Immunity from natural infection and vaccination (hybrid) may provide more durable SARS-CoV-2 antibody responses; whether this increases durability of maternally-derived antibody responses in infants is unknown.2 ≥0.9).Participants with prior SARS-CoV-2 infection in pregnancy (anti-nucleocapsid [anti-N] IgG+ on enrollment or prior RT-PCR+ or antigen+) were enrolled between January 2021-August 2022. Blood samples collected in pregnancy, delivery/birth, 0-< 3 and 3-6 months postpartum were tested for anti-S+ IgG by Abbott Architect (positive: ≥50 AU/mL) and neutralizing antibodies  and median gestational age was 31 weeks (IQR 19.1–37.9). At delivery (median 19.7 weeks [IQR 14.3-30.0] from SARS CoV-2 diagnosis), unvaccinated participants and their infants were less likely to have anti-S IgG+  or neutralizing antibodies  than vaccinated (≥1 dose) participants and their infants  . By 6 months of age, the proportion of infants of mothers who remained unvaccinated at birth with anti-S IgG+ and neutralizing antibody declined to 50% and 14%  compared to 100%  among infants with vaccinated mothers .10 2.95 vs. 4.40 AU/ml; neutralization log10 1:2.37 vs. 1:4.00, all p< 0.01) and through 6 months of age  vs. infants with mothers vaccinated prior to delivery.Infants with anti-S IgG+ or neutralizing antibodies born to unvaccinated mothers had lower median antibody levels at birth  pregnant people with prior SARS-CoV-2 infection during pregnancy and B) their infants by maternal vaccination status *†*Among participants and their infants with positive neutralizing antibodies (ND50 heat ≥20 and R2 ≥0.9). †Maternal vaccination status is at time of blood sample collection; for infants refers to maternal vaccination status at time of delivery.SARS-CoV-2 infection alone during pregnancy did not provide persistent antibody responses in infants through 6 months of age. Maternal vaccination provided more durable antibody responses in participants with prior SARS-CoV-2, potentially providing protection to vulnerable infants in the months prior to their own COVID-19 vaccine eligibility.Sylvia M. LaCourse, MD, MPH, Merck: Grant/Research Support Alex L. Greninger, MD, PhD, MS, MPhil, Abbott Diagnostics: central testing|Cepheid: central testing|Hologic Inc: central testing|Janssen Infectious Disease: central testing|Novavax, Inc.: central testing|Pfizer, Inc.: central testing Alisa B. Kachikis, MD, MSc, Merck: Grant/Research Support|Pfizer: Grant/Research Support Janet A. Englund, MD, Ark Biopharma: Advisor/Consultant|AstraZeneca: Advisor/Consultant|AstraZeneca: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Meissa Vaccines: Advisor/Consultant|Merck: Grant/Research Support|Moderna: Advisor/Consultant|Moderna: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Sanofi Pasteur: Advisor/Consultant Alison L. Drake, PhD, MPH, Merck: Grant/Research Support


The optimal fluid management strategy for patients with sepsis remains a topic of debate. This meta-analysis aims to evaluate the impact of restrictive versus liberal fluid regimens on mortality, adverse events, and other clinical outcomes in patients with sepsis. We systematically reviewed 11 randomized controlled trials published between 2008 and 2023, comprising a total of 4,121 participants. The studies assessed 90-day mortality, 30-day mortality, adverse events, hospital length of stay, ICU admission rate, mechanical ventilation, ventilator-free days, ICU-free days, and vasopressor-free days. Quality assessments indicated minimal bias across the studies. The meta-analysis showed no statistically significant difference in 90-day mortality between restrictive and liberal fluid regimens . Similar results were observed for 30-day mortality . Adverse events were comparable between the two groups . Furthermore, there were no significant differences in hospital length of stay  or ICU admission rate  between the restrictive and liberal fluid regimens. Regarding mechanical ventilation and ventilator-free days, no significant distinctions were observed . ICU-free days and vasopressor-free days also showed no significant differences between the two groups . This comprehensive meta-analysis of clinical trials suggests that restrictive and liberal fluid management strategies have comparable outcomes in patients with sepsis, including mortality, adverse events, and various clinical parameters. However, most studies favored restrictive fluid regimen over liberal approach regarding the number of vasopressor-free days, need for mechanical ventilation, adverse events, 30-day mortality, and 90-day mortality in sepsis patients. Sepsis and septic shock remain critical challenges in modern medicine, contributing significantly to morbidity, mortality, and healthcare costs worldwide . Sepsis Despite advances in medical science, the management of sepsis remains a complex puzzle with numerous therapeutic interventions under scrutiny . Among tHistorically, the liberal approach to fluid resuscitation advocated for the administration of generous amounts of intravenous fluids, aiming to rapidly correct hypovolemia and improve cardiac output . This apIn contrast, the restrictive fluid resuscitation approach emerged from concerns regarding the potential harms associated with fluid overload . This apMethodologyThis meta-analysis was conducted in accordance with the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions . The preSearch Strategy and Data SourcesFor this systemic review and meta-analysis, we performed a comprehensive search in various databases including PubMed, CINAHL Ultimate, Web of Science, and Scopus to identify relevant studies that evaluated liberal versus restrictive fluid regimen in sepsis. The search was carried out by using a combination of various keywords including “hemodynamic support,” or “fluid resuscitation,” or “liberal versus restrictive fluid strategy,” and “sepsis,” or “septic shock.” Furthermore, related terms and alternatives to these keywords were also used for the systemic search. The details of keywords and different Boolean operators used in search are mentioned in the Appendix. To identify more studies related to the topic, a search was also undertaken in Google Scholar. The inclusion criteria of the studies comprised the following: (1) compared the liberal or restrictive fluid regimen in sepsis and septic shock patients, (2) reported clinical outcomes in patients, (3) studies were published in English language. Only patients with sepsis or septic shock were considered for this meta-analysis. Patients who underwent liberal or restrictive fluid regimen but were not suffering from sepsis or septic shock were excluded.Data ExtractionAfter searching various databases, the results were exported to an Endnote file. All the retrieved files from the database search were transferred to Endnote, the reference manager. Then, all duplicates were removed in Endnote. The remaining results were uploaded to Rayyan, a web-based software for conducting systemic reviews . At thisRisk-of-Bias AssessmentThe risk-of-bias assessment tool in Review Manager (RevMan) version 5.3 software, developed by The Cochrane Collaboration in Oxford, UK, in 2014, was used by two authors to independently evaluate the risk of bias. The study's evaluation encompassed several key factors: the presence of proper sequence generation to minimize selection bias, the concealment of allocation to prevent selection bias, the prevention of knowledge regarding assigned interventions during the study to minimize performance bias, the appropriate blinding of participants and personnel to minimize performance bias, the blinding of outcome assessors to minimize detection bias, the adequate handling of incomplete outcome data to minimize attrition bias, the absence of selective outcome reporting in the study's report to minimize reporting bias, and the absence of other potential issues that could introduce bias and jeopardize the study's validity. All issues were effectively settled by the third author.Outcome MeasuresThe primary outcome was 90-day mortality in participants. The secondary outcomes included adverse events, hospital length of stay, ICU admission rate, ICU-free days, mechanical ventilation, ventilator-free days, and vasopressor-free days.Data AnalysisA random-effects meta-analysis was conducted using the DerSimonian and Laird method . This apResultsIncluded StudiesA total of 8,462 articles were generated from the databases . Furthermore, 106 articles were also identified from Google Scholar. After removal of duplicates, 7,873 remained articles, which were further excluded based on the title and abstract of the articles, leaving 1,023 articles for further analysis. Finally, after exclusion of all non-relevant articles by independent reviewers, only 11 articles were included for final analysis.Flow DiagramFigure Characteristics of Included StudiesA total of 11 RCTs were included in the meta-analysis including a total of 4,121 participants    Figure . Data frAdverse Events2 value for the analysis was 37%, which indicates moderate heterogeneity . The Iy Figure .Hospital Length of Stay and ICU Admission Rate2 value for the analysis was 97%, which indicates considerable heterogeneity . The IOther Outcome Measures2 value for the analysis was 0%, which indicates no heterogeneity . The Iy Figure . Number y Figure . Number y Figure .Discussion2=0%) enhances the robustness of this conclusion.Sepsis is a complex and life-threatening condition that requires careful management, and intravenous fluid therapy is a crucial component of its treatment . This me2=37%), suggesting some variability in the reported adverse events across studies. The absence of a significant difference in adverse events between the two approaches is reassuring, as it indicates that a restrictive strategy does not compromise patient safety. Given the potential risks associated with fluid overload, the adoption of a more conservative fluid strategy appears justifiable.It is noteworthy that the results regarding 30-day mortality were also consistent with those of 90-day mortality. This suggests that the short-term effects of fluid management strategies do not significantly impact patient survival. These findings challenge the conventional belief that a more liberal fluid approach might improve outcomes by ensuring adequate tissue perfusion. Another critical aspect of fluid management is the occurrence of adverse events. Our analysis revealed that adverse events were comparable between restrictive and liberal fluid regimens. This finding aligns with the observations of several studies, including those by Andrews et al. , Macdona2=97%). This variability in reported hospital lengths of stay across studies may reflect differences in patient populations, treatment protocols, or healthcare systems. Similarly, ICU admission rates did not significantly differ between the two fluid management strategies, with moderate heterogeneity in this outcome (I2=46%). These findings suggest that fluid strategy alone does not strongly influence the duration of hospitalization or the likelihood of ICU admission in sepsis patients. It is important to note that hospital length of stay and ICU admission rate are influenced by a multitude of factors beyond fluid management, such as comorbidities, severity of illness, and local healthcare practices. Therefore, while our analysis did not identify a significant impact of fluid strategy on these outcomes, clinicians should consider the broader clinical context when making decisions regarding fluid resuscitation.Hospital length of stay and ICU admission rate are essential components of the healthcare burden associated with sepsis. Our analysis found no significant difference in hospital length of stay between restrictive and liberal fluid regimens. However, there was substantial heterogeneity in this outcome (I2=0%). Similarly, the number of ventilator-free days did not significantly differ between the two strategies, but there was considerable heterogeneity (I2=84%). However, the p-value for this parameter was close to statistical significance (P=0.09). Most studies included in the analysis showed that the restrictive fluid group had more ventilator-free days compared to the liberal fluid approach [2=50% and I2=60%, respectively). These findings suggest that restrictive fluid strategies do not compromise patients' respiratory or hemodynamic status when compared to more liberal approaches. The heterogeneity observed in some of these outcomes may be attributed to variations in patient populations, clinical practices, and study methodologies across the included studies. It underscores the need for caution in interpreting these results and highlights the importance of considering individual patient characteristics when determining the appropriate fluid strategy.Additional outcome measures included mechanical ventilation, ventilator-free days, and ICU-free days. Our analysis did not find a significant difference in mechanical ventilation between restrictive and liberal fluid regimens, and there was no heterogeneity in this outcome (Iapproach -22. ICU-LimitationsAlthough the present meta-analysis provides significant evidence regarding the liberal versus restrictive fluid regimen, there are several limitations. First, the analysis demonstrated a lack of consistent statistical significance across certain outcomes. For instance, the observed reduction in mortality among patients receiving restrictive fluid did not reach statistical significance. This could be attributed to the relatively small effect sizes, the variation in study methodologies, or the limitations of the available data. The clinical implications of these findings might be less straightforward than implied by the reported ORs. Second, despite efforts to minimize bias, the risk of publication bias cannot be entirely ruled out. Additionally, the follow-up periods of the included studies varied, which may influence the detection of longer-term outcomes. Finally, the results of this meta-analysis should be considered in conjunction with the clinical context and the condition of patients.In conclusion, this meta-analysis of 11 studies involving more than 4,000 sepsis patients suggests that restrictive and liberal fluid regimens yield comparable outcomes in terms of mortality, adverse events, hospital length of stay, ICU admission rate, and other relevant measures. However, most studies included in the analysis favored a restrictive approach of fluid management. Clinicians should carefully consider the individual patient's clinical status, comorbidities, and specific clinical context when making decisions regarding fluid resuscitation. Further research, including large-scale RCTs, is needed to refine our understanding of optimal fluid management strategies in sepsis and to identify subpopulations that may benefit from specific approaches.


