Serum and CSF levels of E2  appeared not to correlate in the investigated cohort. DHEA serum concentration correlated significantly with E2  in CSF. In addition, a strong correlation was found between DHEA and E2, both measured in CSF . Peripheral DHEA levels might serve as an indicator for central nervous levels of the neuroactive steroids DHEA and E2 in pregnant women.Neuroactive steroids such as dehydroepiandrosterone (DHEA), estradiol (E2), and progesterone (P4) are associated with structural and functional changes in the central nervous system (CNS). Measurement of steroid levels in the CNS compartments is restricted in accessibility. Consequently, there is only limited human data on the distributional equilibrium for steroid levels between peripheral and central compartments. While some neuroactive steroids including DHEA and E2 have been reported to convey excitatory and proconvulsant properties, the opposite was demonstrated for P4. We aimed to elucidate the correlation between peripheral and central DHEA, E2, and P4 levels in women at term pregnancy. CSF and serum samples of 27 healthy pregnant women (22–39 years) at term pregnancy were collected simultaneously under combined spinal and epidural anesthesia and used for DHEA ELISA and E2, and P4 ECLIA. All three neuroactive steroids were detected at markedly lower levels in CSF compared to their corresponding serum concentrations . We found a strong correlation for DHEA between its serum and the corresponding CSF levels ( The neuroactive steroids dehydroepiandrosterone (DHEA), estradiol (E2), and progesterone P4) have been found to modulate neural activity to a variable degree exerting excitatory and inhibitory effects in neural tissue –4. These have beeNeuroactive steroids originate both from peripheral glands and de novo synthesis in the CNS in neurons and glial cells , 11. TheSteroid hormones cross the blood-brain barrier (BBB) to a certain extent, but the intercompartment equilibrium between serum, cerebrospinal fluid (CSF), and neural tissue is unclear . The stuConcerning the clinical impact of neuroactive steroids, there is an ongoing debate on their pathophysiology with contradictory clinical observations and research results . RegularAlthough the status quo of seizure frequency appears to remain controlled during pregnancy in most women with epilepsy, several studies report an increasing seizure frequency in 20–50% of these patients –28. ReliA possible cofactor modulating seizure frequency could be a pregnancy-related change toward stronger estrogen dominance in the concentration ratio of excitatory to anticonvulsant neuroactive steroids. If neuroactive steroids modulate the susceptibility for convulsive disorders in pregnancy, this would certainly also concern women at risk for eclampsia. Eclampsia refers to a new onset of tonic-clonic seizures in pregnancy and typically occurs in women with a hypertensive pregnancy disorder such as preeclampsia, HELLP  syndrome, and gestational hypertension. Women at risk are those with pre-pregnancy overweight or obesity, pregestational diabetes, and hypertension , 31. In Seizures in pregnancy are potentially life threatening for both mother and fetus. Specific diagnostic tests to guide early preventive strategies for women at risk for seizures during pregnancy are not available. Clinical data suggest that neuroactive steroids are etiologically involved in the development of seizures –24 and iThe access to CNS tissue for steroid measurement from individuals without CNS pathology is limited for ethical reasons. Within certain diagnostic or therapeutic clinical procedures including combined spinal-epidural anesthesia, cerebrospinal fluid (CSF) is available and can be utilized for analyses. The aim of the study was to evaluate the correlations of important neuroactive steroid hormone levels between the two compartments in pregnant women.This prospective study was approved by the local institutional ethics committee of the Medical Faculty, RWTH Aachen University, Aachen, Germany, in accordance to the Helsinki Declaration on Ethical Principles for Medical Research Involving Human Subjects and the Guideline for Good Clinical Practice (EK 201/14). All participants signed informed consent. A total of 27 healthy pregnant women in the 38–40th gestational week, who presented themselves for a planned cesarean section between 2014 and 2015 were included. CSF and blood samples were collected simultaneously during combined spinal-epidural anesthesia for elective cesarean section. After epidural puncture liquor was rinsed to verify correct intrathecal needle position. One milliliter of clear CSF without macroscopic blood contamination was then collected and stored in an Eppendorf tube in −80° for further analysis. Blood samples were centrifuged, and serum and CSF were assayed for DHEA, E2, and P4 concentrations in the same laboratory. To measure the DHEA concentrations in serum and CSF, an ELISA was utilized according to the instructions of the manufacturer , <9% inter- and intra-assay variation). In order to measure E2 and P2 in both compartments of the patients, an electrochemiluminescence immunoassay  was performed according to the manufacturer’s instructions. The detection levels of ECLIA for the two hormones were as follows: E2 = LoD: 18.4 pmol/L (5 pg/ml) and LoQ: 91.8 pmol/L (25 pg/ml) and for P4 = LoD: 0.159 nmol/L (0.05 ng/ml) and LoQ: 0.636 nmol/L (0.2 ng/ml). All measured hormone levels in our cohort were within the detection level of the ELISA and ECLIA used, thus none of the patients had to be excluded from the study.r) 0.00–0.19 indicates a very weak correlation, 0.20–0.39 a weak correlation, 0.40–0.59 a moderate correlation, 0.60–0.79 a strong correlation, and 0.8–1.00 a very strong correlation. A p value of < 0.05 was considered significant.Data analysis and visualization were performed using GraphPad Prism . Bivariate correlation of quantitative data was assessed by nonparametric Spearman’s rank correlation. A correlation coefficient of , progesterone (P4), and estradiol (E2) at term pregnancy, we included a total of 27 pregnant women  with elective cesarean section in the 38–40th gestational week in this study Table . In all r = 0.65, p = 0.003)  was detected for P4, only serum and CSF levels of E2  appeared not to correlate in the investigated cohort  decrease to a mean DHEA level in CSF of 0.18 ng/ml (range: 0–0.47 ng/ml) Fig.  from a m03) Fig. . While aort Fig. .Fig. 1ANext, we evaluated if peripheral and central DHEA levels correlated with central E2 and P4 levels and if DHEA could be a suitable indicator for E2.r = 0.58, p = 0.0016) and P4 in CSF  , no significant correlation between DHEA and P4 was evident in this compartment   Fig. . The cor85) Fig. .Fig. 2Dr = 0.65, strong correlation) and E2  in pregnant women. For P4, the intercompartment correlation was weak (r = 0.39) in the tested cohort.In summary, our data suggest that peripheral DHEA levels may serve as a good indicator for central nervous levels of the neuroactive steroids DHEA  and to central DHEA . We were able to find constant correlations between serum and CSF measurements, although the hormone concentrations in the serum showed a wide, pregnancy-typical dispersion.The correlations of serum to CSF concentrations of the measured steroid hormones  vary according to the specific steroid in our cohort of 27 women at term pregnancy. Our results for pregnant women are consistent with the repeated observation in non-pregnant subjects that steroid concentrations broadly differ at least by one to two orders of magnitude between the serum to CNS compartments , 34. We To our knowledge this is the first study observing CSF and serum concentrations of neuroactive steroid hormones in women at term pregnancy. CSF and serum concentrations were measured from simultaneously collected samples. In line with our results, in vivo data of patients, though scarce in number, suggest that the steroidal environment in CNS versus intravascular compartments differs by a magnitude of 10 to 100 with lower concentrations in the CNS. Animal models support these findings , 35. We This study reveals certain limitations. We compared CSF to serum distribution for steroid hormones with neuroactive potential in healthy pregnant women without affection of the blood-brain barrier. The measurement of neuroactive hormone concentrations in CSF is an approximation to the distribution of steroid hormones in brain tissue. Basically, topical CNS tissue concentrations may not be adequately reflected in CSF . Most stPregnancy is a distinct physiological condition that might include changes in blood-brain barrier function as well as central and peripheral steroid metabolism compared to non-pregnant subjects. Therefore, the results may not be valuable for non-pregnant women and men.Statistical evidence base is limited due to a small sample size and observational study design. Our study population of 27 subjects was small, though comparatively large regarding published populations in this field.ECLIA and ELISA testing were not constructed for hormone analysis in CSF , though r = 0.58, defined as moderate correlation). Furthermore, we could show that central DHEA correlates significantly with central E2 levels  as with peripheral levels of DHEA .Nevertheless, we think that our results contain valuable information for further research. The steroidal hormone transport across the blood-brain barrier varies according to the specific hormone ; howeverDHEA is the steroidogenic precursor to E2 aromatization. This is also true for CNS tissue . DHEA paThe DHEA (E2) to P4 ratio would also increase with lower P4 concentrations. Interestingly, Shine et al.  found siChanges in the central nervous neuroactive steroid profile toward estrogenic dominance in the course of pregnancy may be a potential modulator for an increase of convulsive events. In this regard, a peripheral indicator for the central neuroactive steroid potential would be a helpful clinical monitoring tool. From the results of our study, it can be hypothesized that the CSF estradiol concentration seems to be better indicated by the serum DEHA level than by the serum estradiol level. There was also a weak intercompartmental correlation for progesterone that reached statistical significance. This relationship and possible steroid thresholds require clinical verification studies. This could include identifying a risk population for seizures and tracking steroid concentrations and ratios in pregnancy in relation to clinical event progression.


