These lakes eventually drain, creating hazardous subglacial floods that are usually only confirmed after they exit the glacier and reach local river systems, which can be many tens of kilometres from the flood source. Once in the river systems, they travel rapidly to populated areas. Such delayed detection represents a potentially lethal shortcoming in early-warning. Here we demonstrate how to advance early-warning potential through the analysis of four such floods in a glaciated region of Iceland. By comparing exceptional multidisciplinary hydrological, GPS and seismic ground vibration (tremor) data, we show that array analysis of seismic tremor can be used for early location and tracking of the subglacial flood front. Furthermore the timing and size of the impending flood can be estimated, prior to it entering the river system. Advanced warnings of between 20 to 34 hours are achieved for large  are common in volcanic and glaciated environments, and can pose potential threats to communities living downstream. Here, the authors find that seismic tremor signals during subglacial floods can be used to locate and track the speed and size of the flood before it arrives at the river system, and improves previous methods of early glacial flood warning by a factor of 5. Ultimately the accumulated water drains as a flood, which can be hazardous to people, property and infrastructure. For example, a flood in 1981 in Nepal with an estimated peak discharge exceeding 2000 m3/s led to extensive loss of human life, infrastructure and arable land5. The volcanically triggered flood in 1996 in Iceland reached a discharge of 50,000 m3/s causing severe damage to infrastructure6. As subglacial flood waters cannot be directly observed until they break through the glacier terminus, this leads to an outstanding life-threatening challenge in flood early-warning.Glaciers worldwide can host subglacial or dam marginal lakes. These lakes are fed by rivers or accumulate water from ice or snow melt, precipitation or geothermal melting7.Subglacial lakes and jökulhlaups (glacier outburst floods) occur in a range of settings and are common in volcanic environments where lakes are formed by geothermal activity or volcanic eruptions. It remains a challenge to determine the initiation of a flood event, quantify its size, and issue an early-warning as these environments are often remote and monitoring is hindered by ice cover. Warning times for civil defense response can therefore be short in the case of jökulhlaups, even in well hydrologically monitored areas. In the case of a jökulhlaup in Iceland in 2011 only 50 min elapsed between a warning from the local hydrological monitoring system and the flood reaching the country’s main transport artery, where it swept away a bridgeWhile the hydrological network can detect a flood reliably, it only detects it after the flood has progressed from beneath the glacier into the rivers. Methods that provide an earlier warning are therefore of important societal value. Whilst GPS instruments on the glacier surface above a subglacial lake could provide reliable and timely early-warning, a widespread use of this technology is challenging as maintaining GPS instruments in a harsh and heavily crevassed area above a subglacial lake is dangerous and costly and maintaining their telemetry from the ice surface is limited by snow accumulation during winter and electrical power considerations.8, lahars9, to helicopters11. Here, constrained by exceptional multidisciplinary data, we determine how seismic ground vibrations in the form of tremor captured on specifically arranged arrays can be used to estimate key parameters associated with subglacial floods, including their size and propagation speed as they travel beneath the glacier. These new observations and interpretations could lead to more than an order of magnitude improvement in subglacial flood early-warning times.Seismic instruments have been found to be sufficiently sensitive and resilient to record ground vibrations associated with various moving sources; even when the instruments are tens of kilometers from the source. These sources range from landslides12 compared seismic tremor, subglacial discharge, and flow velocity of glaciers in Alaska and Greenland. While they reported no correlation between tremor and glacier motion, they found the best correlation with subglacial discharge for tremor frequencies between 1.5 and 10 Hz. Tremor amplitude varied with seasonal changes of the subglacial discharge but also on an hourly timescale during a subglacial flood.Bartholomaus et al.16. In other cases, tremor was related to englacial water flow in a moulin18, resonance in a water-filled crack or channel21 or repeating icequakes in moving or stationary icebergs24. For a detailed overview of glacial seismic sources such as icequakes and tremor the reader is referred to Podolskiy et al. (2016)25.This and other studies suggest that seismic tremor in glaciated regions is generated by turbulent flow in subglacial conduits and by transported sediment15 and subglacial floods in various glaciological, geomorphological or hydrological studies worldwide30. However, quantifying these relationships, to determine flood location, size or propagation speed has not yet been achieved. Here we quantify the links between ground vibrations and processes associated with a large (~3000 m3/s discharge) flood using seismic, geodetic and hydrological data and three smaller floods (210–380 m3/s peak discharge)  Figs. . We demo32).The seismic vibrations are also referred to as tremor or high-frequency noise based on the signals emergent start and long duration Fig. c, d. Due34.The arrays were installed to study seismic tremor associated with floods originating in the eastern and western Skaftá cauldron  within the watershed of the cauldron accumulate forming a subglacial lake35. The subglacial lakes drain along a  ~40 km long subglacial flood path when the pressure at the bottom of the lake is close to the ice-overburden pressure and a seal near the base of the ice fails35.The 1–3 km wide and 50–150 m deep37 while typical discharges range from 50 to 3000 m3/s with total volumes of 0.05–0.4 km3. The floods are characterized by rapidly rising discharge curves37 where a propagating subglacial pressure wave38 is thought to create the initial pathway for sheet flow of water beneath the glacier39. Once a flood starts, they typically reach maximum discharge in 1–3 days and recede in 1–2 weeks3.Floods occur every 1–5 years30.Note that this is in contrast to floods