treated animals. Whole brain imaging of awake mice showed a focal increase in calcium signals at the area where MENs localized and the signals spread to regions further away. We also found MENs stimulatory effects lasted up to 24 hours post treatment. MEN stimulation increases c-Fos expression but resulted in no inflammatory changes, up to one week, by assessing microglial or astrocytes activations. DISCUSSION/SIGNIFICANCE OF IMPACT: Our study shows, through controlling the applied magnetic field, MENs can be focally delivered to specific cortical regions with high efficacy and wirelessly activated neurons with high spatial and temporal resolution. This method shows promising potential to be a new non-invasive brain modulation approach disease studies and treatments.OBJECTIVES/GOALS: Our goal is to develop a non-invasive stimulation technique using magneto-electric nanoparticles (MENs) for inducing and enhancing neuronal activity with high spatial and temporal resolutions and minimal toxicity, which can potentially be used as a more effective approach to brain stimulation. METHODS/STUDY POPULATION: MENs compose of core-shell structures that are attracted to strong external magnetic field (~5000 Gauss) but produces electric currents with weaker magnetic field (~450 Gauss). MENs were IV treated into mice and drawn to the brain cortex with a strong magnetic field. We then stimulate MENs with a weaker magnetic field via electro magnet. With two photon calcium imaging, we investigated both the temporal and spatial effects of MENs on neuronal activity both


Married and cohabiting couples have important influences on one another’s stress and well-being. Pandemic-related stress may influence the extent to which couples' stress levels are coregulated. This study examined the experience of nonspecific stress and pandemic-related stress and the moderating role of closeness among couples aged 50 and over in which at least one member had hypertension. A total of 30 couples reported their feelings of closeness to one another in a baseline interview and their feelings of nonspecific stress and pandemic-related stress every three hours for 5 days. There was no difference in closeness and nonspecific stress between husbands and wives. Wives reported greater pandemic-related stress than husbands. Actor-partner interdependence models revealed that wives’ nonspecific stress predicted husbands’ nonspecific stress  and that husbands’ nonspecific stress predicted wives’ nonspecific stress in each three hour period  and these associations were not moderated by closeness. Coregulation in pandemic-related stress among husbands and wives was moderated by wives’ feelings of closeness such that when wives’ feelings of closeness were lower, greater husband pandemic-related stress predicted lower pandemic-related stress for wives  whereas when wives’ feelings of closeness were higher, greater husband pandemic-related stress predicted greater pandemic-related stress for wives . These findings indicate that closeness may have detrimental effects especially when considering emotional coregulation in couples regarding the pandemic.


Older adults diagnosed with mild dementia can identify their wishes, values and goals of care with a high degree of accuracy and reliability. However, there is a paucity of research to guide best practices on how to incorporate Advance Care Planning (ACP) in the care of older adults living with mild dementia. Thus, only a minority of them participate in any ACP discussions. We developed an intervention called Voice Your Values (VYV) that healthcare professionals can implement to identify and document values of older adults. This single group pretest and posttest design aimed to determine the feasibility, acceptability and preliminary efficacy of the intervention. A convenience sample of 20 dyads of older adults and their trusted individuals were recruited from 4 geriatric clinics. Tailored VYV intervention was delivered to dyads on a one-on-one basis over two sessions using videoconferencing. Feasibility was determined through recruitment and retention rates, and intervention fidelity. Acceptability was assessed using modified Treatment Evaluation Inventory. Primary outcome was the Surrogate Decision-Making Confidence Scale. Secondary outcomes included an ACP engagement survey to assess older adults’ engagement in ACP; Dementia Knowledge Assessment Tool for trusted individuals; and the Kessler Psychological Distress Scale for all participants. The recruitment rate was 45%, retention rate was 100% and 92% participants rated VYV as highly acceptable. Trusted individuals showed statistically significant improvement in decision-making confidence (p=.02) and psychological distress (p=.02); but no improvement in dementia knowledge (p=.47). Older adults demonstrated statistically significant improvement in ACP engagement (p=<.01). Initial feasibility of VYV was demonstrated.