White blood cell count, serum C-reactive protein, and serum interleukin-6 were elevated in all cases for which these parameters were measured. G-CSF-producing tumors presented large necrotic masses  with marked FDG uptake . Diffuse FDG uptake into the bone marrow was shown in 28 of the 31 cases in which FDG-PET/CT was performed. The signal intensity of bone marrow suggested marrow reconversion in all seven MRI-assessable cases. Bone scintigraphy demonstrated no significant uptake, except in two cases with bone metastases. Splenic FDG uptake was increased in 8 of 10 cases in which it was evaluated. These imaging findings may reflect the effects of tumor-produced G-CSF. The presence of G-CSF-producing tumors should be considered in patients with cancer who show these imaging findings and marked inflammatory features of unknown origin.Granulocyte colony-stimulating factor (G-CSF)-producing tumors have an aggressive clinical course. Here, we report five cases of G-CSF-producing tumors and review the literature, focusing on imaging findings related to tumor-produced G-CSF. In addition to our cases, we identified 30 previous reports of G-CSF-producing tumors on which  Blood culture showed no growth. Contrast-enhanced CT showed a 9.5 cm exophytic mass in the fundus of the gallbladder with geographic hypoattenuation and enhancement in the peripheral component  and elevated CRP (9.2 mg/dL) and serum G-CSF (214 pg/mL) levels. No infectious foci were detected, and blood culture showed no growth. A biopsy of the tumor revealed undifferentiated carcinoma. Bone marrow biopsy showed no neoplastic disease. The patient was treated with combined gemcitabine and cisplatin chemotherapy. After chemotherapy, the tumor size decreased, and improvements in leukocytosis and tumor markers were observed. CT attenuation of bone marrow in the spine and pelvic regions was decreased in parallel with tumor regression and serum WBC count. Chemotherapy was discontinued because of renal dysfunction and interstitial pneumonia, and the patient died of tumor progression 10 months after admission. Additional immunostaining revealed that tumor cells in the initial biopsy were positive for G-CSF.2  and elevated CRP (13.0 mg/dL) and serum G-CSF (549 pg/mL) levels. No infectious foci were detected, and blood cultures showed no growth. Contrast-enhanced CT taken at our hospital showed multiple masses in the liver with geographic hypoattenuation and enhancement in the peripheral component  and elevated levels of CRP (8.4 mg/dL), G-CSF (452 pg/mL), and interleukin-6 . No infectious foci were detected, and blood culture showed no growth. Contrast-enhanced CT showed a round mass of 2.7-cm in the liver with geographic hypoattenuation and enhancement in the peripheral component, and multiple lymph node metastases. MRI showed that the tumor was mildly hyperintense on T2WI and DWI at b = 1000 s/mmA 52-year-old woman was admitted to our hospital for investigation of difficulty swallowing. Upper gastrointestinal endoscopy revealed a tumor in the lower thoracic esophagus. Laboratory tests performed at admission showed leukocytosis  and an elevated CRP level (1.74 mg/dL). Contrast-enhanced CT showed a well-defined, nonnecrotic mass 4.6 cm in diameter located in the esophagus Fig. a. FDG-PEA literature review using the PubMed database was performed focusing on imaging findings related to tumor-produced G-CSF, such as FDG uptake of tumors and bone marrow change. Published English articles were searched from 2000 to 2020 using the following search terms: “Granulocyte colony stimulating factor producing tumor” and “FDG”, or “Granulocyte colony stimulating factor producing tumor” and “hyperplasia bone marrow”, or “Granulocyte colony stimulating factor producing tumor” and “Bone scintigraphy”. After scrutinizing these papers and references, 28 cases were identified from publications and their references –32. AddiThe patients consisted of 26 men and 9 women with a mean age of 62.6 years (range 31–79 years). Although the patients had a wide variety of chief complaints because of their different primary sites, fever was reported in 21 of the 35 cases. In our cases 1–4, prolonged fever was a chief complaint, and it may have been caused by inflammatory cytokines produced by the tumor. Laboratory tests showed marked leukocytosis  and elevated serum CRP levels  in all patients described. However, no infectious foci were described in any of the patients and production of inflammatory cytokines by the tumors was suggested. Previous studies have also reported that G-CSF-producing tumors produce other inflammatory cytokines, such as IL-6 and IL-8 . G-CSF-pImaging findings of our five cases are summarized in Table Imaging findings of the primary tumors in the literature are summarized in Table The tumor size was relatively large , suggesting that they were aggressive. Hypoattenuation suggesting necrosis was shown in 12 of the 13 cases for which imaging findings of the tumors were described. The primary lesions in our cases 1–4 presented with extensive necrosis (geographic necrosis)  was mildly hyperintense on T2WI and DWI at b = 1000 s/mmmax) 20.09, range 6.1–48.7)  Figs. b. This m Figs. b.max values may suggest that the tumors produce G-CSF, but they should be differentiated in conjunction with clinical and other radiological findings associated with tumor-producing G-CSF, such as marked inflammatory features and bone marrow change.G-CSF-producing tumors often presented as large necrotic masses with marked FDG uptake in our cases and the literature. These findings with high SUVThere are many case reports of G-CSF-producing tumors with bone marrow change on radiological examinations, such as diffusely increased FDG uptake of the bone marrow on FDG-PET/CT and bone marrow reconversion on MRI –33. BoneOn MRI, it is possible to evaluate the signal intensities of bone marrow. On T1WI and T2WI, red marrow has a lower signal than that of yellow marrow because of its differences in water and fat content . In two Bone scintigraphy was performed in our two cases and five literature cases , 32, 34.A previous study reported that the CT attenuation of focal hyperplasia in bone marrow was equal to or slightly higher than that of adjacent normal-appearing bone marrow . In our Increased FDG uptake in the spleen was described in 8 of the 10 cases in which splenic uptake was evaluated , 22, 26.Tumor-produced G-CSF has been shown to affect tumor progression by facilitating tumor-associated angiogenesis and enhanced metastatic ability , 62. In Several cases of aortitis developing after G-CSF administration have been recently reported in the literature . G-CSF-aG-CSF-producing tumors should be considered in patients with cancer who have marked inflammatory features of unknown origin. Imaging findings including large necrotic masses, marked FDG uptake by the tumors, diffuse FDG uptake of the bone marrow, increased FDG uptake in the spleen, and MR findings of marrow reconversion may indicate tumor-produced G-CSF in such patients. MRI and bone scintigraphy may be useful for differentiating marrow reconversion from bone metastasis when FDG-PET/CT demonstrates diffuse FDG uptake in bone marrow.


Several non-D2R related mechanisms of action of antipsychotic drugs have been proposed over the last decades, but none has conclusively been proven effective. Furthermore, while the newer antipsychotic drugs produce fewer motor side effects than conventional “first generation” drugs, safety and tolerability concerns about weight gain and endocrinopathies often limit their use  and “negative”  symptoms, as well as cognitive dysfunctions. Although several interrelated causes have been associated with the development of the pathology, it is generally accepted that the hyperfunction of dopaminergic and/or hypofunction of glutamatergic transmission  might underlie the symptoms of schizophrenia . Clinicaheir use . Thus, tBased on this background and recent findings, the present opinion paper was conceived to critically review possible interactions between adenosine and kynurenic acid (KYNA) in this context. These two neuromodulators may be pathophysiologically associated with schizophrenia, and a deeper understanding of their interactions may lead to the development of innovative strategies for the treatment of schizophrenia.It is well recognized that, beside dopamine and glutamate systems, the purinergic system may be also involved in the pathophysiology of schizophrenia . In fact2A receptors (A2ARs), which are highly expressed in the striatum and the olfactory tubercle, exert fine regulation of individual synapses (2ARs regulate synaptic plasticity by promoting adequate (or aberrant) adaptive responses in neuronal circuits  antagonists used as antipsychotics , too, has been proposed as a potential antipsychotic drug target  and depresses postsynaptic neuronal signaling by inducing hyperpolarization -(endo-norborn-2-yl)adenosine (5′-Cl-5′-deoxy-ENBA) reduces the hyperlocomotion caused by amphetamine or the non-competitive NMDA receptor antagonist dizolcipine , which accounts for more than 90% of the degradation of the essential amino acid tryptophan . Throughrocesses . Consequrocesses . These erocesses . Notablyrocesses .The observation that KYNA concentrations are significantly elevated in cortical brain regions and cerebrospinal fluid of individuals afflicted with schizophrenia  raised tin vivo microdialysis study performed in rats, local perfusion of adenosine was shown to rapidly and concentration-dependently raise extracellular KYNA levels in the striatum (1R agonist N6-cyclopentyladenosine (CPA), whereas the selective A2AR agonist 2-p-(2-carboxyethyl) phenylethylamino-5′-N-ethylcarboxamidoadenosine hydrochloride (CGS-21680) was ineffective. Furthermore, local perfusion of the A1R antagonist 8-cyclopentyltheophylline (CPT) attenuated the effect of adenosine on extracellular KYNA levels. As the effect of adenosine on KYNA was not observed in the excitotoxically lesioned, i.e., neuron-depleted, striatum, it appears that neuronal A1R activation influences glial KYNA synthesis indirectly  but also with the NMDAR .While Ahe NMDAR . An A2AReteromer  and in a2AR agonists on prejunctional A1-A2A heteroreceptor complexes , the principal enzyme responsible for the synthesis of rapidly mobilizable KYNA in the mammalian brain  have not been assessed experimentally so far. Hypothesis testing in rats that were prenatally exposed to kynurenine, which have deficits resembling several of the cognitive impairments seen in schizophrenia patients , may be