mentioned above that drain more slowly by melting channels into the ice such as reported by refs. 41 as detailed in the “Methods”. The resulting angle between north and the direction towards the seismic tremor epicenter (back azimuth) and inverse of the apparent velocity (slowness) are plotted alongside seismograms and amplitude spectrograms in Figs. From August 2013 to December 2016, three floods were released from the western Skaftá cauldron and one from the eastern Skaftá cauldron .3/s43 from the Western Skaftá cauldron was recorded in January 2014. Due to a data gap on 15 January we can merely state that Type 1 tremor started at least 34 h before the flood reached the uppermost hydrological instrument   were accompanied by weaker Type 1 tremor and no subsequent Type 2 tremor. The propagation of the flood front was visible in about 38 hours of moving Type 1 tremor on 15–16 June 2015  Fig.  and Sept015 Fig. , and in The propagation of a subglacial pressure wave is observed as a lifting of 0.25 m at the on-glacier GPS station D3, 3 km from the ice terminus around 17:00 on 16 June 2015  tremor amplitudes at one station in JO array. This is complemented by the discharge measured at the hydrological station 25 km downstream (grey). Based on Figs. An overview of tremor amplitude and discharge Fig.  comprise16 who recorded tremor comprising surface waves at more than 1 km distance from the source caused by subglacial water flow. It is apparent from Fig. Despite flood sizes ranging over an order of magnitude Fig. , all fou13. In contrast to these studies, we cannot however produce such a tight similarity between the shape of the discharge and tremor curves in time. We note that although a clear positive correlation between tremor amplitude and discharge is evident, the relationship here for sheet flow is not as well defined as in R-channel flow .The progressive lifting and increased horizontal motion of the glacier initiated by the pressure wave leads to fractures at the base of the ice. A multitude of these icequakes or quakes at the interface of bedrock and ice may merge into the continuous signal that we detect as tremor. However, fluid motion at the base of the glacier or transported sediment are alternative possible mechanisms for tremor generation. Here we focus on the positive correlation between tremor amplitude and discharge Fig. , which iGiven that there is no GPS instrument in the western cauldron and the hydrological station 25 km downstream cannot be used to precisely time the emergence of the flood at the ice terminus, we rely on the seismic recordings in order to calculate the average speed of all four floods. Based on array recordings of Type 1 tremor, it is possible to estimate the speed of the flood front. The subglacial flood from the eastern Skaftá cauldron in 2015 moved 25–42 km (back azimuths of 60–68° to 140°) in 17.5 h and therefore at an average speed of 1.4–2.4 km/h (0.4–0.7 m/s). According to the GPS recordings the floods travelled 12 km from D15 to the glacier terminus outflow at a speed of ~2.0 km/h on the lowermost part of the subglacial flood path. The tremor sources during the flood in January 2014 propagated at 0.9–1.6 km/h, the one in June 2015 at 0.7–1.1 km/h and the one in September 2016 at 0.8–1.3 km/h. These are upper limits of the velocity due to data gaps in the seismic recordings at the beginning of the floods in January 2014 and June 2015. An order of magnitude reduction in flood size led to a 50% reduction in flood propagation speed and in tremor amplitude .26 and a subaerial lake at Kverkfjöll45. Bodvarsson et al.26 stated that the Type 2 tremor was up to 30 min long and visible on most seismic stations in Iceland. They suggest that a sudden pressure drop due to the emptying of the cauldron led to boiling in the subglacial geothermal field. Montanaro et al.45 studied hydrothermal explosions at Kverkfjöll combining field work, laboratory studies, seismic data and analytical models. A flood from a lake led to a lake level drop of 30 m and hydrothermal explosions. The seismic characteristics were surface wave-dominated, 40–50 s long energetic tremor episodes with energy up to 4 Hz and most energy between 0.5 and 2.5 Hz at a station at 19 km distance. They interpreted these several minute long, harmonic tremor episodes as hydrothermal explosions and vigorous boiling and found that it located in an ice-free area. Other generation models for our Type 2 tremor such as a swarm of basal icequakes or basal motion at the bottom of the glacier  seem unlikely due to their similarity to tremor signals generated in an ice-free area. In addition, in this study Type 2 tremor is dominated by body waves and therefore is unlikely to be generated solely at the Earth’s surface.Array analysis results demonstrate that the Type 2 tremor was composed of body waves and was located at or close to the draining cauldron. Tremor episodes with similar spectral content and shape of the mean amplitude per minute recorded at a single seismic station were reported at the end of floods from a subglacial lake at Grimsvötn45 that a likely source mechanism for the tremor are hydrothermal explosions and boiling of the geothermal system in the rocks underlying the subglacial lake, triggered by a pressure drop.We observed that Type 2 tremor started in a time period where most water had drained from the cauldron. It ceased when the roof of the subglacial cavity had settled back on the bedrock. In this time window the geothermal system underwent a pressure drop and due to spectral similarities to the tremor at Kverkfjöll  we follow the interpretation of Montanaro et al.47. The conductivity increase is higher than can be expected from other non-geothermal sources. Anderson et al.48 used an increase in solute concentration during the waning phase of a jökulhlaup from Hidden Creek lake in Alaska to infer a release of long residence time water from the distributed subglacial hydraulic system due to lowering of water pressure in the flood path. This is an unlikely explanation for the conductivity increase in the Skaftá floods, as such water, released from the glacier in late winter, has been observed to have conductivity below 200 μS/cm  and would have caused a lowering in the observed conductivity.We suggest that a second phase of conductivity increase, starting on 2 October 2015  detects an area of rapidly flowing water in a local river to the south east of the array see Fig. f. TremorThe practical application of these observations as a flood early-warning tool depends on the ability