Motixafortide is a novel cyclic-peptide CXCR4 inhibitor with extended in vivo activity. The GENESIS trial was a prospective, phase 3, double-blind, placebo-controlled, multicenter study with the objective of assessing the superiority of motixafortide + G-CSF over placebo + G-CSF to mobilize HSPCs for ASCT in MM. The primary endpoint was the proportion of patients collecting ≥6 × 106 CD34+ cells kg–1 within two apheresis procedures; the secondary endpoint was to achieve this goal in one apheresis. A total of 122 adult patients with MM undergoing ASCT were enrolled at 18 sites across five countries and randomized (2:1) to motixafortide + G-CSF or placebo + G-CSF for HSPC mobilization. Motixafortide + G-CSF enabled 92.5% to successfully meet the primary endpoint versus 26.2% with placebo + G-CSF (odds ratio (OR) 53.3, 95% confidence interval (CI) 14.12–201.33, P < 0.0001). Motixafortide + G-CSF also enabled 88.8% to meet the secondary endpoint versus 9.5% with placebo + G-CSF . Motixafortide + G-CSF was safe and well tolerated, with the most common treatment-emergent adverse events observed being transient, grade 1/2 injection site reactions . In conclusion, motixafortide + G-CSF mobilized significantly greater CD34+ HSPC numbers within two apheresis procedures versus placebo + G-CSF while preferentially mobilizing increased numbers of immunophenotypically and transcriptionally primitive HSPCs. Trial Registration: ClinicalTrials.gov, NCT03246529Autologous hematopoietic stem cell transplantation (ASCT) improves survival in multiple myeloma (MM). However, many individuals are unable to collect optimal CD34 The phase 3 GENESIS trial reports the superiority of the novel CXCR4 inhibitor motixafortide with G-CSF in mobilizing hematopoietic progenitor cells for autologous stem cell transplantation in multiple myeloma. However, the development of high-dose chemotherapy and autologous stem cell transplantation (ASCT), immunomodulatory drugs (IMiDs), proteasome inhibitors (PIs), anti-CD38 monoclonal antibodies (mAbs) and other novel therapies has greatly expanded therapeutic options for newly diagnosed MM. Currently, median OS exceeds 45–82 months with ASCT playing a central role in the treatment paradigm for MM3.Multiple myeloma (MM) is the second most common hematologic malignancy5. However, the effectiveness of ASCT relies, in part, on the ability to collect sufficient hematopoietic stem and progenitor cells (HSPCs), typically from peripheral blood (PB). A minimum of ≥2 × 106 CD34+ cells kg–1 are necessary, while infusion of optimal numbers of ≥5–6 × 106 CD34+ cells kg–1 is associated with improved engraftment, disease-free survival and OS compared with lower transplant doses8. Clinically, CD34 expression remains the most common immunophenotypic cell surface marker defining human HSPCs. However, multicolor fluorescence-activated cell sorting (FACS) and single-cell RNA sequencing (scRNA-seq) have illustrated the heterogeneous nature of CD34+ HSPCs, identifying immunophenotypically and transcriptionally distinct CD34+ subsets ranging from primitive hematopoietic stem cells (HSCs) capable of long-term self-renewal and multilineage potential to relatively differentiated, lineage-committed progenitors10.Autologous stem cell transplantation in MM has been shown to improve event-free survival and OS compared with conventional chemotherapy alone in previously untreated standard-risk MM12. The addition of chemotherapy to G-CSF may incrementally increase mobilization, but also prolongs HSPC mobilization with multiple apheresis days and chemotherapy-related toxicities14. Meanwhile, protracted mobilization substantially increases the financial and logistical burden to both patients and the healthcare system15.Granulocyte colony-stimulating factor (G-CSF) is widely considered the standard agent for PB HSPC mobilization. Nevertheless, despite the use of G-CSF in mobilization of HSPCs to the PB and after multiple days of apheresis, 40–50% of patients with MM remain unable to collect optimal numbers of HSPCs for ASCT16. Previous studies have shown the low-affinity (inhibitory constant (Ki), 652 nM), short-acting CXCR4i, plerixafor + G-CSF enhanced mobilization of CD34+ HSPCs to PB compared with G-CSF17. However, despite up to eight injections of G-CSF, four injections of plerixafor and four apheresis procedures, 15–35% of patients remained unable to mobilize optimal HSPC numbers18. Preclinical and clinical data suggest that CXCR4 expression on CD34+ HSPC subsets is variable, with relatively lower CXCR4 expression on primitive CD34+ HSCs and multipotent progenitors (MPPs) compared with higher expression on certain lineage-committed CD34+ progenitors19. These studies suggest that optimization of CXCR4 blockade may increase CD34+ HSPC mobilization and mobilize differential HSPC subsets19.The interaction between CXCL12 and its receptor, CXCR4, is critically involved in the retention of HSPCs within the bone marrow and blockade of CXCR4 mobilizes HSPCs to PB22. In a phase 1, two-part study (NCT02073019), motixafortide administered to healthy subjects was safe, well tolerated and led to a sustained five- to seven-fold increase in PB CD34+ HSPCs, enabling collection of a median of 11.2 × 106 CD34+ cells kg–1 in one leukapheresis. In another, single-arm, open-label, dose-escalation study (NCT01010880), motixafortide administered before ASCT to patients with MM undergoing standard HSPC mobilization was safe, well tolerated and led to significant increases in PB CD34+ HSPCs.Motixafortide (BL-8040) is a selective cyclic-peptide inhibitor of CXCR4 with high affinity , long receptor occupancy and extended clinical activity (>48 h)NCT03246529). In addition, immunophenotypic and transcriptional profiling was performed via multicolor FACS and scRNA-seq of CD34+ HSPCs mobilized on the GENESIS trial, as well as a contemporaneous, prospectively enrolled cohort of demographically similar patients with MM mobilized with plerixafor + G-CSF (protocol no. 201103349) and three cohorts of healthy, allogeneic HSPC donors  undergoing single-agent mobilization with motixafortide, plerixafor or G-CSF alone .Therefore, this phase 3 study (GENESIS) was designed to compare the safety and efficacy of motixafortide + G-CSF versus placebo + G-CSF in patients with MM undergoing HSPC mobilization before ASCT  or placebo + G-CSF (42 patients) for HSPC mobilization Fig. . Demogra+ HSPCs in the apheresis product was performed by both local and central laboratories. According to the prespecified protocol, all clinical decisions were made based on local laboratory results, including the determination that the patient met the collection goal for the primary endpoint and determining the number of CD34+ cells kg–1 infused for ASCT. Local and central laboratory assessments were included in the prespecified statistical analysis plan, with statistically significant results observed via both assessments favoring the increased effectiveness of motixafortide + G-CSF compared with placebo + G-CSF  analysis  .Mobilization with motixafortide + G-CSF resulted in 92.5% of patients meeting the primary endpoint of collecting ≥6 × 1001) Fig. . Further+ HSPCs before G-CSF administration was similar between the motixafortide + G-CSF and placebo + G-CSF cohorts, at 1.5 and 1.7 CD34+ cells µl–1, respectively  was 116.0 versus 19.0 cells µl–1 in the placebo + G‑CSF cohort (n = 40) (P < 0.001), with PB CD34+ cells µl–1 correlating well with apheresis yields.The baseline level of PB CD34ely Fig. . Followi6 CD34+ cells kg–1 within one apheresis day versus 64.3% with placebo + G-CSF . The median number of CD34+ HSPCs mobilized in one apheresis day with motixafortide + G-CSF was 10.8 × 106 versus 2.25 × 106 cells kg–1 with placebo + G-CSF. The total number of CD34+ HSPCs infused for ASCT was determined independently by each investigator according to local practice, with a median of <6 × 106 cells kg–1 infused for ASCT in both arms (minimum 2 × 106 CD34+ cells kg–1 required according to the protocol). Median time to neutrophil engraftment (TNE) was 12 days in both arms (hazard ratio (HR) not estimable, P = 0.9554). Median time to platelet engraftment (TPE) was 18 days with motixafortide + G-CSF and 17 days with placebo + G-CSF . Graft durability at day 100 post ASCT was 92.2% in the motixafortide + G-CSF arm and 91.9% in the placebo + G-CSF arm . Progression-free survival (PFS) and overall survival (OS) were comparable between the two cohorts and consistent with contemporary outcomes  were defined as starting with the first dose of G-CSF through 30 days following the last apheresis procedure or the first dose of conditioning chemotherapy, whichever occurred first. Overall, TEAEs were reported in 93.8% grade 3, 27.5%) of patients with motixafortide + G-CSF versus 83.3%  with placebo + G-CSF (Table 7.5% of pP < 0.0001). Additionally, patients mobilized with motixafortide + G-CSF required an average of 1.23 apheresis procedures per patient to mobilize optimal CD34+ HSPCs versus 3.24 with placebo + G-CSF (P < 0.0001). No patients mobilized with motixafortide + G-CSF underwent a fourth day of apheresis for primary mobilization and only 1% (n = 1) required remobilization, whereas 63.5% of patients mobilized with placebo + G-CSF required a fourth day of apheresis and 23.8% (n = 10) required remobilization with plerixafor + G-CSF.As a prespecified analysis, healthcare resource utilization was assessed comparing motixafortide + G-CSF with placebo + G-CSF. Patients mobilized with motixafortide + G-CSF received 5.26 G-CSF injections per patient versus 8.12 in the placebo + G-CSF cohort (+ HSPCs from the day 1 apheresis product of patients (n = 51) mobilized with placebo + G-CSF (n = 13), plerixafor + G-CSF (n = 14) and motixafortide + G-CSF (n = 24) as a prespecified correlative analysis demonstrated nine distinct CD34+ HSPC subsets, ranging from primitive HSCs to lineage-committed progenitors , clones 12G5 and 1D9. The 12G5 antibody recognizes an epitope involving the first and second extracellular domains of CXCR4 and competes with motixafortide and plerixafor for CXCR4 binding24. In contrast, the 1D9 antibody binds the N terminus of CXCR4 and is unaffected by motixafortide or plerixafor bound to CXCR4 (ref. 24). Binding of 1D9 to CD34+ HSPCs was similar among all three arms (P = 0.45–0.75). In contrast, both the percentage of 12G5+ cells and total 12G5 antibody-binding capacity were significantly lower in the motixafortide + G-CSF cohort versus placebo + G-CSF (P < 0.0001) and plerixafor + G-CSF (P < 0.0001) for all HSPC subsets, consistent with extended CXCR4 occupancy by motixafortide  revealed an inverse correlation between increasing levels of CD34+ cells kg–1 infused and TPE . A dose–response relationship was also observed, including (1) TPE of 11 days with ≥8 × 106 CD34+ cells kg–1 infused versus 18 days with <8 × 106 CD34+ cells kg–1  and (2) TPE of 10 days with ≥9 × 106 CD34+ cells kg–1 infused versus 18 days with <9 × 106 CD34+ cells kg–1 . TNE was not impacted by total CD34+ cells kg–1 infused   with extended CD34+ immunophenotyping via multicolor FACS revealed that infusion of higher numbers of combined CD34+ HSC, MPP, CMP and granulocyte monocyte progenitor (GMP) subsets was associated with more rapid TPE   . TNE was not impacted by specific CD34+ HSPC subsets infused .In addition, a post hoc pooled analysis of 37 patients  mobilized with placebo + G-CSF (n = 