The presence of eosinophilic inclusion bodies in the breast is very rare and fewer than 20 cases were described in the literature. Herein we report the first case of borderline phyllodes tumour associated with this kind of cells. To the best of our knowledge, this is also the first time that a molecular sequencing is made targeting the stroma cells with inclusion bodies.A 33-yr-old woman presented a large mass in the right breast. Imaging techniques by mammogram and ultrasonographic examination were performed. After multidisciplinary approach, a breast conserving surgery has been decided. Microscopic analysis, immunohistochemical stains and molecular tests were performed on the lesion. The proposed diagnosis is borderline phyllodes tumour with eosinophilic inclusion bodies.Inclusion bodies are typically found in the infantile digital fibromatosis. Finding them in extradigital fibromatosis is rare. Their signification is still unclear. Some studies suggest a disturbance in the metabolism of proliferating myofibroblasts.The presence of inclusion bodies in breast tumour do not seem to have a prognosis impact. It might be interesting to perform others molecular tests on lesions with eosinophilic inclusion bodies to discover potential mutations. •Presence of eosinophilic inclusion bodies in the breast is very rare.•First case of borderline phyllodes tumour associated with this kind of cells.•First molecular sequencing targeting the stroma cells with inclusion bodies. It is a2Here we report a case of a 33-yr-old woman who presented a large mass in the right breast. Her surgical history includes a breast conserving surgery (BCS) in Cambodia in 2019 for a benign lesion without more precise details. She is not using contraception. In her family history, her mother's cousin had breast cancer at the age of 50. The breast examination revealed a large mass with a bluish spot on the skin in the upper external quadrant of the right breast .Fig. 1ClThere was an enlargement of the areola and a retraction of the nipple. The examination of the left breast was unremarkable. Bilateral mammogram was performed and showed dense breasts. In the right breast, we found a mass measuring 8 cm and occupying the entire upper quadrant. The lesion was relatively well delimited. Rare microcalcifications were found but were not suspicious. In the left breast, there were scattered microcalcifications but no suspicious focus. Ultrasound of the right breast showed a vascularised mass measuring 15 × 4.7 cm .Microbiopsy was performed. Histologically, biopsy cores showed a biphasic tumour with a fibroepithelial proliferation and small glandular structures. The fibrous compartment was fibrous, focally myxoid and contained a few irregularly arranged fibroblasts. The proliferation index evaluated by Ki67  was estimated at 10 %. The lesion was classified as B3 in the Nottingham system .After multidisciplinary approach, a BCS has been decided. The patient had no post-operative complications.Macroscopically, the resected lesion measured 11 × 10 × 7 cm, was relatively well delimited and appeared as a multinodular, gray-white, homogeneous mass on the cut surface .Fig. 2ThMicroscopically, the tumour was well delimited. It was composed of fibroepithelial proliferation with an increased but not diffuse stromal cellularity. The stromal cells showed foci of cells with moderate to severe atypia. The atypia were characterized by mild to moderate nuclear pleomorphism. Mitotic count was 4 to 10 mitoses based on the assessment of 10 high-power fields (40×). No stromal overgrowth was present. Neither heterologous malignant element nor necrosis was observed. At a high-power view, the proliferating spindled stromal cells contained round eosinophilic intracytoplasmic inclusion bodies , Fig. 4.The lesion was excised with a microscopic free margins. The distance between the tumour and the closest margin was evaluated at 2 mm.The diagnosis of borderline phyllodes tumour with eosinophilic inclusion bodies was made.Next-Generation Sequencing (NGS) targeting stromal cells with inclusions was done. The library construction was performed using two custom Ampliseq panel targeting in 58 genes . Sequenc3Intracytoplasmic eosinophilic inclusion is a pathognomonic feature in infantile digital fibromatosis (IDF) that was first described by Reye in 1965 , in leioAll the 5 cases were diagnosed as benign phyllodes tumour . Our casThe inclusion bodies in our case were positive for SMA and vimentin. In different published cases, the spindled stromal cells are positive for SMA, desmin or vimentin ,8,11,12.Some studies performed electronic microscopy on the inclusion bodies ,8,10. ThThe presence of inclusion bodies in breast tumour do not seem to have a prognosis impact. In the literature only one case reported a patient's follow-up. She underwent a surgery for a fibroepithelial tumour of the breast with inclusion bodies and there was no recurrence 5 years after surgery .In the future, it might be interesting to perform molecular tests on lesions with eosinophilic inclusion bodies to discover potential mutations.Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Rho kinase (ROCK) inhibitors have gained significant attention as emerging novel treatment options in the field of ophthalmology in recent years. The evidence supporting their efficacy in glaucoma and corneal pathology includes both in vitro and clinical studies. Among the available options, ripasudil and netarsudil have emerged as the leading ROCK inhibitors, and some countries have approved these therapeutic options as treatments for glaucoma. Various dosing regimens have been studied, including monotherapy and combination therapy, especially for patients with secondary glaucoma who are already on multiple medications. Another rising application of ROCK inhibitors includes their use as an adjunct in surgical procedures such as Descemetorhexis Without Endothelial Keratoplasty (DWEK), Descemet Stripping Only (DSO) to accelerate visual recovery, glaucoma surgeries to reduce scarring process and allow better intraocular pressure (IOP) control, or after complicated anterior segment surgery to treat corneal oedema. This article provides a comprehensive overview of the existing literature in the field, offering recommendations for prescribing ROCK inhibitors and also discussing patient selection, drug efficacy, and possible adverse effects. Addressing glaucoma and corneal disease can present substantial difficulties, often necessitating medical therapy as the primary mode of treatment. Polypharmacy is prevalent among patients with glaucoma; half of patients with newly diagnosed glaucoma initially require more than one medication to control IOP, and a further 30% require add-on treatment after one year . Further®), netarsudil (Rhopressa®), and fasudil. Ripasudil has been used in the treatment of ocular hypertension and glaucoma in Japan since September 2014 and has been recently approved for commercial use in the United Kingdom. Netarsudil has been used for glaucoma treatment in the United States since late 2017 and more recently has been approved in Europe in November 2021. Fasudil was originally approved in Japan in 1995 for the treatment of cerebral vasospasms caused by subarachnoid hemorrhage [Three commercially available ROCK inhibitors currently exist: ripasudil  and ROCK2 (ROKα), which may have slightly different effects depending on the isoform ,12. The In glaucoma, endothelin-1 (ET-1)-induced ROCK signaling plays a role in regulating retinal blood flow and vasomotor tone, resulting in the promotion of vasoconstriction . AdminisAdditionally, ROCK inhibitors can alter the trabecular meshwork cell shapes improving the control of intraocular pressure (IOP). In the cornea, ROCK inhibition has been shown to induce metabolic changes in endothelial cells, such as increased mitochondrial metabolic activity and upregulation of oxidative phosphorylation through the AMPK pathway , which wp = 0.669). In Phase 1 and Phase 2 trials, ripasudil has demonstrated a significant reduction in IOP when used as monotherapy in patients with open-angle glaucoma (POAG) or ocular hypertension (OHT) ,20. In pAdditionally, various case series and observational studies ,25,26,27Ripasudil has also been studied as an adjunct to surgical glaucoma procedures such as trabeculectomy . Mimura To date, no studies have compared ripasudil as a monotherapy to first-line glaucoma drugs such as prostaglandins and beta-blockers. However, ripasudil is demonstrating promising results in reducing the IOP when used as a monotherapy or in combination with other agents or procedures. More extensive studies are needed to establish its efficacy as a standalone treatment and further explore its potential in different types of glaucoma.p < 0.001) [p < 0.01) and a higher average at 3 months , 6 months , and 12 months  as compared to the DWEK-only group. Further, peripheral ECD did not significantly change from baseline to 12 months post-operatively  in subjects treated with netarsudil, whereas the observation group had a statistically significant reduction in ECD . Overall, studies have shown patients treated with DWEK/DSO require a longer time to achieve a visual outcome similar to those treated with Descemet’s Membrane Endothelial Keratoplasty (DMEK) [Descemet’s membrane removal in procedures like Descemetorhexis Without Endothelial Keratoplasty (DWEK) or Descemet’s Stripping Only (DSO) for Fuchs Endothelial Corneal Dystrophy (FECD) has been shown to improve corneal clarity and vision and to concurrently reduced the need for corneal graft procedures . In this< 0.001) . A follo< 0.001) . Macsai < 0.001) . Eighteey (DMEK) . Due to y (DMEK) , and mayy (DMEK) . In bothy (DMEK) . RipasudThe adverse effects of ripasudil have been well studied . The mosTanihara et al. later followed up POAG and OHT patients over 12 months and then 24 months ,48 and dp < 0.01). Further, IOP changes from baseline were significantly higher in the eye treated with netarsudil compared to the fellow eye . Interestingly, the EVP decreased in the drug group compared to baseline  and increased in the vehicle group , with a between-treatment difference of −12.6% (p < 0.001 vs. vehicle). These results suggest that netarsudil could influence