A challenging situation in proximal hypospadias is the presentation of patients with successful urethroplasty but with persistent or recurrent ventral curvature (VC) after multiple hypospadias repair.We present a 13 year-old boy with 7 previous surgeries  to treat hypospadias presenting with 60 degrees of VC, in spite of a well-accepted coronally neomeatus. We degloved the penis and artificial erection clearly appointed corporal disproportion causing curvature. We disconnected urethra from corpora. After excision of remnant fibrotic tissue, there was a residual curvature so a lenghtening corporoplasty with dermal graft from groin was performed. We have adjusted the urethral meatus position into a proximal penile shaft. We used a buccal mucosa graft placed in an inverted U-shape position planning a second stage urethroplasty (The aspect after corporoplasty proved satisfactory curvature correction. Patient had an excellent outcome and is scheduled for a second-stage after 6 months.Snodgrass and Bush  reportedSevere curvature associated with hypospadias should undergo a major procedure at early stage to avoid decompensation after dorsal plicature in adolescence. We had a very satisfactory result, the patient awaits the second stage procedure .


We report the case of a 73-year-old male who underwent abdominal multidetector computed tomography with vascular reconstruction that highlighted a congenital variant of iliac arteries. Iliac artery anatomical variants are exceedingly rare and only a few cases have been reported in the literature. We present a case of a 73-year-old male who presented to our emergency department for abdominal trauma due to a car incident. He underwent abdominal multidetector computed tomography that excluded abdominal traumatic pathologies. Vascular coronal volume rendering reconstruction highlighted an asymptomatic congenital anatomical variant, with cranial origin of internal iliac arteries . This pCongenital variants of the iliac arteries are exceedingly rare, and only a few cases have been reported in the literature.With an increase in noninvasive diagnostic vascular imaging, thoracoabdominal vascular anomalies are seen with greater frequency,


Breast-conserving surgery (BCS) is a standard surgical treatment for early-stage breast cancer. The primary goal of BCS is to obtain complete tumor excision because positive resection margins are found to be associated with an increased risk of local recurrence.Using multivariable analysis, this study found that selective use of preoperative MRI was associated with a lower risk of positive resection margins (involved margins > 4 mm) after BCS for patients with screen-detected invasive breast cancer .The study results suggest that selective use of preoperative MRI for women with screen-detected invasive breast cancer promises to minimize the risk of positive resection margins after BCS. Future studies should focus on the prognostic impact of the study findings and investigate the cost-effectiveness of preoperative breast MRI for surgical planning.


A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients with anal fissure, which technique has a lower of incidence anal incontinence: Botox injection or lateral sphincterotomy? The best evidence showed that Botox injection has lower incidence of incontinence. •In patients with anal fissure.•Which technique has a lower of incidence anal incontinence:•Botox injection or lateral sphincterotomy?•Botox injection has lower incidence of incontinence. This fo2A general surgical trainee is consenting a 25 year old female with recurrent anal fissure for examination under anaesthesia plus either Botox injection or lateral sphincterotomy, the patient is wondering which technique provides a lower incidence of incontinence.3[In patient with anal fissure] [Which techniques has lower incidence of incontinence] [Botox injection or lateral sphincterotomy]?4A.Medline ® 1946 to May 2021 and Embase 1974 to May 2021 using OVID interface:B.Medline ® using PubMed interface:[Anal fissure OR fissure-in-ano] AND [incontinence OR anal incontinence] AND [botulinum toxin OR botulinum toxin injection OR BOTOX] AND [sphincterotomy OR lateral sphincterotomy OR lateral internal sphincterotomy].[Anal fissure OR fissure-in-ano] AND [incontinence OR anal incontinence] AND [botulinum toxin OR botulinum toxin injection OR BOTOX] AND [sphincterotomy OR lateral sphincterotomy OR lateral internal Sphincterotomy].Exclusion criteria:Unpublished studies, case reports, letter to the editors, studies in children less than 16 years studies not in English.5A total of 67 articles were identified after the removal of duplicates. Of these 51articles were excluded on the basis of title and abstract. After full-text assessment of the remaining 16 articles another 11 articles were excluded because they did not include the information needed to answer the question. A total of 5 articles  were identified to provide the best evidence to answer the question.6see the 7Lateral internal sphincterotomy (LIS) is usually performed by creating a vertical incision in the intersphincteric groove on one side of the anus, the internal sphincter fibers are then divided up to the level of the proximal extent of the anal fissure . LIS hasThe aim from this review is to assess the best studies which compare the incidence of anal incontinence among those patients undergoing Botox injection vs LIS for anal fissure.Two studies in our review showed no statistically significant difference in the incidence of anal incontinence between LIS and Botox injection these studies were conducted by De Robles et al.  and Çakı8According to the above articles, the best evidence showed a statistically significant lower incidence of anal incontinence among Botox injection group of patients in comparison to the LIS group.91.Small sample size in most articles2.Short period of follow in most articles.3.Lack of multicentric trialsNon.Not applicable.Not applicable.RI: conducted the literature search and wrote the paper. AAR: assisted in the literature search and SA: assisted in writing of paper.AA: assisted in the literature search.AM: design the table and help in editing of writing.Not applicable.Rashid Ibrahim.Non.