4), plerixafor + G-CSF (n = 4) and motixafortide + G-CSF (n = 4), along with CD34+ HSPCs from the apheresis product of healthy allo-donors (n = 6) mobilized with G-CSF alone (n = 2), plerixafor alone (n = 2) and motixafortide alone (n = 2). When compared with the MM cohorts, allo-donor patients were generally younger  and lacked a history of MM or recent chemotherapy exposure. Otherwise, the cohorts were demographically similar.Single-cell transcriptional profiling was performed via scRNA-seq on CD34+ HSPCs were sequenced across all 18 samples . Uniform manifold approximation and projection (UMAP) clustering was performed, with cell identity determined by cross-referencing of gene expression profiles with previously published datasets and genes reported as reliable markers of lineage commitment–2926. A total of 20 transcriptionally distinct CD34+ HSPC subsets were identified, including (1) six transcriptionally unique HSC subclusters (HSC1–6), (2) a large multilineage progenitor (MLP) cluster and (3) ten lineage-biased lymphoid (CLP_Ly1/2), myeloid (GMP), monocytic/dendritic (MDP1/2), megakaryocytic/erythrocytic , histiocytic (HIST) and eosinophil/basophil/mast cell (Eo_B_Mast) progenitors  and in patients with MM  was evaluated  and donor type . Within the HSC1–6 and MLP populations in healthy allo-donors, the HSC1 population was preferentially mobilized at higher numbers by motixafortide compared with either plerixafor or G-CSF , BMI1, PBX1 and MEIS1 and a related network of genes, which have been associated with HSC maintenance, quiescence and self-renewal, were highly expressed in the HSC5 population mobilized by motixafortide relative to plerixafor or G-CSF28. Similarly, HSC2–6 cells mobilized in allo-donors with motixafortide, but not plerixafor or G-CSF, expressed increased levels of JUNB and NR4A1. By contrast, gene expression profiles of the HSC1–6 and MLP populations were more homogenous within the MM cohorts, potentially reflecting the impact of recent MM-targeting induction therapies on the bone marrow niche, as well as increased age and/or a pre-existing diagnosis of MM. Nevertheless, motixafortide + G-CSF preferentially mobilized a higher proportion of the transcriptionally primitive HSC1 population (31.42%) relative to either plerixafor + G-CSF (17.36%) or placebo + G-CSF (22.77%) in patients with MM.Differential gene expression (DEG) analysis across all subsets identified unique transcriptional profiles for each CD34CSF Fig. . When cowal Fig. 30–32. ByGene set enrichment analysis of upregulated genes in the primitive HSC1 population relative to other HSC/MLP populations indicated increased EGF- and TNF-α/NFκB-related signaling, which have been associated with hematopoietic regeneration and/or regenerative potential. Meanwhile, HSC5 expressed upregulated HBO1-related genes associated with self-renewal and quiescence relative to other HSC/MLP populations. To further evaluate EGF, TNF-α/NFκB and HBO1 pathway signaling within each HSC1–6 and MLP subset across patient/treatment/disease characteristics  and mobilization regimen, pathway expression scores were generated for each pathway . Similarly, advances in induction therapy have established three-drug  and four-drug induction regimens  as the standard of care for newly diagnosed transplant-eligible patients with MM35. However, increased age, exposure to lenalidomide and four-drug induction therapy are all associated with impaired HSPC mobilization, further emphasizing the unmet need for more effective HSPC mobilization regimens38.The effectiveness of ASCT relies, in part, on the ability to collect an adequate number of HSPCs. The ‘ideal’ HSPC mobilization regimen would be rapid, robust, reliable, well tolerated and capable of safely mobilizing an optimal number of CD346 CD34+ cells kg–1 within two apheresis days versus 26.2% mobilized with placebo + G-CSF (P < 0.0001). In addition, 88.8% of patients mobilized with motixafortide + G-CSF collected ≥6 × 106 CD34+ cells kg–1 in one apheresis day versus 9.5% with placebo + G-CSF (P < 0.0001), with a median of 10.8 × 106 CD34+ cells kg–1 collected in one apheresis with motixafortide + G-CSF. By comparison, in a contemporary cohort of demographically similar patients with MM prospectively enrolled in parallel to the GENESIS trial and mobilized with plerixafor + G-CSF, 50.0% of patients collected optimal numbers of CD34+ cells kg–1 in one apheresis . Meanwhile, motixafortide + G-CSF was well tolerated with rapid and durable engraftment kinetics. Motixafortide + G-CSF as upfront HSPC mobilization also significantly reduced both G-CSF usage and the number of apheresis days required to collect the optimal number of HSPCs.In this international, phase 3, multicenter, randomized, double-blind, placebo-controlled trial, patients were representative of the typical MM population undergoing ASCT in the current era, with a median age of 63 years and 70% of patients receiving lenalidomide-containing induction therapy. Despite the presence of these risk factors for poor HSPC mobilization, 92.5% of patients treated with one injection of motixafortide + G-CSF collected ≥6 × 106 CD34+ cells kg–1) in the current era of MM therapy are lacking. In addition, comparisons between the present study and previous trials should be undertaken with caution, acknowledging the limitations of cross-trial comparisons. The largest previous RCT comparing plerixafor + G-CSF with placebo + G-CSF in patients with MM was published in 2009, with a median patient age of 58 years and only 5.9% of patients receiving lenalidomide before HSPC mobilization. In the context of relatively younger patients with minimal lenalidomide exposure compared with current practice, 17.3% of patients in the placebo + G-CSF arm and 54.2% in the plerixafor + G-CSF arm mobilized to goal in one apheresis12. Other contemporary studies commonly utilize pre-apheresis PB CD34+ counts to screen for poor mobilizers, and add pre-emptive plerixafor mobilization in patients predicted to fail mobilization with G-CSF alone, making direct comparisons difficult40. Meanwhile, other studies targeted lower mobilization goals (≥2–3 × 106 CD34+ cells kg–1), limited premobilization lenalidomide exposure, used alternative growth factors or allowed more than four apheresis days to collect to goal, again making direct comparisons difficult42. Nevertheless, most RCTs and nonrandomized interventional trials in patients with MM since the development of CXCR4is for HSPC mobilization have reported that currently available regimens frequently yield suboptimal CD34+ numbers despite multiple injections and multiple days of apheresis40. Thus it appears, based on these data, that a single injection of motixafortide added to G-CSF substantially improves on currently approved mobilization regimens in terms of the rapidity, robustness and reliability of HSPC mobilization for ASCT in patients newly diagnosed with MM following modern induction therapy in the current era.Randomized controlled trials (RCTs) comparing the efficacy of G-CSF alone, chemotherapy + G-CSF, plerixafor + G-CSF and motixafortide + G-CSF to mobilize optimal HSPC numbers  comprising nearly 25% of the HSPC graft19. We observed that motixafortide mobilized a similar proportion of pDCPs compared with plerixafor; but also mobilized a significantly higher number of combined HSCs, MPPs and CMPs compared with plerixafor. This unique impact of extended CXCR4i with motixafortide relative to short-acting CXCR4i with plerixafor may be due to the observation that these more primitive HSPC subsets are less strongly CXCR4+ at baseline, and thus are preferentially mobilized at higher numbers by extended CXCR4i with motixafortide. Also of note, scRNA-seq suggests that extended CXCR4i with motixafortide in healthy allo-donors mobilizes transcriptionally unique subsets of HSCs ). Recent work by Desterke et al. revealed that quiescence markers  and other genes (MYB and IER2) were upregulated in long-lived HSCs30. The self-renewal transcription factor EGR3, which suppresses cell cycle progression, is upregulated in motixafortide-treated clusters and is also highly expressed in primitive HSCs during leukemic transformation32. Shepard et al. observed that HSCs in JAK2 mutant myeloproliferative neoplasms harbored defective self-renewal properties, while robust self-renewal capacity and HSC repopulation was noted when BMI1, PBX1 or MEIS1 were overexpressed within mutant myeloproliferative neoplasms44. Additionally, Yang et al. observed that the histone lysine acetyltransferase KAT7 (HBO1) and a related network of genes is necessary for HSC maintenance and self-renewal28.There is also an increasing appreciation of the immunophenotypic and transcriptional heterogeneity of CD34+ HSPC subsets mobilized with various regimens remain unclear. This study was not designed to evaluate how differences in the total number of CD34+ cells infused, or the number of specific HSPC subsets infused, might impact clinical outcomes. In addition, given that extended immunophenotyping was performed on only a subset of patients mobilized at Washington University in St. Louis (n = 37), comparative analyses between cohorts are probably underpowered. Nevertheless, in a post hoc pooled analysis, a significant association was observed between increasing total number of CD34+ cells infused and faster TPE. These data suggest that infusion of higher numbers of CD34+ cells (≥7 × 106 CD34+ cells kg–1) may result in faster TPE. This observation is supported by previous publications suggesting that infusion of >6 × 106 CD34+ cells kg–1 is associated with improved long-term platelet recovery45. In addition, we observed that patients infused with the upper quartile (>75th percentile) of GMPs alone had significantly faster TPE (13 versus 19 days). These data suggest that the number of GMPs within the HSPC graft specifically contributed to platelet engraftment kinetics, which may indicate that the CD34+ HSPC subset immunophenotypically defined in this study as GMPs (CD45RA+/−CD123loCD38+/−CD10–) contains a population of megakaryocytic progenitors capable of rapidly reconstituting platelet engraftment. Based on our gating strategy, this observation is consistent with a recent report demonstrating that unipotent megakaryocyte progenitors lie within the CD34+ CD38+ CD45RA– population46.The clinical implications of the observed immunophenotypic and transcriptional heterogeneity within CD34+ HSPCs in patients with MM undergoing ASCT. Moreover, extended CXCR4i with motixafortide preferentially mobilized increased numbers of immunophenotypically and transcriptionally primitive HSCs. Future studies may consider similar regimens for HSPC-based, gene-edited platforms where the optimal HSPC collection goal is typically much higher (10–15 × 106 CD34+ cells kg–1) than that of ASCT (5–6 × 106 CD34+ cells kg–1), given losses of HSPC-viability-associated gene/base editing48. In addition, regimens mobilizing higher proportions of primitive HSCs may be particularly advantageous for HSPC-based, gene-edited therapies given that the long-term effectiveness of such therapies relies on the successful ability of modified HSPCs to establish stable, long-term engraftment.In conclusion, the upfront use of a single injection of motixafortide added to G-CSF resulted in rapid, robust and reliable mobilization of optimal numbers of CD34NCT03246529) provided written informed consent before