the distal portion of the conventional outflow pathway beyond Schlemm’s canal. Netarsudil has been shown to lower the IOP by improving the outflow facility and reducing the episcleral venous pressure (EVP) . In thisp < 0.01). Although netarsudil did not meet the criterion for noninferiority to latanoprost, authors observed that netarsudil 0.02% had similar efficacy in patients with a baseline IOP ≤ 26 mmHg [One of the first clinical studies by Bacharach et al. compared netarsudil to latanoprost in patients with POAG or OHT. In this double-masked, parallel comparison study, patients were randomized to receive netarsudil 0.01%, netarsudil 0.02%, or latanoprost 0.005% for 28 days. Subjects with POAG or OHT were included. At days 14 and 28 of treatment, all three groups showed a reduction in IOP as compared to unmedicated baseline  . The stuNetarsudil has not been extensively studied as an adjunct therapy in DWEK/DSO, with only three case reports available. However, these studies showed improved endothelial cell density and resolution of corneal edema in patients treated with netarsudil ,67,68. TThe ROCKET  and MERCMERCURY-2 demonstrated that the rate of serious adverse events in the fixed-dose combination group was lower than in either netarsudil or latanoprost monotherapy; none of which were considered to be treatment-related. It is interesting to note that blepharitis is not a common adverse effect of netarsudil in contrast to ripasudil, and the reasons for this remain unclear. As with ripasudil, various studies reported the incidence of honeycomb corneal oedema caused by netarsudil ,71,72. HROCK inhibitors are showing promising results, but their clinical use is still limited. In future, there is the possibility that more specific molecules will be introduced to selectively target the trabecular meshwork, the corneal endothelium, and the optic nerve. More selective ROCK inhibitors could potentially increase their clinical efficacy and reduce the side effects. Further, new studies are focusing on direct genetic modulation of ROCK signaling to clarify the mechanism of aqueous outflow, as well as to find novel glaucoma gene therapies .In cornea, new less-invasive surgical techniques such as DSAEK and DMEK have allowed the treatment of endothelial diseases with better clinical outcomes as compared to PK. These new procedures have the advantage over PK to offer a faster visual recovery, a better refractive outcome, and a lower rejection risk. However, they still require a learning curve, especially for DMEK surgeries, and they are associated with graft rejection risk. In this scenario, the use of ROCK inhibitors has been proposed for tissue engineering therapies . In partAlthough ROCK inhibitors represent an innovative category of topical medications for lowering IOP, it is crucial to conduct more clinical trials and post-marketing studies to establish optimal treatment protocols for glaucoma patients.Lastly, ROCK inhibitors could also serve in modulating wound healing response following glaucoma filtration surgery. The wound healing process depends on various mechanisms such as cell proliferation and migration, necessitating constant and active changes in the cell’s cytoskeleton.In vitro studies revealed the role of Rho-ROCK expression in Tenon fibroblasts (TF), which are central to ocular wound healing. Specifically, they have demonstrated that the use of ROCK inhibitors suppresses wound healing activities of TF in vitro. Exposure to ROCK inhibitors, significantly inhibits fibroblast proliferation, adhesion, and contraction ,78. HonjROCK inhibitors such as ripasudil and netarsudil have shown promise as safe, emerging treatment options across different sub-specialties of ophthalmology. In glaucoma, they have shown efficacy as monotherapy and open new avenues for treatment for patients who have inadequately controlled IOP on maximum medical therapy. By acting on the dysfunctional trabecular meshwork, these agents address the underlying cause of glaucoma, as opposed to other agents like beta-blockers that only reduce aqueous humor secretion. In both glaucoma and corneas, ROCK inhibitors have also proven to be an effective adjunct to surgery, such as trabeculectomy or Descemetorhexis Without Endothelial Keratoplasty. Combination with other pre-existing medications such as brimonidine has shown to have further additive effects compared to monotherapy. For now, it remains unclear whether ripasudil or netarsudil is superior. Only one study so far (J-ROCKET) has compared ripasudil versus netarsudil and concluded that netarsudil had superior IOP-lowering effects with fewer side effects; however, further studies would be needed to confirm this observation as the number of cases of reticular epithelial oedema appears to be higher with netarsudil use.


Funding statement. “This research received fundings from: Telethon Italy under grant agreement, grant number GGP16191 (CF), Telethon-UILDM, grant number GUP19012 (CF and GP) and by Ente Cassa di Risparmio di Firenze, grant number 2018.0987 (CF). This research received fundings from: Telethon Italy under grant agreement, grant number GGP16191 (CF), Telethon-UILDM, grant number GUP19012 (CF and GP) and by Ente Cassa di Risparmio di Firenze, grant number 2018.0987 (CF). We also thank MIUR Italy . We also thank MIUR Italy ”.In the published article, there was an error in the Funding statement appears below.The correct


Systemic concentrations of chemokine CCL2, an agonist at chemokine receptors CCR2/3/5, have been associated with hemodynamic instability after traumatic-hemorrhagic shock. We reported previously that the CCR2 antagonist INCB3284 prevents cardiovascular collapse and reduces fluid requirements after 30min of hemorrhagic shock (HS), whereas the CCR5 antagonist Maraviroc was ineffective. The effects of CCR3 blockade after HS are unknown and information on the therapeutic potential of INCB3284 after longer periods of HS and in HS models in the absence of fluid resuscitation (FR) is lacking. The aims of the present study were to assess the effects of CCR3 blockade with SB328437 and to further define the therapeutic efficacy of INCB3284. In series 1–3, Sprague-Dawley rats were hemorrhaged to a mean arterial blood pressure (MAP) of 30mmHg, followed by FR to MAP of 60mmHg or systolic blood pressure of 90mmHg. Series 1: 30min HS and FR until t = 90min. SB328437 at t = 30min dose-dependently reduced fluid requirements by >60%. Series 2: 60min HS and FR until t = 300min. INCB3284 and SB328437 at t = 60min reduced fluid requirements by more than 65% (p<0.05 vs. vehicle) and 25% (p>0.05 vs. vehicle), respectively, until t = 220min. Thereafter, all animals developed a steep increase in fluid requirements. Median survival time was 290min with SB328437 and >300min after vehicle and INCB3284 treatment (p<0.05). Series 3: HS/FR as in series 2. INCB3284 at t = 60min and t = 200min reduced fluid requirements by 75% until t = 300min (p<0.05 vs. vehicle). Mortality was 70% with vehicle and zero with INCB3284 treatment (p<0.05). Series 4: INCB3284 and SB328437 did not affect survival time in a lethal HS model without FR. Our findings further support the assumption that blockade of the major CCL2 receptor CCR2 is a promising approach to improve FR after HS and document that the dosing of INCB3284 can be optimized. Traumatic injury remains a leading cause of death worldwide and hemorrhagic shock is the major cause of potentially preventable death after injuries . While iVarious chemokines have been identified as key drivers that initiate and amplify the very early inflammatory response to traumatic-hemorrhagic shock and fluid resuscitation, and systemic concentrations of chemokine (C-C motif) ligand 2 (CCL2), an agonist at chemokine (C-C motif) receptor 2 (CCR2), CCR3 and CCR5, have been associated with hypotension and survival in trauma patients .Recently, we reported that blockade of CCR2 with INCB3284 during fluid resuscitation after 30 min of hemorrhagic shock prevents from hemodynamic decompensation and reduces fluid requirements in controlled hemorrhagic shock rat models . In thesINCB3284 and SB328437 were purchased from Tocris, Bio-Techne Corporation .All procedures were performed in accordance with the National Institutes of Health Guidelines for Use of Laboratory Animals and were approved by the Institutional Animal Care and Use Committee of the University of South Florida (IS00008139). The IACUC specifically reviewed and approved the anticipated mortality in the study design. Male Sprague-Dawley rats (300–405 g) were purchased from Envigo . The hemorrhagic shock models were performed as described previously , 12–14. Series 1: To assess the effects of SB328437 treatment after hemorrhagic shock and fluid resuscitation, and to be able to compare findings with our previous study on the effects of CCR2 and CCR5 inhibition, rats were hemorrhaged to a mean arterial blood pressure (MAP) target of 30 mmHg for a period of 30 minutes. At the end of the hemorrhagic shock period (t = 30 min), animals were injected with either vehicle (1 mL lactated Ringer’s solution (LR), n = 5), 0.25 μmol/kg SB328437 (n = 3) or 1.1 μmol/kg SB328437 (n = 3) in 1 mL LR, followed by fluid resuscitation with 1 mL bolus injections of LR to maintain a systolic blood pressure of 90 mm Hg or an MAP of 60 mm Hg until t = 90 min, as we described [escribed . To avoiSeries 2: Rats were hemorrhaged to a MAP target of 30 mmHg for a period of 60 min, followed by fluid resuscitation until t = 300 min as in Series 1. At the end of the hemorrhagic shock period (t = 60 min), animals were injected with 1 mL of normal saline (NS) (n = 6), 5 μmol/kg (n = 6) INCB3284 in 1mL NS or 1.1 μmol/kg SB 328437 (n = 6) in 1 mL NS at t = 60 min. At t = 0 min, 60 min, 120 min, 180 min, 240 min and 300 min, blood samples (0.3 ml) were obtained and used for arterial blood gas analyses and measurements of laboratory parameters. At t = 300 min, surviving animals were euthanized .Series 3: Rats were hemorrhaged to a MAP of less than or equal to 30 mmHg for a period of 60 min, followed by fluid resuscitation until t = 300 min as in Series 2. At the end of the hemorrhagic shock period (t = 60 min) and at t = 200 min, animals were injected with 1 mL of NS (n = 7) or with 