to reliably detect systematic changes in the back azimuths that lie above the scatter associated with individual measurements. The sensitivity of such a system depends on the location of the array with respect to the draining water source. Ideally it should detect weak signals at the beginning of a flood and be able to resolve tremor source location changes (migration) as a large change in back azimuth. For the floods analysed here, the slow initial change in back azimuth is due to the network geometry and is not a source characteristic. We need at least a 12 h long time window in order to unambiguously resolve flood movement. Critical points are the distance between the array, the flood source region that affects the amplitude of the signal, and the azimuth of the array relative to the flood movement direction. In an ideal array configuration the array would be both close to the initiation point of the flood and perpendicular to the flood propagation direction.In the case presented here for the JO array, it is 40 km from the flood source region at an angle of ~15° to the initial flood path direction. Consequently, although Type 1 tremor signals can clearly be seen at flood initiation (up to 20 h before the flood is detected in the Skafta river), it does not appear to migrate at first due to this geometric configuration. However, a conservative estimate based on an examination of Fig. 20. Bartholomaus et al.12 showed that the tremor amplitude correlated with long-term variations in the subglacial discharge as well as short-term variations due to a slowly-rising flood with a delay in the tremor amplitude of a few hours. Our findings for fast-rising and ice-sheet lifting subglacial floods in volcanic environments show that flood size, location and speed can be determined as well and can be adapted to other environments worldwide. We envisage that in the future arrays located at a location from which the observed back azimuths during the flood are almost perpendicular to the flood path, will allow the resolution of the flood speed continuously along the whole path. We demonstrate that array-detected seismic tremor represents a new quantitative tool for early-warning during subglacial floods in various flooding environments and has the potential to give advanced warning of flood arrival-time, size and expected duration.Subglacial floods were also reported in non-volcanic environments such as Greenland and Antarctica50 in the volcanic zone of Iceland.Two seismic arrays were installed southwest of Vatnajökull glacier around Skaftá river in order to monitor floods from the eastern and western Skaftá cauldron see Fig. . The arr41. A shorter moving time window of 35 periods in length (66.5–87.5 s) and 20% overlap is used to perform a grid search in a horizontal slowness grid (stepsize 0.02 s/km and limit of  ±1.0 s/km). Based on the coherence of waveforms of the array stations, the array processing determines a time series of absolute power, semblance, back azimuth and slowness. The back azimuth gives the direction between north and the incoming seismic wave, the slowness is the inverse of the apparent seismic wave velocity through the ground and contains information about the steepness of the incoming wave and therefore the wave type (e.g. surface or body waves). We require a minimum semblance of 0.3 and determine the uncertainty in back azimuth and slowness based on the location and shape of the main lobe of the array response function. The back azimuth and slowness of all points with a power of at least 95% of the maximum are determined and their standard deviation is given as uncertainty. All points with uncertainties above 12° in back azimuth and 0.2 s/km in slowness are discarded.We instrument correct, detrend, downsample the data to 20 Hz and cut it into 1 h long time windows before performing an array processing between 1.4 and 3.0 Hz as implemented in refs. 42. We instrument-corrected, detrended, tapered and filtered the vertical component of the seismic recording between 1.3 and 4.0 Hz. We divided the seismic recording into 15 min long time windows and calculated the root median square of the signal. We repeated this iteratively allowing 20% overlap.Additionally and completely independent of the array processing, we calculate the Root median square (RMeS) of the seismic amplitude in order to assess the tremor amplitude and give less weight to shorter transients such as earthquakes3/s52. Part of the river discharge bypasses the hydrometric station in large floods such as the September to October 2015 flood. This increases uncertainty in measured flood discharge substantially and explains difference in estimated maximum of ~3000 m3/s  and the uncertainty on the estimate of discharge that bypasses the hydrometric station (±350 m3/s)52. Base flow in the river, due to sources other than the jökulhlaup’s flood water, is estimated using the hydrological model WaSiM53 and subtracted from the discharge measured at the hydrometric station. This further increases the uncertainty of estimated flood discharge by ±12 m3/s47.The discharge of the jökulhlaups in Skaftá was measured by the Icelandic Meteorological Office (IMO) at an hydrometric station at Sveinstindur, 25 km downstream of the glacier margin Fig. . The dis3/s Fig.  and meas3/s Fig.  with max31, as the dammed water in subglacial lakes over geothermal areas has higher amount of total dissolved solids than water from other runoff sources54. The sensor often gets clogged with sediments, which can make the measurements unreliable as is the case for the January 2014 and September 2016 floods.Electric conductivity of the river water is measured at the hydrometric station at Sveinstindur. Increased conductivity is used as an indication of flood water in the river55 with the continuous GPS station at JO  as base. The standard deviation of unfiltered positions around a daily mean during periods of slow motion and low melt is lower than 4 cm in the vertical coordinates and may be used as an indication of the precision of the GPS measurements. GPS measurements are not available from D15 in the June 2015 jökulhlaup due to power problems, and neither from D3 in the September to October 2015 jökulhlaup as the instrument was washed away when a small part of the flood reached the ice surface by hydrofracturing the ice 3 km from the terminus.In 2015 a streaming GPS instrument was maintained by the IMO in the eastern Skaftá cauldron (SKA2) and two GPS instruments were installed on the ice surface above the flood path on Skaftárjökull (Fig.