Is the sex or age of a blood donor associated with morbidity or mortality in very low-birth-weight infants receiving blood transfusion?In this cohort study of 181 very low-birth-weight infants at 3 centers, infants receiving red blood cell transfusion from female donors had a lower risk of death or serious morbidity compared with those who received transfusion from male donors. The protective association between female donor and adverse outcomes increased with increasing donor age, but diminished with increasing number of blood transfusions.These findings suggest that characteristics of blood donors, such as sex and age, may be associated with recipient outcomes in very-low-birth weight infants receiving blood transfusions. This cohort study evaluates the association between blood donor sex and age on mortality or serious morbidity in very low-birth-weight (VLBW) infants receiving blood transfusions. There are conflicting data on the association between blood donor characteristics and outcomes among patients receiving transfusions.To evaluate the association of blood donor sex and age with mortality or serious morbidity in very low-birth-weight (VLBW) infants receiving blood transfusions.This is a cohort study using data collected from 3 hospitals in Atlanta, Georgia. VLBW infants (≤1500 g) who received red blood cell (RBC) transfusion from exclusively male or female donors were enrolled from January 2010 to February 2014. Infants received follow-up until 90 days, hospital discharge, transfer to a non–study-affiliated hospital, or death. Data analysis was performed from July 2019 to December 2020.Donor sex and mean donor age.The primary outcome was a composite outcome of death, necrotizing enterocolitis (Bell stage II or higher), retinopathy of prematurity (stage III or higher), or moderate-to-severe bronchopulmonary dysplasia. Modified Poisson regression, with consideration of covariate interactions, was used to estimate the association between donor sex and age with the primary outcome, with adjustment for the total number of transfusions and birth weight.P for interaction = .005) and between female donor and number of transfusions (P for interaction < .001). For the typical infant, who received a median (interquartile range) of 2 (1-3) transfusions, RBC transfusion from exclusively female donors, compared with male donors, was associated with a lower risk of the primary outcome . The protective association between RBC transfusions from female donors, compared with male donors, and the primary outcome increased as the donor age increased, but decreased as the number of transfusions increased.In total, 181 infants were evaluated, with a mean (SD) birth weight of 919 (253) g and mean (SD) gestational age of 27.0 (2.2) weeks; 56 infants (31%) received RBC transfusion from exclusively female donors. The mean (SD) donor age was 46.6 (13.7) years. The primary outcome incidence was 21% (12 of 56 infants) among infants receiving RBCs from exclusively female donors, compared with 45% (56 of 125 infants) among those receiving RBCs from exclusively male donors. Significant interactions were detected between female donor and donor age (These findings suggest that RBC transfusion from female donors, particularly older female donors, is associated with a lower risk of death or serious morbidity in VLBW infants receiving transfusion. Larger studies confirming these findings and examining potential mechanisms are warranted. Although these trials indicate that more liberal approaches to RBC transfusion are not harmful in preterm infants, they lacked measurement and evaluation of blood donor characteristics.Very low-birth-weight (VLBW) infants commonly receive red blood cell (RBC) transfusions.6 in critically ill adults have reported associations of female donor sex and younger donor age with an increased risk of mortality. Other studies8 have reported no association, when controlling for total transfusion exposure. To our knowledge, only 1 prior study9 specifically evaluating donor sex has been conducted of VLBW infants and reported that transfusion of RBCs from female donors, compared with male donors, was associated with a higher risk of morbidity and mortality in preterm infants, but this association was no longer significant after accounting for the number of transfusions. In addition, the study9 reported an interaction between female donor and number of transfusions with recipient outcome. Another study10 reported that 83% of RBC transfusions administered to VLBW infants who went on to develop necrotizing enterocolitis (NEC) were from male donors. To our knowledge, no prior studies have evaluated the effect of donor age on recipient outcomes in preterm infants receiving RBC transfusions.Several studies12 and the inflammatory profile of donor blood varies according to sex and age.13 In addition, RBCs from female donors and older donors are associated with increased antioxidant capacity, compared with male and younger donors, respectively.14 Prior studies in preterm infants have shown that RBC transfusions increase proinflammatory cytokine levels16 and non–transferrin-bound iron but not oxidant stress,17 although none of the aforementioned studies has evaluated the effect of blood donor characteristics. Understanding the effects of donor sex and age may help to understand heterogeneity in the effects of RBC transfusion in preterm infants.There is biological plausibility regarding the effects of both donor sex and age on recipient outcomes based on differences in RBC characteristics. RBCs from female donors demonstrate less hemolysis and changes in rigidity during storage compared with those from male donors,In this cohort study, we evaluated the association of donor sex and age on mortality or serious morbidity in VLBW infants receiving transfusions while controlling for the total number of RBC transfusions. We hypothesized that the characteristics of the RBCs transfused into VLBW infants, specifically the sex and age of the blood donor, would be associated with the risk of death, bronchopulmonary dysplasia (BPD), NEC, or retinopathy of prematurity (ROP).19 and this study included an extended cohort of 598 infants, as described elsewhere.20 We included VLBW infants born in 3 hospitals in Atlanta, Georgia: Grady Memorial Hospital, Emory University Hospital Midtown, and Northside Hospital. Among the infants enrolled in the parent study from January 2010 to February 2014 , we included infants who received an RBC transfusion from exclusively female or exclusively male donors. Infants who received RBC transfusions from both male and female donors were excluded because of the inability to assign a single consistent donor sex exposure. Donor data were linked from information provided by a single blood supplier for all 3 hospitals. However, donor sex information was not recorded on the blood units and was not available to the blood bank personnel as part of routine practice or used to decide allocation of blood units. Standard blood banking practices at the study centers included the use of irradiated, leukocyte reduced, cytomegalovirus seronegative, citrate phosphate dextrose adenine solution, O negative units, regardless of infant blood type, which was not changed during the study period. In addition, the study centers used dedicated single-donor units for each infant to minimize donor exposure for neonatal transfusion. Additional information on donors, such as smoking history, pregnancy history, parity, or medication use, was not available. Parents or guardians provided written informed consent before enrollment of their infant into the Transfusion-Transmission of Cytomegalovirus study. This study was approved by the institutional review board and/or research oversight committees at participating centers and is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.21We performed an analysis of data from the Transfusion-Transmission of Cytomegalovirus study. The study design and results of the study have been previously reported,23 the role of oxidant stress and/or inflammation in the pathogenesis of these diseases,24 and prior studies27 reporting potential associations between RBC transfusion and an increased risk of components of the composite outcome. In addition, a similar composite outcome was used in a prior trial comparing neonatal transfusion thresholds.28 We did not evaluate intraventricular hemorrhage,29 because we evaluated all RBC transfusions, including those administered after the typical timing of detection of intraventricular hemorrhage. NEC was defined as Bell stage II or higher, with adjudication of staging as described elsewhere.20 Moderate-to-severe BPD was defined according to the 2001 consensus definition by the National Institutes of Health,30 which was used as the definition at the time the parent study was conducted. ROP was defined as stage III or higher in either eye. Baseline illness severity was assessed using the Score for Neonatal Acute Physiology.31 Infants received follow-up until 90 days, hospital discharge, transfer to a non–study-affiliated hospital, or death.The primary outcome was a composite of death, BPD, NEC, or ROP. This composite outcome was selected on the basis of the importance of these outcomes to the risk of long-term neurodevelopmental impairment,33 which was included because of its interaction with number of transfusions on the risk of the primary outcome. Interaction between female donor and donor age was tested for in the multivariable model, as well as female donor and number of transfusions, on the basis of a prior study.9We used a conceptual model to guide modeling of the associations between the study exposures and outcomes  of death, BPD, NEC, or ROP, we modeled the primary composite outcome using a modified Poisson regression model with a robust error variance, implemented using the geeglm function in the geepack R package . The main exposures of interests were female donor and donor age. To reliably and consistently assess the association between donor sex and the primary outcome, we performed the analysis using data from infants who exclusively received RBC transfusion from only female donors or only male donors. Donor age for an infant was measured as the mean donor age of all RBC transfusions an infant received, which was then centered at the mean across infants. Birth weight, mean donor age of all RBC transfusions an infant received, and the number of RBC transfusions were specified as continuous variables. Interaction terms to determine whether the association between donor sex and the primary outcome depended on donor age or number of transfusions were retained in the model only if they were significant (P < .05). In the presence of significant interactions, RRs were presented graphically at different levels of the risk factors in addition to reporting of the regression model parameter estimates.The sample size was fixed according to enrollment into the parent study and study selection criteria. Funding for this secondary study was obtained on July 1, 2019, and initial analyses were completed on December 9, 2020. Missing data were reported, when present, although they were sparse given the quality assurance efforts in the Transfusion-Transmission of Cytomegalovirus study. All statistical tests were 2-sided and conducted at the significance level of 7 This model included donor age and birth weight, but no interaction terms, because there could be no plausible interaction with the number of transfusions and the smaller sample size. Finally, we evaluated the association between donor sex and each individual component of the composite outcome. Because of the relatively small number of events for some of the components, we analyzed each outcome separately with exact logistic models with the main effects of donor sex, donor age, total number of transfusions, and birth weight and reported odds ratio estimates from the exact logistic regression.34Next, we conducted sensitivity analyses to evaluate the alternative assumptions that additional biasing paths between donor characteristics and the primary outcome exist through gestational age, duration of RBC storage or storage after irradiation, baseline illness severity, exposure to multiple donors, or center, that may not have been fully accounted for by adjustment for the number of transfusions. In addition, we performed a sensitivity analysis of a subset of infants who received only a single RBC transfusion, similar to a prior study evaluating donor sex.Among an available population of 598 infants, we included 343 infants who received RBC transfusion. We had covariate and RBC donor information available for 324 infants (95%) who received 1650 RBC transfusions, of which 655 (40%) were from female donors. Among these 324 infants, 143 received RBC transfusions from both male and female donors and were excluded, allowing for analysis of 181 infants who received 499 RBC transfusions. Of these 499 RBC transfusions, 136 (27%) were from female donors.The mean (SD) birth weight of the cohort was 919 (253) g, and the mean (SD) gestational age was 27.0 (2.2) weeks. Fifty-six (31%) of the 181 included infants received RBCs from exclusively female donors, and the remainder received RBCs from exclusively male donors. The average of the mean (SD) donor age was 46.6 (13.7) years . Female donors were 2 years younger than male donors  , with 44 infants with moderate-to-severe BPD, 17 infants who died, 13 infants with NEC, and 4 infants with severe ROP. The primary outcome incidence was 21% (12 of 56 infants) among infants receiving RBCs from exclusively female