enrollment. Institutional Review Board (IRB) approval of the study protocol, investigator brochure, amendments, informed consent and any other documents provided to the subject was performed by the following: Washington University IRB; University of Miami IRB; Mayo Clinic IRB; University of Oregon Oregon Health & Science University IRB; University of Kansas Medical Center IRB; University of Maryland IRB; Western Cooperative Group IRB; The Loyola University Chicago Health Sciences Campus IRB; UCLA IRB; University of Utah IRB; University of Cincinnati IRB; The Weill Cornell Medical College IRB; UT M.D. Anderson Cancer Center IRB; Ethics Committee Catania 1 Azienda Ospedaliero-Universitaria ‘Policlinico-Vittorio Emanuele’ Catania; Ethics Committee South Reggio Calabria Division Grande Ospedale Metropolitano ‘Bianchi-Melacrino- Morelli’; University of Cologne Ethics Committee; University of Debrecen, Clinical Center, Clinic of Internal Medicine, Hematology Scientific Council for Health – Ethical Committee for Clinical Pharmacology, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases Scientific Council for Health – Ethical Committee for Clinical Pharmacology. Please see All patients treated on the GENESIS trial  of patients with MM mobilizing ≥6 × 106 CD34+ cells kg–1 within two apheresis days. The preplanned review of these Part 1 data led the independent data monitoring committee (DMC) to recommend transitioning to Part 2 of the study. In the prospective, phase 3, double-blind, placebo-controlled, multicenter Part 2 of the study, 122 patients undergoing ASCT were enrolled at 18 sites across five countries and were randomized 2:1 to receive either motixafortide + G-CSF or placebo + G-CSF for HSPC mobilization before ASCT for MM. Key eligibility criteria included: patients 18–78 years of age with a confirmed diagnosis of MM; an Eastern Cooperative Oncology Group performance status of 0–1; and adequate organ function undergoing first ASCT in first or second complete response (CR) or partial response (PR) (according to IMWG Response Criteria). Sex and/or gender were recorded for demographic purposes, as self-reported by the participant. Patients were excluded if they had undergone prior HCT or failed previous HSPC collection attempts . Randomization of eligible patients was performed using an interactive web response system and was conducted in permuted blocks with stratification by response status (CR versus PR) and baseline platelet count (<200 × 109 l–1 or ≥200 × 109 l–1). Randomization was performed by the clinical research coordinator, who was not involved in direct patient care. All patients, investigators and providers/staff were blinded to treatment assignment. All patients received G-CSF (10 mcg kg–1) on days 1–5 . Patients received either motixafortide  or placebo on day 4 . Apheresis began on day 5 (four blood volumes), with the primary and secondary endpoints of collecting ≥6 × 106 CD34+ cells kg–1 in up to two or one apheresis days, respectively. Apheresis continued on days 6–8 if needed. Total CD34+ cells kg–1 were analyzed locally to determine whether patients met the primary endpoint, and all samples were subsequently sent for assessment by a central laboratory. Patients who did not collect ≥2 × 106 CD34+ cells kg–1 by day 8 proceeded to rescue mobilization. To assess the impact of each mobilization regimen on PB CD34+ cells and the relationship to collection of CD34+ HSPCs via apheresis, peripheral blood CD34+ HSPC counts were assessed using both local and central laboratories at the following time points: day 0 (baseline), before first dose of G-CSF; day 4, before first dose of motixafortide/placebo but after four doses of G-CSF; and day 5 (apheresis day 1), after first administration of motixafortide or placebo and after five administrations of G-CSF. The number of CD34+ cells infused for ASCT was determined independently by each investigator according to local practice; however, a minimum of ≥2 × 106 CD34+ cells kg–1 was required. Although initial power calculations called for 177 patients to be enrolled in Part 2 of the study, a preplanned interim analysis after 122 patients were enrolled was performed by an independent unblinded statistician and these results were communicated only to the independent DMC for review, leading the DMC to recommend halting the study due to statistically significant efficacy favoring the motixafortide + G-CSF mobilized cohort (prespecified threshold P ≤ 0.0108678).The GENESIS trial included a preplanned, lead-in, single-arm, open-label period previously reportedn = 14) undergoing mobilization with plerixafor + G-CSF (regardless of PB CD34+ cell count preapheresis) for ASCT for MM were prospectively enrolled on a parallel tissue-banking protocol (no. 201103349). All patients with MM received G-CSF (10 mcg kg–1) on days 1–5 . Patients then received either motixafortide (1.25 mg kg–1) or placebo on day 4  via subcutaneous injection, or plerixafor (0.24 mg kg–1) on day 4  via subcutaneous injection. Apheresis began on day 5 . Three healthy allo-donor cohorts underwent single-agent mobilization with either (1) G-CSF alone (10 mcg kg–1) on days 1–5 followed by apheresis beginning on day 5 (protocol no. 201106261); (2) plerixafor alone (0.24 mg kg–1) on day 1 followed by apheresis within 4 h of plerixafor administration (NCT00241358); or (3) motixafortide alone (1.25 mg kg–1) on day 1 followed by apheresis within 3 h of motixafortide administration (NCT02639559). Study samples were obtained from the apheresis product on the first day of apheresis in all patients, and CD34+ cells were analyzed as detailed below for correlative studies.All patients who participated in correlative studies provided written informed consent before enrollment on their respective protocols. GENESIS trial patients were enrolled and mobilized as previously described. In addition, a demographically similar, contemporaneous cohort of patients  and TNE (absolute neutrophil count ≥ 0.5 × 109 l–1 ×3 days) based on the total number of CD34+ cells kg–1 infused without regard to mobilization regimen, as well as the total number of specific CD34+ HSPC subsets infused. CD34+ HSPC immunophenotyping was performed via multicolor FACS, as detailed below.Although the number of CD34+ HSPC counts were assessed using a Stem Cell Enumeration Kit  at both local and central laboratories. For correlative studies, CD34+ HSPCs from n = 51 patients  were purified from apheresis product collected on the first day of apheresis via CD34+ immunomagnetic selection using an AutoMACS device (Miltenyi Biotech). CD34+ HSPCs were washed in PBS and stained for 15 min at room temperature with a LIVE/DEAD Fixable Aqua Dead Cell Stain kit (Invitrogen). Cells were then washed in PBS supplemented with 0.5% bovine serum albumin and 2 mM EDTA and incubated for 10 min at room temperature with human Fc Block and Brilliant Stain Buffer (BD Biosciences). Samples were then incubated for 30 min at room temperature with pretitrated saturating dilutions of the following fluorochrome-labeled antibodies : CD45-BUV395 ; CD123-BUV737 ; CD49f-BV421 ; CD14-BV650 ; CD45RA-BV785 ; CD34-VioBright515 ; CD10-PECF594 ; CD38-PE-Cy7 ; CD90-APC ; CD303-APCVIO770 ; CD184-PE ; and CD184-PE . Fluorescence minus-one controls were used to assess background fluorescence intensity and set gates for negative populations. After washing twice, samples were analyzed on a ZE5 (Bio-Rad) flow cytometer. Single-stain compensation controls were obtained using UltraComp eBeads (Thermo Fisher Scientific) and data were analyzed using FCS Express (DeNovo Software). The antibody-binding capacity per cell of the different CD34+ HSPC subsets was determined for CD184 clones 12G5 and 1D9 using saturating concentrations of antibody and the Quantum Simply Cellular  system for fluorescence quantitation according to the manufacturers recommendations.Peripheral blood CD34+ HSPCs from n = 12 patients with MM , and from n = 6 healthy allogeneic HSPC donors , were purified from apheresis products collected on the first day of apheresis via CD34 immunomagnetic selection. Transcriptional profiling was performed by 10×, 5’ scRNA sequencing. For sample preparation on the 10X Genomics platform, the Chromium Next GEM Single Cell 5’ Kit v.2, 16 rxns (no. PN-1000263), Chromium Next GEM Chip K Single Cell Kit, 48 rxns (no. PN-1000286) and Dual Index Kit TT Set A, 96 rxns (no. PN-1000215) were used. The concentration of each library was accurately determined through quantitative PCR utilizing the KAPA library Quantification Kit according to the manufacturer’s protocol (KAPA Biosystems/Roche), to produce cluster counts appropriate for the Illumina NovaSeq6000 instrument. Normalized libraries were sequenced on a NovaSeq6000 S4 Flow Cell using XP workflow and a 151 × 10 × 10 × 151 sequencing recipe according to the manufacturer’s protocol. A median sequencing depth of 50,000 reads per cell was targeted for each gene expression library.CD34n = 2,000). Any merged analysis or subsequent subsetting of cells/samples underwent the same scaling and normalization method. Cells were clustered using the original Louvain algorithm, and the top30 principal component analysis dimensions via functions ‘FindNeighbors’ and ‘FindClusters’ (with parameters: resolution = 0.5). The resulting merged and normalized matrix was used for subsequent analysis.For each sample we obtained the unfiltered feature-barcode matrix by passing demultiplexed FASTQs to Cell Ranger v.6.0.1 ‘count’ command using default parameters and the prebuilt GRCh38 genome reference (no. GRCh38-2020-A), and Chemistry flag (Single Cell 5’ PE) for scRNA (data files available via the gene expression omnibus (accession no. GSE223972). Seurat 4.1.0 was used for all subsequent analyses. Cells were further filtered to maintain only those cells with <20% human mitochondrial DNA content and a minimum of at least 200 and maximum of 20,000 genes expressed. We constructed a Seurat object using the unfiltered feature-barcode matrix for each sample. Each sample was scaled and normalized using Seurat’s ‘SCTransform’ function to correct for batch effects ’, variable.features –2926.Cell types were assigned to each cluster by manually reviewing the expression of a comprehensive set of marker genes derived from several publicationshttps://cole-trapnell-lab.github.io/monocle3/) was used for pseudotime analysis. Analysis was completed following the standard tutorial for construction of single-cell trajectories (https://cole-trapnell-lab.github.io/monocle3/docs/trajectories/).Monocle3 . The resulting DEGs were then filtered for adjusted www.gsea-mdsigdb.org. The TNFA_NFKB_Score gene set was derived from the HALLMARK_TNFA_SIGNALING_VIA_NFKB pathway. EGF_Score was derived from NAGASHIMA_EGF_SIGNALING_UP and MIT_EGF_RESPONSE_40_HELA. HBO1_score was derived from Yang et al28, including the following genes: KAT7, MPL, TEK, GFI1B, EGR1, TAL1, GATA2, ERG, PBX1, MEIS1, HOXA9 and GATA1. For all gene sets, the percentage of cells expressing each gene in the set was calculated for each treatment group. Any genes with <10% expression across a given treatment group were filtered out and not used in the final gene score annotation.Gene expression scores for each cell were annotated using the AddModuleScore function in Seurat. Gene sets were extracted from As a prespecified analysis, healthcare resource utilization items were collected alongside