Neuropilin1 (NRP1) participates in cancer cell proliferation, migration, and metastasis as a multifunctional co‐receptor by interacting with multiple signal pathways, but few studies have addressed the precise function of NRP1 in pancreatic cancer (PACA) cells. We aimed to study whether NRP1 gene silencing involved in the proliferation and migration of PACA cells in vitro.A lentiviral vector expressing NRP1 shRNA was constructed and transfected into human PACA cells (CFPAC‐1 and PANC‐1). The expression of NRP1 protein and mRNA was detected by Western blot and quantitative real‐time polymerase chain reaction (qRT‐PCR) assay, respectively. CCK‐8 assay, wound healing assay, and transwell assay were conducted to examine the effect of NRP1 silencing on cells proliferation and migration capability.P < .05). The invasion and migration capability of PACA cells in NRP1 shRNA group was lower significantly than that in the NC group (P < .01).Results of qRT‐PCR and Western blot showed successfully established, stably transfected shRNA‐NRP1 cells in PACA cells. The proliferation capacity of PACA cells in NRP1 shRNA group was lower significantly than that in the negative control (NC) group (NRP1‐shRNA lentiviral interference vectors can effectively decrease NRP1 gene expression in PACA cells, thereby inhibiting cells proliferation and migration, which provides a basis for finding a valuable therapeutic target for PACA therapy. ECLEnhanced chemiluminescenceEDTAEthylenediaminetetraacetic acidEMTEpithelial mesenchymal transitionFBSFetal bovine serumNRP1Neuropilins1NSCLCNon‐small cell lung cancerRNAiRNA interferenceshRNAShort hairpin RNATGF‐βTransforming growth factor βVEGFVascular endothelial growth factor1Pancreatic cancer (PACA) is one of the most aggressive human cancer types, accounting for about 2% of all malignant tumors. Owing to the special biological characteristics of the pancreas and its anatomical location, the cancer is associated with high malignancy rate, low early diagnosis rate, and poor prognosis.NRP1 was first found as an axon adhesion protein in the nervous system of frogs, encoding a single type I transmembrane glycoprotein of molecular weight 120‐130 kDa.However, to our knowledge, the expression level, biological function, and underlying mechanisms of NRP1 in PACA remain poorly understood.22.12 at 37°C. When the cell density was consistent with the density indicated in the previous article, lentivirus transfection and cell function assays were carried out.CFPAC‐1 and PANC‐1 cells were purchased from the Shanghai Cell Bank and cultured under standard condition containing PMRI 1640 medium (Gibco) supplemented with 1% Penicillin‐Streptomycin  and 10% fetal bovine serum (Gibco) with 5% CO2.2Based on the results of bioinformatics, we selected three short hairpin RNA (shRNA) targeting human NRP1 sequence . The sh1 NRP1 was finally selected for subsequent experiments. The lentivirus vector used in this experiment was produced and provided by a company (Hanyin Biotechnology Limited Company). More concretely, two single‐stranded DNA were designed and synthesized: 5′‐gatccAAGCCCCGGGTACCTTACATTTCAAGAGAATGTAAGGTACCCGGGGCTTTTTTTTTg‐3′ and 5′‐aattcAAAAAAAAAGCCCCGGGTACCTTATTCTCTTGAAATGTAAGGTACCCGGGGCTTTg‐3′. Then, double‐stranded DNA, formed by annealing the single‐strands, was connected to the linearized vector and was transformed into competent cells. The plasmid was extracted, enzyme digested and sequenced, and the lentivirus was packed into 293T cells. According to the instructions provided by the company, CFPAC‐1 and PANC‐1 cells were transfected transiently with the above lentivirus. We have a scrambled/non‐targeting control , which is named NC group, and we set cell lines transfected with the empty vector as a control and it was named Blank group.2.3In this work, qRT‐PCR was performed according to the previously reported method.2.4In this study, protein extraction and WB assays were carried out according to the previous method.2.5To determine cell proliferation activity, we performed CCK‐8 assay, experiments in 6 replicates. To determine cell invasion and cell migration capability, we performed transwell assay and wound healing assay, experiments in 3 replicates. The above assays were carried out according to the previous method.2.6t test and ANOVA (Tukey's multiple comparison test) were used to compare statistical significance in the various groups. P < .05 was considered statistically significant difference.All data were analyzed using SPSS 20.0 software (IBM Corp.), and were summarized and presented as the mean ± SD. Student's 33.1P < .01; Figure In order to detect the transfection efficiency of sh1 NRP1, sh2 NRP1, and sh3 NRP1, on the third day after transfection, mRNA was extracted from all types of cells. Then, the expression level of NRP1 mRNA was detected by qRT‐PCR. Results showed that NRP1 mRNA level in three shRNA targeting groups reduced significantly compared to that in the negative control (NC) group , under a fluorescence microscope (Olympus Corp.). The fields of view were randomly selected to determine transfection efficiency of PACA cells under the fluorescent microscope, and take pictures of the same under fields of bright vision and fluorescence Figure . Meanwhi3.3P < .01). CFPAC‐1 cells showed the same trend, and the proliferation ability of NRP1 shRNA group was apparently worse than that of NC and blank groups in the 7 day (P < .05), hence suggesting that the proliferation capacity of NRP1 shRNA group was apparently lower. The results revealed that eliminating NRP1 can continuously and effectively impair proliferation in PANC‐1 and CFPAC‐1 cells . CFPAC‐1 cells show the same trend, the average number of transmembrane cells being 42.3 ± 5.2 in the NRP1 shRNA group, 219.6 ± 4.9 in the NC group, and 223.6 ± 5.8 in the blank group. In the PANC‐1 cell wound healing assay, we measured the relative blank area of the three groups at 0, 36, and 72 hours after scratching. The difference between NRP1 shRNA group and other two groups (NC group and blank group) was confirmed to be statistically significant at 72 hours . In the CFPNC‐1 cell, the time is 0, 36, 60, and 90 hours, and the difference between NRP1 shRNA group and other two groups (NC group and blank group) was confirmed to be statistically significant at 90 hours . Results of the above two assays supported each other, and revealed that silencing NRP1 can effectively impair invasion and migration in PANC‐1 and CFPAC‐1 cells.For the PANC‐1 transwell migration assay, the average number of transmembrane cells was 46.5 ± 3.8 in the NRP1 shRNA group, 228.4 ± 6.7 in the NC group, and 256.1 ± 5.6 in the blank group. Compared to the NC and blank groups, the number of transmembrane cells in the NRP1 shRNA group was reduced significantly  technology was used to explore the relationship between silencing NRP1 and the ability of proliferation, invasion, and migration in PANC‐1 and CFPAC‐1 cells. RNAi can not only inhibit the expression of certain oncogenes in tumor cells, but also further inhibit tumor proliferation and metastasis thereby aiding the prevention and treatment of cancer with high efficiency, high specificity, and low toxicity features.Previous studies have shown that the silencing of NRP1 in pancreatic ductal adenocarcinoma has multiple cellular and molecular antitumor effects. Although different methods are used, the experimental results are consistent with our results that NRP1 silencing can inhibit the proliferation and migration of pancreatic cancer cells. In addition, we discussed the CFPAC‐1 cell line and to determine cell invasion and cell migration capability, we performed transwell assay and wound healing assay.5This study has shown that NRP1‐shRNA lentiviral interference vectors can effectively decrease NRP1 gene expression in PANC‐1 and CFPAC‐1 cells, thereby inhibiting cell proliferation and migration. These findings contribute in several ways to our understanding of NRP1 and provide a basis for finding a valuable potential therapeutic target for PACA therapy.The authors declare that there is no conflict of interest with respect to the research, authorship, and publication of this article.Li‐hong He, Yong‐lin He, Yue Kang, and Ling‐yun Wang conceived and designed the study, performed the experiments, and wrote the article; Wen‐hang Zuo and Huan Xue analyzed the data, and designed the tables and figures; Yun‐liang Zhang and Yong Meng discussed results and advised during the completion of the study. All authors read and approved the final article.Not applicable.Sup infoClick here for additional data file.


