Background: We conducted this systematic review to provide comprehensive evidence on the prevalence, clinical features and outcomes of young extraosseous Ewing sarcoma (EES) cases. Methods: PubMed, Scopus, Web of Science, and Google Scholar were searched for articles reporting the occurrence of EES among children and adolescents (<21 years). The primary outcome included the rate of occurrence of EES among children and adolescents, while the secondary outcomes included the descriptive analyses of the demographic characteristics, tumor characteristics, and clinical outcomes of the affected cases. The data are reported as the effect size (ES) and its corresponding 95% confidence interval (CI). Results: A total of 29 studies were included. Twenty-four reported instances of childhood disease among all the EES cases , while five studies reported extraosseous cases among the pediatric EES cases . The thorax is the most common location of childhood EES  followed by the extremities . Concurrent chemotherapy and radiotherapy  was the most commonly implemented management protocol in the pediatric EES cases. The rate of no evidence of disease and 5-year overall survival was 69% for both outcomes. Mortality occurred in 29% of cases, while recurrence and secondary metastasis occurred in 35% and 16% of cases, respectively. Conclusions: Our findings provide insight into the clinical features and outcomes of EES among children and adolescents. The Ewing sarcoma family of tumors (ESFT) is a collection of small, rounded tumor cells that have similar neural histological and genetic characteristics ,2,3,4. EBased on a previous report, the incidence of EES is 0.4 per million individuals, which is lower than that of ES of the bone by 10-fold . AlthougThe management of EES includes surgery  and chemTo date, there is no clear picture regarding the occurrence rate of EES among children and adolescents (<21 years), as well as their demographic characteristics, tumor characteristics , treatment modalities, and clinical outcomes . Therefore, we conducted this systematic review and meta-analysis to provide collective evidence regarding the clinical characteristics and outcomes in this patient population.This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . A protoWe used a combination of keywords and terms in our search, which included the following: (“Ewing Sarcoma” OR “Ewing’s Sarcoma”) AND (adolescen* OR Child* OR Pediatric* OR “young adult”) AND  AND . The terms of the Medical Subject Headings (MeSH) were also added (particularly in PubMed) to retrieve all the possibly relevant articles. The detailed search criteria used for each database are described in Moreover, we conducted a manual search to find any relevant articles that may have potentially been excluded during the screening phase or were not found during the database search ,25. ThisThe methodology and design of this review were conducted as per the PICO framework ,27, inclFor articles to be included, a study had to: (1) report original data, (2) include cases of EES, (3) report cases aged <21 years. On the other hand, studies were excluded if they were compliant with one of the following criteria: (1) non-original research , (2) animal, in vivo, and in vitro studies, (3) case reports and case series of <5 cases, (4) studies reporting EES cases of mixed ages  without stratifying the cases according to their age, (5) studies reporting Ewing sarcomas of mixed origin  in children without stratifying the cases according to their origin, and (6) duplicated records. Following the retrieval of records through the database search , the refSignificantly, upon reviewing the literature, two categories of articles were found to be consistent with our eligibility criteria. The first group of articles included patients with EES, among whom pediatric cases were counted, and the second group of articles included pediatric cases, of whom the origin of Ewing sarcoma was determined . Both of these categories were included, extracted, and presented separately in our review.The data extraction process was carried out in a similar manner as the screening stage . The senI2 statistic, where a value of >50% or a p-value of <0.05 indicates significant heterogeneity. All quantitative analyses were conducted using the STATA software (version 17) with the metaprop command . The exaA summary of the results of the electronic database search, as well as the screening stage, is provided in The baseline characteristics of the included studies are presented in Among the five studies that reported the rate of EES among children with ES, one study was conducted in the Netherlands, three in the US, and one in China. Three studies were retrospective chart reviews, one was a multicenter cohort study, and one was a secondary analysis of two clinical trials. The sample size of included pediatric patients with Ewing sarcoma ranged from 18  to 1039 2 = 99.01%]. Out of the pediatric cases diagnosed with EES, 52.45% were males (224 out of 427 patients).The demographic characteristics of the included patients are illustrated in 2 = 19.28%]. Out of the pediatric cases diagnosed with EES, 54.70% (122 out of 223) were males.Among the studies that included pediatric cases of Ewing sarcoma regardless of its origin, the rate of presentation with a disease of extraosseous origin ranged from 10% (6 out of 60 cases)  to 55.55Among the included studies, only 13 reported data regarding the location of EES among the pediatric cases . The pooAmong the included studies, the management modalities in childhood EES were described and reported in ten studies , among wThe clinical outcomes associated with childhood EES are presented in There is limited evidence regarding the occurrence rate and clinical characteristics of EES in children. Our systematic review is the first to comprehensively discuss the prevalence, clinical features, and outcomes of EES patients of pediatric age (less than 21 years). A summary of our key findings can be found in In addition, five studies included children affected with ES at baseline, and then the origin of the tumor was analyzed in these cases. The rate of EES out of all the ES types ranged from 10% to 55.55% among the individual studies. Again, the difference in reported rates could be related to the design and methodology implemented in each study. That being said, in our meta-analysis, the rate of EES occurrence among the pediatric ES cases was 22%, of whom 54.70% were males.Data on the location of EES among pediatric cases is scarce, since the majority of the available studies in the literature include patients with mixed ages and tend to stratify the outcomes  based on age (children vs. adults or the elderly), without stratifying the clinical characteristics or tumor characteristics based on the age of the examined patients. Therefore, the data reported in our review regarding the EES location in the pediatric cases rely mainly on case series with a case-by-case description of the tumor characteristics. Thirteen studies reported relevant data on the location of EES, and our pooled meta-analysis revealed that the thorax is the most predominant origin for EES in children and adolescents, followed by the extremities, the head and neck, the pelvis, the abdomen, the spine, and the intracranial space, respectively. In certain cases, the EES originated in the orbit among the pediatric cases; however, the occurrence rate did not surpass the rare event assumption (>5%). Additionally, other sites, such as the great toe , the mesThere is a debate on the best management approach for EES cases occurring in children, and this uncertainty is related to the rarity of EES, the discrepancy in its clinical presentation, and the differences in the patients’ characteristics . In addiIn our study, we found that a great proportion of pediatric EES patients have a preferable prognosis in terms of their 5-year overall survival , which is consistent with that of cases with no evidence of disease following treatment . However, mortality was documented in almost one-third of the pediatric EES population . Additionally, recurrence was reported in 35% of cases, while secondary metastasis was reported in 16%. That being said, these rates should be based on the available data of 11 studies out of the 29 studies included in our review. Therefore, the presented data are not generalizable to the whole EES pediatric population.Meanwhile, our review has several limitations. The most important is the fact that our estimates regarding the prevalence of childhood EES among EES cases  or the prevalence of cases of extraosseous origin among the pediatric Ewing sarcoma cases could be overestimated, since the majority of the included studies investigated EES cases and not the Ewing sarcoma population as a whole. In addition, most of these studies are based on retrospective analyses and not cross-sectional in design, which further limits the generalizability of our findings.Although it is difficult to draw solid conclusions, our results highlight the proportion of children affected by extraosseous Ewing sarcoma, with a special focus on the demographic characteristics, tumor characteristics, and clinical outcomes of the affected patients.