the GENESIS trial in each treatment arm, including (1) the number of motixafortide and G-CSF doses, (2) the number of apheresis procedures used in primary mobilization and (3) the proportion of patients requiring rescue mobilization due to inadequate primary mobilization.6 CD34+ cells kg–1 within up to two apheresis sessions in preparation for auto-HCT following G-CSF and a single administration of BL-8040/placebo. Prespecified secondary endpoints included the proportion of patients mobilizing ≥6 × 106 CD34+ cells kg–1 in one apheresis, the proportion of patients mobilizing ≥2 × 106 CD34+ cells kg–1 in one apheresis, TPE, TNE, graft durability, OS and PFS. The primary endpoint, prespecified secondary efficacy endpoints and graft durability were analyzed using the Cochran–Mantel–Haenszel (CMH) test with calculation of OR, two-sided 95% CI and P values. Time to engraftment, PFS and OS secondary endpoints were analyzed using Cox’s proportional hazards model, and time-to-event analyses (Kaplan–Meier method) with calculation of HR, two-sided 95% CI and P values. Analyses of all prespecified primary and secondary endpoints were performed on an ITT basis unless otherwise stated. P < 0.05 was considered statistically significant unless otherwise stated. Pearson correlation was performed to assess associations between total CD34+ cells kg–1 infused and specific CD34+ subset cells kg–1 infused and TPE/TNE. Sensitivity analyses were performed using time-to-event analyses (Kaplan–Meier method) to determine thresholds for both total CD34+ HSPCs infused and specific HSPC subsets infused above which TPE was significantly faster. Mean HSPC subset yields in apheresis were compared using analysis of variance, followed by post hoc Tukey–Kramer test for pairwise comparisons among groups. Two-sided statistical analyses were used.The primary endpoint was the proportion of patients mobilizing ≥6 × 10Further information on research design is available in the Any methods, additional references, Nature Portfolio reporting summaries, source data, extended data, supplementary information, acknowledgements, peer review information; details of author contributions and competing interests; and statements of data and code availability are available at 10.1038/s41591-023-02273-z.Supplementary InformationClinical trial protocol.Reporting SummarySupplementary Table 1+ HSPC immunophenotyping. BDB, BD Biosciences; BL, BioLegend; MB, Miltenyi Biotech; PBMCs, peripheral blood mononuclear cells; hPBMCs, human PBMCs; mPBMCs, murine PBMCs; hALL, human acute lymphoblastic leukemia; hAML, human acute myeloid leukemia.Antibodies for correlative CD34


Objectives: Surgical handwashing is one of the most important measures to prevent surgical site infection (SSI). We evaluated the effectiveness of the intervention program on surgical handwashing compliance of healthcare workers (HCWs) at Hung Vuong Hospital. Methods: This research was conducted from July 2019 to November 2019 in 3 phases. In the first phase, we determined the surgical handwashing compliance rate before the intervention. In the second phase, we implemented an intervention bundle as follows. We provided reminders of compliance in the form of video screen and automatic timers at surgical handwashing sinks. We provided links and QR codes for online access and live streaming of instructional videos on implementation of the hospital’s surgical hand sanitation procedures in the surgical handwashing area. We conducted direct monitoring to remind and guide HCWs to follow the procedures in combination with camera surveillance to accurately reflect compliance. Finally, we provided feedback in multiple steps: feedback to individual, feedback to head of department or department heads, cited names in briefings and sent names to the general planning department to suspend surgery privileges. In the third phase, we re-evaluated the surgical handwashing compliance rate after the intervention. Results: The total number of surgical handwashing checklists observed before and after the intervention was 787. The surgical handwashing compliance rate improved significantly from 48.8% to 71.8% . The compliance rate in camera monitoring also increased from 22.1% to 57.9% . The compliances rates of both surgeons and scrub nurses improved significantly after the intervention (P < .01). Conducting the new surgical handwashing procedure increased from 90.2% to 99.5% after this intervention. Conclusions: This intervention program improved surgical handwashing compliance of HCWs.


Streptococcus pneumoniae as the causative agent. Vancomycin-ceftriaxone combination therapy was initiated. Based on the patient’s history of two episodes of pneumococcal meningitis, a detailed immunological analysis was performed and found to be normal, excluding immune deficiency. Cranial computed tomography (CT) was performed because cranial skeletal defects can cause recurrent meningitis. The cranial CT revealed a bony defect in the left lamina cribrosa  analysis showed CSF pleocytosis, elevated CSF protein level (448 mg/dL), and decreased CSF glucose level (8 mg/dL), suggestive of bacterial meningitis. Blood and CSF cultures were negative. Polymerase chain reaction (PCR) of the CSF revealed cribrosa . For a dcribrosa -3. These,,,Frontoethmoidal encephalocele is a protrusion of intracranial contents through a defect in the joint between the frontal and ethmoidal bones, directly connecting the brain with the external region, leading to pathogenic invasion


The immunogenicity and safety of a booster dose of tetanus toxoid-conjugate quadrivalent meningococcal vaccine (MenACYW-TT), alone or co-administered with MenB vaccine, were assessed in healthy 13–25-year olds who received MenACYW-TT or a CRM-conjugate vaccine (MCV4-CRM) 3–6 years earlier.This phase IIIb open-label trial (NCT04084769) evaluated MenACYW-TT-primed participants, randomized to receive MenACYW-TT alone or with a MenB vaccine, and MCV4-CRM-primed participants who received MenACYW-TT alone. Functional antibodies against serogroups A, C, W and Y were measured using human complement serum bactericidal antibody assay (hSBA). The primary endpoint was vaccine seroresponse  30 days post booster. Safety was evaluated throughout the study.The persistence of the immune response following primary vaccination with MenACYW-TT was demonstrated. Seroresponse after MenACYW-TT booster was high regardless of priming vaccine . Co-administration with MenB vaccines did not affect MenACWY-TT immunogenicity. No vaccine-related serious adverse events were reported.MenACYW-TT booster induced robust immunogenicity against all serogroups, regardless of the primary vaccine received, and had an acceptable safety profile.A booster dose of MenACYW-TT induces robust immune responses in children and adolescents primed with MenACYW-TT or another MCV4 (MCV4-DT or MCV4-CRM), respectively.Here, we demonstrate that MenACYW-TT booster 3–6 years after primary vaccination induced robust immunogenicity against all serogroups, regardless of the priming vaccine (MenACWY-TT or MCV4-CRM), and was well tolerated.Persistence of the immune response following previous primary vaccination with MenACYW-TT was demonstrated.MenACYW-TT booster with MenB vaccine co-administration did not affect MenACWY-TT immunogenicity and was well tolerated.These findings will facilitate the provision of broader protection against IMD particularly in higher-risk groups such as adolescents. Neisseria meningitidis. IMD is a leading cause of mortality and morbidity globally, with a fatality rate of 8–15%.1 It is often associated with long-term sequelae amongst survivors, such as neurological complications, hearing loss, loss of limbs and paralysis.2 The incidence of IMD peaks in infants under 1 year of age with a second smaller peak in incidence observed in adolescents and young adults in many countries.3 Notably, carriage rates have been observed to be highest in this latter age group.4Invasive meningococcal disease (IMD) is a life-threatening illness caused by the obligate human bacterium, 6 The dominant serogroup varies by geographical region and fluctuates unpredictably over time. In Western Europe and Canada, meningococcal serogroup C (MenC) outbreaks in the late 1990/early 2000s led to a steep rise in the incidence of IMD, while an increased incidence of MenW has been more recently observed in these countries.7 In the US, most outbreaks over the past two decades have also been caused by C and more recently B, with a smaller proportion of IMD cases caused by Y and W.8 Vaccination campaigns with monovalent (MenC) and quadrivalent (MenACWY) polysaccharide-protein conjugate vaccines have successfully reduced IMD incidence in many countries where this has been implemented.12 The recent development of two novel recombinant protein vaccines against MenB offers additional protection against IMD caused by serogroup B.Of the 12 meningococcal serogroups identified, 6  are the causative agent in the majority of cases of IMD worldwide.13 Several European countries also recommend MCV4 vaccination in toddlers and/or adolescents.14 Since their launch in 2015, MenB vaccines have been introduced into routine national vaccination programs, often in infants, in a number of European countries, and other countries worldwide including the UK, US and Australia.17In the United States, the Advisory Committee on Immunization Practices (ACIP) recommends routine primary vaccination with a meningococcal conjugate vaccine (MCV4) in children aged 11 or 12 years, and a booster dose at age 16.21 and more recently in infants from 6 weeks of age.22 A dose of MenACYW-TT in those primed 4–10 years previously with an MCV4 (MCV4-DT or MCV4-CRM), at age 10 years or older, was previously demonstrated to boost the immune response in adolescents and adults.23 Similarly, a dose of MenACYW-TT in children aged 4–5 years who received a primary dose of MenACYW-TT or MCV4-TT as toddlers also demonstrated robust boosting of the immune response.24MenACYW-TT  is a quadrivalent meningococcal polysaccharide  tetanus toxoid-conjugate vaccine, and does not contain an adjuvant. It was licensed in the US for use in individuals aged ≥2 years of age, and individuals aged ≥12 months in the EU, Australia, Canada, Brazil, and other countries. MenACYW-TT has been extensively evaluated in toddlers, children, adolescents and adults (including those over 65 years),The aim of this phase IIIb study was to evaluate the immunogenicity and safety of a booster dose of MenACYW-TT 3–6 years after a priming vaccination with either MenACYW-TT or MCV4-CRM  in adolescents and adults in the US, with and without co-administration of a MenB vaccine, and to evaluate the persistence of the immune response to MenACYW-TT and MCV4-CRM 3–6 years after vaccination.This was a phase IIIb, open-label, partially randomized, parallel-group, active-controlled, multicenter study to evaluate the immunogenicity and safety of a booster dose of MenACYW-TT when administered alone or co-administered with licensed MenB vaccines in adolescents and adults . The study was conducted between September 2019 and September 2020 at 29 centers in the United States and 1 center in Puerto Rico.The study was approved by the appropriate independent ethics committees and institutional review boards before its initiation. The conduct of this study was consistent with standards established by the Declaration of Helsinki and