donors, compared with 45% (56 of 125 infants) among infants receiving RBCs from exclusively male donors. Similarly, among infants who developed the primary outcome, 18% (12 of 68 infants) received RBC transfusions from exclusively female donors, compared with 39% (44 of 113 infants) among those who did not develop the primary outcome. Additional blood donor characteristics are listed in P for interaction = .005), female donor and number of transfusions (P for interaction < .001), and number of transfusions and birth weight (P for interaction = .006) , storage age of RBCs (model 3), storage age following irradiation of RBCs (model 4), multiple donor exposure and Score for Neonatal Acute Physiology (model 5), and center (model 6) yielded similar estimates as the primary analysis . In addition, the protective association between RBC transfusions from exclusively female donors, compared with male donors, and a lower risk of death or serious morbidity increased with increasing donor age. These findings suggest that blood donor sex and age may be associated with recipient outcomes in VLBW infants receiving transfusions. Because many VLBW infants receive transfusions repeatedly and often receive multiple transfusions from a single donor because of the common practice of dedicated donor units, we believe this is an ideal population to assess the potential impact of blood donor characteristics on transfusion recipient outcomes.9 which did not find association between donor sex and morbidity or mortality in preterm infants after adjusting for the number of RBC transfusions. This may be the result of the inclusion of infants who received both male and female donor RBCs as an exposure group, or other differences in modeling approaches, study populations, or transfusion practices. Of note, infants who received transfusion of RBCs from both male and female donors and were excluded in our study received a median of 7 transfusions, compared with a median of 2 transfusions for infants who were included. This suggests that infants who received transfusions from both male and female donors may have had greater illness severity, as also suggested by the high incidence of adverse outcomes in this group. We believe this is the most likely explanation for the differences in findings between our study and that of Murphy et al.9 Both our study and the one by Murphy et al9 found an interaction between female donor sex and the number of transfusions. In our study, the protective association between female donor sex and a lower risk of death or serious morbidity diminished with an increasing number of RBC transfusions. This finding may be the result of the higher incidence of the composite outcome as the number of RBC transfusions increased, because most infants receiving high numbers of transfusions either die or survive with morbidity.35Our results differ from those of the single-center study by Murphy et al,6 and others no association8 after controlling for total transfusion exposure. These studies suggest the potential for confounding by transfusion intensity because those patients who receive more RBC transfusions may be more likely to receive units with less common donor characteristics. Because of this, our conceptual model focused on this key biasing path, and all models controlled for the total number of transfusions. In addition, the results of our primary analyses were consistent in a sensitivity analysis in a subset of infants who received only 1 RBC transfusion. To test alternative assumptions, we also conducted 5 sensitivity analyses to evaluate the possibility that additional biasing paths between donor characteristics and outcome exist that are not accounted for by adjustment for transfusion intensity. The estimates from these analyses, which included adjustment for gestational age, RBC storage age, RBC storage age after irradiation, baseline illness severity , exposure to single or multiple donors, and center, were consistent with the primary model results with minimal to no change in estimates for the 2 exposures of interest. In addition, the age and sex of blood donors are not considered in the allocation of RBC units by blood banks to specific infants, so we did not consider confounding by indication to be a likely source of bias. Furthermore, routine practice at study centers was to provide only type O blood, and storage duration was not determined according to donor characteristics. Considering this along with the similar duration of storage age of transfused RBCs among infants with and without the primary outcome, and the lack of change in model estimates after adjusting for storage age, it is unlikely that storage age confounded the associations between the study exposures and primary outcome.The association between donor characteristics and outcomes has been conflicting in adult studies, with several demonstrating an association4 By contrast, in our study we found female donor sex to be associated with a lower risk of death or serious morbidity. This may be due to different mechanisms, as immune-mediated transfusion reactions are uncommon in preterm infants. In contrast, transfusion of adult RBCs into neonates36 and RBC deformability may potentially influence blood flow,37 and there is better deformability of RBCs among female donors compared with male donors.12 In addition, RBC transfusions in preterm infants may be inflammatory,16 potentially through release of factors from hemolysis, and the inflammatory profile of RBCs is reduced in female and older donors.13 However, these potential mechanisms are speculative, and additional studies are needed to further evaluate the potential biological mechanisms that may explain the associations observed in this study.In adults, female donor sex has been associated with worse outcomes, possibly because of immunological changes that occur during pregnancy.3 comparing higher vs lower hemoglobin transfusion thresholds in preterm infants have found no differences in short-term or long-term adverse outcomes. These findings suggest that more liberal RBC transfusion may not be harmful in preterm infants. In contrast, the present study focused on the RRs of donor characteristics for a fixed number of transfusions that a VLBW infant may receive. Therefore, donor sex could potentially be associated with recipient outcomes, even with RBC transfusion approaches using higher or lower thresholds. Our findings support the importance of measurement and evaluation of blood donor characteristics in future studies examining the relative benefits and harms of RBC transfusion.The results from recent multicenter randomized clinical trials38 pregnancy,4 or medication use39 affect donor RBC characteristics and may explain the associations observed between donor sex and age with the study outcome, although we considered these as explanatory rather than confounding factors. We approached our modeling strategy with a conceptual framework that may not have accounted for all potential biasing paths. However, expanded models in our sensitivity analyses that tested alternative assumptions were consistent with the primary analyses. In addition, the use of a composite outcome may be limited by divergent associations within individual components of the composite outcome. However, we found estimates of association with each component of the composite that were directionally consistent with the overall primary analysis, with the exception of ROP. In addition, there is the potential that outcomes such as death or NEC may have occurred after the follow-up period, although on the basis of our prior study,40 few deaths occur after 90 postnatal days and most initial cases of NEC occur before 60 postnatal days.20 Furthermore, we believe our findings should be validated in larger cohort studies, and, if confirmed, evaluated in clinical trials as is currently being done for RBC transfusion for adults.41Our study has limitations. We were unable to determine additional donor characteristics. Smoking,In conclusion, in this cohort study, RBC transfusion from female donors, particularly older female donors, was associated with a lower risk of death or serious morbidity in VLBW infants receiving transfusions. Larger studies confirming our findings and examining potential mechanisms are warranted.


Leptospira). Orthohantavirus infections are more prevalent during periods of high rainfall (rainy season) with peak transmission in August; females are more likely to be infected than males and infections are more likely among patients from urban rather than rural parishes in Barbados.Background: Hantavirus pulmonary syndrome (HPS) is well-known in South and North America; however, not enough data exist for the Caribbean. The first report of clinical orthohantavirus infection was obtained in Barbados, but no other evidence of clinical orthohantavirus infections among adults in the Caribbean has been documented. Methods: Using enzyme linked immunosorbent assay (ELISA) tests followed by confirmatory testing with immunofluorescent assays (IFA), immunochromatographic (ICG) tests, and pseudotype focus reduction neutralization tests (pFRNT), we retrospectively and prospectively detected orthohantavirus-specific antibodies among patients with febrile illness in Barbados. Results: The orthohantavirus prevalence rate varied from 5.8 to 102.6 cases per 100,000 persons among febrile patients who sought medical attention annually between 2008 and 2016. Two major orthohantavirus epidemics occurred in Barbados during 2010 and 2016. Peak orthohantavis infections were observed observed during the rainy season (August) and prevalence rates were significantly higher in females than males and in patients from urban parishes than rural parishes. Conclusions: Orthohantavirus infections are still occurring in Barbados and in some patients along with multiple pathogen infections (CHIKV, ZIKV, DENV and  Orthohantaviruses are single-stranded negative-sense RNA viruses approximately 120 to 160 nm in diameter from the Hantaviridae virus family that are maintained in rodent reservoirs . OrthohaDobrava-Belgrade orthohantavirus . O. On = 19Germany)  and specGermany)  (Figure controls  (Figure


The meager regenerative capacity of adult mammalian hearts appears to be driven by the proliferation of endogenous cardiomyocytes; thus, strategies targeting mechanisms of cardiomyocyte cell cycle regulation, such as the Hippo/Yes-associated protein (Hippo/Yap) pathway, could lead to the development of promising therapies for heart disease. The pharmacological product TT-10 increases cardiomyocyte proliferation by upregulating nuclear Yap levels. When intraperitoneal injections of TT-10 were administered to infarcted mouse hearts, the treatment promoted cardiomyocyte proliferation and was associated with declines in infarct size 1 week after administration, but cardiac function worsened at later time points. Here, we investigated whether encapsulating TT-10 into poly-lactic-co-glycolic acid nanoparticles (NPs) before administration could extend the duration of TT-10 delivery and improve the potency of TT-10 for myocardial repair. TT-10 was released from the TT-10–loaded NPs for up to 4 weeks in vitro, and intramyocardial injections of TT-10–delivered NPs stably improved cardiac function from week 1 to week 4 after administration to infarcted mouse hearts. TT-10–delivered NP treatment was also associated with significantly smaller infarcts at week 4, with increases in cardiomyocyte proliferation and nuclear Yap abundance and with declines in cardiomyocyte apoptosis. Thus, NP-mediated delivery appears to enhance both the potency and durability of TT-10 treatment for myocardial repair.  