To reanalyze a clinical trial on the effectiveness of a Brief Intervention (BI) delivered by non-professionals to reduce risky alcohol drinking. Our previous null-hypothesis test of the effects of the BI yielded a ‘non-significant’ p-value, yet remained uninformative. Here we use the Bayesian paradigm which allows for expressing the probability of different effect sizes to better inform public policy decisions.The posterior probability of the odds of risky drinking at follow-up favored a marked effect of the BI, with 96% of the probability mass being less than OR = 1, and 84% being less than OR = 0.8. Our findings show that there is a high probability that the BI delivered by health technicians lowered risky alcohol use. The posterior distributions of the BI’s effects are presented to help contextualize the evidence for policy making in Chile. Excessive alcohol drinking is the leading cause of mortality and disability in the Chilean population . To addrThis conclusion followed the convention that p-values over 0.05 indicate that a null effect cannot be ruled out; however, this convention is problematic for a number of reasons [The null hypothesis test paradigm (NHTP) offers little help in answering these questions since it typically dichotomizes the evidence instead of presenting the whole picture. These difficulties in analyzing and communicating our results motivated us to redo the analyses from a Bayesian perspective. Inference in the Bayesian framework differs from the classical approach. The parameter being estimated  is considered a random variable with a probability distribution. Inference starts with a "prior" distribution representing our state of knowledge about that parameter, which is then updated according to the observed data. This updated probability distribution is often called a "posterior" distribution, and it informs about the compatibility of different effect sizes with the observed data . So, theThe clinical trial was conducted in five primary care facilities in the city of Santiago—Chile and compared two interventions in people with risky alcohol use  total score between 8 and 15) .Our outcomes were the AUDIT risk category (primary outcome), and the AUDIT-total and AUDIT-C scores , measured 6 months after enrollment. For practical reasons, the only outcome measurement was a one-year retrospective AUDIT. This minimal outcome collection allowed protocol implementation without changing much the way the program operates in the real world.All analysis were conducted on participants that completed follow-up n = 294) using Chi-squared and T-tests accordingly. Then, mixed-effects regressions were used to adjust for demographic variables as fixed-effects  and the health center as random effects. See the main paper for a detailed description of the trial [ using ChWe used Bayesian inference to estimate the same mixed-effects regression models specified in the original analysis. The alcohol risk status , was modeled with a Bernoulli distribution with fixed effects for all the covariates, and random intercepts for health centers. The model for the primary outcome is presented in Eq. AUDIT-total and AUDIT-C scores , were modeled with normal distributions with fixed effects for all covariates and random intercepts for health centers. The model for the secondary outcomes is presented in Eq. Hamiltonian Markov chain Monte Carlo was used for Bayesian inference. For each model, 50,000 iterations were run with 25,000 warm-up iterations in four chains. The analyses were run using R with R-Stan version 2.21.0 on a Mac mini M1.The marginal posterior probability distribution for the fixed effect OR of risky drinking is shown in Fig. We used Bayesian analysis to reanalyze a clinical trial on the effectiveness of a BI to reduce risky alcohol drinking and found that there was marked evidence suggesting that the intervention reduced risky alcohol use . In concordance with most evidence on BIs , 9, thisFirst, we address an important difference with respect to scientific inference from the original analysis and this reanalysis. Our current results show the degree to which the data from the trial support the BIs effectiveness, indicating a 96% probability of a positive effect. However, our previous analyses following a NHTP framework obtained a p-value of 0.07; that is, in a hypothetical world where there is exactly no difference between exposure to the BI or the pamphlet, the probability of observing the data from the trial was 7%. Conventionally, this means that a null effect cannot be ruled out, since only extreme observations yielding p-values less than 0.05 are regarded as strong evidence under this paradigm . This usWith the Bayesian analysis conducted herein, we obtained a probability distribution over the effects of the BI (in comparison to the pamphlet), allowing us to assess the evidence in a continuous rather than dichotomic manner. This makes it possible to interpret the results in context of existing evidence, specific decision-making contexts, and other available interventions. In our models, we used normal priors centered around the null which encode a conservative view of the effects of the intervention before the data was consulted. Bayesian inference entails updating this prior assumption with the data, migrating to the posterior-probability distributions summarized in Table Another factor for inference is some degree of inaccuracy in our measurements: as this trial was conducted in real world conditions, we refrained from using more precise but demanding instruments. In fact, we used the AUDIT with a one-year retrospective window, which is less sensitive to changes occurred during the last six months . However, despite using a one-year retrospective questionnaire, our data strongly indicate that the intervention had an effect.Altogether, our analyses indicate effectiveness of the BI, and so, the use of HTs as providers is supported by this evidence. Based on this evidence, non-professional health care personal could remain delivering BIs in Chilean primary care: this strategy uses the available health workers to implement a crucial preventive program that otherwise would not be feasible. A related question remains on how these HT-delivered BIs compare in effectiveness to a physician or nurse-delivered BI. Most of the evidence on effectiveness and cost-effectiveness of BIs derives from professional-delivered BIs, so a comparison among both delivery methods would be informative for low- and middle-income countries.A health technician-delivered BI reduced risky drinking after six months as compared with the delivery of a pamphlet. The entire posterior distribution of this effect is presented to help contextualize the evidence for policy making in Chile.A more informative analysis could be perused by incorporating previous knowledge on Brief Interventions . We used less informative assumptions to remain conservative and comparable to our previous analysis.


MET exon 14 skipping. Objectives of this population pharmacokinetic (PK) analysis were to evaluate the dose–exposure relationship of tepotinib and its major circulating metabolite, MSC2571109A, and to identify the intrinsic/extrinsic factors that are predictive of PK variability.Tepotinib is a highly selective, potent, mesenchymal–epithelial transition factor (MET) inhibitor, approved for the treatment of non-small cell lung cancer (NSCLC) harboring Data were included from 12 studies in patients with cancer and in healthy participants. A sequential modeling approach was used to analyze the parent and metabolite data, including covariate analyses. Potential associations between observed covariates and PK parameters were illustrated using bootstrap analysis-based forest plots.A two-compartment model with sequential zero- and first-order absorption, and a first-order elimination from the central compartment, best described the plasma PK of tepotinib in humans across the dose range of 30–1400 mg. The bioavailability of tepotinib was shown to be dose dependent, although bioavailability decreased primarily at doses above the therapeutic dose of 500 mg. The intrinsic factors of race, age, sex, body weight, mild/moderate hepatic impairment and mild/moderate renal impairment, along with the extrinsic factors of opioid analgesic and gefitinib intake, had no relevant effect on tepotinib PK. Tepotinib has a long effective half-life of ~ 32 h.Tepotinib shows dose proportionality up to at least the therapeutic dose, and time-independent clearance with a profile appropriate for once-daily dosing. None of the covariates identified had a clinically meaningful effect on tepotinib exposure or required dose adjustments.The online version contains supplementary material available at 10.1007/s00280-022-04423-5. MET exon 14 skipping  for patients with cancer was illustrated using bootstrap analysis-based forest plots (see ESM 1 for method details). In the bootstrap analysis, N = 100 new data sets were generated with replacement from the analysis data set. The sampling was stratified by study, and the final models were fit to each of the resampled data sets. In the bootstrap for MSC2571109A, the parameter estimation was conditioned on the individual parameter estimates from the final tepotinib model. For categorical covariates, the mean and its 5th and 95th percentiles of PK parameters for each category were computed. For continuous covariates, the mean and its 5th and 95th percentiles of PK parameters, corresponding to the 0–5th and 95–100th percentile of the covariate, were computed. The impact of the covariates in the forest plots were presented on a relative scale. The reference value was the arithmetic mean of the corresponding PK parameter.The association or lack of association between the observed covariates and model-derived secondary PK parameters [e.g., area under the concentration–time curve over the dosing interval at steady state , of which 24 were classified as having moderate renal impairment (eGFR ≥ 30 and < 60 mL/min/1.73 m2) and contributed 390 tepotinib PK observations .The analysis included 591 participants with an evaluable baseline eGFR  and 16 were classed as having moderate hepatic impairment , according to the NCI-ODWG criteria for hepatic dysfunction. Only three participants were classed as having severe hepatic impairment .The fraction of participants with missing covariate values ranged between 0 and 18%. The three covariates with the largest fraction of missing values were hepatitis B virus/hepatitis C virus (HBV/HCV) status at screening, serum-albumin and total protein at baseline, with 18%, 17% and 13% missing values, respectively.par, first-order absorption rate constant (ka), zero-order absorption duration (D1), and bioavailability of parent drug (Fpar).A two-compartment model with sequential zero- and first-order absorption, and