5 μmol/kg INCB3284 in 1mL NS (n = 7). At t = 0 min, 60 min, 120 min, 180 min, 240 min and 300 min, blood samples (0.3 ml) were obtained and used for arterial blood gas analyses and measurements of laboratory parameters. At t = 300 min, surviving animals were euthanized .Series 4: The purpose of these experiments was to determine whether treatment with the chemokine receptor antagonists increases shock tolerance, blood pressure and survival time without additional fluid resuscitation. As such, death is an intentional endpoint. Earlier endpoints are unable to answer these questions and alternatives are not available. Rats were hemorrhaged 40% total blood volume (TBV) within 10 min. At t = 15 min, animals were injected with vehicle , 5 μmol/kg INCB3284 in 1mL NS (n = 5) or 1.1 μmol/kg SB 328437 in 1 mL NS (n = 5). Animals were then hemorrhaged 2% TBV every 5 minutes until death.Arterial blood gases, electrolytes, creatinine, lactate, hematocrit and hemoglobin were analyzed in series 2 and 3 in 60 min intervals using the Element point of care veterinary blood gas, electrolyte and critical care analyzer .Data are presented as mean ± standard error (SE). Data were analyzed by 2-way analysis of variance (ANOVA) with Dunnett’s multiple comparisons tests. Survival curves were analyzed using the log-rank test. Proportions were compared with the Fisher’s exact test. All data analyses were calculated with the GraphPad Prism program (GraphPad Software Version 9.3.1 (350), December 7, 2021). A two-tailed p<0.05 was considered significant.To assess whether blockade of CCR3 affects hemodynamics and fluid requirements after hemorrhagic shock, we employed the same animal model that we previously utilized to characterize effects of the CCR2 and CCR5 antagonists INCB3284 and Maraviroc, respectively . Due to To assess therapeutic efficacy of SB328437 and INCB3284 in a more severe model of hemorrhagic shock and during clinically more relevant periods of fluid resuscitation, we treated animals with vehicle, 1.1 μmol/kg SB328437 or 5 μmol/kg INCB3284 after 60 min of hemorrhagic shock and performed fluid resuscitation until t = 300 min. As in series 1, there were no differences among groups at baseline and the hemorrhage volumes to achieve the target MAP of 30 mmHg were indistinguishable . MAPs duThe half-life of INCB3284 has been reported to be 168 min in rats . In combGiven that fluid requirements and other physiological parameters of vehicle treated animals were comparable in series 2 and 3, our observations suggest that the lack of mortality after vehicle treatment in series 2 was a chance observation caused by a small sample size, which argues against a survival disadvantage with single dose SB328437 treatment. The combined mortality in vehicle-treated animals from series 2 and 3  was 38.5% and median survival time remains undefined, which is not significantly different from zero mortality that we observed with double dosing of INCB3284. This indicates that larger cohort sizes are required to clarify whether double dosing of INCB3284 provides a relevant survival benefit. Nevertheless, our finding that double dosing of INCB3284 prevented the steep increase in fluid requirements that was detectable in all vehicle treated animals in series 2 and 3 and in animals after single dose treatment with INCB3284 in series 2, demonstrates that dosing of INCB3284 can be optimized to increase its fluid sparing effects during resuscitation from hemorrhagic shock and suggests that treatment of animals with an optimized dosing regimen of INCB3284 also prevents, or at least delays, hemodynamic decompensation in a more severe model of hemorrhagic shock.To assess whether INCB3284 or SB328437 may increase tolerance to severe hemorrhagic shock, we utilized a model designed to mimic continuous bleeding in the absence of fluid resuscitation. As shown in Taken together, our observations suggest that blockade of CCR3 during resuscitation results in fluid sparing effects that depend on the duration of the hemorrhagic shock period and are lost when the duration of the shock period is extended. Moreover, our findings on the effects of INCB3284 further support the assumption that blockade of CCR2 is a promising pharmacological approach to reduce fluid requirements and to prevent or delay hemodynamic decompensation even after prolonged periods of hemorrhagic shock. Our observations document that the therapeutic efficacy of the CCR2 antagonist INCB3284 can be optimized and prolonged by an improved dosing regimen. This study is limited in scope by a relatively small sample size in each series of experiments and by a maximal resuscitation period of 4 hours. As such, it remains to be determined whether any of the drugs affect survival after longer time periods and whether the fluid sparing effects of INCB3284 can be maintained over extended time periods by subsequent redosing or by continuous drug infusion. Although we did not observe adverse effects of INCB3284 and SB328437, we performed only a limited physiological assessment with measurements of basic laboratory parameters. In addition, our study was designed as an efficacy testing to evaluate fluid sparing effects during resuscitation from hemorrhagic shock. As such, this study does not provide information on physiological and molecular mechanisms by which CCR3 and CCR2 blockade affect resuscitation fluid requirements and on the possible side effect profile of the drugs. Based on previous observations indicating that CCL2 and CCR2 are involved in the regulation of vascular function, however, it appears likely that direct effects of CCR2 blockade on endothelial or vascular smooth muscle function mediate the observed effects –18. We b


Oral sulopenem is a bilayer tablet composed of sulopenem etzadroxil and probenecid, an organic anion transport inhibitor that delays renal excretion of sulopenem. The goal of the studies described herein was to characterize the pharmacokinetics-pharmacodynamics of sulopenem against a diverse panel of Enterobacterales using a dynamic in vitro infection model. Bacteria (1 x 106 CFU/mL) were exposed to sulopenem concentrations that mimicked human free-drug plasma concentration-time profiles  following oral drug administration. For the dose-fractionation studies, a single challenge isolate (Escherichia coli NCTC 13441 MIC = 0.125 mg/L) was exposed to five different total daily exposures, fractionated equally into doses administered every 4, 8, or 12 hours . In the dose-ranging studies, 10 Enterobacterales clinical isolates  were exposed to a range of sulopenem q8h doses representing free-drug (f) %T >MIC values ranging from 0 to 98.8%. Relationships between change in log10 CFU/mL from baseline at 24 hr and each of fCmax:MIC ratio, f%T > MIC, and fAUC:MIC ratio were fit using Hill-type models.A series of 24-hour dose-fractionation and dose-ranging studies were completed using the one-compartment 2 of 0.90 measuring the tightness of data around the fitted function, the relationship between sulopenem f%T > MIC and change in bacterial burden best described the activity of sulopenem using the dose-fractionation study data . The median sulopenem f%T > MIC values associated with achieving net bacterial stasis, and 1- and 2-log10 CFU/mL reductions from baseline were 40.9, 50.2, and 62.6% based on the data from the dose-ranging studies .As evidenced by the highest rf%T > MIC was the PK-PD index that best described sulopenem activity. The f%T > MIC targets for efficacy based on these data will be useful to support sulopenem dose selection for patients with uUTI.The results of these analyses demonstrated that Brian D. VanScoy, B.S., Adagio Therapeutics, Inc.: Grant/Research Support|Albany Medical Center: Grant/Research Support|Amplyx Pharmaceuticals, Inc.: Grant/Research Support|AN2 Therapeutics: Grant/Research Support|Antabio SAS: Grant/Research Support|Arcutis Biotherapeutics, Inc.: Grant/Research Support|B. Braun Medical Inc.: Grant/Research Support|Basilea Pharmaceutica: Grant/Research Support|BioFire Diagnostics LLC: Grant/Research Support|Boston Pharmaceuticals: Grant/Research Support|Cidara Therapeutics Inc.: Grant/Research Support|Cipla USA: Grant/Research Support|Crestone Inc.: Grant/Research Support|CXC: Grant/Research Support|Debiopharm International SA: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Genentech: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Hoffmann-La Roche: Grant/Research Support|ICPD: Employee|Inotrem: Grant/Research Support|Insmed Inc.: Grant/Research Support|Iterum Therapeutics Limited: Grant/Research Support|Kaizen Bioscience, Co.: Grant/Research Support|KBP Biosciences USA: Grant/Research Support|Matinas Biopharma: Grant/Research Support|Meiji Seika Pharma Co., Ltd.: Grant/Research Support|Melinta Therapeutics: Grant/Research Support|Menarini Ricerche S.p.A.: Grant/Research Support|Mutabilis: Grant/Research Support|Nabriva Therapeutics AG: Grant/Research Support|Paratek Pharmaceuticals, Inc.: Grant/Research Support|Qpex Biopharma: Grant/Research Support|Sfunga Therapeutics: Grant/Research Support|Spero Therapeutics: Grant/Research Support|Suzhou Sinovent Pharmaceuticals Co.: Grant/Research Support|Theravance: Grant/Research Support|tranScrip Partners: Grant/Research Support|University of Wisconsin: Grant/Research Support|Utility Therapeutics: Grant/Research Support|ValanBio Therapeutics Inc.: Grant/Research Support|VenatoRx: Grant/Research Support Sean Jones, B.S., Adagio Therapeutics, Inc.: Grant/Research Support|Albany Medical Center: Grant/Research Support|Amplyx Pharmaceuticals, Inc.: Grant/Research Support|AN2 Therapeutics: Grant/Research Support|Antabio SAS: Grant/Research Support|Arcutis Biotherapeutics, Inc.: Grant/Research Support|B. Braun Medical Inc.: Grant/Research Support|Basilea Pharmaceutica: Grant/Research Support|BioFire Diagnostics LLC: Grant/Research Support|Boston Pharmaceuticals: Grant/Research Support|Cidara Therapeutics Inc.: Grant/Research Support|Cipla USA: Grant/Research Support|Crestone Inc.: Grant/Research Support|CXC: Grant/Research Support|Debiopharm International SA: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Genentech: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Hoffmann-La Roche: Grant/Research Support|ICPD: Employee|Inotrem: Grant/Research Support|Insmed Inc.: Grant/Research Support|Iterum Therapeutics Limited: Grant/Research Support|Kaizen Bioscience, Co.: Grant/Research Support|KBP Biosciences USA: Grant/Research Support|Matinas Biopharma: Grant/Research Support|Meiji Seika Pharma Co., Ltd.: Grant/Research Support|Melinta Therapeutics: Grant/Research Support|Menarini Ricerche S.p.A.: Grant/Research Support|Mutabilis: Grant/Research Support|Nabriva Therapeutics AG: Grant/Research Support|Paratek Pharmaceuticals, Inc.: Grant/Research Support|Qpex Biopharma: Grant/Research Support|Sfunga Therapeutics: Grant/Research Support|Spero Therapeutics: Grant/Research Support|Suzhou Sinovent Pharmaceuticals Co.: Grant/Research Support|Theravance: Grant/Research Support|tranScrip Partners: Grant/Research Support|University of Wisconsin: Grant/Research Support|Utility Therapeutics: Grant/Research Support|ValanBio Therapeutics Inc.: Grant/Research Support|VenatoRx: Grant/Research Support Haley Conde, B.S., Adagio Therapeutics, Inc.: Grant/Research Support|Albany Medical Center: Grant/Research Support|Amplyx Pharmaceuticals, Inc.: Grant/Research Support|AN2 Therapeutics: Grant/Research Support|Antabio SAS: Grant/Research Support|Arcutis Biotherapeutics, Inc.: Grant/Research Support|B. Braun Medical Inc.: Grant/Research Support|Basilea Pharmaceutica: Grant/Research Support|BioFire Diagnostics LLC: Grant/Research Support|Boston Pharmaceuticals: Grant/Research Support|Cidara Therapeutics Inc.: Grant/Research Support|Cipla USA: Grant/Research Support|Crestone Inc.: Grant/Research Support|CXC: Grant/Research Support|Debiopharm International SA: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Genentech: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Hoffmann-La Roche: Grant/Research Support|ICPD: Employee|Inotrem: Grant/Research Support|Insmed Inc.: Grant/Research Support|Iterum Therapeutics Limited: Grant/Research Support|Kaizen Bioscience, Co.: Grant/Research Support|KBP Biosciences USA: Grant/Research Support|Matinas Biopharma: Grant/Research Support|Meiji Seika Pharma Co., Ltd.: Grant/Research Support|Melinta Therapeutics: Grant/Research Support|Menarini Ricerche S.p.A.: Grant/Research Support|Mutabilis: Grant/Research Support|Nabriva Therapeutics AG: Grant/Research Support|Paratek Pharmaceuticals, Inc.: Grant/Research Support|Qpex Biopharma: Grant/Research Support|Sfunga Therapeutics: Grant/Research Support|Spero Therapeutics: Grant/Research Support|Suzhou Sinovent Pharmaceuticals Co.: Grant/Research Support|Theravance: Grant/Research Support|tranScrip Partners: Grant/Research Support|University of Wisconsin: Grant/Research Support|Utility Therapeutics: Grant/Research Support|ValanBio Therapeutics Inc.: Grant/Research Support|VenatoRx: Grant/Research Support Catherine E. Vincent, Ph.D., Adagio Therapeutics, Inc.: Grant/Research Support|Albany Medical Center: Grant/Research Support|Amplyx Pharmaceuticals, Inc.: Grant/Research Support|AN2 Therapeutics: Grant/Research Support|Antabio SAS: Grant/Research Support|Arcutis Biotherapeutics, Inc.: Grant/Research Support|B. Braun Medical Inc.: Grant/Research Support|Basilea Pharmaceutica: Grant/Research Support|BioFire Diagnostics LLC: Grant/Research Support|Boston Pharmaceuticals: Grant/Research Support|Cidara Therapeutics Inc.: Grant/Research Support|Cipla USA: Grant/Research Support|Crestone Inc.: Grant/Research Support|CXC: Grant/Research Support|Debiopharm International SA: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Genentech: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Hoffmann-La Roche: Grant/Research Support|ICPD: Employee|Inotrem: Grant/Research Support|Insmed Inc.: Grant/Research Support|Iterum Therapeutics Limited: Grant/Research Support|Kaizen Bioscience, Co.: Grant/Research Support|KBP Biosciences USA: Grant/Research Support|Matinas Biopharma: Grant/Research Support|Meiji Seika Pharma Co., Ltd.: Grant/Research Support|Melinta Therapeutics: Grant/Research Support|Menarini Ricerche S.p.A.: Grant/Research Support|Mutabilis: Grant/Research Support|Nabriva Therapeutics AG: Grant/Research Support|Paratek Pharmaceuticals, Inc.: Grant/Research Support|Qpex Biopharma: Grant/Research Support|Sfunga Therapeutics: Grant/Research Support|Spero Therapeutics: Grant/Research Support|Suzhou Sinovent Pharmaceuticals Co.: Grant/Research Support|Theravance: Grant/Research Support|tranScrip Partners: Grant/Research Support|University of Wisconsin: Grant/Research Support|Utility Therapeutics: Grant/Research Support|ValanBio Therapeutics Inc.: Grant/Research Support|VenatoRx: Grant/Research Support Sujata M. Bhavnani, PharmD; MS; FIDSA, Adagio Therapeutics, Inc.: Grant/Research Support|Albany Medical Center: Grant/Research Support|Amplyx Pharmaceuticals, Inc.: Grant/Research Support|AN2 Therapeutics: Grant/Research Support|Antabio SAS: Grant/Research Support|Arcutis Biotherapeutics, Inc.: Grant/Research Support|B. Braun Medical Inc.: Grant/Research Support|Basilea Pharmaceutica: Grant/Research Support|BioFire Diagnostics LLC: Grant/Research Support|Boston Pharmaceuticals: Grant/Research Support|Cidara Therapeutics Inc.: Grant/Research Support|Cipla USA: Grant/Research Support|Crestone Inc.: Grant/Research Support|CXC: Grant/Research Support|Debiopharm International SA: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Genentech: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Hoffmann-La Roche: Grant/Research Support|ICPD: Ownership Interest|Inotrem: Grant/Research Support|Insmed Inc.: Grant/Research Support|Iterum Therapeutics Limited: Grant/Research Support|Kaizen Bioscience, Co.: Grant/Research Support|KBP Biosciences USA: Grant/Research Support|Matinas Biopharma: Grant/Research Support|Meiji Seika Pharma Co., Ltd.: Grant/Research Support|Melinta Therapeutics: Grant/Research Support|Menarini Ricerche S.p.A.: Grant/Research Support|Mutabilis: Grant/Research Support|Nabriva Therapeutics AG: Grant/Research Support|Paratek Pharmaceuticals, Inc.: Grant/Research Support|Qpex Biopharma: Grant/Research Support|Sfunga Therapeutics: Grant/Research Support|Spero Therapeutics: Grant/Research Support|Suzhou Sinovent Pharmaceuticals Co.: Grant/Research Support|Theravance: Grant/Research Support|tranScrip Partners: Grant/Research Support|University of Wisconsin: Grant/Research Support|Utility Therapeutics: Grant/Research Support|ValanBio Therapeutics Inc.: Grant/Research Support|VenatoRx: Grant/Research Support Christopher M. Rubino, PharmD, Adagio Therapeutics, Inc.: Grant/Research Support|Albany Medical Center: Grant/Research Support|Amplyx Pharmaceuticals, Inc.: Grant/Research Support|AN2 Therapeutics: Grant/Research Support|Antabio SAS: Grant/Research Support|Arcutis Biotherapeutics, Inc.: Grant/Research Support|B. Braun Medical Inc.: Grant/Research Support|Basilea Pharmaceutica: Grant/Research Support|BioFire Diagnostics LLC: Grant/Research Support|Boston Pharmaceuticals: Grant/Research Support|Cidara Therapeutics Inc.: Grant/Research Support|Cipla USA: Grant/Research Support|Crestone Inc.: Grant/Research Support|CXC: Grant/Research Support|Debiopharm International SA: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Genentech: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Hoffmann-La Roche: Grant/Research Support|ICPD: Ownership Interest|Inotrem: Grant/Research Support|Insmed Inc.: Grant/Research Support|Iterum Therapeutics Limited: Grant/Research Support|Kaizen Bioscience, Co.: Grant/Research Support|KBP Biosciences USA: Grant/Research Support|Matinas Biopharma: Grant/Research Support|Meiji Seika Pharma Co., Ltd.: Grant/Research Support|Melinta Therapeutics: Grant/Research Support|Menarini Ricerche S.p.A.: Grant/Research Support|Mutabilis: Grant/Research Support|Nabriva Therapeutics AG: Grant/Research Support|Paratek Pharmaceuticals, Inc.: Grant/Research Support|Qpex Biopharma: Grant/Research Support|Sfunga Therapeutics: Grant/Research Support|Spero Therapeutics: Grant/Research Support|Suzhou Sinovent Pharmaceuticals Co.: Grant/Research Support|Theravance: Grant/Research Support|tranScrip Partners: Grant/Research Support|University of Wisconsin: Grant/Research Support|Utility Therapeutics: Grant/Research Support|ValanBio Therapeutics Inc.: Grant/Research Support|VenatoRx: Grant/Research Support Steven I. Aronin, MD, Iterum Therapeutics Limited: Stocks/Bonds Sailaja Puttagunta, MD, Iterum Therapeutics Limited: Full time employee|Iterum Therapeutics Limited: Stocks/Bonds Paul G. Ambrose, PharmD; MS; FIDSA, Adagio Therapeutics, Inc.: Grant/Research Support|Albany Medical Center: Grant/Research Support|Amplyx Pharmaceuticals, Inc.: Grant/Research Support|AN2 Therapeutics: Grant/Research Support|Antabio SAS: Grant/Research Support|Arcutis Biotherapeutics, Inc.: Grant/Research Support|B. Braun Medical Inc.: Grant/Research Support|Basilea Pharmaceutica: Grant/Research Support|BioFire Diagnostics LLC: Grant/Research Support|Boston Pharmaceuticals: Grant/Research Support|Cidara Therapeutics Inc.: Grant/Research Support|Cipla USA: Grant/Research Support|Crestone Inc.: Grant/Research Support|CXC: Grant/Research Support|Debiopharm International SA: Grant/Research Support|Entasis Therapeutics: Grant/Research Support|Genentech: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Hoffmann-La Roche: Grant/Research Support|ICPD: Ownership Interest|Inotrem: Grant/Research Support|Insmed Inc.: Grant/Research Support|Iterum Therapeutics Limited: Grant/Research Support|Kaizen Bioscience, Co.: Grant/Research Support|KBP Biosciences USA: Grant/Research Support|Matinas Biopharma: Grant/Research Support|Meiji Seika Pharma Co., Ltd.: Grant/Research Support|Melinta Therapeutics: Grant/Research Support|Menarini Ricerche S.p.A.: Grant/Research Support|Mutabilis: Grant/Research Support|Nabriva Therapeutics AG: Grant/Research Support|Paratek Pharmaceuticals, Inc.: Grant/Research Support|Qpex Biopharma: Grant/Research Support|Sfunga Therapeutics: Grant/Research Support|Spero Therapeutics: Grant/Research Support|Suzhou Sinovent Pharmaceuticals Co.: Grant/Research Support|Theravance: Grant/Research Support|tranScrip Partners: Grant/Research Support|University of Wisconsin: Grant/Research Support|Utility Therapeutics: Grant/Research Support|ValanBio Therapeutics Inc.: Grant/Research Support|VenatoRx: Grant/Research Support