compliant with the International Conference on Harmonization guidelines for Good Clinical Practice, including all local and/or national regulations, and directives.25 or had received a routine MCV4-CRM vaccine  3–6 years prior. Exclusion criteria included anyone who had received any vaccine in the 4 weeks preceding the study vaccine, except for influenza which could be received at least 2 weeks prior to the study, and had received any other meningococcal vaccination since the participation in the previous study of MenACYW-TT, had a known or suspected congenital/acquired immunodeficiency or had received immunosuppressive therapy or systemic corticosteroid therapy (for ≥2 consecutive weeks) within 6 or 3 months prior to the study, respectively, had a personal history of Guillain–Barré syndrome, or had received oral or injectable antibiotic therapy within 72 h prior to the first blood draw. Participants aged ≥13 to <18 years of age signed an assent form and their parent or guardian signed and dated the informed consent form (ICF) before any procedure or treatment associated with the trial performed. Those ≥18 years of age signed and dated the ICF themselves.Participants were eligible for inclusion if they were aged ≥13 to <26 years on the day of screening, and had participated in and completed any of two previous studies of MenACYW-TT  in the US (MET50 [NCT02199691] or MET43 [NCT02842853]),Participants who had previously received a priming dose of MenACYW-TT (MenACYW-TT primed) were randomized 2:1:1 to receive a booster dose of MenACYW-TT either alone (Group 1), or co-administered with a single dose of a licensed MenB vaccine, MenB-T  or 4CMenB . Participants who had previously received a priming dose of MCV4-CRM were assigned to receive a booster dose of MenACYW-TT vaccine alone (Group 2). Only laboratory technicians were blinded to treatment assignment.4. Each 4CMenB dose was presented as 0.5 mL containing recombinant N. meningitidis group B Neisseria Heparin Binding Antigen, group B Neisseria adhesin A protein, group B fHbp fusion protein and outer membrane vesicles from N. meningitidis group B strain NZ98/254 adsorbed on Al(OH)3. Second and third (if applicable) MenB doses were offered 30 and 180 days after the first MenB dose, respectively, in line with the US FDA-approved schedules for the respective MenB vaccines. These vaccinations were performed outside of study procedures and were not described in the study protocol.The booster dose of MenACYW-TT was administered intramuscularly (IM) into the deltoid muscle of the arm. Each MenACYW-TT dose was presented in 0.5 mL of saline solution containing 10 μg of each meningococcal capsular polysaccharide serogroups A, C, Y and W, and approximately 55 μg of tetanus toxoid protein carrier. MenB-T and 4CMenB were administered IM into the deltoid muscle of the opposite arm to that used for MenACYW-TT administration. Each MenB-T dose was presented in 0.5 mL containing factor H binding protein (fHBP) subfamily A, fHBP subfamily B, adsorbed on AIPOBlood samples for immunogenicity analyses were obtained prior to (Day 0) and 30 (+14) days after booster vaccination. A subset of the first 50 participants enrolled into groups 1  and 2  provided additional post-vaccination samples on Day 6 (±1 day).26 The lower limit of quantification for the hSBA assay was 1:4. Vaccine seroresponse for serogroups A, C, Y and W was defined as hSBA pre-vaccination titer <1:8 for participants with a post-vaccination titer ≥1:16; or a ≥4-fold increase in titer post-vaccination for participants with a pre-vaccination titer ≥1:8. Vaccine seroprotection was defined as hSBA titers ≥1:8.Functional antibody titers against meningococcal serogroups A, C, W and Y were measured by a serum bactericidal antibodies assay using human complement , as described previously.The primary immunogenicity endpoints of this study were vaccine seroresponse rates against meningococcal serogroups  following a booster dose of MenACYW-TT in participants primed with MenACYW-TT 3–6 years previously, based on hSBA titers pre-booster and 30 days post booster. The secondary immunogenicity endpoints were hSBA seroresponse and seroprotection rates and geometric mean titers (GMTs) against serogroups A, C, W and Y in MenACYW-TT- or MCV4-CRM-primed participants, pre-  and 30 days post-MenACYW-TT booster and, for a subset of participants, at 6 days post booster. In addition, vaccine hSBA seroresponse, seroprotection and GMTs to serogroups A, C, W and Y were determined following MenACYW-TT booster alone or co-administered with MenB-T or 4CMenB.Participants were observed for 30 min after vaccination to ensure their safety, during which, any unsolicited systemic adverse event (AE) was recorded. The occurrence of solicited injection site  and systemic reactions  were recorded up to 7 days after vaccination in the participant’s diary card provided to the parents/guardians. Parents or guardians were asked to inform the investigators of any potential serious adverse events (SAEs) immediately.Unsolicited AEs were collected from Day 0 to Day 30 and medically attended AEs (MAAEs) and (SAEs) including AEs of special interest (AESIs) were recorded throughout the study . Adverse events classified as AESIs were generalized seizures (febrile and non-febrile), Kawasaki disease, Guillain–Barré syndrome and idiopathic thrombocytopenia purpura.Adverse events were assessed by the investigator for relatedness to the study vaccine and for intensity .A total of approximately 600 participants were planned to be enrolled. Three full analysis sets (FAS) were defined: FAS1 included participants who received at least one study vaccine booster dose and had a valid Day 6 serology result; FAS2 included participants who received at least one booster dose and had a valid Day 30 serology result; and FAS3 (for antibody persistence) included participants who had a valid Day 0 serology result. Two per protocol analysis sets (PPAS) were defined: PPAS1 for Day 6, and PPAS2 for Day 30 samples, each comprising participants from FAS1 or FAS2, respectively, who had no protocol deviations. Participant data in the FAS and PPAS were analyzed according to the groups that the participants were randomized to.The safety analysis set (SafAS) was defined as all participants who received at least one dose of the study vaccine(s) and had safety data available. Safety was analyzed for participants in the SafAS according to the vaccine(s) they had received at Day 0.Immunogenicity analyses were performed in the FAS2 and PPAS2 for Day 30 results and in the FAS1 and PPAS1 for Day 6 results; antibody persistence was assessed on the FAS3. Vaccine seroresponse sufficiency (primary objective) was demonstrated if the lower limit of the 1-sided 97.5% confidence interval (CI) calculated using the Clopper–Pearson method for the percentage of participants with hSBA vaccine seroresponse against serogroups A, C, W and Y, was greater than 75%. Seroresponse sufficiency was evaluated separately for Group 1  and Group 2 . Data from participants of the MET50 and MET43 studies were used to evaluate antibody persistence and overall trends over 3–6 years post-priming with MenACYW-YY or MCV4-CRM. Antibody titers and corresponding 95% CIs were calculated on Log10 transformed data, assuming a normal distribution for the transformed data, with antilog transformations applied to provide GMTs and their 95% CIs. Participants who were previously primed with MCV4-CRM outside of prior studies were not included in the assessment of antibody persistence.A total of 570 participants were enrolled in the study: 381 from the MET50 trial and 140 from the MET43 trial who had received either MenACYW-TT or MCV4-CRM, and 49 participants who received MCV4-CRM as part of routine immunization. Of these, 191 Group 1 (MenACYW-TT primed) participants and 190 Group 2 (MCV4-CRM primed) participants received MenACYW-TT booster alone, 95 MenACYW-TT primed participants received MenACYW-TT booster +MenB-T (Group 3) and 94 MenACYW-TT primed participants received the MenACYW-TT booster +4CMenB (Group 4) . Day 30 GMTs were also comparable between Group 1 and Group 2 for serogroups A, W and Y, with higher GMTs for serogroup C in Group 1 . The Day 6 GMTs were also comparable in Group 1 and Group 2 for serogroups A and Y, and were higher for serogroups C and W in Group 1  experienced an immediate unsolicited AE of Grade 2 presyncope, related to the study vaccination. Solicited reactions were reported at similar frequencies between Group 1 and Group 2 participants  Table . SolicitNo participants experienced a serious AE (SAE) within 30 days of vaccination, and no participants experienced AEs or adverse reaction (AR) which led to study discontinuation. During the study, six SAEs were reported: two cases of Grade 3 appendicitis (one each in Group 1 and Group 2), two cases of Grade 3 suicidal ideation (one each in Group 1 and Group 2), one case of Grade 3 major depression and suicidal ideation (Group 3) and one case of Grade 3 accidental overdose (Group 3). All occurred between Day 31 and the 6-month follow-up contact and were not considered related either by the investigator or by the sponsor. No deaths or AEs of special interest were reported.24 and is indicative of immune memory in these participants. Such a rapid anamnestic response is important to be able to rapidly boost protection against infection among groups of at-risk individuals whose protective antibody levels may have waned over time and thus may otherwise be at risk of a potential outbreak. Vaccination with MenACYW-TT as a booster in adolescents and adults vaccinated 3–6 years earlier with MenACYW-TT or MCV4-CRM was found to be well tolerated with no safety concerns identified. There were no SAEs within 30 days of the booster, or discontinuations due to AEs.This phase IIIb, open-label, partially randomized, parallel-group, multicenter trial demonstrated that a booster dose of MenACYW-TT in adolescents and adults who had been vaccinated 3–6 years earlier with a single dose of MenACYW-TT or MCV4-CRM was immunogenic and well tolerated, with in the sufficiency of seroresponse demonstrated at Day 30 post booster. We observed a robust response to a booster dose of MenACYW-TT, with over 93% seroresponse for all serogroups in adolescents and adults. The seroresponse rate was greater than 75% for all serogroups in both Groups 1 and 2 by Day 6, suggesting a quick onset of the immune response, regardless of the priming vaccine (MenACYW-TT or MCV4-CRM). This observation supports previous studies of a booster dose of MenACYW-TT which have shown similar results,25 suggesting the persistence of the immune response in these participants. GMTs were also higher pre-booster in those primed with MenACYW-TT compared to those primed with MCV4-CRM for serogroups C, W and Y. These results demonstrate for the first time persistence of the immune response in adolescents and young adults and are in line with previous studies of a booster dose of MenACYW-TT findings showing persistence of the immune response in a younger population.24When examining the persistence of the immune response, 3–6 years after the priming vaccination with either MenACYW-TT or MCV4-CRM, prior to the booster vaccination, seroprotection ranged from 52% to 91% across the serogroups and vaccine groups. GMTs at Day 0, pre-booster, were higher than those prior to the priming vaccine in participants from