a first-order elimination from the central compartment, with an additive residual error on the log scale, best described the plasma PK of tepotinib in humans across the dose range of 30–1400 mg , and after fasting , compared with a typical participant taking TF2 with a non-high-fat meal.Several covariates were found to have a statistically significant influence on tepotinib PK parameters based on the ASR SCM procedure; all are listed in Table τ,ss is illustrated in Fig. par for a dose of 500 mg.The bioavailability of tepotinib was shown to be dose-dependent, with decreasing bioavailability at high doses Fig. . The mod2 for a typical individual receiving 500 mg of tepotinib led to CLpar values of 16.2, 18.6, 19.7 and 20.9 L/h, respectively). Intake of opioid analgesics caused a 16.7% reduction in apparent CL of tepotinib, but the influence on tepotinib AUCτ,ss also appeared to be limited. No statistically significant influence of gefitinib co-administration on tepotinib PK was identified. Refer to ESM 12 for observed vs. predicted tepotinib plasma concentrations. The equations for the final pop PK model are available in ESM 13.Liver dysfunction (defined by NCI-ODWG) slightly reduced tepotinib bioavailability (7.29%) after oral administration, causing decreased total exposure in participants with liver dysfunction or cirrhosis. The apparent CL of tepotinib was found to be positively correlated to eGFR, but with a seemingly limited influence on exposure , central volume of metabolite distribution , inter-compartmental metabolite clearance (Qmet) and peripheral volume of metabolite distribution .The fraction metabolized (FM) is unknown and unidentifiable from the current data, thus this parameter was fixed to 1 but the associated IIV was estimated. The IIV terms are also included on apparent CL of metabolite .Goodness-of-fit plots for the final models of tepotinib (ESM 3 and ESM 4) and MSC2571109A (ESM 5 and ESM 6) indicated that these final models well described the plasma concentrations of both the parent and metabolite. Tepotinib PK appeared to be time-independent, i.e., the PK after a single dose was predictive of the PK at steady state.The prediction-corrected VPC showed a strong agreement for the observed and model-predicted median PK profiles. Plots of the individual random effects on tepotinib apparent CL (ESM 7 and ESM 8) and bioavailability (ESM 9 and ESM 10), estimated with the base and final models and plotted against individual covariates, confirm that including covariates in the tepotinib model removed the trend in the random effect versus covariates observed with the base model. Model diagnostic plots demonstrated a strong model performance, supporting its usability to derive individual predictions of exposure.2, INR = 1.06) receiving the clinical dose of 500 mg/day tepotinib TF3 with food.In Fig. τ,ss after 500 mg QD dosing for different ethnicity categories . Given the negligible contribution of MSC2571109A to the clinical efficacy of tepotinib, it is unlikely that these covariate effects are clinically relevant.The mean effect on MSC2571109A AUCPopulation PK modeling of tepotinib and MSC2571109A provides comprehensive model-based analytical tools to integrate both parent and metabolite PK profiles of 613 participants from 12 studies. These participants were administered four different formulations of tepotinib across a broad dose range of 30–1400 mg/day. These data have been well fitted to a two-compartment model with sequential zero- and first-order absorption and a first-order elimination from the central compartment for tepotinib, as well as a two-compartment model with input from the central compartment in the tepotinib model, scaled by FM and a first-order elimination from the central compartment for MSC2571109A. Since FM was unknown and could not be estimated from the data, it was fixed to 1 while the metabolite model was developed conditionally on the (fixed) tepotinib model. The fixed FM will only affect the numerical values of the primary metabolite PK parameters (CL and V) while the predicted metabolite concentrations and derived secondary parameters are unaffected. The model-predicted PK parameters are in agreement with the non-compartmental analyses of data from reported studies with tepotinib , 10, 14.Tepotinib showed moderate PK IIV (33.5% for CL and 28.3% for bioavailability). No direct estimate of the intra-individual variability in tepotinib CL was obtained in the population PK analysis, but, given that the residual variability was 33.7% , it may be concluded that the intra-individual variability in tepotinib PK is less than the IIV.Tepotinib PK are approximately dose-proportional up to the therapeutic dose of 500 mg. At higher doses, tepotinib PK was shown to increase sub-proportionally to doses with limited exposure increases (less than a doubling) seen between 500 and 1400 mg. This finding should be interpreted with caution as most data for doses beyond 500 mg were obtained with the CF2 formulation in Study 001.Tepotinib exhibits time-independent PK and has a long effective half-life of ~ 32 h with small peak-trough fluctuations, all of which support QD dosing. This differentiates tepotinib from other MET inhibitors, such as capmatinib, that require twice-daily dosing .τ,ss was 2% higher in patients with moderate renal impairment (39.4 mL/min/1.73 m2 ≤ eGFR ≤ 59 mL/min/1.73 m2) in comparison to the mean observed eGFR value of 99.8 mL/min/1.73 m2. As expected, renal excretion minimally contributes to the total elimination: in the mass balance study, the majority (77.9%) of the total radiolabeled material was excreted via feces [Mild and moderate renal impairment has been shown to have no clinically relevant effects on tepotinib PK (based on data from patients enrolled in the VISION study). In the covariate analysis, renal function was assessed using eGFR as determined by the MDRD formula. This metric was preferred over Cockcroft–Gault-predicted creatinine clearance as eGFR is independent of body weight and potentially leads to lower multi-collinearity with body mass covariates and less selection bias in the SCM procedure. The forest plot suggested that the apparent clearance of tepotinib did not show clinically meaningful association with eGFR: AUCia feces . Urinarypar translates into lower total tepotinib AUC in participants with mild to moderate hepatic impairment , albeit to a not clinically relevant extent  following ICH E17 principles , which cN = 5) for this patient group and the impact of other confounding factors.There were no clinically relevant effects of age (> 18 years), sex, or body weight, hence no dose adjustments are required on the basis of any of these factors and a flat-dose regimen is supported by the analysis. Tumor type did not appear to influence tepotinib PK, and although lower exposures were seen in patients with renal cell carcinoma, this result must be considered in light of the low sample size  in the first-in-human study . MicroniOpioid analgesics were included as continuous covariates based on the ability of µ-opioid receptor agonists to influence gastrointestinal motility. Twenty-four percent of the tepotinib observations were associated with concomitant administration of opioid analgesics. However, the observed effect of concomitant opioid use on CL/F did not lead to clinically meaningful changes in AUC.Although, based on its ADME properties, no interaction with the EGFR inhibitor gefitinib was expected, concomitant administration of gefitinib was included as a covariate as patients in Study 006 received both drugs. Co-administration of tepotinib with gefitinib had no effect on tepotinib or gefitinib exposure .The PK of tepotinib and MSC2571109A were both well described using a two-compartment model with first-order elimination. Tepotinib has dose-dependent bioavailability above 500 mg and time-independent CL, with a profile appropriate for QD dosing.The intrinsic factors of race, age, sex, body weight, mild/moderate hepatic impairment, and mild/moderate renal impairment, along with the extrinsic factors of opioid analgesic and gefitinib intake, had no relevant effect on tepotinib PK. Accordingly, no dose adjustment is required for any of these factors.Supplementary file1 (DOCX 1934 kb)Below is the link to the electronic supplementary material.


Bivalirudin is a common anticoagulant during percutaneous coronary intervention (PCI); however, since its application in China, it still lacks comprehensive evaluation of adverse events (AEs) or adverse drug reactions (ADRs) under the real-clinical setting conditions with a large-sample-size population. Therefore, this prospective, multi-center, intensive monitoring study aimed to comprehensively investigate the occurrence and risk factors of AEs and ADRs during PCI with bivalirudin as an anticoagulant.A total of 3,049 patients who underwent PCI with bivalirudin as anticoagulant from 27 Chinese medical centers were enrolled. Safety data (AEs/ADRs) were collected from hospital admission to 72 h after bivalirudin administration; then, patients were followed up at the 30th day with the safety data collected as well.A total of 414 (13.58%) patients occurred AEs, among which 31 (1.02%) cases suffered from severe AEs and 8 (0.26%) cases died due to AEs. Importantly, 118 (3.87%) patients occurred bivalirudin related ADRs, among which 7 (0.23%) cases suffered from severe ADRs while no case (0%) died due to ADRs. Of note, 7 (0.23%) patients showed new ADRs, 34 (1.12%) patients experienced bleeding, and 79 (2.59%) patients had thrombocytopenia. Furthermore, age, renal function impairment, CRUSADE high risk stratification independently correlated with total ADRs risk; CRUSADE high risk stratification, emergency operation, full dose bivalirudin independently associated with bleeding risk; age, renal function impairment independently related to thrombocytopenia risk.Bivalirudin is well-tolerated as an anticoagulant for PCI procedure; meanwhile, older age, renal function impairment, and CRUSADE high risk stratification serve as independent risk factors of bivalirudin related ADRs. Cardiovascular disease, as the most common cause of mobility and mortality, is a critical issue affecting global human health . PleasinBivalirudin, a synthetic analog of natural anticoagulant hirudin which consists of 20 amino acid peptides, is an explicit and irreversible thrombin inhibitor with concentration-dependent competitive and non-competitive thrombin repressing effect , 9. UnliTherefore, the current prospective, multi-center, intensive monitoring study enrolled 3,049 patients who underwent PCI with bivalirudin as anticoagulant from 27 Chinese medical centers, then aimed to comprehensively investigate the occurrence and risk factors of AEs and ADRs, especially for bleeding and thrombocytopenia.This was a