Adult T cell leukemia/lymphoma (ATLL) is a CD4-positive peripheral T cell lymphoma caused by human T cell lymphotropic virus type 1 (HTLV-1). Although ATLL is quite difficult to be cured, up-regulation of cellular immunity such as HTLV-1 Tax-specific cytotoxic T lymphocytes (CTLs) has been proved to be important to obtain long-term survival. At present, no efficacious method to activate ATLL-specific cellular immunity is available. This study aimed to investigate whether live attenuated varicella-zoster virus (VZV) vaccination to ATLL can activate HTLV-1 Tax-specific cellular immune response. A total of 3 indolent- and 3 aggressive-type ATLL patients were enrolled. All aggressive-type patients had the VZV vaccination after completing anti-ATLL treatment including mogamulizumab, which is a monoclonal antibody for C–C chemokine receptor 4 antigen, plus combination chemotherapy, whereas all indolent-type patients had the VZV vaccination without any antitumor treatment. Cellular immune responses including Tax-specific CTLs were analyzed at several time points of pre- and post-VZV vaccination. After the VZV vaccination, a moderate increase in 1 of 3 indolent-type patients and obvious increase in all 3 aggressive-type patients in Tax-specific CTLs percentage were observed. The increase in the cell-mediated immunity against VZV was observed in all indolent- and aggressive-type patients after VZV vaccination. To conclude, VZV vaccination to aggressive-type ATLL patients after mogamulizumab plus chemotherapy led to the up-regulation of HTLV-1 Tax-specific CTLs without any adverse event. Suppression of regulatory T lymphocytes by mogamulizumab may have contributed to increase tumor immunity in aggressive-type ATLL patients. Japan Registry of Clinical Trials number, jRCTs051180107. As a result, 3 indolent- and 3 aggressive-type ATLL patients were enrolled. Written informed consent was obtained from all participants.The study was approved by Japanese Red Cross Nagasaki Genbaku Hospital Ethical Review Board , the BIKEN institutional Ethical Review Board , and Shiga University of Medical Science Clinical Research Review Board  and was conducted in accordance with the Declaration of Helsinki (registered number: UMIN000021750 and jRCTs051180107).2 at day 1), cyclophosphamide (750 mg/m2 at day 1), vincristine , and prednisolone (40 mg/m2 at days 1–5). The VCAP-AMP-VECP (mLSG15) regimen consists of the following 3 regimens: VCAP  at day 1; AMP  at day 8; and VECP . The EPOCH regimen consists of continuous intravenous infusions at days 1–4 of etoposide (50 mg/m2), vincristine (0.4 mg/m2), and doxorubicin (10 mg/m2), with bolus doses of cyclophosphamide (750 mg/m2 at day 6) and oral prednisolone (60 mg/m2 at days 1–6).All 3 aggressive-type ATLL patients were treated with MOGA plus chemotherapy, whereas indolent-type ATLL patients were not treated with any agents. CHOP, VCAP-AMP-VECP, and EPOCH therapies were used in this study as the chemotherapy regimens , 8, 22. Aggressive-1 patient was treated with 6 cycles of MOGA plus CHOP. Aggressive-2 patient was treated with 3 cycles of MOGA plus mLSG15 and then 2 cycles of MOGA plus EPOCH. The Aggressive-3 patient was treated with 3 cycles of MOGA plus mLSG15, 1 cycle of MOGA plus EPOCH, and then 1 cycle of MOGA monotherapy. The regimen alteration from mLSG15 to EPOCH was made owing to bone marrow suppression by mLSG15 in Aggressive-2 and Aggressive-3 patients. CR was confirmed before VZV vaccination in all aggressive-type patients.Before VZV vaccination, anti-VZV antibody titration by EIA and IAHA for humoral immunity and lymphocyte blastoid transformation (LBT) test by PHA and Con-A stimulation for cellular immunity were conducted in all patients. All of these laboratory tests were performed by SRL corporation .Live attenuated VZV vaccine , developed in 1974 , 15, is Vb gene repertoire of total CD8-positive T lymphocytes by flow cytometry according to the manufacturer’s instructions. These analyses were conducted at several time points of pre-VZV vaccination and 2 weeks, 45–60 days, 3 months, 6 months, and 12 months after completing the VZV vaccination.Each patient’s HLA was determined using peripheral blood mononuclear cells (PBMNCs) by SRL corporation . PBMNCs were drawn from each patient and HLA-A*02:01-restricted and HLA-A*24:02-restricted TaxCTLs were analyzed without any stimulation. HLA-A*02:01-restricted Tax tetramer  and HLA-A*24:02-restricted Tax tetramer  were used for detecting Tax-specific CTLs. The percentages of CD4- and CD8-positive T lymphocytes in PBMNCs and percentages of abnormal lymphocytes in white blood cells were measured. The sIL-2R and HTLV-1 provirus load were measured by SRL corporation . The Beta Mark TCR Vb repertoire kit  was used to analyze TCR 2 for 9 days. For responder measurement, the cells were stained with the following antibody cocktail: anti-CD3-BV785 , anti-CD4-PC7 , annti-CD45RA-BV421 , anti-CD45RO-PE , and anti-CD197 (CCR7)-APC , and measured on the flow cytometer. VZV-specific CD4+ memory T cells were defined as the CD3+CD4highCD45RA−RO+ lymphocytes. VZV-specific CD8+ effector T cells were defined as the CD3+CD4−CD45RA+RO+ lymphocytes, and VZV-specific CD8+ memory T cells were defined as the CD3+CD4−CD45RA−RO+ lymphocytes.Skin test for VZV antigen and whole-blood stimulation with VZV antigen (ex vivo) to measure VZV-specific CMI were conducted. Varicella virus antigen  was used for skin test. Briefly, 0.1 mL of varicella virus antigen was injected intradermally into the forearm. The erythematous change was judged 48 h after injection. The longest diameter was used for the test results. Ex vivo VZV-specific CMI was performed at BIKEN according to a previously described method . BrieflyThe patients’ characteristics are presented in Table Changes in TaxCTLs are presented in Fig. Before the first VZV vaccination, the values of TaxCTLs were 0 or very low 0.02%) in all aggressive-type patients. After the vaccination, the CTLs were clearly induced and maintained until the end of the study in Aggressive-1. Significant elevation of the CTLs (0.17%) was observed after approximately 3 months after the first vaccination in Aggressive-2. The value of the CTLs continued to increase up to 0.83% even after second vaccination and then gradually decreased but were maintained at a high level (0.26%) at the end of the study. A similar pattern in Aggressive-2 was observed in Aggressive-3. The value of the CTLs definitely increased (0.24%) after approximately 6 months after the first vaccination. After second vaccination, the CTLs were maintained with high levels until the end of the study  before the first VZV vaccination and elevated at a high level (94.1%) after the second vaccination. Then, the values decreased but were maintained with high levels (more than 44%) until the end of the study. However, the value of VZV-specific CD8+ memory T cells was high (70.3%) before the first vaccination. Contrary to the CD8+ effector T cells, the CD8+ memory T cells decreased to 1.8% after the first vaccination and gradually elevated and were maintained with high levels as much as the CD8+ effector T cells until the end of the study. In Aggressive-3 patients, VZV-specific CD8+ memory T cells rapidly elevated to a high level (59.7%) after the first VZV vaccination, and the value further elevated up to 86.7% after the second vaccination and the CD8+ T cells were maintained with high level (71.4%) at the final examination. Both VZV-specific CD4+ and CD8+ T cells were not measured at the 12-month time point after the second VZV vaccination because of the limitation of supported period form March 27, 2018, to December 31, 2019, by BIKEN .The percentages of both effector and memory VZV-specific CD8nts Fig. a. Data oNo intolerable adverse event was observed after the VZV vaccination. All indolent-type patients did not transform into aggressive-type ATLL until the end of the study, and all aggressive-type patients had maintained CR throughout the study.Before MOGA was used to treat ATLL, we had experienced some aggressive-type ATLL patients who had herpes infection after obtaining CR and long-term survival . TaxCTLsThe reasons why treatment naïve indolent-type patients were included in this study are as follows: (1) The prognosis of indolent-type patients was not necessarily good. The mean overall survival was only 2.9 years without plateau . (2) No Vb1 in Indolent-1 and Vb2 in Indolent-2, were activated after the VZV vaccination  The disease status was controlled by immunochemotherapy including MOGA only in aggressive-type patients. Therefore, the aggressive-type patients remained to be in a more sensitive condition to VZV vaccination than in the indolent-type patients. (2) Reversal of the CD4-to-CD8 ratio had been already obtained with immunochemotherapy at the study entry only in all aggressive-type patients Fig. d. The inAn attempt using Tax peptide-pulsed dendritic cell vaccine for previously treated ATLL patients has been recently reported . This thEven if TaxCTLs are activated and amplified by VZV vaccination, an important issue is whether these CTLs have sufficient killing ability against ATLL tumor cells. It has been reported that Tax is substantially expressed at sites where ATLL cells are actively proliferating, but in quiescent conditions, such as in PB, Tax expression is extremely low and cannot be identified by flow cytometry, but can only be detected by reverse transcription polymerase chain reaction (RT-PCR) . HoweverMore than 90% of adults have been infected by VZV and are at risk of herpes zoster by the reactivation of latent VZV . It was The live attenuated VZV vaccination after MOGA plus chemotherapy was safely conducted and led to definite up-regulation of TaxCTLs in all aggressive-type ATLL patients. This immune intensification may play a role in combination with immunochemotherapy and may exert to inhibit relapse of ATLL. Although only 1 of 3 indolent-type patients exhibited a moderate elevation of TaxCTLs, a few memory CTL clones were recognized by TCR repertoire assays in other 2 indolent-type patients. The VZV vaccination after MOGA treatment, leading to a decreased number of regulatory T lymphocytes, may become a possible treatment option for indolent-type ATLL via up-regulation of TaxCTLs.