Breast cancer (BC) presents important physical and psychological challenges that should be appropriately addressed through continuous, integrated and individualized rehabilitation programs after treatment. In this study, we aimed to collect more information on the rehabilitation patterns and utilization of healthcare services by women with BC.We retrospectively analyzed data from two archives of the Lazio Regional Health System Database to assess rehabilitation patterns in women diagnosed with BC in the Lazio region  in 2008.A total of 5538 women diagnosed with BC were considered in the present study. Most patients (81.7%) received outpatient rehabilitative care, consisting mainly of pathology-related interventions and, more rarely, disability-related interventions . Few patients followed an inpatient (1.3%) or an intensive outpatient rehabilitation program (1.0%).Most patients do not receive adequate rehabilitation care during the first year after diagnosis. More information and better rehabilitation services should be provided to help patients with BC access rehabilitation programs. The study also suggests the importance of psychosocial and cognitive interventions, which is a major unmet need in women with BC. Breast cancer (BC) is one of the most common forms of cancer among women and the second-leading cause of cancer-related deaths worldwide . In ItalThe recent advances in diagnosis and treatment have considerably improved the survival time and quality of life (QoL) of women with BC . HoweverRehabilitation interventions are recognized as an important aspect of care for women with BC. The World Health Organization (WHO) has defined rehabilitation as “the use of all means aimed at reducing the impact of disabling and handicapping conditions and at enabling people with disabilities to achieve optimal social integration”. Based on this bio-psycho-social model, cancer rehabilitation requires a multidisciplinary approach, including medical, psychological and physiotherapeutic treatment, as well as occupational therapy and functional therapy, depending on the specific needs of the patient. The timely delivery of these services, provided both through inpatient or outpatient programs, is crucial to support women after surgery and throughout the post-treatment survivorship stages . These rMultiple studies have investigated the effects of different rehabilitation interventions in women who are treated for BC, reporting positive results . AccordiDespite the availability of multiple studies on rehabilitation interventions, no clear indication exists on which is the best strategy for women with BC. Some complicating factors derive from the heterogeneity of women’s needs and the need of implementing an individualized approach. Moreover, each patient presents a complex mix of mental, psychological, social, emotional, spiritual and physical symptoms caused by the illness and its treatment. All these physical and social psychological factors influence each other according to a cause-effect relationship . DespiteFurthermore, literature data on the utilization of these services is rather scarce. The few available studies have reported the existence of numerous barriers, which arise from human, logistic and financial sources, which may restrict access to rehabilitative care for women with BC , 22.In order to improve the information on the utilization of rehabilitation services by women with BC, we conducted a retrospective analysis to assess the pattern of rehabilitation care and utilization of public health services by women diagnosed with BC in the Lazio region  in 2008. This study was part of the research project, Health Organization of Cancer Units for Rehabilitation Activities (HO CURA), supported by the Italian National Ministry of Health 2007–2010.Sistema Informativo dei ricoveri ospedalieri in Riabilitazione post-acuzie [RAD-R]) and outpatient interventions . The RAD collects and stores fully integrated real-world patient-level data on the utilization of health services . The database includes data from patients admitted to one of the hospitals located in the Lazio region, covering a population of more than 5,000,000 residents. The other databases contain data on rehabilitation programs, categorized as inpatients rehabilitation after hospital discharge for acute disease (RAD-R), intensive rehabilitation pathways provided outside the hospital setting (SIAR) and rehabilitation services provided in the outpatient setting (SIAS).In this retrospective cohort study, we collected data from two main sources: 1) the Lazio Regional Health System Database (RAD) and 2) the rehabilitation pathways databases for inpatient  or linked to a disability (set “Rehabilitation”).Data from these databases were combined to identify patients diagnosed with BC (ICD-9 code 174) who were admitted to one of the hospitals in the Lazio region and used a rehabilitation service within 12 months after being discharged. Patients were included if they were diagnosed between 1 January 2008 and 31 December 2008, were aged ≥18 years at the time of the first discharge (index date) and received rehabilitation interventions after the index date. We excluded patients with previous hospital admissions for BC (ICD-9 code 174) from the study in the 2 years before 1 January 2008.Patterns of rehabilitation care were analyzed during a follow-up of 12 months after patients were enrolled in the study, defined as the day of first hospital discharge for BC.For each patient, we collected data on the rehabilitation services used in the inpatient and/or outpatient settings, including number of rehabilitative interventions delivered between 2008 and 2009, clinical records, length of treatment and time from index date to start of rehabilitation. Data on the inpatient rehabilitation programs included the number of concurrent deficits at admission and the Barthel Index (BI). This score, which ranges from 0 to 100, measures the ability of the patient to perform daily activities of life, with lower scores indicating increasing disability and higher scores indicating greater independence. In the outpatient setting, we collected data on the utilization of neuro-motor rehabilitation programs, and number and type of interventions provided.Descriptive statistics were used to summarize relevant study information. Categorical variables were reported as frequencies and percentages, while continuous variables were summarized by mean values or median and range, as appropriate.During the study period, we identified 11,656 discharges after an initial or