prospective, multi-center, intensive monitoring study. The case enrollment and information collection of this study were carried out in 27 Chinese medical centers shown in . In the This study was conducted between July 2018 and June 2019. To observe a 0.1% incidence of ADRs , the required sample size was 3,000, with a power of 95%. A total of 3,050 patients were recruited, among which, one patient was excluded subsequently due to that the patient only received an angiography without PCI. Finally, 3,049 patients who underwent PCI with bivalirudin used as anticoagulant in the 27 medical centers were enrolled and analyzed in the current study. The inclusion criteria were: (1) underwent PCI or percutaneous coronary angioplasty (PTCA); (2) using bivalirudin as anticoagulant; (3) age over 18 years; (4) understand the study content and voluntarily participated in the study. Patients without use of bivalirudin were excluded from the study.Clinical data were collected after hospital admission. The mainly collected data covered the following: (1) basic information: age, gender, height, and weight; (2) medical history: allergy, cardiac surgery, critical respiratory disease, diabetes or thrombolysis, and tumor; (3) renal function impairment and severity; (4) clinical features: clinical presentation, CRUSADE score (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines), and CRUSADE risk stratification; (5) PCI-related information: timing limitation of operation (emergency or elective), types of coronary interventional therapy, arterial access, operative time, and time of bivalirudin infusion; (6) treatment: full-dose use of bivalirudin, and glycoprotein IIb/IIIa inhibitor use; (7) Thrombolysis in Myocardial Infarction (TIMI) grade: pre-procedure TIMI grade, and post-procedure TIMI grade.Safety data were collected from hospital admission to 72 h after completion of bivalirudin administration. In addition, patients were followed up at the 30th day, and the data were also collected at that time. The primary safety data included any AEs, which were required to be documented in detail during the period of intensive monitoring. Classification of AEs was coded using the Systematic Organ Classification (SOC) and Preferred Term (PT) of the International Conference on the Coordination of International Drug Registration (ICH) International Dictionary of Medical Terms (MedDRA) 23.0. The intensive monitoring ADRs were bleeding and thrombocytopenia, among which, the bleeding was graded in terms of Bleeding Academic Research Consortium (BARC) consensus classification criteria . All theAEs were defined as any unfavorable and unintended sign , symptom, or disease temporally associated with the use of a medical treatment that may or may not be considered related to the medical treatment. Severe adverse events (SAEs) were defined as one of the following events: (1) leading to death; (2) life-threatening consequences; (3) leading to carcinogenesis, teratogenesis, and birth defects; (4) leading to significant or permanent human disability or organ function damage; (5) resulting in hospitalization or prolonged length of stay; (6) leading to other important medical events, if not treated, the above-listed conditions may occur. ADRs were defined as the harmful reaction of qualified drugs which was irrelevant to the purpose of medication under normal usage and dosage. New ADRs were defined as the adverse reactions not specified in the drug instructions. Moreover, if the nature, extent, consequence, or frequency of adverse reactions were inconsistent with the drug instructions but more serious than those described in the instructions, they were also regarded as new ADRs.P < 0.05 was regarded as significant significance.SAS 9.4  was applied to complete data analysis. Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables were described as times, numbers, and percentages, as well as 95% confidence intervals (CI). Summary of AEs and ADRs was presented as number of times, incidence rate, and 95%CI. Detailed AEs, ADRs, and new ADRs in SOC were described as the number of times and incidence rate. Incidence of ADRs , bleedinThe enrolled patients exhibited a mean age of 64.78 ± 11.39 years with 2,131 (69.89%) males and 918 (30.11%) females. There were 1,244 (40.81%), 414 (13.58%), 1,034 (33.91%), and 352 (11.54%) patients who showed clinical presentation of ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTMI), unstable angina (UA), and spontaneous coronary artery dissection (SCAD), respectively; while 5 (0.16%) showed unknown clinical presentation. Furthermore, CRUSADE risk stratification identified 722 (23.68%), 1,014 (33.26%), 729 (23.91%), 342 (11.22%), 194 (6.36%), and 48 (1.57%) as very low risk, low risk, moderate risk, high risk, very high risk, and unknown risk, respectively. The detailed characteristics of patients are shown in Regarding the characteristics of PCI, 1,351 (44.31%) performed emergency operation while 1,698 (55.69%) performed elective operation. Operative duration and duration of bivalirudin infusion were 69.60 ± 48.00 min and 91.15 ± 77.40 min, respectively. Besides, 1,942 (63.69%) and 2,221 (72.84%) had full-dose use of bivalirudin and glycoprotein IIb/IIIa inhibitor use, respectively. The detailed characteristics of the PCI procedure are shown in A total of 414 (13.58%) patients occurred AEs, among which 31 (1.02%) cases suffered from SAEs and 8 (0.26%) cases died due to AEs . ImportaThe most common AEs were gastrointestinal disorders (3.58%), general disorders and administration site conditions (3.31%), respiratory, thoracic, and mediastinal disorders (3.18%), then blood and lymphatic system disorders 2.66%) . Meanwhi6% . MeanP = 0.022), renal function impairment  , and CRUSADE high risk stratification  were discovered to dependently relate to ADRs occurrence (Univariate logistic regression model identified that age (>75 years), history of diabetes or thrombolysis, renal function impairment (moderate or severe), and CRUSADE high risk stratification correlated with increased ADRs occurrence . Then afcurrence .P = 0.004), operative timing (emergency vs. elective) , full dose use of bivalirudin   independently correlated with increased bivalirudin related bleeding events occurrence (Univariate logistic regression model disclosed that age (>75 years), moderate renal function impairment, CRUSADE high risk stratification, operative timing (emergency vs. elective), and full dose use of bivalirudin in STEMI patients correlated with increased bivalirudin related bleeding events occurrence . After acurrence .P = 0.013) and renal function impairment  were independently associated with elevated thrombocytopenia risk (Univariate logistic regression model exhibited that age (>75 years), history of cardiac surgery, history of diabetes or thrombolysis, history of tumor, renal function impairment , CRUSADE high risk stratification, and radial artery access correlated with thrombocytopenia risk . Post adnia risk .Accumulating reports demonstrate that anticoagulant use of bivalirudin during PCI is of very good tolerance, while some minor AEs or ADRs still need attention, such as bleeding , cardiac/cardiovascular events , cerebrovascular events , stent thrombosis, and so on –21. It wIn order to provide the precise and strict information about the adverse events/adverse reactions related to bivalirudin application as anticoagulant during PCI for further drug choice guiding, we evaluated ADRs of bivalirudin during PCI, which were defined as the harmful reaction of qualified drugs that was irrelevant to the purpose of medication under normal usage and dosage. It was discovered that 3.87% patients experienced bivalirudin related ADRs, among which 0.23% cases suffered from SADRs, while no case died due to ADRs. However, there has been no previous study analyzing the bivalirudin related ADRs during PCI. This current study is the first to provide the overall information about it –23. GeneFurthermore, 0.23% patients showed new ADRs of bivalirudin, 1.12% patients experienced bivalirudin related bleeding, and 2.59% patients had bivalirudin related thrombocytopenia during PCI. These informed us that the occurrence of bleeding and thrombocytopenia, directly induced by bivalirudin, were less than the previous opinions , 19, 22.Despite these interesting findings, the current study still faces some limitations. First, the sample size of this study was calculated and set to 3,049 based on the purpose to observe the ADR with at least 0.1% incidence, while some SADRs or even deadly ADRs might be below 0.1% incidence. Therefore, these SADRs might not be easily discovered in this study. Hence, an even larger sample size population study would be needed in the future. Second, the medical centers participating in this study were almost first-class hospitals in China which could not represent all-level hospitals, therefore the physicians' skill and patients' bias would exist. Third, since the total ADRs, especially bivalirudin related bleeding events and bivalirudin related thrombocytopenia, rarely occurred, the risk factors analyzed by logistic regression analysis might have relatively low statistical power. Fourth, a long-term follow-up could be conducted to explore the safety of bivalirudin.In conclusion, bivalirudin is well-tolerated as anticoagulant for a PCI procedure; meanwhile, older age, renal function impairment, and CRUSADE high risk stratification serve as independent risk factors of bivalirudin related ADRs.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Ethics Committee of Beijing Anzhen Hospital Affiliated to Capital Medical University (KS2019012) and Peking University People's Hospital (2018PHA092-001). The patients/participants provided their written informed consent to participate in this study.PL and HZ made substantial contributions to the design of the present study. Data acquisition and interpretation were performed by PL, HZ, CL, ZJ, ZZ, ZL, FW, JL, and LH. PL, HZ, JL, and LH critically revised the manuscript for important intellectual content. All authors approved the final version of the manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of the work are appropriately investigated and resolved.