previous studies,Based on the GMTRs at Day 30 post booster dose for Groups 1 (MenACYW-TT primed) and 2 (MCV4-CRM-primed), possible evidence of a statistically significant difference for serogroups C and Y (considering 95% CIs do not cross 1) was observed; however, it must be noted that a formal statistical hypothesis to evaluate such a difference was not a part of the planned analysis and is a post-hoc observation. The co-administration of the MenACYW-TT booster with a MenB vaccine did not affect the immunogenicity of serogroups A, C, Y and W, compared to the administration of the MenACYW-TT booster alone.32 Co-administration of these vaccines will be important in a number of countries globally, including the US, to facilitate the provision of broader protection against IMD particularly in higher-risk groups such as adolescents.Solicited AEs were mostly of mild intensity but showed a numerical increase, particularly in malaise and myalgia, likely influenced by the known reactogenic profile of MenB vaccines.25While this study assessed the co-administration of MenACYW-TT and MenB vaccines, the immunogenicity of MenB vaccines when co-administered with MenACYW-TT was not assessed in this study due to non-availability of relevant assays. It will be important to address this in future studies. In addition, we did not have pre- or post-priming vaccine data for the 49 participants who had not participated in the previous MET50 or MET43 clinical studies and as such these participants were not included in the analysis of antibody persistence. This study may also have benefitted from the inclusion of an additional group of participants as a control to assess the response of a single dose of MenACYW-TT in vaccine-naïve participants; however, studies showing robust immunogenicity of a single dose of MenACYW-TT in this age group have been published previously.This study offers key data about the immunogenicity and safety of MenACYW-TT when administered as a booster alone or co-administered with a MenB vaccine, in participants primed with MenACYW-TT or MCV4-CRM. A booster dose of MenACYW-TT produced a comparable and robust response to all serogroups in adolescents and adults who had received a priming dose of either MenACYW-TT or MCV4-CRM 3–6 years earlier. In addition, no interference of the immune response to MenACYW-TT was observed when MenACYW-TT was co-administered with MenB-T or 4CMenB vaccines.Supplementary Materials


Clinical exacerbations characterized with neurological symptoms are observed in around 10% of Behçet’s disease (BD) patients and may culminate in severe disability. Although certain immunological factors have been associated with disease activity in neuro-Behçet’s disease (NBD), biomarkers for monitoring the clinical outcome of NBD have not been properly investigated.Levels of neurofilament light chain (NFL), homeobox protein Hox-B3 (HoxB3), and YKL-40 were measured in cerebrospinal fluid (CSF) samples of 23 parenchymal (n = 16) and nonparenchymal (n = 7) NBD patients obtained during NBD attacks by ELISA. Parameters of clinical progression and outcome were assessed for an average follow-up period of 3.9 ± 1.3 years.Parenchymal NBD patients showed elevated CSF levels of NFL, HoxB3, and YKL-40 as compared to nonparenchymal patients. NBD patients showing an increase in modified Rankin score (mRS) values during follow-up had significantly higher CSF NFL levels. Patients with relatively lower CSF NFL levels (<1000 ng/L) did not develop attacks or cognitive impairment interfering with daily life activities during follow-up. NFL levels correlated with disease duration and mRS at the last follow-up visit, while HoxB3 levels correlated with a number of attacks during follow-up.CSF level of NFL appears to predict the prospective somatic and cognitive disability in NBD patients and may thus be potentially used as a biomarker of clinical outcome in this disease. Behçet’s disease (BD) is a multisystem inflammatory disorder characterized by recurrent oral aphthae, genital ulcerations, and uveitis . CentralNBD often presents with attack and remission periods and a significant accumulation of disability can be observed in some patients after a few attacks occurring in a short time frame ,5. CerebIn this context, neurofilament light chain (NFL) and chitinase-3-like protein 1, which is also known as YKL-40, have stood out as potential prognostic and monitoring biomarkers in several neuroimmunological and neurodegenerative disorders –13. NFL In this study, we aimed to test whether NFL, HoxB3, and YKL-40 could potentially be used for the prediction of disease activity and clinical outcomes in NBD. For this purpose, we measured levels of these biomarkers in CSF samples obtained and stored during NBD attacks and looked for potential correlations with clinical activity parameters of NBD documented over several years of follow-up.Twenty-three NBD patients fulfilling the diagnostic criteria for BD  were enrAll CSF samples were collected during NBD attacks and stored at −80 °C until use. The levels of NFL , YKL-40 , and HoxB3 (SunRed Biotechnology Company) were measured by ELISA according to the manufacturer’s instructions. Normal values of NFL were measured between 112 and 821 pg/mL as per the manufacturer’s instructions. Optical densities were measured at 450 nm and concentrations were calculated by reference to the standard curves.A comparison of parametric data among patient subgroups was conducted by Student’s t-test. mRS and Δ mRS values were compared by Mann-Whitney U. Categorical parameters were compared with chi-square test. Correlation studies were accomplished by Spearman’s correlation test. P-value below 0.05 was defined as statistical significance.NBD patients (13 men and 10 women) had an average age (± standard deviation) of 40.5 ± 14.9 years and were classified as parenchymal NBD (n = 16) and nonparenchymal NBD (n = 7). The average mRS recorded during attacks (when CSF samples were obtained) was 1.5 ± 1.1 and was increased to 1.9 ± 1.5 during a follow-up duration of 3.9 ± 1.3 years (range 2–6 years). Thirteen of 23 NBD patients exhibited elevated mRS and 5 patients declared significant cognitive impairment during follow-up . While 8Parenchymal and nonparenchymal NBD patients showed comparable age, gender, disease duration, and follow-up duration. However, parenchymal NBD patients had higher initial mRS, final mRS and number of attacks in total and after CSF collection. Also, 12 of 13 NBD patients with elevated mRS and all 5 NBD patients, who developed significant cognitive impairment during follow-up, were within the parenchymal group. CSF NFL, HoxB3, and YKL-40 levels of parenchymal NBD patients were significantly higher than those of nonparenchymal patients .To better evaluate the association of CSF biomarkers with the clinical progression of NBD, patients were grouped as those having exhibited (n = 13) and not exhibited (n = 10) an increase in their mRS values during follow-up. While these two groups were matched in terms of age, gender, NBD duration, follow-up duration, and initial mRS, the elevated-mRS group showed a higher number of patients with parenchymal involvement and cognitive impairment and significantly elevated final mRS values and attack numbers. Moreover, patients with increased mRS displayed significantly elevated CSF NFL levels than patients with a relatively stable disease course. By contrast, CSF levels of HoxB3 and YKL-40 were comparable among mRS subgroups . The eleSince CSF HoxB3 and YKL-40 levels did not show any association with clinical worsening, we focused on CSF NFL levels for the remainder of our study. To have a better insight into the association between CSF NFL levels and clinical progression of NBD, patients with higher and lower CSF NFL were compared. While patients with higher and lower NFL levels showed comparable age, gender, NBD duration, follow-up duration, the total number of attacks, initial and final mRS scores, NBD patients with CSF NFL levels of ≥1000 ng/L were more likely to have parenchymal involvement, new attacks and cognitive impairment during follow-up. As a matter of fact, NBD patients with CSF NFL levels <1000 ng/L did not exhibit any NBD attacks or symptoms of cognitive impairment in a follow-up duration of 3.6 ± 1.2 years. CSF levels of HoxB3 and YKL-40 were comparable among NBD patients with high and low NFL levels . When onNext, we investigated potential correlations between CSF NFL levels and clinical, demographic, and CSF biomarker variables listed in In this study, we measured CSF levels of NFL, HoxB3, and YKL-40 in NBD patients for the first time, to our knowledge. We preferred CSF over serum measurements since CSF levels of biomarkers are expected to be more closely related to disease activity in inflammatory and degenerative disorders. Moreover, we recently showed that CSF HoxB3 and YKL-40 levels had a higher predictive value than serum HoxB3 and YKL-40 levels in the evaluation of disability progression in MS patients . SeveralAn intriguing feature was that CSF YKL-40 levels were highly elevated (>900 pg/mL) in all NBD patients regardless of disease activity. This is in contrast with MS patients of our outpatient clinic, who display CSF YKL-40 levels in an approximate range of 40–1200 pg/mL and an average of around 700 pg/mL . CriticaIn MS, increased CSF NFL levels predict enhanced disability in the upcoming years. Higher CSF NFL is usually linked to more advanced disability and a greater likelihood of cognitive dysfunction in MS . Our resInterestingly, there was no correlation between CSF NFL levels versus mRS values and attack numbers documented during the NBD attack. This finding suggests that cross-sectional NFL level is not a good indicator of NBD-related disability accumulated in the past. This is the opposite of the MS experience, which suggests that CSF NFL is correlated with both cross-sectional and longitudinal and prospective disability in MS patients .It was also notable that NFL level was only marginally correlated with an increase in mRS values during follow-up, despite showing a stronger association with attack numbers and cognitive dysfunction. This weak association with mRS, mostly an indicator of somatic disability, might be because this scoring system is not an ideal method for measuring disability in BD/NBD. Since BD is a systemic disease, patients may show physical impairment due to nonneurological or noninflammatory factors, such as severe mechanical joint problems or peripheral blood vessel occlusion ,30. ThusIn our study, diagnosis of cognitive dysfunction was based on patients’ statements and complaints and thus we could only pinpoint patients with the most severe cognitive problems. Thus, a major limitation of our study was the absence of formal cognitive tests that would more accurately diagnose cognitive dysfunction and also single outpatients with milder cognitive impairment. Likewise, the absence of imaging data obtained during the final follow-up visit prevented assessment of the association between NFL levels and brain atrophy.In brief, our results suggest that CSF NFL levels higher than 1000 ng/L might indicate an unfavorable prognosis in NBD and thus these patients should be more closely monitored and alternative treatment options such as cyclophosphamide should be considered. These results should be further validated by higher numbers of patients with longer follow-up durations.