The endogenous regenerative capacity of adult mammalian hearts is exceptionally limited  and cann11H10FN3OS2) is a fluorine substituent of TAZ-12, and it appears to promote cardiomyocyte proliferation: in mice, intraperitoneal injections of TT-10 reduced infarct size 1 week after MI but did not prevent progressive declines in cardiac function at later time points : total Yap levels in hiPSC-CMs treated with or without TT-10 were similar, but phosphorylated Yap (p-Yap) was less abundant in TT-10–treated cells. Thus, because p-Yap is sequestered and degraded in the cytosol, while unphosphorylated Yap translocates to the nucleus where it induces the expression of genes that regulate cell proliferation and survival, these results suggest that the effect of TT-10 treatment on cell cycle progression and apoptosis in cultured cardiomyocytes was likely mediated, at least in part, by increases in Yap signaling.The effect of TT-10  on cardiMI was induced via permanent ligation of the left anterior descending (LAD) coronary artery, and then the animals were randomly assigned to treatment with Dulbecco’s PBS (DPBS), empty PLGA NPs (Empty-NPs), TT-10 solution (TT-10–SOL), or TT-10–loaded PLGA NPs (TT-10–NPs). A fifth group of animals (the sham group) underwent all surgical procedures for MI induction except arterial ligation. Before TT-10 administration, the mean diameters of the Empty- and TT-10–NPs were 123.3 ± 1.7 nm and 155.4 ± 0.7 nm, respectively . LoadingFour mice died from MI induction. In the surviving animals, echocardiographic  assessmeTo determine whether the improvements in myocardial recovery observed in TT-10–NP mice were at least partially attributable to the activation of Hippo/Yap signaling and cardiomyocyte proliferation, subsets of mice were sacrificed 1 week after MI induction, and then cardiomyocytes expressing Ki67 , PH3 Fi, and nucThe primary mechanism of cardiomyocyte renewal both for maintaining cardiac homeostasis and during recovery from myocardial injury appears to be the proliferation of preexisting cardiomyocytes , 12. HowThe Hippo signaling pathway impedes proliferation by sequestering YAP and TAZ in the cytosol. Once activated, YAP and TAZ translocate to the nucleus, where they interact primarily with transcription factors of the TEA domain (TEAD) family and the YAP/TAZ-TEAD complex induces the expression of genes that control cell proliferation and apoptosis . TT-10 iHere, we focused on the use of PLGA-NPs for TT-10 administration, which is more efficient than conventional systemic delivery and, consequently, could enable patients to be treated with lower drug doses, thereby reducing the risk of treatment-related adverse events as well as the demand for large-scale TT-10 manufacturing protocols. The beneficial effects associated with free (unencapsulated) TT-10 administration in Hara et al.  were achOur results indicated that targeted PLGA-NP–mediated TT-10 delivery improved both the potency and durability of the benefits associated with TT-10 administration: infarct sizes were significantly smaller by ~20%), and cardiac performance was significantly better, in animals treated with TT-10–NPs than those in the TT-10–SOL, Empty-NP, or DPBS treatment groups. While functional parameters remained stable from weeks 1 to 4 in TT-10–NP animals, measurements in the other 3 groups that underwent MI induction worsened over the same period. TT-10–NP administration was also associated with increases in the frequency of Ki67, PH3, and nuclear Yap expression among cardiomyocytes 1 week after treatment, as well as with declines in cardiomyocyte apoptosis on day 3, which was consistent with observations in cultured hiPSC-CMs and suggests that the benefits of treatment evolved, at least in part, via the Yap/TAZ-induced activation of cell cycle progression and cardioprotective mechanisms. However, proliferating cardiomyocytes were nearly undetectable 4 weeks after TT-10–NP delivery, which may be beneficial, because proliferating cardiomyocytes are typically immature and, consequently, could increase the risk of arrhythmia and disrupt contractile activity. TT-10–NP administration also promoted angiogenesis in the peri-infarct region, which (to our knowledge) has not been previously reported, and Yap/TAZ signaling can be activated by hypoxia in some cancers , 15, as %, and caStudies of fluorine-containing pharmaceuticals, such as TT-10, are becoming increasingly common, because these pharmaceuticals are metabolically stable  and, conIn summary, the results from our investigation in a mouse MI model demonstrate that measures of cardiac function and infarct size are significantly better when the animals receive intramyocardial injections of TT-10–loaded NPs rather than TT-10–SOL. Thus, PLGA-NP–mediated delivery appears to enhance the potency of TT-10, which may also reduce the occurrence of treatment-related side effects and other safety concerns by enabling the drug to be administered at lower doses. Collectively, these observations support the continued development of TT-10–NPs for the treatment of cardiac disease and provide proof of concept for the PLGA-NP–mediated delivery of other therapeutic agents.g for 10 minutes to remove bulk aggregates, and the supernatant was centrifuged at 45,000g for 20 minutes to collect the NPs. The NPs were washed twice by resuspending them in 50 mL Milli-Q water; they were then recollected via centrifugation  and frozen at –80°C overnight, lyophilized for 48 hours, and stored at –80°C.PLGA NPs were prepared via a single-emulsion (oil/water phase) technique as described previously . BrieflyNP size measurements were performed via NP-tracking analysis with a NanoSight NS300 Instrument (NanoSight), and scanning electron microscopy was performed with a Quanta FEG 650 (FEI). For TT-10–loaded NPs, TT-10 release was monitored with a Slide-A-Lyzer MINI Dialysis Device (Thermo Fisher Scientific); the molecular weight cutoff was set at 20,000, and the elution medium consisted of DPBS with 0.1% BSA. Suspensions were incubated at 37°C with constant shaking (300 rpm), and 14.5 mL samples of the elution medium were withdrawn and replaced at the indicated time points. TT-10 concentrations in the collected samples were measured with a UV/Vis spectrophotometer ; measurements of TT-10 absorbance (λ = ~200 nm) in samples were compared with a curve constructed from known TT-10 concentrations using the Beer-Lambert Law.The hiPSCs were maintained in 6-well plates with mTeSR medium (Stem Cell Technologies) until 80% confluent and then differentiated into hiPSC-CMs. Briefly, the hiPSCs were cultured in RPMI 1640 medium with 2% B27 minus insulin , 10 μM CHIR99021 (Stem Cell Technologies), and 1 μg/mL insulin (MilliporeSigma) for 24 hours; in RB medium containing 3 μM CHIR99021 for 48 hours; in RB medium containing 10 μM IWR1 (Stem Cell Technologies) for 48 hours; in RB medium for 48 hours; and then in RPMI 1640 medium supplemented with 2% B27 supplement (Gibco). Differentiated hiPSC-CMs were purified via metabolic selection in glucose-free RPMI 1640 medium (Gibco) containing B27 supplement (Gibco) and 4 mM lactate (MilliporeSigma) for 5 days and then maintained in RPMI 1640 medium supplemented with 2% B27 supplement (Gibco). Experiments were conducted 30 days after differentiation was initiated.2 for 24 hours; washed twice with DPBS (pH 7.4); and visualized with a fluorescent microscope.hiPSCs-CMs were seeded onto a Lab-Tek chamber slide system , treated with coumarin-6–loaded NPs (2 μg/mL), incubated at 37°C and 5% COEight- to twelve-week-old male and female C57BL/6 mice (The Jackson Laboratory) were anesthetized with inhaled isoflurane (2%), intubated, and ventilated with 2% isoflurane. A left thoracotomy was performed, and the LAD coronary artery was ligated with an 8 to 0 nonabsorbable suture . AnimalsAnimals were lightly anesthetized with 1%–1.5% inhaled isoflurane, and heart rates remained stable at 400–500 bpm. Then, B-mode and 2-dimensional M-mode images were obtained from long-axis and short-axis views with a high-resolution microultrasound system . Data were analyzed with Vevo analysis software, and LVEF, LVFS, LVEDD, and LVESD were calculated ; blocked with 10% donkey serum (Life Technologies) for 30 minutes; incubated at 4°C overnight with primary antibodies; and incubated for 40 minutes with fluorophore-linked secondary antibodies; then, nuclei were stained with DAPI at room temperature for 10 minutes. For heart sections, tissues were fixed in ice-cold 4% PFA for 4 hours, immersed in 30% sucrose overnight at 4°C, and cut into 10 μm sections; then, the sections were washed with PBST for 10 minutes, permeabilized with cold acetone for 3 minutes, immobilized with 4% PFA for 10 minutes, blocked with 10% donkey serum for 30 minutes, incubated with primary antibodies at 4 °C overnight, and incubated with fluorophore-linked secondary antibodies for 40 minutes; then, nuclei were stained with DAPI at room temperature for 10 minutes. After staining, analyses were conducted with a fluorescence microscope.2 at 37°C for 12 hours, fixed with ice-cold 70% ethanol  for 15 minutes, and then stained with a BrdU Labeling and Detection Kit (Roche Life Science Inc.) as directed by the manufacturer’s instructions.hiPSC-CMs were incubated with BrdU (10 μmol) in a humidified atmosphere containing 5% COTUNEL staining was performed with an in situ cell death detection kit (Roche). Briefly, cells or heart sections were fixed with 4% PFA at room temperature for 15 minutes, TUNEL-labeled as directed by the manufacturer’s instructions, washed with PBST, blocked with 10% donkey serum (Life Technologies) for 30 minutes, incubated with primary antibodies at 4°C overnight, and incubated with fluorophore-linked secondary antibodies at room temperature for 40 minutes. Then, nuclei were stained with DAPI. Apoptosis was quantified as the proportion of cells that were TUNEL positive.Antibodies. HRP-conjugated secondary antibody was used at 1:4000 dilution for detection. Finally, the membranes were developed with Immobilon Western Chemiluminescent HRP Substrate (MilliporeSigma). Protein signals were imaged with a Bio-Rad ChemiDoc System and analyzed by ImageJ. The housekeeping protein, GAPDH, was used for normalization.hiPSC-CMs were lysed with M-PER Mammalian Protein Extraction Reagent (Thermo Fisher Scientific) supplemented with Halt Protease and Phosphatase Inhibitor Cocktail (Thermo Fisher Scientific). Extracted protein was quantified by BCA protein assay kit (Thermo Fisher Scientific) and denatured by heating at 95°C for 10 minutes. Equal quantity of protein were loaded and separated by 4%–15% precast SDS-PAGE gels (Bio-Rad), and then transferred onto a polyvinylidene difluoride membrane (Bio-Rad). The membranes were blocked with 5% nonfat dry milk and incubated at 4°C overnight with primary antibodies, as described in The following primary antibodies and second antibodies were used in the study: mouse anti–cardiac troponin T monoclonal antibody ; rabbit anti–cardiac troponin T monoclonal antibody ; mouse anti–cardiac troponin T monoclonal antibody ; goat anti–cardiac troponin I polyclonal antibody ; rabbit anti-Ki67 monoclonal antibody ; rabbit anti–phospho-histone H3 (Ser10) polyclonal antibody ; mouse anti–Aurora B monoclonal antibody ; goat anti-human NKX2.5 polyclonal antibody ; rabbit anti-YAP monoclonal antibody ; rabbit anti-phospho YAP monoclonal antibody ; fluorescein-labeled GSL I IB4 ; rabbit anti-α smooth muscle actin polyclonal antibody ; CyTM 3 donkey anti-rabbit polyclonal antibody ; Alexa Fluor 488 donkey anti-mouse polyclonal antibody ; Alexa Fluor 647 donkey anti-goat polyclonal antibody ; and anti-rabbit HRP linked antibody .t test, and comparisons among 3 or more groups were conducted via 1- or 2-way ANOVA with adjustment. P < 0.05 was considered statistically significant.All data are presented as mean ± SEM and were evaluated for significance with GraphPad Prism 7 software. Comparisons between 2 groups were conducted with the 2-tailed Student’s Guide for the Care and Use of Laboratory Animals .All protocols were approved by the Institutional Animal Care and Use Committee of the University of Alabama at Birmingham and were performed in accordance with the WC and JZ conceived and designed the project. WC and DP performed the experiments and analyzed the data. WC and JZ wrote the manuscript. WC, YZ, JY, YN, and JZ revised the manuscript. JZ supervised the whole project. All the authors approved the submission and publication of the manuscript.