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Lactobacillus delbrueckii subsp. bulgaricus (LDB) and Lactobacillus rhamnosus GG (LGG) into Ca2+‐complexed polymer microspheres for effective prevention of cholestatic DILI. Upon entering intestinal tract of the constructed living materials, LGG is released because of pH‐triggered dissolution of outer enteric polymer coating. The released LGG can inhibit hepatic bile acids (BAs) synthesis by activating intestinal farnesoid X receptor‐fibroblast growth factor 15（FGF‐15) signaling pathway. BAs excretion is also facilitated by LGG through increasing the abundance of bile salt hydrolase (BSH)‐active gut commensal bacteria. Furthermore, exposed positively‐charged chitosan shell can absorb the excessive BAs via electrostatic interaction, which leads to steady BAs fixation by the imprisoned LDB, decreasing the total BAs amounts in enterohepatic circulation. Together, the fabricated living materials, obtained here, can effectively prevent cholestatic DILI through dredging cholestasis via gut‐liver axis modulation. The therapeutic effect is demonstrated in α‐naphthylisothiocyanate and clinical antiepileptic drug valproate acid‐induced cholestatic DILI mouse models, which reveal the great potential for effective cholestatic DILI management.Cholestatic drug‐induced liver injury (DILI) induced by drugs or other xenobiotics is a severe and even fatal clinical syndrome. Here, living materials of hierarchy‐assembled dual probiotics system are fabricated by sequentially encapsulating probiotic  Hierarchy‐assembled dual probiotics system is developed, which reveal great potential to ameliorate cholestatic drug‐induced liver injury via gut‐liver axis modulation. Currently, the commonly used intervention strategies are to suppress the hepatic inflammatory effect by using anti‐inflammatory drugs or nanomaterials, or to suspend the offending drugs and avoid re‐exposure. In fact, these therapeutic methods are only palliatives and usually restricted. Especially, no definitive therapy is available in the idiosyncratic DILI. Therefore, developing new therapeutic strategies for idiosyncratic DILI intervention is urgently needed. It was reported that the perturbation of bile acids (BAs) homeostasis is a common early event in DILI. Particularly, drug‐induced cholestasis is one of the prominent characteristic and risk factor in the idiosyncratic DILI. Beyond causing serious liver injury, the long period of cholestasis in liver tissue is very possible to finally result in more serious liver diseases like choleplania, primary sclerosing cholangitis (PSC), hepatic fibrosis, cirrhosis, and cancers , et al. In view of these, desludging the hepatic and intestinal BAs drainage could be a promising therapeutic opportunity in the prevention of cholestatic DILI.Cholestatic drug‐induced liver injury (DILI) triggered by drugs or other xenobiotics is a common clinical challenge with respect to diagnosis and treatment.1, 2 The remaining primary BAs are enzymatically deconjugated and modified by the resided gut bacteria to produce a group of secondary BAs, which in turn regulate the hepatic BAs metabolism and affect multiple enterohepatic diseases. As a matter of course, a promising therapeutic opportunity could be provided by modulating biliary gut‐liver axis circulation and gut microbiota mediated BAs metabolism for effective intervention of cholestasis‐related diseases. For example, in order to dispose the cholestasis, commercial positively charged resin polymers like cholestyramine and colestipol are mostly applied to scavenge BAs through electrostatically adsorbing the free BAs in intestinal tract. In fact, many negatively charged molecules like proteins and fatty acids can disturb the polymeric sequestration of BAs, so that the clearance effect is significantly limited. To achieve the ideal intervention result, a high dose of these resin polymer drug is necessary to be administrated, which inevitably interferes with normal nutrient absorption. Additionally, these polymeric drugs only take away the intestinal BAs, while the hepatic BAs are rarely stirred because the cholesterol metabolism could be activated and replenish the BAs pool. Natural ursodeoxycholic acid (UDCA) is the most established medical treatment for cholestasis anesis by promoting hepatic BAs excretion and decreasing intestinal BAs reabsorption, but the independent UDCA therapy could be also restricted by inadequate response and drug resistance.Primary BAs are synthesized in hepatic tissue from cholesterol and conjugated with taurine or glycine to generate the conjugated BAs. These molecules can be released into the intestinal tract to aid in the absorption of lipids and vitamins. Then, over 95% BAs are reabsorbed by ileum and transported to the liver via the enterohepatic circulation.9 The  and emergingly applied in biosensing, self‐repairing and regeneration, protein production, antipathogens, and diseases treatment. Particularly, by utilizing the unique ability of microorganisms, many intractable diseases have the chance to be well treated, including kidney failure, colon cancer, colitis, and alcoholic liver disease, etc. These works indicated the feasibility of employing microorganisms and functional materials, especially life unit‐involved polymers (LIP), to rationally build living materials to treat DILI through relieving cholestasis. Previous literatures reported that some probiotics like Lactobacillus delbrueckii subsp. bulgaricus (LDB) can actively gather the BAs by multiple mechanisms including bacterial transmembrane proton gradient driven transportation and bacterial S‐layer proteins mediated binding. Additionally, it was also found that Lactobacillus rhamnosus GG (LGG) can inhibit hepatic BAs synthesis and enhance BAs secretion through activating intestinal farnesoid X receptor (FXR)‐fibroblast growth factor 15 (FGF‐15) signaling pathway and regulating gut microbiota‐mediated primary BAs deconjugation. Therefore, combining LDB and LGG has the potential to thoroughly dredge the blockage of BAs in liver and intestine via modulating BAs circulation in gut‐liver axis and facilitating gut microbiota‐guided BAs metabolism.Recently, by uniting the alive traits of microorganisms with the versatile properties of functional materials, the customized materials‐assisted microorganisms (MAMO) were well fabricated,16 and2+‐coordinated polymer microspheres , LGG was released due to the pH‐dependent dissolution of enteric polymer coating. The released LGG can decrease hepatic BAs synthesis through activating intestinal FXR‐FGF‐15 signaling pathway, and promote BAs excretion through enhancing the richness of bile salt hydrolase (BSH)‐active gut commensal microbes. The followingly exposed chitosan shell can prolong the retention time of calcium alginate microspheres in intestinal tract, play crucial role to absorb the excessive BAs, promote the steady fixation of BAs by the imprisoned LDB in calcium alginate microspheres, and finally decrease the total BAs amounts in enterohepatic circulation along with the excretion out of LDB‐trapped calcium alginate microspheres (Scheme α‐naphthylisothiocyanate (ANIT) and clinical antiepileptic drugs valproate acid (VPA)‐induced mouse models of cholestatic DILI by employing LCA/LGG‐LDB. It was found that LCA/LGG‐LDB can significantly dredge cholestasis via gut‐liver axis modulation, indicating great potential to serve as general strategy for cholestatic DILI treatment.In this study, living materials of hierarchy‐assembled dual probiotics system were constructed by orderly encapsulating LDB and LGG into Cas Scheme 1A. LDB ws Scheme . The eff22.12+‐complexed alginate microspheres via microemulsion method. As shown in Figure 2+ to lock LGG onto the surface of microspheres tightly. Fluorescence image displayed that cyanine 5 (Cy5)‐labeled LGG bacteria (red) were incorporated onto the surface of chitosan‐modified calcium alginate microspheres by enteric polymers  about −10.91 mV, while the zeta potential was reversed into positively charged ≈48.05 mV after chitosan modification . When coating with enteric polymers, the zeta potential was changed into negatively charged of −0.55 mV, suggesting that the final LCA/LGG‐LDB is negatively charged. The zeta potential of LCA/LGG‐LDB was again converted to positively charged after incubating in SIF, meaning that the outer enteric polymers was dissolved. The dissolution effect of LCA/LDB‐LGG was measured in SGF and SIF. As shown in Figure According to construction principle, electrostatic interaction is the main assembling force of LCA/LGG‐LDB. The zeta potential was tested by orderly mixing the used components for expediently monitoring the potential changes during establishment of dual probiotics system Figure . The zet2.2 The therapeutic process was shown in Figure α (TNF‐α), interleukin‐1β (IL‐1β), and interleukin‐6 (IL‐6) were also tested for evaluating inflammatory level. As showed in Figure A typical mouse model of ANIT‐induced intrahepatic cholestasis and acute liver bile duct injury was constructed to investigate the potential therapeutic effect of synthesized dual probiotic system.27 The2.3 Thus, the disorganization of these tight‐junctional complexes can reflect the pathogenesis of cholestasis to some extent. To further clarify the therapeutic effect of the synthesized dual probiotic system in ANIT‐induced liver injury, the integrity of tight‐junctional protein zonula occludens‐1 (ZO‐1) was first analyzed by immunofluorescence staining. As shown in Figure According to previous report, hepatic tight‐junctional structures that seal the bile canaliculus are responsible for providing a barrier to diffusion between bile and blood, which also drive the bile formation by maintaining the bile‐to‐blood gradients.28 Thu FXR, a member of the steroid/thyroid hormone receptor family of ligand‐activated transcription factors, is associated to BAs synthesis and circulation. Hepatic FXR is involved in the feedback repression of BAs synthesis via small heterodimer partner (SHP) by mainly reducing the expression of a rate‐limiting enzyme of the cytochrome p450 enzymes cholesterol 7α‐hydroxylase (CYP7A1) for BAs synthesis. Ileal FXR play critical role in the process of BAs reabsorption through regulating BAs transporter expression. In particular, the activation of ileal FXR can accelerate the expression of a hormone of FGF‐15, which is transported into liver through portal blood to suppress the expression of CYP7A1. Thus, the hepatic FXR and intestinal FXR coordinate to regulate CYP7A1. To research whether the reduction of BAs in liver and serum was also ascribed to activation of FXR‐FGF‐15 signaling pathway, the mRNA expressions of related genes were evaluated. As shown in Figure Fxr and its target gene Shp were reduced in ANIT treatment group as well as LCA, LCA/LDB treatment groups, while the mRNA expressions of the two genes were significantly enhanced in LCA/LGG‐LDB treatment group. The concentration of FGF‐15 protein in ileum and serum was further tested. Results showed that the prominent FGF‐15 reduction was found in the groups of ANIT and cotreating with LCA, LCA/LDB, and LCA/LGG. After LCA/LGG‐LDB treatment, the concentration of FGF‐15 was significantly elevated in both ileum and serum , a hepatic BAs transporter, was further detected. After ANIT treatment, the Bsep mRNA level was low. But Bsep mRNA expression was significantly upregulated after LCA/LGG‐LDB treatment, which