Formation damage is a well-known problem that occurs during the exploration and production phases of the upstream sector of the oil and gas industry. This study aimed to develop a new drilling mud formulation by utilizing eco-friendly bio-polymers, specifically Carboxymethyl Cellulose (CMC), along with nanostructured materials and a common surfactant, sodium dodecyl sulfate (SDS). The rheological properties of the drilling fluid and the impact of additives on its properties were investigated at the micromodel scale, using a flow rate of 20 mL/h. The polymer concentration and nano clay concentration were set at two levels: 0.5 wt% and 1 wt%, respectively, while the surfactant content was varied at three levels: 0.1 wt%, 0.4 wt%, and 0.8 wt%. The results of the interfacial tension (IFT) analysis demonstrated a significant decrease in the interfacial tension between oil and water with the increasing concentration of SDS. Furthermore, following the API standard, the rheological behavior of the drilling fluid, including the gel strength and thixotropic properties of the mud, was evaluated with respect to temperature changes, as this is crucial for ensuring the inherent rheological stability of the mud. The rheological analysis indicated that the viscosity of the mud formulation with nanoparticles experienced a reduction of up to 10 times with increasing shear rate, while other formulations exhibited a decline of 100 times. Notably, the rheological properties of the Agar specimen improved at 150 °F due to its complete solubility in water, whereas other formulations exhibited a greater drop in viscosity at this temperature. As the temperature increased, drilling fluid containing nanostructured materials exhibited higher viscosity. This damage can be minimized by using appropriate drilling fluids. Different types of drilling fluids, including oil-based drilling mud (OBDM), water-based drilling mud (WBDM), gas-based drilling mud (GBDM), and their respective additives, are used in combination with suitable clay additives2. This system provides wellbore stability, low torque and drag, excellent fluid loss control and filter cake quality, appropriate rheological properties for hole cleaning, and temperature stability4. Shale formations tend to swell when infiltrated by water-based drilling fluids (WBDF), leading to instability of the well wall. To prevent swelling, OBDM is often preferred since there is no interaction between oil and shale. However, in order to address environmental concerns, water-based muds (WBM) can also be utilized. Thus, drilling fluids play a crucial role in the oil and gas industry6.The choice of the base drilling fluid significantly influences its behavior during drilling operations. OBDM is widely recognized as the superior system due to its lubricating properties9. These drilling fluid functions are achieved through the use of complex chemistry based on additives. Additives are used to enhance the properties of drilling fluids, such as density, rheology, fluid loss, alkalinity, salt content, solid content, oil–water ratio, sand content, electrical stability, and other relevant properties. The density of the drilling fluid is particularly important, as excessive increases can lead to formation failure11. From Rheological properties, including apparent viscosity (AP), plastic viscosity (PV), and yield point (YP), are crucial characteristics during drilling operations13. Among the various rheological properties, gel strength (GS) is defined as the mud’s ability to keep mud particles suspended15. The strength property of the mud plays a key role in drilling horizontal and multi-branch wells.Drilling fluids serve numerous functions in drilling operations, including well cleaning, formation pressure control, cuttings suspension, sealing permeable formations, wellbore stability, reduction of formation damage, cooling, lubrication, support for the bit and drilling assembly, hydraulic energy transfer to tools and bit, ensuring adequate formation evaluation, corrosion inhibition, environmental impact reduction, and simplifying cementing and completion drilling mud19. The investigations result showed that nanoparticles can be used as suitable additives to improve drilling fluid properties22. The unique mechanical, hydrodynamic, thermal, electrical, chemical properties, and interaction potential of nanoparticles make them an excellent choice for drilling fluid applications24.Loss of the gelatinous property can cause suspended particles in the drilling fluid to settle, leading to accumulation around the drill bit and sticking in the drill string. In recent years, there have been advancements in nanomaterials technologies, and researchers have explored their application in the petroleum industry25 observed that the addition of Fe2O3 nanoparticles with a particle size ranging from 3 to 30 nm in WBDM at a concentration of 5 wt% of nanoparticles improves the rheology of the drilling fluid. Barry et al.26 used Fe2O3-clay hybrid nanoparticles with sizes of 3 and 30 nm in WBM containing 5 wt% bentonite. They observed that the addition of these nanoparticles enhances the rheological performance of the drilling fluid. Wang et al.27 employed nanoparticles with sizes of 10–20 nm in WBDF with 4 wt% bentonite, and concluded that an optimal concentration range between 0.05 and 0.5% by weight leads to improved rheology, filtration properties, and thermal properties of the drilling fluid. Javeri et al.28 utilized SiO2 nanoparticles with a particle size of 50 nm at concentrations of 5 wt% in WBDF. They found that these additives reduce the thickness of the mud cake. Cheraghian et al.29 investigated the use of nano silica in 5% by weight of WBDF and observed its effect on the rheology of the drilling mud. Agarwal et al.30 studied the use of nano clay and nano silica in high-pressure high-temperature (HPHT) invert emulsion-based drilling fluids and their impact on the rheology of the drilling mud. Abdo and Haneef31 employed nano clay with a particle size between 10 and 20 nm in WBDF with bentonite and discovered that the addition of nano clay controls viscosity under high temperature and pressure conditions. Cheraghian29 also concluded that the addition of nano clay has a positive effect on the rheology and filtration properties of WBDF.Jung et al.32 successfully synthesized a polymer-nanocomposite (TiO2/PAM) for use in the WBDF system. Their results demonstrated that the nanocomposite improved rheological properties, as well as the volume of fluid loss and thickness of mud cake. Aftab et al.33 synthesized and characterized a ZnO-Acrylamide composite, which modified the chemical and thermal properties of drilling fluids. The composite exhibited modifications in filtrate loss, lubricity, yield point, and gel strength, making it a suitable additive for modifying shale swelling. Huang et al.34 investigated the effects of a nanocomposite of SiO2/acrylic resin with a core–shell structure on the rheological characteristics and thermal properties of WBDM. They found that drilling fluids with acrylic/SiO2 nanoparticles increased plugging efficiency and reduced fluid invasion.Sadeghalvaad and Sabbaghi35 used a new drilling fluid with clay nanoparticles to improve thermal conductivity. They concluded that the presence of nano clay in the drilling fluid enhances thermal stability. William et al.36 evaluated the use of CuO and ZnO nanoparticles in 0.4 wt% XG in WBDF to improve thermal properties under high-pressure/high-temperature (HP/HT) conditions. Wang et al.37 focused on the mechanical performance of drilling fluids designed with silica nanoparticles for use in natural gas hydrate exploration. They observed that the use of hydrophilic silica nanoparticles in drilling fluids resulted in 10% less hydrate formation compared to ultrapure water.In another study, Khani et al.20 conducted a study on the effect of zinc titanate nanoparticles on the rheological and filtration properties of WBDF. They discovered that the use of nanoparticles in WBM improved rheological properties, and the addition of electro spun ZnTiO at a concentration of 0.3 w/v% reduced fluid loss by almost 30%. Kafashi et al.23 conducted a study on the rheological properties and the possibility of nano -bentonites nanoproducts to meet the required drilling mud properties. According to the results obtained from flow properties tests for the mixture, it indicated that the mixture was not adequate to be a suitable drilling fluid. In another study, Kakashi et al.24 investigated nanoclay absorbents and additives’ effects on modification of rheological properties of drilling fluids in porous media using glass micromodel. Their results showed that 75 wt% of nanoclay suspension and polyanionic cellulose (PAC) could successfully improve the rheological properties. Later, Alkalbani et al.38 evaluated the use of SiO2 nanoparticles in WBM to improve the rheological properties of drilling fluid in deep reservoirs. Their results indicated that the silica nanoparticles improved the rheological properties and produced greater viscosity and yield point by more than 50%. Recently, Mikhienkova et al.39 evaluated the use of SiO2 nanoparticles in OBM to enhance the rheological properties of drilling fluid. They found that the addition of SiO2 nanoparticles resulted in a reduction of filtration losses in oil-based drilling fluids by 50–70%. Additionally, the inclusion of these nanoparticles significantly increased the colloidal stability of oil-based drilling fluids.Perveeen et al.The presented work proposes a novel approach to formulating drilling fluid by utilizing a combination of carboxymethyl cellulose (CMC), eco-friendly Agar polymer, nanostructure material, and typical surfactants. Subsequently, the rheological properties of the drilling fluid and the impact of additives are investigated using the micromodel scale to achieve rheological stability. The innovation of this study lies in the utilization of biocompatible agar polymer in drilling mud and the exploration of agar polymer compounds combined with nano clay and CMC to effectively control the thickness of the mud cake. CMC, which serves as a base polymer in general drilling mud formulations, is employed in this study. Furthermore, the addition of nanoclay to the drilling mud formulation and its injection into a glass micromodel enables the precise measurement and reporting of the mud cake’s exact quantity. Furthermore, the introduction of nanoclay and biocompatible agar polymer into the formulation allows the measurement and reporting of the flower cake amount for the first time in a glass micromodel. The rheological behavior of the polymer nanocomposite and the quantities of key indicators are examined and presented. One of the advantages of employing nanoclay over other nanoparticle structures is its cost-effectiveness, performance, and enhanced compatibility with bentonite. Additionally, agar, being a bio-ecological polymer indigenous to Iran, offers substantial added value compared to other polymers.In this work, all materials used were commercial grades obtained from a petrochemical company. Bentonite with a particle size of 200 mesh and Montmorillonite Cloisite 30B with a surface spacing of 1–5 nm were purchased from the National Iranian Oil Company. The properties of the oil and sodium dodecyl sulfate (SDS) are presented in Tables Carboxymethylcellulose sodium salt with a medium molecular weight was obtained from PRS Panreac Química SAU (Barcelona), and Agar bacteriological dehydrated, suitable for laboratory applications, was provided by Quelab/UK. Agar is insoluble in cold water but exhibits significant swelling properties. It has the ability to absorb water up to 20 times its own weight. Agar is soluble in water at 80 °C and can form a stable gel at concentrations below 0.5% by weight.Due to limitations in the number of experiments, the experimental procedures were conducted using the D-Optimal method proposed by Minitab software. Four factors were considered: flow rate, polymer concentration, surfactant content, and nano clay concentration. The penetration of drilling fluid into the micromodel was recorded six times. The experiments were classified to assess the penetration of drilling fluid into the micromodel. The following parameters were studied: a flow rate of 20 mL/h for the micromodel, polymer and nano clay concentrations at two levels (0.5% and 1% by weight), and surfactant content at three levels .The drilling fluid was prepared following API standards. The procedure involved weighing 10.5 mg of bentonite and adding it to 350 mL of water. The mixture was stirred using a WiseStir overhead stirrer at 25 °C and a stirrer speed of 250 rpm for 2 h. The mixing process was then conducted in an ultrasonic bath, specifically utilizing the Elma Ultrasonic S80H from the USA. A base frequency of 40 kHz was employed, and the process was repeated three times, with each iteration lasting 15 min. The objective of this approach was to enhance the stability of the suspension. After achieving homogeneity, the mixing process was stopped and the temperature was controlled. The rheological properties of the drilling fluid were determined using an MCR300 rheometer at ambient temperature. The interfacial tension (IFT) between oil–water systems, in terms of SDS content in the aqueous solution, was measured using the pendant drop method. Finally, the drilling fluid was injected into the micromodel, and the behavior of the two-phase fluid in the porous media was observed using an optical microscope. It is important to note that all experiments on the drilling fluid formulation followed the same procedure.The rheological behavior of the drilling fluid was measured using an MCR300 rheometer from Anton Paar, Graz, Austria. The experiments followed the rheological test procedure for drilling fluids. The required time to reach a steady state was investigated at ambient temperature. Subsequently, the fluid loss was measured using a filter press low-pressure low-temperature (LPLT) instrument. A pressure of 100 psi was applied, and the amount of filtrate discharged