Lung malignancies have become increasingly prevalent. Occasionally, an unusual tumour is diagnosed, or a common tumour type presentsunusually. This case report reviews 3 cases of thoracic neoplasm, including two cases of uncommon cancers  and an atypical presentation of malignant mesothelioma. Her chestradiograph and computed tomography (CT) scan revealed aninhomogeneous mass occupying nearly the whole right hemithorax,with an associated small pleural effusion Mr MG is a 65-year-old man who presented with left-sided chestpain. He was a non-smoker, and also reported profound weightloss. His chest radiograph showed a white-out of the left hemithoraxwith mediastinal shift. A CT scan revealed the presence of a leftmain bronchus mass with associated left lung atelactasis andcomplex collections extending to the chest wall consistent with aleft empyema neccesitans. A pigtail catheter was placed to drain thefluid. The purulent fluid aspirated did not yield any organisms onculture. A bronchoscopy was performed which revealed a left upperlobe bronchus that was partially occluded by the tumour. The biopsyconfirmed an adenoid cystic carcinoma (ACC) Mrs AM is a 53-year-old woman from the Democratic Republic ofCongo who presented with a 3-month history of generalised bodypain. On examination, she had many subcutaneous soft tissue masses. Her chest radiograph and CT chest showed a large roundedmass in the right hemithorax as well as a rounded lesion in the lefthemithorax. An ultrasound guided biopsy established a diagnosis ofa desmoplastic small round-cell high-grade sarcoma 6] The common presentationincludes marked chest wall pain and pleural effusions often with associated pleural thickening and volume loss. The patient presenteduncharacteristically, with pulmonary mass lesions with no identifiablerisk factors. The mortality is unfortunately still unacceptably higheven with chemotherapy, radiation and surgeryMMs are aggressive neoplasms arising from mesothelial surfacesof the pleura, peritoneal surfaces and tunica vaginalis. Eightypercent will arise from pleural surfaces where 70% of patients willreport exposure to asbestos. Other risk factors include radiation,carbon nanotube exposure and genetic factors such as mutations inBRCA1 associated protein 1(BAP1).[7] They are considered slowgrowing tumours, usually arising from the proximal tracheobronchialtree. The solid histological pattern has been associated with a moreaggressive clinical course and early distant metastases, in contrastto the cribriform type which shows a more benign behaviour.[8] The mainstay of therapy is surgery. Our patient probably had postobstructive pneumonia and an empyema as a result of the tumour inthe left upper lobe.Primary adenoid cystic lung cancers are rare salivary gland neoplasmsmaking up 0.04 - 0.2% of all lung cancers.[9] They are characterised histologicallyby nests of small tumour cells surrounded by cellular and vascularcollagenous stroma.11] Mostly arising in the abdominal and pelviccavity, these tumours can also originate in other sites, such as thelung and pleura.[12] DSRCTs are rare and aggressive malignanciescommonly affecting young males with only a few hundred cases reported in the literature. The prognosis is poor and therapy is stillnot well defined.Desmoplastic small round cell tumours (DSRCTs) are mesenchymaltumours arising from cells with multi-lineage potential. Firstdescribed in 1989 by Gerald and Rosai, these tumours have distinctmolecular and immunohistochemical characteristics. The molecularhallmark of DSRCT is the Erwing sarcoma and Wilms tumour gene(EWS-WT1) fusion protein.Unfortunately, all 3 patients presented with advanced disease andwere referred for oncological assessment and palliative care. This series serves as a reminder of the wide spectrum of presentations ofthoracic neoplasms.