indicated that the accumulative BAs in liver could be rapidly excreted into intestinal tract, and finally excreted out along with feces , which is proved to active hepatic FXR and inhibit CYP7A1 expression, was also significantly elevated in LCA/LGG‐LDB treatment. The gut microbiota analysis proved that LCA/LGG‐LDB can effectively correct disordered gut microbiota caused by ANIT. The abundance enhancement of highly BSH‐active bacteria induced by LCA/LGG‐LDB indicated the higher intestinal BSH content and more BAs excretion, which was consistent with above BAs and BSH tests. These evidences demonstrated that cholestatic DILI caused by ANIT can be prevented by LCA/LGG‐LDB through modulating the composition and metabolism of gut microbiota.As shown in Figure 29 Aftp Figure . Besidesβ‐muricholic acid (T‐β‐MCA) concentration was significantly elevated in ANIT‐treated mice. The two BAs levels were reversed by LCA/LGG‐LDB treatment  method. It was found that mRNA expressions of both Fxr and Shp were lowered after VPA treatment, which were upregulated by LCA/LGG‐LDB treatment (Figure Cyp7a1 was quantified. Results proved that the upregulated mRNA expression of Cyp7a1 by VPA treatment was downregulated after LCA/LGG‐LDB treatment, which agreed with the inhibition of hepatic BAs synthesis induced by LCA/LGG‐LDB (Figure Shp and Bsep in LCA/LGG‐LDB treatment were also higher than VPA‐treated group, which revealed the decreased synthesis and accelerated excretion of hepatic BAs (Figure Bsep in VPA‐treated group than control group could be ascribed to the activated adaptive mechanism of liver tissue in attempt to attenuate bile acid accumulation and protect against further liver injury. Importantly, fecal BSH content in LCA/LGG‐LDB treatment was also higher in comparison to VPA‐treated group, meaning that more conjugated BAs were translated into hydrophobic deconjugated BAs after LCA/LGG‐LDB treatment, which could greatly promote BAs excretion from intestinal tract (Figure To evaluate the prevention mechanisms of LCA/LGG‐LDB toward VPA‐induced cholestasis and corresponding hepatotoxicity, total BAs in liver and serum were first tested. Results showed that hepatic and serosanguineous BAs were obviously increased after VPA treatment, while the elevation was abrogated after LCA/LGG‐LDB treatment Figure 6A,B. Fect Figure . Similart Figure . To veriB Figure . Additios Figure . The higr injury.32 Impt Figure . Collect32+‐coordinated polymer microspheres to construct dual probiotics system. The established dual probiotic system exhibited high stability and strictly protected bacterial activity owing to the presence of enteric polymer coating. Charge reversal induced by pH‐dependent dissolution of enteric polymer coating conferred the strong bio‐adhesive ability of the exposed chitosan‐modified calcium alginate microspheres, which tremendously prolonged the retention time of calcium alginate microspheres in intestinal tract and greatly promoted BAs fixation by imprisoned LDB through preadsorbing BAs onto surface of calcium alginate microspheres. In ANIT‐induced mouse model of cholestatic DILI, the dual probiotics system significantly activated FXR‐FGF‐15 signaling pathway, altered hepatic BAs composition and enhanced BESP expression, which resulted in repressive hepatic BAs synthesis and accelerated hepatic BAs excretion. Meanwhile, the dual probiotics system also changed the composition of gut microbiota, elevated the richness of BSH‐active intestinal commensal bacteria, which are beneficial to BAs excretion from intestinal tract through converting conjugated BAs to deconjugated BAs. Along with BAs fixation effect of LDB‐imprisoned calcium alginate microspheres, the satisfactory scavenging effect of intestinal BAs was eventually achieved. In view of the potent BAs depuration effect of dual probiotics system, ANIT and VPA‐induced cholestasis was signally ameliorated, and corresponding liver injury was healed. This strategy exhibited great potential to serve as a universal strategy for cholestatic DILI intervention.In this work, probiotic LDB and LGG were hierarchically encapsulated into CaThe authors declare no conflict of interest.Supporting InformationClick here for additional data file.


Clinical practice guidelines.The objective was to update the 2016 version of the Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI).The guidelines are relevant for inpatient, outpatient and community SCI rehabilitation settings in Canada.The guidelines were updated in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management  after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations.The working group identified and reviewed 46 additional relevant articles published since the last version of the guidelines. The panel agreed on 3 new screening and diagnosis recommendations and 8 new treatment recommendations. Two key changes to these treatment recommendations included the introduction of general treatment principles and a new treatment recommendation classification system. No new recommendations to model of care were made.The CanPainSCI recommendations for the management of neuropathic pain after SCI should be used to inform practice. Neuropathic pain (NP) presents significant challenges to those living with spinal cord injury (SCI), with negative effects on function participation, , and quality of life. For clinicians, providing support for those with NP after SCI continues to be a challenge. The 2016 CanPainSCI Clinical Practice Guidelines (CPG) formalized a series of recommendations for the rehabilitation management of NP after SCI , treatmeThe current document presents updates to the CanPainSCI CPG based on additional relevant literature that has been published since the first iteration of the guidelines. The ongoing goals of these CPG are to (1) provide practical and actionable guidelines with a strong rating on the AGREE-II scale, (2) support standardized care in the rehabilitation management of NP after SCI, and (3) identify opportunities for further research in this area.As in the 2016 CPG, an international group of experts formed a Working Group (WG) that would update the CanPainSCI guidelines under the direction of the Steering Committee (SC).The scope and purpose of these guidelines are unchanged from the 2016 version. The target population to which these CPG apply includes adults living with SCI who are in the subacute phase of inpatient rehabilitation management to those living in the community. It excludes those being cared for in an acute care setting immediately after their initial injury. These guidelines are intended to be used by clinicians who care for those with SCI. Researchers and health policy experts will also find these guidelines valuable.The overall CPG update process was overseen by the SC  with ongoing input and review from the WG. A facilitator (EJM) assisted with organizing and planning meetings. The CPG update methodology followed a similar process as the initial 2016 CPG, in accordance with the AGREE II tool. The main steps of this process involved: (1) identifying experts for the new 2020 WG, (2) updating literature search and review, (3) evaluating the quality of evidence using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, (4) discussing the updated evidence with WG members to develop and suggest modifications to existing recommendations or to propose new recommendations, and (5) voting on the recommendations and guidelines. The update was funded by the Ontario Neurotrauma Foundation (ONF); guideline development was editorially independent from the funder.Experts who were involved in the initial 2016 CanPainSCI CPG WG were invited to participate in the 2020 WG. New members were recruited if previous WG members were unable to participate or if their discipline/area of professional expertise was not represented in the 2016 WG composition. Representation from a broad spectrum of disciplines that reflected a national and international geographic distribution was sought. Experts from physiatry, pain medicine, psychology, pharmacy, occupational therapy, physical therapy, nursing, and research were included. Those with lived experience were also included in the WG, as were representatives from the ONF and a peer advocacy organization (SCI-Ontario) . ‘Spinal cord injury’ and ‘neuropathic pain’ key words were searched in combination with ‘intervention’, ‘diagnosis’, and ‘model of care’ key words (see Appendix Articles which investigated interventions for the treatment of NP in people with SCI were included if they met the following inclusion criteria: (1) the study population was comprised of ≥50% individuals with traumatic or non-traumatic SCI, (2) the study population had NP or mixed pain, (3) there were ≥3 human adult participants (≥18 years) with SCI and neuropathic or mixed pain, (4) the study was conducted in a rehabilitation, outpatient, or community setting, (5) the effect of treatment on pain intensity was assessed. Articles which investigated screening or diagnostic tools or models of care for NP in people with SCI were also included. Articles were excluded if: (1) they involved participants with musculoskeletal pain only, (2) were conducted in an acute setting, (3) were reviews, case studies/reports, study protocols, or qualitative studies.After removing duplicates, articles were first screened for eligibility based on title and abstract, then based on full text, by two independent reviewers . Any discrepancies were resolved by a third reviewer (EL). Additionally, any other articles identified following the review of the reference lists of articles identified using the search strategy or those which were deemed to be of relevance by the expert panel were included.The methodological quality of each article was assessed by two independent reviewers  using a modified GRADE approach. Pain intensity was the primary outcome assessed with GRADE for articles investigating treatment modalities. If agreement on an individual GRADE level assignment was not achieved, discrepancies were resolved by a third reviewer. WG members provided input on the assessment of evidence quality during their discussions. If a change in the assigned quality of evidence was proposed, the WG voted on a potential change. If 75% or more of the panellists agreed, the GRADE assignment was adjusted.GRADE criteria were modified in an identical process as the original 2016 CPG. Due to the generally smaller sample size in the SCI literature, the reviewers did not necessarily downgrade the quality of evidence for studies with a small sample size  from January 2020 to April 2020. Each group was assigned different treatments for which new evidence was available. One group was assigned additional literature to review related to diagnosis and screening. Each group was provided with evidence tables that summarized existing literature for that treatment (if any), updated and new literature, and the modified GRADE rating. Groups reviewed the new and existing literature and provided input on the modified GRADE assignment. If there was disagreement over a particular treatment’s evidence base because of conflicting study results, the WG could request a meta-analysis to attempt to resolve this conflict. New and modified recommendations were proposed by the small discussion groups for presentation to the full WG.In accordance with the GRADE process and the AGREE II tool, the groups assigned a GRADE rating and a level of strength (strong or weak) to each proposed recommendation. Clinical experience, side-effect profile, effectiveness in other populations with NP, and any other factors that the panel considered relevant were used to determine the strength of each recommendation.Proposed recommendations were summarized and presented to the WG for discussion at two additional meetings attended by all members. These meetings (2–3 h) were held over videoconference  on June 15 and June 25, 2020. The WG was divided into small groups. Each group reviewed and discussed all new and modified recommendations. Groups also reviewed all 2016 treatment recommendations for which there was new evidence but no new or modified recommendations, to ensure that this was appropriate. The WG also discussed the best means with which to present and frame the recommendations. A full group discussion was held at the end of each meeting to summarize each group’s key discussion points.