in 30 min was measured. The water-bentonite suspension (base mud) was injected into the micromodel, and the penetration of fluid into the porous media was measured by continuously taking pictures. The thickness of the mud cake was assessed under a microscope at a flow rate of 1 mL/h after 50 min of injection. The same experimental method was employed for all drilling fluid formulations. It should be mentioned that all experiments were conducted three times and the average values were reported. The uncertainty in IFT, particle size, and viscosity were ± 3%, 7%, and 5%, respectively.40.A glass micromodel consists of a flow network etched onto the surface of a glass plate. There are two main categories of patterns: geometric network patterns and rock-look-alike patterns. In this study, a geometric network pattern representing a porous media was prepared using computer software, specifically Corel Draw. The porous media model was designed with real dimensions, including the size of pore throats and pores, using Corel Draw software and applied to the glass surface41. The addition of materials to the formulation depends on their swelling properties, which lead to changes in viscosity. Particle size analysis was conducted using both the simultaneous gravity and centrifuge methods, with a centrifuge speed of 500 RPM. The average diameter of bentonite particles in stable and unstable suspensions was found to be 8.34 µm and 4.72 µm, respectively. The increase in average particle diameter from a stable to an unstable state in the prepared suspension demonstrates the swelling behavior of bentonite.The particle size was measured using an SA-CP3 particle size analyzer from Shimadzu, Kyoto, Japan. Figure Regarding Agar, the prepared suspension is insoluble at ambient temperature but swells twenty times in water at this temperature. The mesh size of Agar in the solid phase is 150 µm. Therefore, 1% by weight of Agar was added to 100 mL of water to determine the extent of its swelling. Two scenarios were studied to evaluate the increase in average diameter in the mixed and unmixed conditions Fig. . The ave42. Figure The interfacial tension (IFT) between the oil–water system was determined by calculating it using the pendant drop methodThe addition of surfactant significantly decreases the interfacial tension, facilitating the movement of oil and water in porous media. This leads to an expansion of the invaded zone, as depicted in Fig. In the glass micromodel, where mineral clay is absent, the water-blocking phenomenon and the consequent reduction in absolute permeability, which are typically addressed by using surfactants, do not occur. Therefore, the application of surfactant in this context could have adverse effects, leading to an increase in the invaded zone. Figure 43.The rheological behavior of the drilling fluid was analyzed using an Anton Paar MCR 300 rheometer . Various rheological measurements, including the determination of gel strength, flow curve analysis, and assessment of fluid stability, were performed at ambient temperature. The objective of these rheological measurements was to identify the optimal drilling mud formulation by considering factors such as gel strength and the modification of thixotropic properties of the drilling fluid−1 at ambient temperature. Figure 44.The time stability of the drilling fluid was assessed by plotting the viscosity against time at various shear rates ranging from 0.01 to 100 sHowever, the base mud, which lacks the polymer additives that improve fluid properties, also shows a decreasing trend in viscosity. On the other hand, drilling muds containing Carboxymethyl Cellulose or Agar demonstrate better stability with increasing time at different shear rates. The drilling fluid that exhibits the highest stability at different time intervals consists of 1% wt of Agar, 1% wt of Carboxymethyl Cellulose, and 1% wt of Nano clay. The diagram clearly demonstrates the increased stability of the A1C1 + Nano 1% drilling fluid over time.Figure The behavior of the drilling fluid containing Agar at the lowest and highest shear rates is similar to that of the base fluid at 120 °F. While the fluid containing Carboxymethyl Cellulose has the highest viscosity at the lowest shear rate, its viscosity drop is greater than that of the A1C1 drilling fluid as the shear rate increases at 120 °F.However, the addition of Agar helps reduce the drop in viscosity. In the case of the A1C1 + Nano 1% wt drilling fluid, the viscosity drop is the lowest compared to other fluids as the shear rate increases. Therefore, the stability of the A1C1 + Nano 1% wt drilling fluid is higher than that of all other fluids in terms of shear rate at 120 °F. It is noteworthy that for other formulations, the viscosity drop is more significant at 150 °F compared to 120 °F. The viscosity drop in formulations containing nanoparticles at 150 °F is 6–8 times higher compared to that at 120 °F. At low shear rates, the nano clay acts as a lubricant, facilitating the movement of bentonite particles. However, at high shear rates, the nano clay forms a structure, leading to a drop in viscosity.Furthermore, it is mentioned that the rheological properties of the Agar specimen alone were improved at 150 °F due to its complete solubility in water. However, in other formulations, a higher drop in viscosity is observed at this temperature. The presence of nanoparticles in the formulation causes a more significant viscosity drop at 150 °F compared to 120 °F, approximately 6–8 times higher.At low shear rates, the presence of nano clay in the drilling fluid acts as a lubricant, promoting easy movement of the bentonite particles. This lubricating effect helps maintain the viscosity of the fluid at lower shear rates, allowing for better fluid flow and stability.However, as the shear rate increases, the nano clay particles start to form a structure within the fluid. This structure formation leads to a drop in viscosity at high shear rates. The interactions between the nano clay particles and the surrounding fluid matrix result in a reduction in the resistance to flow, causing the viscosity of the fluid to decrease.This behavior is commonly observed in shear-thinning fluids, where the viscosity decreases as the shear rate increases. The presence of nano clay in the drilling fluid can alter the flow behavior and rheological properties, providing both lubricating and structuring effects depending on the shear rate applied.The presence of SDS surfactant in the drilling fluid formulation has several effects on viscosity. Firstly, the surfactant has an anionic nature, which can reduce water blocking in clay formations. This leads to an increase in the viscosity of the drilling fluid as the surfactant concentration is raised. The anionic surfactant interacts with the clay particles, promoting their swelling in water and consequently increasing the viscosity of the suspension. Furthermore, both Agar and carboxymethylcellulose are ionic compounds, and the presence of anionic surfactant enhances the interaction between these polymers and the surfactant, resulting in changes in viscosity. Figure It is worth noting that the viscosity changes associated with low surfactant concentrations are relatively small. The thixotropy measurements were also conducted to examine the recovery of the fluid’s structure after the application of high shear. Thixotropy refers to the phenomenon where a fluid’s viscosity decreases under shear stress but recovers over time when the shear stress is removed. These measurements provide insights into the structural behavior and stability of the drilling fluid under different shear conditions.−1 , and the surfactant content was studied at three levels . Additionally, the interfacial tension (IFT) between oil–water systems was measured using the pendant drop method, focusing on the SDS content in the aqueous solution. The following conclusion could be drawn from this study.−1.The results of the IFT analysis revealed a significant decrease in interfacial tension between oil and water with an increase in SDS concentration. The rheological results demonstrated that fluids containing nanoparticles exhibited the highest stability as the shear rate increased. The complete dissolution of Agar in water resulted in improved rheological properties at 150 °F. The viscosity drops observed at 150 °F were approximately 5–10 times higher than those at 120 °F. With an increase in the concentration of the anionic surfactant, viscosity showed a slight increment. The behavior of Agar, characterized by an immediate increase in viscosity, restricted permeation into porous media, while CMC only slowed down the permeation process. The overall viscosity of the A1C1 final formulation increased over time due to the dominance of CMC’s rising viscosity over the thinning effect caused by Agar’s presence. Furthermore, the drilling fluid containing nano clay exhibited a lower viscosity drop compared to other formulations. Although the viscosity of the drilling fluid containing Agar at 150 °F remained stable, the viscosity of the base mud displayed unstable behavior. Moreover, the stability of the polymer viscosity significantly influenced the stability of the A1C1 compound at a shear rate of 1022 sIn micromodel experiments, initially, the base drilling fluid caused the most formation damage, followed by the penetration of filtrate into the porous media. In highly permeable formations, a large amount of mud could enter the formation, where Agar bridging agent could be employed to prevent fluid loss. In contrast, CMC was unable to form a filter cake on the wellbore, resulting in a larger invaded zone. Therefore, better results could be achieved by reducing the content of CMC. It was observed that in the A1C1 formulation, CMC reduced the thickness of the filter cake. Finally, the mud cake formed in the A1C1 + nano1 wt% formulation exhibited minimal penetration and showed great potential for effectively sealing high permeable areas with a thin and smooth filter cake.


Currently, various immunotherapeutic strategies have been applied in clinical practice, including immune‐checkpoint blockade, cancer vaccines, adoptive T cell transfer (ACT)‐based therapies, oncolytic viruses, cytokine‐based therapies and so on. However, poor immunogenicity of tumours  and complex immune‐suppressive tumour microenvironment have limited the clinical effectiveness of antitumor immunotherapy. Thermal therapy, a widely used cancer treatment, primarily involves raising the temperature of the entire body or tumour tissue to treat malignant tumours through thermal effects and their secondary effects. Studies have shown that thermal therapy can not only cause direct thermal damage to tumour tissues, but also induce immunogenic cell death (ICD) of tumour cells, activate the immune response of the body, and enhance the infiltration and accumulation of immune cells or drugs in tumour tissues by expanding the intratumoral blood vessels, thereby assisting in improving the effectiveness of immunotherapy. Therefore, combined thermal therapy and immunotherapy also named “thermal immunotherapy” is a synergistic therapeutic strategy for cancer treatment with enormous clinical potential. Currently, several relevant clinical studies are ongoing and have achieved promising results. However, the non‐specific accumulation of immunotherapeutic and/or thermotherapeutic agents not only influences their anti‐tumour activities but also can result in adverse events. Therefore, the key to achieving effective combination therapy is to efficiently deliver the therapeutic agents to tumours.With the development of nanotechnology, nanomedicines have brought new hope for cancer therapy. It can not only improve the solubility and pharmacokinetic properties of hydrophobic drugs but also use tumour cell‐specific characteristics to achieve targeted drug delivery and controlled release, thereby reducing the toxicity and side effects of drugs while improving their bioavailability and efficacy. At least 20 nanomedicines are currently in clinical use as cancer therapies globally, and more than 566 clinical trials involving anti‐cancer nanomedicines were conducted between 2016 and 2020.3 For example, nanomedicine based on thermal immunotherapy as in situ cancer vaccines can overcome the disadvantage of existing cancer vaccines in which immune responses are mounted against only a limited number of antigens. In addition, these vaccines utilize thermal therapy to trigger tumour ICD and release tumour‐specific antigens, thereby effectively enhancing the anti‐tumour immune response.Herein, recent development strategies for nanomedicines used in various thermal immunotherapies are comprehensively summarized by researchers at the School of Life Science and Technology, Xi'an Jiaotong University.Despite the potential of nanomedicine‐mediated thermal immunotherapy to improve the efficacy of antitumor therapy, several challenges should be overcome before these strategies can be applied in clinical practice. First, the “heat sink effect” has been demonstrated to slow the increase in local tumour temperature during hyperthermia (particularly radiofrequency ablation), thereby influencing the effects of thermal therapy.The development and clinical translation of nanomedicines suitable for thermal immunotherapy are also arduous tasks. First, because the effectiveness of nanomedicines in achieving tumour enrichment through passive targeting (enhanced permeability and retention effect) and active targeting ligand modification has been questioned, more innovative strategies are required to promote the enrichment of nanomedicines in tumour tissues, such as through physical means  to promote the permeability of the vascular wall or to generate NO, which in turn stimulates the normalization of tumour blood vessels.Overall, only through the collaboration of multidisciplinary expert teams can efficient thermal‐immuno nanomedicines be developed, ultimately making them a safe and effective anti‐tumour sharp weapon in clinical practice (See Figure The authors declare no conflict of interest.