Sarocladium strictum has only been shown to cause neurological disease in immunocompromised patients, where antifungal therapy was not effective. We report a case of Sarocladium strictum meningoencephalitis in an apparently immunocompetent young woman who presented with severe headache and slight fever after undergoing transnasal endoscopic repair of cerebrospinal fluid rhinorrhea. Chronic sinusitis and suspicious intracranial fungal lesions were observed on enhanced magnetic resonance imaging (MRI). Both culture and metagenomic next-generation sequencing of her cerebrospinal fluid were positive for Sarocladium strictum. After local debridement, treatment with amphotericin B plus voriconazole and Ommaya reservoir implantation, the patient improved significantly. Unfortunately, her symptoms worsened again despite plenty of antifungal therapy for a month.As an opportunistic phytopathogen,  Sarocladium, under the order Hypocreales, has traditionally been considered an opportunistic phytopathogen, and only a very few species of this pathogen can infect patients with predisposing conditions  count with predominance of mononuclear cell (~70%) and high protein (95.40 g/L). The CSF-to-serum glucose ratio decreased to 0.53. Based on this evidence, she was diagnosed with meningoencephalitis and treated with a full course of intravenous meropenem (2.0 g per 8 h) and vancomycin (0.5 g per 6 h). However, her condition continued to deteriorate. Despite switching to anti-infective treatment with meropenem (as before), linezolid (1.0 mg/kg per 12 h intravenously), and fluconazole , the patient's headaches persisted. Moreover, she began to present with blurred vision, epileptic seizures, and hallucination. In addition, her intracranial pressure rose higher than before (380 mmH2O).Three months before admission to Xuanwu Hospital, the patient experienced spontaneous cerebrospinal rhinorrhea and underwent a transnasal endoscopic repair surgery in a regional hospital, after which she began to develop night fever with intermittent headache. Meanwhile, multiple enhanced sinus magnetic resonance imaging (MRI) revealed increasingly severe bilateral nasosinusitis. In addition, her intracranial pressure was >300 mmHS. strictum was verified through culture and mNGS of CSF samples on March 24th and March 19th, respectively. Thereafter, the patient was treated with amphotericin B  and 5-fluorocytosine , instead of antibacterial drugs. Moreover, she underwent sinus debridement, but the effect was not ideal. It was only after changing the antifungal therapy to amphotericin B plus voriconazole (4.0 mg/kg per 12 h intravenously) that her headache and epileptic seizures got relieved than before with normal body temperature. The WBC count in her CSF also reduced gradually  and culture were done on collected CSF specimens 5 times during hospitalization. The infection of radually . At the Soon afterwards, the patient accepted Ommaya reservoir implantation to extract CSF and inject amphotericin B (0.2 mg per day) in a regional hospital, with intravenous amphotericin B (20.0 mg per day), which was extremely effective against intracranial hypertension. Her headache was relieved further, with no more epileptic seizures and hallucination, and her eyesight was partially restored. Unfortunately, although under a plenty of antifungal therapy, the patient's condition worsened again within a month. On June 29, 2021, the patient began to present with worsening headache and blurred vision, with unstable standing and poor coordination of fine movements. The WBC count in her CSF was also elevated again, and MRI revealed multiple new punctured abnormal signals in her bilateral cerebellum. After the addition of itraconazole orally, the WBC count in her CSF decreased, but her symptoms remained unrelieved. Eventually, the patient requested to take itraconazole orally  at home, and she still suffered from headache and blurred vision on September 29, 2021. The clinical case was approved by the Ethics Committee of the Xuanwu Hospital of Capital Medical University, China. Written informed consent was obtained from all the patients.S. strictum was isolated and identified at the Clinical Laboratory of Xuanwu Hospital. BD BACTECTM FX (PEDS plus) was used for both blood and CSF cultures, but only CSF was positive on the third day (3d2h58m) of incubation. Floccus grew in a positive culture bottle of CSF, and fungal hyphae could be visualized on Gram staining  and was finally identified by ITS sequencing. It had 99% homology with known strains of S. strictum in GenBank.In our study, staining . Positivstaining . Lactophstaining . These fftp://ftp.ncbi.nlm.nih.gov/genomes) to identify all probable pathogens. Moreover, mNGS revealed S. strictum in the CSF samples on the second day after lumbar puncture, with coverage and abundance shown in CSF samples were transferred to dry ice for PACEseq mNGS detection . DNA was extracted using the QIAamp DNA Micro Kit (Qiagen). QIAseq™ Ultralow Input Library Kit (Illumina) was used to construct the DNA libraries. After purification, the quality of the libraries was analyzed using a Qubit (Thermo Fisher) and Agilent 2100 Bioanalyzer (Agilent Technologies). The NextSeq 550 platform (Illumina) was used to sequence all the DNA reads in the libraries. After sequencing, short, low-quality, and low-complexity reads were removed from the raw data. Human DNA was also filtered out according to the human reference database. The clean reads were aligned to the microbial genome database  were also caught by mNGS of CSF. However, this microbe was previously discovered in Dictyostelium discoideum fruiting bodies and always found in the background of mNGS, including negative controls due to the use of multiple reagent buffers  can be found below: National Genomics Data Center, accession no: PRJCA006827.The studies involving human participants were reviewed and approved by the Ethics Committees of the Xuanwu Hospital of Capital Medical University, China. Written informed consent was obtained from the patient.YC provided the initial and subsequent draft of the submission. JM, JZ, LWa, and HY provided patient details and time activity curves. HX and JC provided images and microbiological analysis. LWu helped to create subsequent drafts of the submissions and coordinated the editing process. All authors contributed to the article and approved the submitted version.This work was supported by grants from the Ministry of Science and Technology of China (No. 2019YFC0118600) to LWu, National Key Research and Development Program of China Research on the Precision Diagnosis, Treatment, and Integrated Prevention, Control for the Elderly with Common Infectious Disease (2020YFC2005403) to Professor Yan Zhang, and the Xuanwu Hospital Teaching Reform Foundation (2020XWJXGG-09) to JC.HX was employed by the company Hugobiotech Co., Ltd. The remaining 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.