®). As for the 2016 CPG, recommendations achieving at least 75% agreement were adopted. Remaining treatments with new evidence were designated as “requiring further research” if appropriate and are summarized within the CPG. Existing recommendations from the 2016 CPG for which there was no new evidence remain unchanged in the current edition.Proposed new and modified recommendations arising from the final meetings were summarized for presentation to the panel. The WG anonymously voted on the format of the CPG, any new/modified recommendations, GRADE ratings of the recommendations (if disagreement was voiced during the WG discussions) and the strength of new/modified recommendations using online survey software . Given the model of care recommendations have not changed, please refer to the 2016 version (https://www.nature.com/articles/sc201691). As there has been extensive reframing of the treatment recommendations for the 2021 update, the entire treatment guidelines are presented in this document, including recommendations and treatments requiring further research that are unchanged from 2016. Key 2021 updates are identified within the guideline text.For the screening and diagnosis recommendations, only the three new recommendations are discussed in this document. Detailed discussion on the other recommendations can be found in the 2016 version of the CanPainSCI CPG ) and Neuropathic Pain Symptom Pain Inventory (NPSI) can be used to supplement the diagnosis of neuropathic pain for people with spinal cord injury.1.10 The NPSI can be used to supplement the assessment and documentation of neuropathic pain.1.15 The NPSI can be used to supplement the evaluation of treatment response.Level of Evidence: HighStrength of Recommendation: StrongThree new studies were identified that addressed screening and diagnosis of NP after SCI –9. Two cr > 0.4) were described  = 4.99, p = 0.03) [One RCT of pain in patients with SCI found a reduction in the pain perception score in the treatment group compared with the control group after 3 months ( = 0.03) . HoweverA case series with a mixed pain population of patients with SCI presented no statistically significant data on pain intensity reduction .A prospective-controlled trial, which included a comparison between acupuncture and massage, found that massage did not produce a significant reduction compared with acupuncture in SCI-related NP intensity . No evidAn RCT found a 16% reduction in the perception of SCI-related NP during treatment but not at later time points . No signOne RCT showed no significant difference in reduction in intensity of NP between duloxetine and placebo in patients with SCI or stroke, although a trend was seen toward a decrease in the mean pain score with duloxetine, demonstrating the potential for benefit . A good −1 over 30 min [−1 over 40 min [IV lidocaine has demonstrated benefit in three well-conducted RCTs of SCI-related NP , 120. Onr 30 min , 120, whr 40 min . Light-hp = 0.01), allodynia compared with placebo and wind-up-like pain compared with placebo. As the response of continuous pain to therapy was only measured before and after the infusion, the duration of response is uncertain. The IV mode of administration of alfentanil makes this therapy a short-term management option with a short duration of effect.A single double-blind cross-over study of nine patients with central dysesthetic pain after SCI evaluated alfentanil and ketamine compared with placebo  . AlfentaOne RCT that compared intrathecal clonidine with placebo  found no statistically significant difference in reduction of pain intensity in patients with SCI-related pain, and the evidence quality of the study was downgraded because of a lack of description of the randomization process or patient allocation .p = 0.0084) [One double-blind cross-over study of 15 patients that compared intrathecal administration of clonidine, morphine, clonidine plus morphine and saline (placebo) found a significant reduction in pain intensity only for the combination of intrathecal morphine and clonidine compared with placebo ( 0.0084) . Two of One small, double-blind, placebo-controlled, cross-over study of IV morphine in patients with SCI- or stroke-related NP found no significant difference in spontaneous pain between placebo and IV morphine but a 90-min post-injection reduction in allodynia with morphine . The eviThese guidelines represent the most up-to-date version of the CanPainSCI CPG. As in the 2016 CPG, the primary outcome for treatment options evaluated through the GRADE process was pain intensity. The WG is aware this is not the only relevant outcome, nor is it the most important outcome in all cases. Although not formally evaluated within this version of the CPG, the WG considered other outcomes  in their discussions. Future editions of the CPG will formally assess other relevant pain outcomes using GRADE.A limitation of the 2016 CPG was the lack of high-quality studies; it was recognized by the 2016 panel that further research is required for most treatment options including those that were developed into recommendations. In the intervening time since the initial 2016 CanPainSCI guidelines, the overall study quality on which recommendations are based has not drastically improved. Of the 43 new articles reviewed in the treatment category, all but five articles were considered moderate to very low in quality.A case could certainly be made that the evidence is too weak for many of the CanPainSCI recommended treatments to be presented as specific recommendations. The CPG WG panel discussed this issue at length. The WG agreed that although the overall evidence base remains weak, it is unacceptable for those with NP after SCI, and for clinicians, to have no guidance on management. Although study quality is limited, extensive work has been done within NP and SCI, and the consensus of the CanPainSCI panel represents a best effort to summarize existing work and to develop a framework to guide management decisions. High quality trials of NP treatments after SCI can be challenging to produce given the low prevalence of SCI, which is further complicated by variations in etiology, level, and severity. As such, the WG noted that significant improvements in the overall quality of the evidence base could take years, if not decades, to achieve. It is, therefore, important to have a document that provides a framework for NP management after SCI, and the panel agreed on the importance of the guidelines to serve as a reference point for clinicians and to identify areas for research for NP after SCI.The CanPainSCI panel made the decision to restructure the classification of treatment recommendations from first to fourth line to the current “first-line”, “B”, “C”, and “D” system, to account for the inherent challenges of working with a limited evidence base. An additional general recommendation regarding the pursuit of self-management strategies that those with SCI find successful (G1) was also included as a response to the limited evidence that underlies many treatment options.The process of updating the CanPainSCI CPG was discussed by the panel. While formal updates are intended to occur every 4–5 years, the panel noted it may be less onerous to conduct smaller updates more frequently, and would keep the CPG continually up-to-date. A living guidelines process was discussed, with updates and reviews to be performed on a yearly basis, involving smaller, rotating groups within the WG. The full panel would review any changes at the 4–5-year point as scheduled, and issue a formal update of the CPG at that time. We expect the living guideline process to begin at the end of 2021.The next steps for implementation of the CPG will be refinement of existing clinical algorithms to allow easier uptake at point-of-care. Alternative means of disseminating the guidelines, including via phone app, are in development. Appendix Appendix 1 - Search StrategyAppendix 2 - GRADE scoring criteriaAppendix 3 - Visual representation of a clinical algorithm for the screening/diagnosis and treatment of neuropathic pain following SCI