Studies on coronary slow flow are receiving increasing attention, but objective evaluations are still lacking. The purpose of this study was to visualize the current status and research hotspots of coronary slow flow through bibliometric analysis.All relevant publications on coronary slow flow from 2003 to 2022 were extracted from the Web of Science Core Collection database and analyzed by VOSviewer and CiteSpace visualization software. Year of publication, journal, country/region, institution, and first author of each paper, as well as research hotspots were identified.A total of 913 publications were retrieved. The journal with the most publications was Coronary Artery Disease. The country/region with the most publications was Turkey, followed by China and the United States. The institution with the largest publication volume was Turkey Specialized Higher Education Research Hospital. The author with the largest publication volume was Chun-Yan Ma from China. Keyword analysis indicated that “treatment and prognosis”, “pathogenesis and risk factors” and “diagnosis” were the clustering centers of coronary slow flow, and the research hotspots gradually changed with time, from pathogenesis to treatment and prognosis.Future research will focus on the search for effective and non-invasive detection indicators and treatments of coronary slow flow. Collaboration needs to be enhanced between different institutions or countries/regions, which would improve clinical outcomes for patients with coronary slow flow. Coronary slow flow (CSF) was first proposed by Tambe et al.  in 1972,Bibliometric analysis is a literature-mining method based on mathematics and statistics that can predict the research status and hotspots within specific domains through information visualization , 7. BaseWe searched the WoSCC database from January 2003 to December 2022. The search strategy used to retrieve the data was TS = (coronary slow flow OR slow coronary flow). Only English articles of categories “Article” and “Review” were considered in this study.Bibliometric analysis was used to analyze the year of publication, journal, country/region, institution, and first author of each paper, as well as research hotspots of publications on CSF. The full records and cited references were exported from the WoSCC database in plain text format. VOSviewer software (version 1.6.18) was used to perform keyword co-occurrence analysis and generate visual maps. CiteSpace software (version 6.2. R2) was used to perform keyword burst analysis and explore the changing trend of publications on CSF.A total of 913 publications on CSF were retrieved from the WoSCC database, including 835 primary articles and 78 reviews (Table n = 27), and the International Journal of Cardiology, from Ireland (n = 26). The journal with the highest impact factor (IF) was the Journal of the American College of Cardiology , which had the most total citations (1210).The retrieved publications on CSF were published in 340 different journals, the top 15 of which by publication volume are listed in Table n = 219), followed by China (n = 179) and the United States (n = 167).The retrieved publications on CSF were distributed among 56 countries/regions, the top 15 of which by publication number are listed in Table VOSviewer software was used to generate a visual map of countries/regions. Figure n = 22), followed by Capital Medical University (n = 21).The retrieved publications on CSF were distributed among 1379 institutions, the top 15 of which by publication volume are listed in Table VOSviewer software was used to generate a visual map of institutions. Figure n = 14), followed by Mustafa Cetin from Turkey (n = 13) and Yong-Huai Wang from China (n = 12).The retrieved publications on CSF included 4892 authors, the top 15 of whom by publication number are listed in Table VOSviewer software was used to generate a visual map of the authors. Figure We conducted keyword co-occurrence analysis to reveal the research hotspots on CSF via VOSviewer software. The small clusters of keywords that appeared fewer than 10 times were filtered out, and a keyword co-occurrence map of CSF high-frequency keywords containing 3 main clusters was generated.In Fig. We conducted keyword burst analysis to reveal the changing trend of publications and research frontiers on CSF via CiteSpace software. The 15 keywords with the strongest citation bursts are shown in Fig. It has been more than 50 years since the first detection of CSF . As coroThis study found that the author with the most publications was Chun-Yan Ma from China. The studies of her team have mainly concentrated on the novel echocardiography-based technique to assess CSF and gene polymorphisms in the pathogenesis of CSF , 9. Six The research direction of cluster 1 in the keyword co-occurrence analysis was associated with the treatment and prognosis of CSF. Our keyword burst analysis revealed that the treatment and prognosis of CSF was the main research frontier in recent years, with keywords, such as mortality, outcome, and management. Most studies have focused on pharmacotherapy of CSF, but there is still no safe and effective drug supported by evidence-based medicine. A growing number of studies have found that statin therapy can improve coronary blood flow and coronary flow reserve , 13. NiuThe high-frequency keywords in cluster 1 included PCI, acute myocardial infarction, and no-reflow phenomenon. Slow flow/no-reflow phenomenon after PCI in myocardial infarction was one main focus of research on CSF. Shah et al.  found thCluster 2 in our keyword co-occurrence analysis was associated with the pathogenesis and risk factors for CSF, including keywords, such as atherosclerosis, inflammation and endothelial function. The keywords in the keyword burst analysis were nitric oxide and endothelial function from 2003 to 2014. Earlier studies on the pathogenesis of CSF focused on endothelial dysfunction . A varieThe diagnostic methods of CSF have not received enough attention in previous studies. The diagnosis of CSF is based on coronary angiography. Since coronary angiography is invasive and expensive, the diagnosis and follow-up of CSF are difficult. A series of explorations have been performed to find non-invasive diagnostic markers of CSF , 33. TheThere are some limitations to this study. First, only the publications in the WoSCC database were searched, which may have caused some biases in the results. Second, with the rapid updating of publications in the field of CSF, our literature search may have missed some research hotspots.The study of CSF is of great clinical value. This bibliometric analysis of the literature on CSF reflects the research status and hotspots over the last two decades, visualized with dedicated software. The Journal Coronary Artery Disease, country/region Turkey, and author Chun-Yan Ma were top ranked. Collaboration needs to be enhanced between different countries/regions and institutions, which would improve clinical outcomes for patients with CSF. “Treatment and prognosis”, “pathogenesis and risk factors”, and “diagnosis” were the clustering centers of CSF in the keyword co-occurrence analysis. The research focus gradually moved from pathogenesis to disease-related research to treatment and prognosis over the years. The search for effective and non-invasive detection indicators and treatments of CSF will be the future trends in research. This study will help researchers find relevant literature and academic partners, offer a direction for journal submissions, and provide a reference for the identification of hotspots in the field of CSF.


No single biomarker currently risk stratifies chronic obstructive pulmonary disease (COPD) patients at the time of an exacerbation, though previous studies have suggested that patients with elevated troponin at exacerbation have worse outcomes. This study evaluated the relationship between peak cardiac troponin and subsequent major adverse cardiac events (MACE) including all-cause mortality and COPD hospital readmission, among patients admitted with COPD exacerbation.Data from five cross-regional hospitals in England were analysed using the National Institute of Health Research Health Informatics Collaborative (NIHR-HIC) acute coronary syndrome database (2008–2017). People hospitalised with a COPD exacerbation were included, and peak troponin levels were standardised relative to the 99th percentile . We used Cox Proportional Hazard models adjusting for age, sex, laboratory results and clinical risk factors, and implemented logarithmic transformation (base-10 logarithm). The primary outcome was risk of MACE within 90 days from peak troponin measurement. Secondary outcome was risk of COPD readmission within 90 days from peak troponin measurement.There were 2487 patients included. Of these, 377 (15.2%) patients had a MACE event and 203 (8.2%) were readmitted within 90 days from peak troponin measurement. A total of 1107 (44.5%) patients had an elevated troponin level. Of 1107 patients with elevated troponin at exacerbation, 256 (22.8%) had a MACE event and 101 (9.0%) a COPD readmission within 90 days from peak troponin measurement. Patients with troponin above the upper limit of normal had a higher risk of MACE  and COPD hospital readmission  when compared with patients without elevated troponin.An elevated troponin level at the time of COPD exacerbation may be a useful tool for predicting MACE in COPD patients. The relationship between degree of troponin elevation and risk of future events is complex and requires further investigation. Comorbidities are common in people with COPD. Specifically, ischaemic heart disease (IHD) and cardiac arrhythmias are the most prevalent comorbidities, and account for a significant proportion of deaths.−1 at exacerbation are at increased risk of death post hospital discharge.9Furthermore, people with COPD have an increased risk of acute CV events around the time of an exacerbation.Together with typical symptoms, elevation of troponin assays now form an important component for diagnosis of acute coronary syndrome, often in conjunction with ECG abnormalities.This study was conducted using data collected from the electronic National Institute of Health Research Health Informatics Collaborative (NIHR-HIC) acute coronary syndrome database. This database contained information on 257,948 patients across five hospitals , starting from 2010  until 1 April 2017. 156,410 (60.6%) patients had an inpatient troponin assay recorded. The dataset contained detailed information on patient demographics, diagnoses at admission, biochemistry/ haematological results, echocardiography and mortality. Diagnoses were defined from the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) discharge codes. 134,517 patients (86% of recorded troponin) had ICD-10 discharge codes recorded.The inclusion criteria were patients with a diagnosis of a COPD exacerbation at initial admission . An exacThe primary outcome was time to MACE within 90 days from peak troponin measurement. MACE outcome was defined as non-fatal myocardial infarction , admission with heart failure or stroke (defined as diagnostic positions 1 and 2 after troponin measurement during the same time period), coronary revascularisation (defined as having PCI (Percutaneous Coronary Intervention) or CABG (Coronary Artery Bypass Grafting)) or having died from any cause within 90 days from peak troponin measurement. Time to COPD hospital readmission within 90 days was also investigated as secondary outcome.Variables were included based on previous clinical knowledge and included demographic and clinical risk factors for cardiovascular disease. Demographic factors were age and gender. Clinical risk factors included the following comorbidities: hypertension, previous myocardial infarction, hypercholesterolaemia, heart failure, peripheral arterial disease (PAD), malignancy, chronic kidney disease (CKD) and diabetes mellitus (DM). Other variables included haematological and biochemistry results e.g., C-reactive protein (CRP), haemoglobin, white cell count, creatinine and platelet counts. Comorbidities and risk factors were defined based on combinations of keywords that had been developed during curation of the database to correspond to ICD-10 code definitions as per previous methodology.13Peak hsTrop measurements  were standardised to allow for differing troponin assays. Standardisation was calculated by dividing the troponin result by the ULN, giving a ratio relative to the ULN. If only one troponin assay was recorded, this was used as the peak troponin. A standardised troponin value that was ≥1 typically described a clinically significant elevation as it indicated a troponin level above the ULN.10Descriptive analyses were summarised as median  for continuous variables and number (percentage) for categorical variables. Mann–Whitney tests were implemented to compare medians between patients with and without elevated troponin and Chi-square tests were used to compare proportions between the same groups of patients.We compared time to MACE within 90 days and time to COPD readmission within 90 days from peak troponin measurement between patients with elevated troponin level and patients with non-elevated levels. Cox proportional hazard regression modelling was utilised to calculate hazard ratios (HRs) and 95% confidence interval (CI) for these comparisons. Three model specifications were implemented for these comparisons: unadjusted, adjusted only for demographic variables (age and gender) and fully adjusted .10 troponin) using statistically significant polynomial terms up to fourth degree.14We log-transformed standardised troponin using base-10 logarithm to consider troponin distribution skewness and to evaluate the association of each 10-fold increase of standardised troponin.Where relationships were non-linear , we have included graphical representations of the relationship and the corresponding tables with estimates for representative troponin values based on Stata commands margins and marginsplot. These visual aids are only utilised to make complex non-linear model-based effects more tangible by computing predicted or expected values for hypothetical or prototypical cases.We estimated the overall predictive performance of this model using Harrell’s C and Gonen and Heller’s K concordance coefficients. In addition, we evaluated the overall predictive performance of Cox regression models that included significant standardised troponin polynomial terms for patients with elevated troponin.10 troponin) using statistically significant polynomial terms up to fourth degree. We also evaluated the overall predictive performance of this model using Area under ROC curve (AUC). As our sample size was relatively small, we estimated Leave-One-Out-Cross-Validation (LOOCV) AUC that has been shown to be a suitable resampling technique for this sample size magnitude.16We investigated the relationship between peak standardised troponin and having at least one MACE event within a year using logistic regression. As with the Cox models, we implemented logarithmic transformation (base-10 logarithm) in our analysis  and Stata/MP 17.0 with statistical significance set to a two-tailed p-value <0.05.Given troponin elevations can be caused by other clinical events, e.g. pulmonary embolism, heart failure, myocarditis, myocardial contusion and sepsis, we repeated the analysis excluding individuals who had any of those conditions in the secondary diagnostic position.There were 2487 patients included in our analysis.Out of 1107 patients with an elevated troponin level, 256 (23.1%) had a MACE event and 101 (9.1%) had a COPD readmission within 90 days from peak troponin measurement. For 1380 patients with a non-elevated troponin measurement, the corresponding numbers of patients were 121 (8.8%) and 102 (7.4%), respectively. Using a Chi-square test, we found that the percentage of patients with elevated troponin who had a MACE event within 90 days from peak troponin measurement (23.1%) was significantly higher compared with the corresponding percentage for patients with non-elevated troponin (8.8%) (p<0.001).Patients with elevated troponin had a higher risk of MACE when compared with patients without elevated troponin; unadjusted HR 2.88 (95% CI 2.32–3.58). Adjusted for demographic variables HR 2.64 (95% CI 2.12–3.30) and full adjustment HR 2.20 (95% CI 1.75–2.77). COPD patients with elevated troponin levels experienced COPD readmissions quicker when compared with patients without elevated troponin; unadjusted HR 1.39 (95% CI 1.06–1.83). This was attenuated on adjusting for confounders; fully adjusted HR 1.37 (95% CI 1.02–1.83).We implemented sensitivity analysis by excluding patients with at least one of the following diagnoses in any secondary position at baseline: pulmonary embolism, heart failure, myocarditis, myocardial contusion and sepsis. Out of 2487 patients, 265 (10.7%) were excluded from our analysis. Our sensitivity analysis sample included 2222 patients.In this sample, patients with elevated troponin had a higher risk of MACE when compared with patients without elevated troponin. The unadjusted HR was 3.07 (95% CI 2.41–3.90). Adjusting for demographic variables, the adjusted HR was 2.84 (95% CI 2.23–3.63). The full adjustment HR was 2.43 (95% CI 1.89–3.13). COPD patients with elevated troponin were more likely to experience COPD readmissions quicker when compared with patients without elevated troponin. The unadjusted HR was 1.47 (95% CI 1.10–1.98). The corresponding fully adjusted HR was 1.47 (95% CI 1.08–2.00).For each 10-fold increase of troponin, the effect increased and then decreased twice, below and above peak troponin threshold  and b. THarrell’s C coefficient (the default option using Stata estat concordance command) was estimated to be equal to 0.73. Gonen and Heller’s K coefficient was not sensitive to the degree of censoring as Harrell’s C coefficient and it was slightly lower (0.68). Both coefficients were comparable to the Area under the ROC curve (AUC) statistic for binary logistic regression models.We explored the relationship between troponin value and time to COPD readmission within 90 days. In this case, we found a significant linear effect for both unadjusted  and adjusted association . Harrell’s C coefficient and Gonen and Heller’s K coefficient were estimated to be equal to 0.60. We also investigated the relationship between troponin value and time to COPD readmission within 90 days for patients with elevated troponin (n = 1107)  and b.FWe investigated the relationship between peak troponin value and having at least one MACE event within a year . For each 10-fold increase of troponin, the effect increased and then decreased twice, below and above peak troponin threshold .Table 3PThe Area under ROC curve for the model was 0.72 (95% CI 0.70–0.74). The AUC estimate is likely to be optimistic10 troponin) using a linear term . In addition, for patients with elevated troponin we investigated the relationship between troponin value and having at least one MACE event within a year . We implemented logarithmic transformation (base-10 logarithm) in our analysis  is derived from a few hundred relatively healthy individuals. However, 1 in 20 hospital patients (in- or out-patients) undergoing a blood test for any reason has a hsTrop above the ULN, even though in the vast majority there is no suspicion of a cardiac event.24These previous findings are consistent with our study and indicate that there is potential clinical value in using hsTrop levels to predict outcome in patients admitted with exacerbation of COPD. However, such risk stratification would be of much greater value if future research could yield a pathway in which detection of elevated troponin then led to precise diagnosis and intervention that altered the subsequent event rate. The next step would be to conduct a trial in which troponin elevation is aggressively investigated in one arm using CTCA and stress MRI to detect potential avenues for interventional management for those detectable underlying conditions.This study had several strengths, including the use of ICD-10 codes to define diseases. However, there are several important limitations in our work. The majority of MACE were due to all-cause mortality, we were not able to explore non-fatal or cardiovascular-specific mortality events. We cannot be sure that those people who had troponin measured at the time of exacerbation really are generalisable to all people hospitalised with a COPD exacerbation. Despite the database being considerably large and cross-regional, there were missing data for many of the variables. We were also not able to explore COPD-specific factors such as disease severity or medications in the analysis. We were also unable to adjust for a history of previous exacerbation episodes, which is a major predictor of further rehospitalisation.An elevated troponin level at the time of COPD exacerbation may be a useful tool for predicting MACE events in patients with COPD. The relationship between degree of troponin elevation and risk of future events is complex and demands further investigation.