Intrathecal administration of anticancer drugs is an effective strategy to treat meningeal leukemia and lymphoma. Topotecan is an anticancer drug, and its anticancer effect is expected via intrathecal administration. In this study, we developed a method to measure the concentration of topotecan in the cerebrospinal fluid (CSF) for clinical monitoring of personalized medicine. By controlling the unique structural feature of topotecan, a pH-dependent lactone ring-opening/closing reversible reaction, we established a simple high-performance liquid chromatography (HPLC) method to measure the total topotecan concentration in the CSF and confirmed that this method can be applied to clinical samples. In the present situation, wherein the concentrations were monitored, the disappearance of topotecan in the CSF was delayed, and signs of adverse effects were confirmed when a high concentration of topotecan was observed.Intrathecal administration of anticancer drugs is an effective dosage strategy, but the elimination of intraventricular drugs is not uniform in all patients. For safety, a system to evaluate local pharmacokinetics in the ventricles after administration is desired. In this study, we developed a simple and reproducible method to measure topotecan concentration in the cerebrospinal fluid (CSF) and confirmed its clinical applicability. High-performance liquid chromatography (HPLC) analysis was performed using a C18 column to measure the total topotecan concentration in the CSF. Clinical CSF samples were obtained from a 1-year old child with poor CSF absorption and stagnation. The patient received topotecan via an intraventricular subcutaneous reservoir. The HPLC method complied with the validation criteria. The lower limit of quantitation of this method was 0.04 µM. Using the developed method, we could determine the difference in topotecan CSF concentrations at 24 and 48 h after administration. The patient’s topotecan elimination rate was extremely low, and signs of adverse effects were observed at high CSF concentration of topotecan. The developed method could detect the delay in topotecan elimination after intrathecal injection. The findings of this study are valuable for the development of personalized treatments for the intrathecal administration of anticancer drugs. The intrathecal administration of anticancer drugs has the advantage of maintaining high drug concentrations in the cerebrospinal fluid (CSF) and minimizing systemic adverse effects . It is aTopotecan is an anticancer drug that exerts an antitumor effect by inhibiting topoisomerase I, thus preventing cell division in tumors . TopotecEvaluation of CSF topotecan concentration after intrathecal administration is limited to phase I clinical studies ,9,10. ThTopotecan was obtained from Sigma-Aldrich . Liquid chromatography–mass spectrometry (LC-MS)-grade acetonitrile was obtained from Merck . Camptothecin, high-performance liquid chromatography (HPLC)-grade methanol, and HPLC-grade water were obtained from FUJIFILM Wako . Dimethyl sulfoxide, acetic acid, ammonium acetate, sodium hydroxide (NaOH), and hydrochloric acid (HCl) were obtained from Nacalai Tesque .Chromatographic analysis of topotecan was performed using a Prominence Ultra-Fast Liquid Chromatography system . Analyst software  was used for data acquisition and analysis of chromatograms.The separation was performed at 40 °C using an InertSustain AQ-C18 HP column . Mobile phase A was ammonium acetate buffer  and mobile phase B was acetonitrile. The chromatographic separation was achieved through gradient elution at a flow rate of 0.8 mL/min; 18.75% of mobile phase B for 4.5 min increased linearly to 43.75% in 1 min, held constant for 2.5 min, decreased to 18.75% over 1 min, and held constant for 1 min to equilibrate between injections. The detector was set at an excitation wavelength of 380 nm and an emission wavelength of 520 nm [Stock solutions of topotecan (25 mM) and the internal standard (IS)  were prepared in dimethyl sulfoxide and stored at −20 °C. The IS standard was diluted with water to a working solution concentration of 28.70 µM.For drug-free CSF, samples left-over after CSF testing were used. The pooled CSF mixture from several patients was checked to ensure that it did not contain topotecan or IS. Calibrators were prepared daily by adding an accurately diluted stock solution to pooled CSF. The final topotecan concentrations in the calibration samples were 0.04, 0.08, 0.16, 0.32, 0.64, and 1.28 µM. The lower limit of quantitation (LLOQ) (0.04 µM) and three quality control (QC) samples at low (0.10 µM), intermediate (0.50 µM), and high (1.00 µM) concentrations of topotecan were prepared by adding a diluted stock solution to drug-free CSF.CSF samples collected from patients receiving topotecan intrathecally were used as clinical specimens. Spiked specimens were prepared by adding an accurately diluted stock solution to drug-free CSF.v/v)) and vigorously vortexed for 10 s. The mixture was centrifuged , and 20 µL of this supernatant was injected into the chromatograph.To establish the conditions for ring-form conversion of topotecan, topotecan stock solution diluted with water, topotecan-spiked CSF, and clinical CSF samples were mixed in equal amounts with water, 0.1 M HCl aquation, or 0.1 M NaOH aquation. Three hundred microliters of this mixture were then mixed with 600 µL of the mobile phase -acetonitrile ) and 15 µL of IS working solution and vigorously vortexed for 10 s. The mixture was then centrifuged , and 20 µL of this supernatant was injected into the chromatograph.Based on the established conditions, the calibration samples, QC samples, or clinical samples were mixed in equal amounts with 0.1 M HCl aquation for the ring-form conversion of topotecan. Three hundred microliters of this mixture were then mixed with 600 µL of the mobile phase -acetonitrile  value should not exceed 20%.The carry-over effects of topotecan and IS were evaluated by testing the response of a blank CSF sample immediately following the highest concentration of the calibration sample. The peak area of the blank CSF sample is required to be less than 20% of the peak area of the LLOQ sample for topotecan and 5% for the IS. The ordinary least squares method was used to fit the peak area ratio versus analyte concentration for linearity.To evaluate the accuracy and precision, five replicates of the LLOQ and QC samples at three levels were analyzed. The mean accuracy is required to be within ±15% of the nominal values for the QC samples, except for the LLOQ, which is required to be within ±20% of the nominal value. The CV values should not exceed 15% for the QC samples and 20% for the LLOQ samples.Three QC samples at low (0.10 µM), intermediate (0.50 µM), and high (1.00 µM) concentrations of topotecan were used to evaluate recovery rate. Topotecan was spiked at three QC concentrations in blank CSF, and spiked CSFs were treated by sample preparation described above (A). Topotecan was spiked at three QC concentrations in the final supernatant obtained by sample preparation of blank CSF (B). Three replicates of the above samples were injected into the chromatograph. The peak areas of samples A and B were obtained. The recovery rate (%) was then calculated as A/B ×100.Stability tests were performed by evaluating the accuracy of the QC samples at three levels under two conditions . Five replicates of QC samples at three levels were analyzed. The accuracy of the QC samples for the stability test is required to be within ±15%.Clinical CSF samples were obtained from a 1-year old child receiving topotecan. The patient presented with poor absorption and stagnation of CSF due to communicating hydrocephalus after surgical resection of a brain tumor. Topotecan was administered via an intraventricular subcutaneous reservoir. The dosage was started at 0.2 mg and gradually increased to 0.3 and 0.4 mg at the discretion of the attending physician, when the adverse effects were tolerated. Informed consent was obtained from the patient’s parents to measure topotecan in the CSF. CSF samples were collected at 24, 48, and 72 h after topotecan administration at each dosage . The collected CSF samples were stored at −80 °C until analysis.The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Review Committee of the Faculty of Medicine at the University of Miyazaki, Japan (Project identification code: O-0638).www.r-project.org, accessed on 8 March 2021) was used for statistical analyses.R v.4.0.3. . as topotecan, also undergoes a pH-dependent ring-opening/closing reaction, producing a lactone form and a carboxylate form. Arimori et al.  reportedThe correlation between CSF topotecan concentration and clinical efficacy or toxicity is still unclear. In previous studies, where topotecan was intrathecally administered and the CSF concentration was monitored, transition at a concentration of 0.1 µM or higher was reported . Thus, tThis study had some limitations. In the proposed method, it is possible to separate lactone form and carboxylate form by chromatography, but this method does not have a sample preparation process that can reflect the abundance ratio of both forms in the living body. The LLOQ of this method needs to be further discussed in the future, because no information on the safety and efficacy of CSF topotecan concentration has been established. Ring-form conversion of topotecan by pH adjustment in this method is possible for CSF samples, but it has not been verified whether it is an analytical method applicable to other biological samples such as serum and urine. Components such as proteins and lipids can affect conversion efficiency.We developed a method to measure the total topotecan concentration in the CSF; this method can sufficiently detect the delay in topotecan elimination after intrathecal injection. The realization of daily topotecan monitoring enables timely adjustment of the topotecan dosage and injection interval for intrathecal administration of topotecan. The findings of this study are valuable for the development of personalized treatments for the intrathecal administration of anticancer drugs.