Systematic reviews of 591 primary studies of the modes of transmission for SARS-CoV-2 show significant methodological shortcomings and heterogeneity in the design, conduct, testing, and reporting of SARS-CoV-2 transmission. While this is partly understandable at the outset of a pandemic, evidence rules of proof for assessing the transmission of this virus are needed for present and future pandemics of viral respiratory pathogens. We review the history of causality assessment related to microbial etiologies with a focus on respiratory viruses and suggest a hierarchy of evidence to integrate clinical, epidemiologic, molecular, and laboratory perspectives on transmission. The hierarchy, if applied to future studies, should narrow the uncertainty over the twin concepts of causality and transmission of human respiratory viruses. We attempt to address the translational gap between the current research evidence and the assessment of causality in the transmission of respiratory viruses with a focus on SARS-CoV-2. Experimentation, consistency, and independent replication of research alongside our proposed framework provide a chain of evidence that can reduce the uncertainty over the transmission of respiratory viruses and increase the level of confidence in specific modes of transmission, informing the measures that should be undertaken to prevent transmission. Our increasing proficiency in demonstrating viruses has produced a disconcerting but not entirely unwelcome paradox—the spectacle of new information leading to confusion.” . The first four postulates can be considered a practical application of Hill’s criteria of strength and temporality, but the fifth is Hill’s experiment: “Because of an observed association some preventive action is taken. Does it, in fact, prevent? Is the frequency of the associated events affected?” . The postulates present the first convergence of causality and transmission as they represent a detailed checklist of the chain of transmission of respiratory viruses and require an experiment to test whether the hypothesised mode of transmission can be interrupted. The Gwaltney–Hendley postulates, however, omit Hill’s criteria of “specificity” and “consistency”. Specificity is a particular problem concerning viral respiratory infections. Since the clinical presentation cannot distinguish those viral infections that present with similar clinical features, laboratory identification of the responsible agent becomes necessary. Evans pointed this out in 1991 in his “Five Realities of Acute Respiratory Disease”  17]. . 17]. As any practising clinician knows, it is impossible to distinguish with absolute confidence an acute respiratory infection caused by rhinovirus from one caused by adenovirus, or to be able to rule out any co-infection with two or more viruses, based on clinical presentation alone. Proof requires microbiological identification and evidence for the chain of transmission, which is now possible with the advent of genomics .As knowledge of genetics grew, Fredricks and Relman in 1996 proposed reformulation of the original Koch’s postulates incorporating the state of knowledge at the time  21]. . 21]. This list contains many previously raised points, and, crucially, includes the seventh postulate: the issue of consistency or reproducibility of results. Further reformulations were proposed by Lipkin  in 2013 Certainty (or diminution of uncertainty) is essential for all Gwaltney’s and Hendley’s postulates, especially on the crucial issues of correct identification of those who have an active infection and are contagious, i.e., capable of infecting contacts. This simple concept has been lost in a plethora of information overload of hurried low-quality studies in the current pandemic (in line with Huebner’s prescient observations). Clinical details of the exposed patient and a chain of transmission with laboratory confirmation of active infection in the exposed susceptible person are necessary to reduce the uncertainty over transmission. Across 591 studies, we identified laboratory confirmation of active infection as a critical result for interpreting the circumstances and finality of transmission. However, our reviews ,11,12,13Overall, we found that none of the 591 studies carried out serial viral cultures; of the 379 studies which used PCR as a diagnostic tool, 121 (32%) reported a cycle threshold and only 48 (13%) attempted to correlate its significance with viral culture .Few reported a positive culture and the culture methods used. This is an undesirable approach, but in the absence of evidence, such an argument at least requires the extensive use of positive controls.Another review of studies of viral cultures for SARS-CoV-2 infectious potential assessment found that only 11/29 studies reported date of symptom onset in relation to the date of specimen collection .To efficiently use all possible information and reduce uncertainty over the interpretation of the mode of transmission, we built a four-level hierarchical structure, similar to the levels of evidence used in evidence-based medicine , based oLevel 1: Binary PCR or nucleic acid antigen result in the absence of clinical data.Lack of agent specificity means there are often no distinctive signs or symptoms readily attributable to a specific respiratory virus; reporting only PCR or other nucleic acid amplification tests as binary positive/negative does not identify current active infection. At the lowest level of confirmation, residual non-infectious RNA or DNA of the responsible viruses can be harboured and shed for weeks to months ,26,27. Level 2: Single Quantitative PCR result.Adding further information, such as log concentrations of virus or PCR cycle threshold (Ct) values, reduces some of the uncertainty for identifying those with active infection but is not definitive. Current evidence shows that the lower the Ct representing a higher concentration of virus particles, the more likely a “positive” has infectious potential ,26. ContLevel 3: Cytopathic Effects (CPE).More certainty is provided by cell culture and observation of the effects of inoculation of specimen washouts on the cells. Observed structural changes in host cells caused by viral invasion leading to visible cell lysis and other cytopathic phenomena are further indicative of viral replication. Clinically the patient may be still symptomatic, but the viral concentration may be too low to infect, and the CPE may be classed as weak. Therefore, coinfection or contamination cannot be fully ruled out. For example, Lednicky et al.  reportedLevel 4: Serial Viral Culture or validated viral load surrogate and genome sequencing.Immunohistochemistry directed at specific viruses and genome sequencing excludes co-infection and indicates a higher probability of the correct identification of the agent and viral similarity between donor and recipient, which are crucial for determining proof of transmission. Here again, accurate contact history and the clinical picture will provide chronological evidence of the likely chain of transmission. Patients within the early incubation period of the relevant respiratory virus, or of symptom onset, severe symptoms or pre-existing pathologies fall in this category. Sequencing does not require the presence of a viable virus, so only its coupling with repeated serial cultures will diminish the uncertainty around both transmission and causation. The presence of replicating virus, the absence of co-infection, and the similarity of the viral lineage of the presumed source gives rise to the strongest evidence of transmission and causation. During the SARS-CoV-2 pandemic an increasing body of evidence has shown the close relationship between viral load  and the likelihood of culturing replication competent virus. A decreasing Ct meaning an increasing genome copy number point to the high likelihood of the donor’s infectiousness without recourse to viral cultures. Such a relationship is reinforced if PCR methods are validated and harmonised on a national of subnational basis to increase consistency ,31.To prove transmission from one person to another requires two viral sequences to share an otherwise statistically improbable number of identical mutations. Genome sequences are required to exclude the possibility that the second person was infected by another circulating virus from elsewhere in the environment. The quantity of genome needing sequencing depends upon the spontaneous mutation rate (the rate of drift of the sequences). Ideally, these would be “silent” mutations (random sequence noise) unconnected to phenotypes subject to selection .To document how the second person became infected requires evidence that they were exposed in their environment (the route) and that the source was sufficiently infectious (low Ct) with infectious material (cultivatable virus) capable of transmitting via one or more routes to another person. Availability of all such evidence provides a high standard of proof of transmission in the age of genomics.Our hierarchical Framework for Assessing Transmission Causality of Respiratory Viruses is synthesized in the As the next higher level of evidence is reported, clinical and transmission relevance increase with more reliable detail added, as symbolised by the arrows on the right. As reliability increases so does credibility and reproducibility, forming a hierarchy symbolised by the pyramid in the background.The hierarchy allows an understanding of transmission evidence across our reviews and its uncertainties. Across our five reviews, the results interpreted by using our proposed framework show a lack of higher-level evidence. The hierarchical framework could be used in any situation where viral transmission needs investigating and reporting, especially with new emerging viral infections. Given the fleeting nature of some respiratory infections and the narrow window in which to study transmission events, a generally accepted framework would require less time in devising study design and more could be devoted to investigating and reporting. If some parts of the transmission chain cannot be documented, authors could indicate as such and reach tentative conclusions and identify existing gaps.Assigning causation relies on a consistent body of evidence which either excludes other biologically plausible alternative explanations for the events or makes them unlikely. Experimentation and consistency alongside our proposed framework provide a chain of evidence that can reduce the uncertainty over the transmission of respiratory viruses and increase the level of confidence in specific modes of transmission. The addition of a sixth postulate to Gwaltney–Hendley’s work requires the validation of the transmission chain by independent replication of results. To date at least one SARS-CoV-2 challenge study has been carried out . Its resEvidence that follows Bradford Hill’s principles for assessing causation: strength, temporality and experimentation  along with independent replication and the hierarchy of transmission outcome events provides a coherent framework for assessing causation for the transmission of respiratory viruses. Continued uncertainty and lack of understanding of the major mode(s) of transmission and their respective frequency in any given setting with respect to SARS-CoV-2, underscores the critical importance of applying a framework for assessing causality in transmission of respiratory viruses. Given the current global COVID-19 pandemic and that more than two years since its historic arrival as a “modern-day plague”, we still do not have the fundamental questions definitively answered regarding the mode(s) and frequency of transmission, whether multiple modes can co-exist in the same setting, nor the minimal infective dose or the serological correlates of infection. It is imperative to provide high-quality evidence so that optimal intervention measures may be applied to achieve prevention of lives lost and protection against global economic and social demise.