This systematic review aims to evaluate the diagnostic accuracy of cerebrospinal fluid (CSF) lipoarabinomannan (LAM) assays in detecting tuberculous meningitis (TBM).A systematic review search was conducted in PubMed and five other databases up to April 2023. Studies that evaluated the diagnostic accuracy of CSF LAM assays were included with either definitive or composite reference standard used as the preferred reference standard. The quality of the included studies was assessed using the QUADAS-2 tool. We performed a bivariate random-effects meta-analysis and calculated the summary diagnostic statistics.Q = 73.82, p < 0.01; I2 = 86.45, 95%CI: 79.64–93.27) and specificity . Regression analysis indicated that the study design (retrospective vs. prospective) was associated with the heterogeneity of pooled sensitivity and specificity .A total of six studies, including a sample size of 999, were included in the final analysis. The pooled sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of CSF LAM for diagnosing TBM were determined to be 0.44 (95% CI: 0.31–0.58), 0.89 (95% CI: 0.81–0.93), and 0.76 (95% CI: 0.73–0.80), respectively. Significant heterogeneity was observed in both sensitivity  should be considered to improve its performance. Tuberculous meningitis (TBM) is a serious disease with a fatality rate as high as half of all cases . A delayMycobacterium tuberculosis. It can account for up to 15% of the total bacterial weight and serves as an immunogenic virulence factor released by metabolically active or degrading bacterial cells during TB infection (Lipoarabinomannan (LAM) is a structurally important 17.5 kD heat-stable glycolipid found in the cell walls of nfection . Currentnfection –10. Addinfection , 11.Thus, recent studies on LAM detection have highlighted its potential diagnostic usefulness for TBM. Testing for LAM in cerebrospinal fluid (CSF) samples may provide significant clinical benefits. However, to date, no systematic review of the current evidence on CSF LAM assays for TBM diagnosis has been conducted. Hence, we reviewed diagnostic studies and analyzed the accuracy of the LAM antigen in CSF samples for the diagnosis of TBM.The literature search was performed on 19 April 2023. Databases, specifically PubMed, Embase, Scopus, Web of Science, CINAHL, and the Cochrane Library, were searched using a defined search strategy outlined in the online Original studies that reported the diagnostic accuracy of CSF LAM assays for TBM were included in the study. Only English literature was included, but time restrictions were not imposed. We excluded duplicates, animal studies, bench studies, case reports (less than 10 cases), chapters, conference abstracts, editorials, comments, and reviews. The eligibility of the study was assessed by two investigators (CYL and ZMM) who independently screened titles and abstracts, which was followed by a full-text review. A third reviewer (GCP) determined eligibility in the event of any discrepancies.The diagnostic criteria for TBM include both definite and clinical diagnoses. The definite TBM diagnosis is made based on histological examination, acid-fast bacilli (AFB) smear, TB-PCR, or culture using central nervous system (CNS) samples. A clinical diagnosis (probable or possible TBM) is made following a composite reference standard (CRS), which outlines symptoms, abnormal CSF features, abnormal CNS radiological evidence, or non-CNS TB evidence. The control subjects were healthy subjects or non-TBM patients. The cutoff value for urinary LAM assays was used to determine the positive/negative events for CSF LAM assays.The included studies were critically appraised by two independent reviewers (CYL and ZMM) for methodological quality in the review using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool . This toData collection was performed independently by two reviewers (Y-LC and M-MZ), and the following variables were collected: first author, publication year, country, sample size, TBM diagnostic criteria, controls, sex, age, HIV status, CD4, LAM assays , and diagnostic performance . Any discrepancy that arose between the reviewers was resolved by the third reviewer (C-PG).I2. A random effect model was used for estimation. Meta-regression analyses were implemented independently for each variable, and the following variables were taken into consideration: study design, definite or CRS TBM, HIV status, CSF collection, unprepared or supernatant CSF, enzyme-linked immunosorbent assay (ELISA), or lateral flow (LF) assay. Publication bias was evaluated using Deeks’ funnel plot asymmetry test. A p-value of less than 0.05 was considered statistically significant.Statistical analysis was performed using Stata software . The pooled sensitivity, specificity, area under the curve (AUC), and corresponding 95% confidence intervals (CIs) were assessed. Heterogeneity was statistically assessed using the Q test and n = 824) were identified using EndNote software and removed from the list. Second, non-English literature (n = 19) and studies without original data (n = 8) were excluded. Two independent reviewers screened the titles and abstracts, and 1,116 records were removed. Finally, 15 full-text studies were assessed for eligibility. Nine studies were excluded because they were comments, replies (n = 3), or conference abstracts (n = 3) and because they featured antibody detection (n = 2) and non-CNS samples (n = 1). Therefore, six studies (999 cases) were included in the final analysis.A total of 1,982 records were retrieved from the five databases. n = 6) were published after 2009 and conducted in African countries, including South Africa (n = 2) (n = 3) (n = 1) (n = 3) prospectively. Only one study had a study period of less than 1 year (n = 1) ( (n = 2) , 15, Uga (n = 3) , 17, 19, (n = 1) . Three ( (n = 1) , 16, 17 n 1 year –17, 19.  (n = 1) –16, and  (n = 1) , 15.I2, was observed in the sensitivity , respectively. The regression analysis revealed that the study design (retrospective vs. prospective) was associated with the heterogeneity of pooled sensitivity and specificity .The pooled sensitivity , left, sTo fully outline the factors associated with heterogeneity, subgroup analyses of study design (retrospective vs. prospective), diagnostic criteria , HIV status, CSF collection (lumbar puncture vs. fourth ventricle), CSF samples (unprepared vs. supernatant CSF), and LAM assay (ELISA vs. LFA) were performed subsequently, and the results are presented in The early diagnosis of TBM is difficult. Until recently, clear criteria for defining TBM have been lacking, and the diagnosis of TBM still largely relies on routine CSF biomarkers such as protein, white blood cell, and glucose levels. The introduction of the CSF LAM assay was revolutionary for TBM diagnosis and may address current issues in TBM diagnosis. Our study demonstrated that the CSF LAM assay had an unsatisfactory performance for TBM diagnosis, with a sensitivity, a specificity, and an AUC of 0.44 (95% CI: 0.31–0.58), 0.89 (95% CI: 0.81–0.93), and 0.76 (95% CI: 0.73–0.80), respectively. Despite a positive result, the CSF LAM assay demonstrated poor sensitivity and required further improvement.LAM may be detected in various bodily fluids during infection as part of the mycobacterial cell wall. Therefore, it can be a promising biomarker for TB-related diseases . CommercCurrently, definite cases of TBM are still difficult to diagnose, and microbiological confirmation is not always achievable. Traditional microbiological examinations, such as AFB smears, nucleic acid amplification (NAA) tests, and the mycobacterial culture of CSF samples, have been evaluated systematically. For example, an AFB smear, while quick, is highly insensitive in most settings . It has via meta-regression analysis, and study design is one of the factors that explain the variance in diagnostic accuracy across studies. This point was also confirmed via subgroup analysis. Moreover, the subgroup analysis also found that variation in sensitivity between studies is associated with CSF collection (lumbar puncture vs. fourth ventricle) and CSF samples (unprepared and supernatant CSF). Prior to the assay, CSF samples drained from the fourth ventricle were centrifuged at 10,000 rpm for 15 min, and the supernatant was used for CSF LAM testing. Although a previous study supported that CSF LAM positivity is associated with a positive HIV status and a low CD4 count  or incorporating it into the Marais scoring system . MoreoveThe original contributions presented in the study are included in the article/M-SW and Y-AZ designed the study and drafted the initial manuscript. Y-LC and M-MZ performed the screening and collected the data. C-PG supervised the data collection process. All authors contributed to the article and approved the submitted version.This project was supported by the Taishan Scholar Project of Shandong Province (NO.tsqn202211358).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.