secondary diagnosis of BC (ICD-9 code of 174)  died during the first hospital admission and were excluded from the study; the remaining 5448 women (mean age: 61.2 [47.2–75.2] years) were discharged alive from the hospital and received medical and/or rehabilitation care after the index date. Moreover, during the 12 months after discharge for an acute disease a diagnosis of BC, 70 (1.3%) women followed an inpatient rehabilitation program, 54 (1.0%) were included in an intensive outpatient rehabilitation program and 4452 (81.7%) required specific outpatient rehabilitative care. Data on the rehabilitation care provided to patients in the 12 months after discharge are summarized in Table In total, 70 patients  were admitted to an inpatient rehabilitation program after hospital discharge, for a total of 84 admissions . Regarding standard admissions, in 78% of the cases the first admission occurred within 30 days from discharge, and the mean duration of hospital stay was 41 days (interquartile range [IQR]: 22–58) (Table The median BI score measured before the start of rehabilitation was 52 (IQR:31–77) (Table After discharge at home (occurred in 73.8% of women), 41.1% of the patients did not follow an additional rehabilitation path, 13.0% followed a standard inpatient rehabilitation program and 27.3% an outpatient program.A total of 54 patients  were addressed to a personalized outpatient program with intensive rehabilitation plan or maintenance plan. Overall, 69 rehabilitation programs were delivered, including 28 intensive programs (40.6%) and 41 maintenance programs (59.4%), classified as requiring low (17.4%), medium (53.6%) or high interventions (29%). Most of the patients were referred to the program by their general practitioners (91.3%), while in the remaining 5.8% of the cases the rehabilitation program was prescribed by a specialist.The median BI score measured before the start of rehabilitation was 90 IQR: 72–96) (Table –96 Tabl. NotablyThe median number of effective days in which the rehabilitation program was delivered was 53 (IQR: 49–79) Table . After tAfter hospital discharge, a total of 4452 (81.7%) women were followed through specialized outpatient rehabilitation programs and received overall 187,680 rehabilitation interventions and 102,086 prescriptions during the study period. In the majority of the cases (81%), the rehabilitation interventions focused on disease-related needs (set “disease”), in 0.5% of the cases consisted of disability-related interventions (set “rehabilitation”) and 18.6% of the patients received both disease and disability-related support , after-care (14.7%) and follow-up (13.3%). A total of 72% of the interventions consisted in medical/surgical services to treat the neoplastic disease or its collateral effects, 14.7% were related to the treatment of collateral effect or management of medical devices (mainly delivered by nurses) and 13.3% consisted in medical-surgical monitoring of patients’ status  and 0.4% consisted in the evaluation of cognitive functioning through tests or interviews , accessed an inpatient rehabilitation program, whereas an even smaller percentage (1.0%) received a personalized intensive outpatients rehabilitation plan. Most of the patients (81.7%) received specialist care in the outpatient setting, consisting mainly in pathology-related interventions and only in a limited number of cases in disability-related interventions. Of note, disability-related interventions were delivered long after hospital discharge (median: 161 days) and usually later compared with disease-related services (median: 45 days). Moreover, our findings suggest that women with BC received fragmented rehabilitation services, in particular in the outpatient setting. It is important to note that literature data suggest that outpatient rehabilitation programs are as beneficial to patients as inpatients programs, but with an important cost saving for the National Health System, thus suggesting the need for a more consistent implementation of rehabilitation services in this setting .One of the main services provided to women in the outpatient setting, accounting for 81.5% of all the disability-related interventions, was motor rehabilitation, consisting in exercise, occupational therapy and physio-kinesiotherapy. Exercise and physical activity interventions are the most studied type of rehabilitation; according to literature data, they are indeed feasible, safe and effective in improving women’s physical outcomes, and have also reported predominantly positive effects on fatigue and QoL , 28. ConThe limited use of inpatients and especially personalized intensive outpatient’s rehabilitation plans observed in our retrospective analysis suggest the lack of rehabilitative offer and the existence of barriers to patients’ access. Although only few studies have specifically evaluated the barriers to rehabilitation in women with BC , 22, litIncreasing the level of information and understanding of oncological rehabilitative services is an important step to overcome the existing barriers and to promote a more equal and comprehensive access of rehabilitation interventions in women with BC .We acknowledge some limitations of this study, including the retrospective design and the fact that the source of this analysis are administrative data, which lack compete clinical information. On the other hand, by using the archives of the Lazio Regional Health System, we could evaluate the utilization of rehabilitation services in a large cohort of patients, and we had access to a comprehensive database of rehabilitative pathways, from post-acute hospital admissions up to outpatient treatments.In addition, the long interval from data collection and our analysis could be considered a possible limitation of the study; however, no relevant changes have been made over the last 10 years in the regional health system in terms of availability of public rehabilitation services. Consequently, presented data are still representative of the current clinical practice.Our retrospective analysis on the utilization of rehabilitation services in a large cohort of women with BC clearly shows that the majority of women do not receive adequate rehabilitation care during the first year after diagnosis. These results underline the need of improved availability of rehabilitation services and of further information to help BC patients access rehabilitation programs; the study also suggests that more focus should be put on psychosocial and cognitive interventions, which is a major unmet need in women with BC.