To report two cases with idiopathic unilateral diffuse opacification of the posterior hyaloid membrane (PHM) completely separated from the retina, the mechanism of which is possibly due to glial cell proliferation and migration.Two Japanese women at age 75 and 84 with no systemic or ocular history developed diffuse opacification in one eye resembling a ground glass sheet almost all over the surface of the PHM, but not within the vitreous gel or fluid. The retinas were funduscopically normal; however, optical coherence tomography demonstrated hyperreflective icicle-like anterior protrusions from the surface of the fovea. The patients received pars plana vitrectomy, resulting in visual improvement. Cell block preparations of the vitreous in one case revealed a cluster of cells immunoreactive for glial fibrillary acidic protein in consistence with gliosis, while denying vitreoretinal lymphoma from lack of atypical cells and vitreous amyloidosis due to no staining for Congo red or direct fast scarlet. The lesions did not recur during follow-up with no new funduscopic abnormalities.To our knowledge, this is the first to demonstrate such peculiar cases of vitreous opacity with idiopathic and unilateral onset. Histological assessments revealed the possible pathogenesis of gliotic opaque PHM separation to cause its ground-glass-sheet appearance.The online version contains supplementary material available at 10.1186/s12886-021-02072-5. Vitreous opacity is one of the frequent vision-threatening abnormalities. The causative diseases of vitreous opacity include intraocular inflammation, vitreoretinal lymphoma, and vitreous amyloidosis, each of which develops distinct opaque features resembling snowball in sarcoid uveitis , glass wA 75-year-old female presented with blurred vision of both her eyes gradually worsening for 12 months. The patient had no remarkable personal or family medical history except for Basedow disease in her twenties.Her decimal best-corrected visual acuity (BCVA) was 0.07 OD and 0.2 OS with mild hyperopia. The cornea and anterior chamber were clear OU. Funduscopic examination revealed no obvious abnormal findings via impaired visibility due to severe cataract OU. The patient received cataract surgery with no complication OU, and her BCVA improved to 0.9 OD and 0.6 OS with her complaint of persistent blurred vision OS. Three months postoperatively, the BCVA was almost unchanged, leading to thorough workup to find the cause of persistent blurred vision OS. Funduscopic examination showed no abnormal retinal findings with clear vitreous media OD  seen in idiopathic epiretinal membrane  and prolThe etiology of the present cases remains largely unknown because no explainable backgrounds, whether systemic or ophthalmic, could be identified so far. The two patients inflicted no occupational exposure to toxic metals or organic solvents, and shared neither genetic relationship nor any particular living environment. It would be interesting to note, however, that there were two common ocular findings in the affected eyes of both patients: subclinical vascular leakage barely detected with fluorescein angiography and icicle-like anterior protrusions clearly presented with OCT. Although these two abnormalities may have coexisted coincidentally, a possible mechanistic link is likely to be inflammation-driven migration of some undetermined retinal cells or resultant deposition of cellular debris. From lack of further evidence clinically collected, it is too speculative at present to state that such minimal vasculitis causes glial cell migration out of the retina onto the entire PHM, given that the affected eyes exhibited no signs of active or convalescent uveitis. We did not check any inflammatory cytokines such as chemotactic factors. Nevertheless, the two retinal findings associated with gliotic opaque PHM separation would definitely be worth considerable attention in terms of mechanistic insight. These limitations in the present study warrant future and further investigations into other similar cases.In conclusion, to the best of our knowledge, this is the first to report such peculiar cases of ground-glass-sheet opacity confined diffusely to the PHM surface completely separated from the retina. Immunopositivity for GFAP suggested, at least in one case, gliotic modification to the pathogenesis of this undocumented vision-threatening disorder, leading us to propose its nomenclature “gliotic opaque PHM separation” as a new clinical entity.Supplemental Figure S1 Ophthalmological findings in Case 1. Top left Fundus photograph showing normal appearance OD. Top right Late-phase fluorescein angiography showing no abnormal findings OD. Bottom left Goldmann perimetry showing normal appearance except for slight enlargement of a blind spot OS. Bottom right Dark-adapted 20 J single-flash electroretinography showing normal amplitudes OU. Supplemental Figure S2. Ophthalmological findings in Case 2. Top left Fundus photograph showing normal appearance OD. Top right Late-phase fluorescein angiography showing no abnormal findings OD. Middle OCT showing no abnormal findings at the macular region OD. Bottom left Humphry perimetry showing normal appearance OS. Bottom right Dark-adapted 20 J single-flash electroretinography showing normal amplitudes OU.