Autoantibodies to multiple cytokines have been identified and some, including antibodies against granulocyte-macrophage colony-stimulating factor (GM-CSF), have been associated with increased susceptibility to infection. High levels of GM-CSF autoantibodies that neutralize signaling cause autoimmune pulmonary alveolar proteinosis (aPAP), an ultrarare autoimmune disease characterized by accumulation of excess surfactant in the alveoli, leading to pulmonary insufficiency. Defective GM-CSF signaling leads to functional deficits in multiple cell types, including macrophages and neutrophils, with impaired phagocytosis and host immune responses against pulmonary and systemic infections. In this article, we review the role of GM-CSF in aPAP pathogenesis and pulmonary homeostasis along with the increased incidence of infections (particularly opportunistic infections). Therefore, recombinant human GM-CSF products may have potential for treatment of aPAP and possibly other infectious and pulmonary diseases due to its pleotropic immunomodulatory actions. Autoantibodies (AAbs) against cytokines are detectable in the plasma of both healthy and diseased individuals, but the role and potential pathology of anti-cytokine autoantibodies are not fully known . CytokinInborn errors of immunity involving mutations affecting selected cytokines or their signaling pathways can increase susceptibility to infections. Anti-cytokine AAbs can produce the same effects as pathogenic gene mutations or variants causing inborn errors of immunity, a phenomenon known as “autoimmune phenocopies of primary immunodeficiencies” . To datevia Fc-mediated effects, assuming the autoantibodies do not interfere with the cytokine’s biological activity  cases these AAbs are associated with cytokine-neutralizing activity , 8, 14. activity . AlternaAspergillus can produce AAbs that cross-react with IFN-γ (due to shared epitopes) and neutralize IFN-γ function, suggesting that molecular mimicry may play a role in the generation of these antibodies  mutations, which could inhibit the antiviral immune response and predispose patients to infections and infection-related complications , ATP-binding cassette subfamily A member 3 (ABCA3), and thyroid transcription factor-1 (TTF1).Autoimmune PAP (previously known as idiopathic PAP) accounts for approximately 90% of all PAP cases . The remAutoimmune PAP is characterized by high concentrations of GM-CSF AAbs that bind to GM-CSF, decreasing its level and biological activity . DefectiHigh-resolution CT imaging of the lungs shows diffuse bilateral alveolar infiltrates, with patchy ground-glass opacities in a characteristic “crazy paving” pattern . Broncho-/-Csf2)  GM-CSF AAbs are found in all patients with aPAP. Elevated serum GM-CSF AAb levels diagnostic of aPAP are considered sufficient to effectively neutralize all GM-CSF activity, suggesting that aPAP is functionally equivalent to knockout mice deficient in GM-CSF production sf2-/-) , 35. Low-/- , 35GM-CSF is an immunomodulatory cytokine produced by multiple cell types including macrophages, lymphocytes, endothelial cells, fibroblasts, and alveolar epithelial cells. It acts to stimulate the proliferation and differentiation of hematopoietic stem cells into granulocytes and macrophages, including the terminal differentiation of alveolar macrophages, and to promote the growth, activation, and survival of myeloid cells . GM-CSF via complement (–/–Csf2rb) mice suggest GM-CSF is essential for mitochondrial function and turnover, including fatty acid β-oxidation  were generated via targeted ablation of the GM-CSF gene , has been shown to stimulate pulmonary GM-CSF expression and to increase the number of alveolar macrophages or alter their function –72. Usin-/-Csf2 mice have been invaluable in deciphering the pathogenesis underlying the development of aPAP. Such mice recapitulate the pathological findings in PAP, have defective macrophage and neutrophil function, and exhibit compromised clearance of surfactant. As a result, -/-Csf2 mice show increased susceptibility to a variety of pulmonary and systemic infections including streptococcal, Pseudomonas aeruginosa, Pneumocystis carinii, malaria, and adenovirus infections  should be assessed for GM-CSF functional signaling and serum GM-CSF concentration Figure 3Alterations in GM-CSF signaling can be detected by flow cytometry functional assays based on the ability of GM-CSF to stimulate cell-surface CD11b expression and intracellular STAT5 phosphorylation. The resulting CD11b stimulation index can effectively discriminate between healthy individuals and those with aPAP who exhibit significantly reduced induction of cell surface CD11b expression. This method has a reported sensitivity and specificity of 100%, aiding in the diagnosis of aPAP . QuantifSerum GM-CSF should be measured for patients with normal GM-CSF AAb levels who do not have obvious causes of secondary PAP . ElevateIn summary, detection of GM-CSF AAb levels, along with functional assays and determination of serum GM-CSF levels, can confirm or rule out a suspected diagnosis of aPAP and may also aid in monitoring disease persistence.Infections are common in patients with aPAP. Additionally, individuals with GM-CSF AAbs can develop unusual pulmonary and extrapulmonary infections at rates exceeding expected complications of their lung disease . The onsNocardia, mycobacteria, and fungal infections , more often reports have identified opportunistic microbial pathogens (Mycobacterium tuberculosis), of which at least half were pulmonary infections  suppresses alveolar macrophage function and facilitates pulmonary infections. Defective alveolar macrophage function could also contribute to extrapulmonary dissemination of infections seen in aPAP. GM-CSF is known to regulate alveolar macrophage production of multiple factors involved in local and systemic response to infection including prostaglandins, leukotrienes, and oxygen radicals . This dyfections . Studiesfections . In micefections .The lungs are the predominant site for aPAP-related infections. However, extrapulmonary infections also can occur, in some cases concurrent with respiratory infections. In aPAP, deficient pulmonary macrophages may result in an ineffective pulmonary barrier, thereby facilitating dissemination beyond the lung .Nocardia , molgramostim (bacteria-derived), and regramostim (Chinese hamster ovary cell–derived); however, sargramostim is the only form commercially available. The efficacy of inhaled rhu GM-CSF, particularly following whole-lung lavage, indicates that this approach may serve as a useful therapy in aPAP –104. Prein vivo is not known, but this is an area of active investigation.While preliminary data does not seem to support that administration of inhaled rhu GM-CSF leads to an increase in GM-CSF AAb levels, current assays measure only the concentration of “free” GM-CSF AAb . If administration of exogenous GM-CSF saturates available GM-CSF AAbs, it could hinder the ability to accurately measure AAb levels. Currently, the concentration of GM-CSF needed to saturate such AAbs Patients with GM-CSF AAbs and aPAP are known to be at increased risk of infection, especially from opportunistic microorganisms. Deficiencies in the immune functions of alveolar macrophages and neutrophils, such as impaired phagocytosis and cytokine production, and increased surfactant accumulation are believed to enhance the risk of infection, even in otherwise immunocompetent patients. In addition to localized pulmonary infections, patients with GM-CSF neutralizing AAbs are also at risk for disseminated infections by opportunistic intracellular pathogens and of subsequent development of aPAP , 97. TheIn some autoimmune diseases and infections, the level of certain cytokine AAbs may correlate with disease severity and progression. For those disease conditions in which levels of anti-cytokine AAbs do correlate with changes in clinical symptoms, such as lupus and rheumatoid arthritis, AAb levels might serve as surrogate markers of disease progression and/or response to therapy , 109. ThGreater use of testing for GM-CSF AAbs in general has been recommended to improve the noninvasive detection and diagnosis of aPAP , 112. SuNocardia, especially in the absence of other apparent comorbidities. Awareness of this lag could provide additional rationale for clinicians to evaluate GM-CSF AAb levels in all patients with opportunistic infections who otherwise appear immunocompetent to confirm or rule out an underlying diagnosis of aPAP.It should be noted that diagnosis of aPAP takes several months, often 18 months or longer after initiation of symptoms . Part ofPneumocystis jiroveci and Nocardia spp. suggests that trimethoprim/sulfamethoxazole prophylaxis could be considered for all patients with significant disease (Given the increased risk of infections (particularly opportunistic infections) with aPAP, it is imperative that such patients be monitored for possible infections and infectious complications. Routine preventive vaccinations for influenza and pneumococcal infection are also important . Althoug disease . Such pr disease , 11, 114In vitro, at least three non–cross-competing antibodies are required to generate stable immune complexes with GM-CSF and trigger their Fc-dependent degradation (Patients with certain chronic autoimmune disorders such as rheumatoid arthritis and psoriasis can have increased levels of GM-CSF in serum and affected tissues, suggesting a possible role for this cytokine in the pathogenesis of these conditions and providing the rationale for therapeutic targeting of GM-CSF using exogenous GM-CSF monoclonal antibodies , 116. Thradation . TreatmeThis review highlights opportunities for enhanced awareness of testing for GM-CSF AAbs in immunocompetent individuals with certain infections. More research is needed on the intrapatient correlation of GM-CSF AAb levels and severity of disease to help guide treatment. Further study is warranted on optimal treatment strategies and the potential use of sargramostim in patients with high GM-CSF AAb levels, aPAP, and concurrent infection.All authors contributed to co-development of the manuscript including conceptualization, selection of content for inclusion, and review, editing, and revising of content. All authors approved submission for publication and accept accountability for the content.This work was supported by Partner Therapeutics, Inc.AA serves on the Medical and Scientific Advisory Board of the PAP Foundation. VK received support for attending workshops, meetings, and education in leadership roles for Workshop in Primary Immunodeficiencies, College of American Pathologists, and Clinical Immunology Society, and served as President/Past President of the Association of Medical Laboratory Immunologists. BCC’s institution received an NIH-funded R01 grant related to the content of the manuscript. Outside of the current work, BC is a consultant to Partner Therapeutics, Inc. and serves on the Board of Directors and as Secretary/Treasurer of the PAP Foundation. EL’s institution received NIH-funded grants related to the content of the manuscript. EL has served as a consultant to Guidepoint Global and has received travel support from the PAP Foundation and the Rare Lung Disease Consortium. TW’s institution received a fellowship grant funded by Partner Therapeutics, Inc. TW received consultant fees from Partner Therapeutics for research outside of the current work; participated on an Advisory Board for IQVIA; and serves on the Board of Directors, Medical and Scientific Advisory Board, and as Vice President and Clinical Director of the PAP Foundation.The authors declare this study received funding from Partner Therapeutics, Inc. The funder had the following involvement with the study: Professional medical writing, graphic artist, and publication fees for this manuscript.The remaining author declares 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.


Three unsymmetrically substituted triarylboranes as well as their iridium‐catalyzed C−H borylation products are reported. These borylated triarylboranes contain one to three positions that can subsequently be orthogonally functionalized in follow‐up reactions, such as Suzuki‐Miyaura cross‐couplings or Sonogashira couplings.A novel and convenient methodology for the one‐pot synthesis of sterically congested triarylboranes by using bench‐stable aryltrifluoroborates as the boron source is reported. This procedure gives systematic access to symmetrically and unsymmetrically substituted triarylboranes of the types BAr A widely applicable one‐pot synthetic approach to air‐ and moisture‐stable triarylboranes with up to three different aromatic rings starting from bench‐stable boron precursors is reported. In addition, these compounds are shown to be easily post‐functionalized, thus making them versatile building blocks for the syntheses of functional materials. The electronic and optical, physical, biological, and chemical properties of such systems can be tuned by variation of the substituents on the three aryl rings attached to the boron atom.BpinArBrArMe in a Suzuki‐Miyaura cross‐coupling reaction with methyl iodobenzoate  should be addressed to the authors.SupplementaryClick here for additional data file.