We adopted a vision-based tracking system for augmented reality (AR), and evaluated whether it helped surgeons to localize the recurrent laryngeal nerve (RLN) during robotic thyroid surgery. We constructed an AR image of the trachea, common carotid artery, and RLN using CT images. During surgery, an AR image of the trachea and common carotid artery were overlaid on the physical structures after they were exposed. The vision-based tracking system was activated so that the AR image of the RLN followed the camera movement. After identifying the RLN, the distance between the AR image of the RLN and the actual RLN was measured. Eleven RLNs  were tested. The mean distance between the RLN AR image and the actual RLN was 1.9 ± 1.5 mm (range 0.5 to 3.7). RLN localization using AR and vision-based tracking system was successfully applied during robotic thyroidectomy. There were no cases of RLN palsy. This technique may allow surgeons to identify hidden anatomical structures during robotic surgery. Although robotic thyroid surgery offers a three-dimensional magnified operative view, tremor filtering system, and endo-wrist movement, the surgeon cannot use tactile sense, and identifying covered anatomical structures is difficult, compared to open surgery2.Robotic thyroid surgery has become popular over the past decade because it does not leave a scar on the neck, unlike traditional open surgery3. Thus, during thyroid surgery, preservation of recurrent laryngeal nerve (RLN) function is very important. However, because the RLN is located posteriorly to the thyroid glands, it is difficult to identify, making it susceptible to injury during exploration. During robotic thyroid surgery, it is challenging to preserve RLN function because the surgeon cannot use tactile sense.Injury to the RLN is a major complication of thyroid surgery that can result in vocal cord palsy, aspiration, and poor quality of life6. Currently, application of AR in surgery is unpopular because it is a cumbersome process: AR images do not follow the robot’s camera movement, so they must be manually relocated according to camera movement. To overcome this limitation, we applied a vision-based tracking system that allows the AR image to move in line with the actual organ, following camera movement. We evaluated whether this system aids the surgeon to localize the RLN during robotic thyroid surgery.Augmented reality (AR) in surgery is a new technique that enables virtual images of the organs to be overlaid onto the actual organs during surgeryIn the pilot study, seven RLNs (4 right and 3 left) from six patients were used to measure the distance between the actual RLN and the trachea Table . The meaIn this prospective study, nine patients were enrolled and 11 RLNs (9 right and 4 left) were tested Table . After a7. Identifying the RLN, the most time-consuming step during thyroid surgery, is more challenging during robotic thyroid surgery compared to open surgery. AR is a technology that superimposes images of objects onto physical objects9. AR approaches are employed in surgery for hidden or deeply located tumors such as parathyroid, liver, or brain tumors12. The technology is also applied in robotic surgery7. However, the AR image is unable to follow camera movement during surgical procedures, thus it requires continuous manual overlaying or the use of additional instruments for image localization14.Identification of hidden structures is more challenging during robotic surgery than open surgery because of the loss of tactile feedback and difficulties with hand-eye coordination with instruments16.In this study, we developed a semi-automatic registration method to enable an AR image to be automatically overlaid on the actual organs followed by manual fine-tuning. Constructing AR images of the common carotid artery, trachea, and RLN took about 30 minutes in total. For automatic overlaying, the color and axis of the trachea were used as a landmark. The actual tracheal region was segmented using the thresholding method which is a technique used to detect color difference. The angles of the long and short axes of the segmented trachea regions were determined. The AR image of the trachea was overlaid onto the actual tracheal region at the predetermined angle. To enable the AR of the RLN to follow camera movement, we applied simultaneous localization and mapping (SLAM) technology19. The proposed tracking system is also capable of detecting respiratory movement, as shown in Supplementary Video. This technology does not require training with images and is widely used across a range of fields including navigation, robotic mapping, odometry for virtual reality, and AR23. In this study, vision-based tracking was performed in three steps: (1) SLAM application on the physical surgical image, (2) semi-automatic organ overlay, and (3) vision-based organ tracking for AR images to follow camera movement in real-time.SLAM technology constructs a 3D map of the surrounding environment almost in real-time while simultaneously tracking an object’s locationThere are limitations to this study. We were unable to display AR on the surgeon’s binocular monitor (on the robot) because integration of AR on the robotic monitor is prohibited by the equipment’s license. Instead, we used a separate monitor to display and manipulate the AR. Integration will be possible in the future when manufactures make surgical robots accessible by AR software. Another limitation of this technique is that the current system does not compensate for tissue deformation. We constructed AR images for the non-deformable structure (trachea) and the deformable structures (common carotid artery and RLN). However, we did not use a deformable registration method in this study for two reasons: First, the common carotid artery and RLN can be regarded as fixed organs because their position is relatively fixed, although their nature is deformable. Second, a minor inaccuracy in the location of the RLN is not clinically significant and was acceptable to the surgeon. The role of AR in this study was not to predict the exact location of the RLN, but to suggest the probable location of the RLN and help the surgeon to explore the area around the RLN.In summary, we developed a vision-based tracking system for AR using SLAM technology and showed that RLN can be successfully localized during robotic thyroidectomy. This technique may be helpful for surgeons to identify hidden anatomical structures during robotic surgery.This prospective study was approved by the Institutional Review Boards of SMG-SNU Boramae Medical Center and Seoul National University Bundang Hospital (IRB No. L-2018-377 and B-1903/531-403). All methods were carried out in accordance with regulations and institutional guidelines. This study was performed in patients who underwent bilateral axillo-breast approach robotic thyroid surgery due to papillary thyroid carcinoma tumor from March to April 2019. Patients were counseled about using AR and vision-based tracking system and informed consent was provided by each patient before surgery. The robot model used in this study was the Xi model of the da Vinci Surgical System .Based on the DICOM files, AR images of the structures of interest  were constructed using open source software Seg3D .24. The surface of the AR image was post-processed with smoothing using MeshMixer .Figure In the pilot study, AR images of the trachea and common carotid artery were constructed based on CT images. The images were overlaid on the actual organs during surgery. After the RLN was identified, the distance between the actual RLN and the AR image of the trachea was measured.In the prospective study, AR images of the trachea, common carotid artery, and the RLN were constructed using CT images. The AR image of the RLN was positioned to the side of the trachea at the distance determined by the pilot study. During robotic thyroid surgery, the AR images of the trachea and common carotid artery were overlaid on the actual structures after they were exposed. The vision-based tracking system was activated so that the AR image of the RLN followed the camera movement. After identifying the actual RLN, the distance between the AR image of the RLN and the actual RLN was measured.Figure Figure 26. SLAM achieves 3D point mapping via stereo matching using motion parallax between the first and subsequent camera images. The points are tracked and 6 degrees of freedom (6-DoF) camera pose is estimated. The tracking algorithm first calculates a rough relative pose between contiguous images by frame-to-frame matching, and projects the 3D points onto the current image by the pose. Then, the algorithm searches their corresponding images to gather matched pairs between 3D and 2D27. The final pose is optimized iteratively from the pairs28. If the image includes an unknown scene, some feature points are extracted from the unknown scene, triangulated by epipolar geometry, and added to the 3D point map29.SLAM technology, using MAXST AR SDK software , was applied to create a 3D map of the operative field with the ability to hold AR images after semi-automatic overlay. This technology has the ability to track an object or a space without any prior knowledge in real-time using only visual information from a camera30 (ESM) algorithm for precise tracking. When a camera moves fast, the correspondence search often fails due to the large search range. To overcome this problem, the input image is configured into a four-level image pyramid and the smallest image is utilized in the coarse step where a rotation of only 3-DoF pose is calculated quickly between contiguous images via the ESM algorithm. The rough 3-DoF pose reduces the correspondence search range in the fine step, where the small image patches tagged with 3D coordinate are searched on the input image via the ESM algorithm. The ESM algorithm matches quickly between the two images and shows sub-pixel matching accuracy. The software used in this study is free for public use, except for MAXST AR SDK which was used to overlay AR images onto the robotic surgery view. Clinicians without knowledge of bioengineering can use the software.To apply SALM in this study, the surgeon moved the robotic camera continuously for about 5-10 seconds at various angles to create an initial 3D point map. Then, the vision-based tracking system was applied for AR images to follow camera movement in line with the actual organs, in real-time. This method employs a coarse-to-fine strategy to cope with motion blur or fast movement of a camera and efficient second-order minimizationThe distance between the center point of the AR image of the RLN and that of the actual RLN was measured using the Root Mean Squared Error (RMSE) approach. For the pixel unit to mm unit conversion, the width of the surgical instrument was pre-measured in millimeters and matched to the width of the surgical instrument in pixel units which appeared on the monitor. The measured width of the surgical instrument was 5 mm, and the pixel unit on the screen could be converted into mm unit regardless of camera magnification. Figure Supplementary information.Supplementary Video S1


As with other receptors, the detection and degree of inverse agonism depend on the cells and tissues under investigation, i.e., they are greatest when the model has a high intrinsic tone/constitutive activity for the response being studied. Accordingly, they may differ between parts of a tissue, for instance, atria vs. ventricles of the heart, and within a cell type, between cellular responses. The basal tone of endogenously expressed receptors is often low, leading to less consistent detection and a lesser extent of observed inverse agonism. Extent inverse agonism depends on specific molecular properties of a compound, but inverse agonism appears to be more common in certain chemical classes. While inverse agonism is a fascinating facet in attempts to mechanistically understand observed drug effects, we are skeptical whether an a priori definition of the extent of inverse agonism in the target product profile of a developmental candidate is a meaningful option in drug discovery and development.As many, if not most, ligands at G protein-coupled receptor antagonists are inverse agonists, we systematically reviewed inverse agonism at the nine adrenoceptor subtypes. Except for β Wh. Wh15]. 2-AR upregulation to study IA. This was observed with betaxolol in NG 108-15 cells transfected with a CAM and to a lesser extent, when transfected with a WT receptor, whereas this was not seen with alprenolol with either [s protein or mRNA, and depended on de novo protein synthesis. Additional studies from the same group confirmed the upregulation and demonstrated that it could be prevented by the neutral antagonists dihydroalprenolol and propranolol [2-AR was also shown in transfected HEK cells for betaxolol, diyhydroalprenolol, ICI 118,551, or labetalol [Several studies have used βh either . Interespranolol . Upregulabetalol ; for betabetalol ; and forabetalol . In H9C2abetalol .1-, α2-, or β-ARs as a subfamily, but less so to directly link it to a specific subtype within a subfamily. Another limitation largely applicable to the in vivo studies is the difficulty of understanding whether a given response opposite to that of an agonist can be attributed to IA or alternatively explained by classic antagonism of endogenously present agonists [Studies with isolated tissues and in vivo are particularly important in two ways: Firstly, they allow researchers to study tissue or whole organism consequences of IA, and secondly, by exploring responses with direct physiological relevance, they are more likely to be representative for effects related to a therapeutic situation if endogenously expressed receptors are studied. However, a key limitation of most of these studies is that employed tools typically allow researchers to assign IA to αagonists ,93; thisagonists  in which2+ stores in rat aorta strips [2+-free medium to deplete internal Ca2+ stores; after refilling of the intracellular stores, spontaneous increases in resting tone were observed, which were inhibited by antagonists such as benoxathian and WB 4101 in the absence of agonists.One of the earliest reports on IA at AR in a complex physiological system was based on indirectly measuring the depletion of intracellular Caa strips  and this+-induced contractions in the guinea pig ileum and left atrium, but not in the aorta, whereas various Ca2+-channel inhibitors exhibited comparable inhibition in all three tissues [1-AR as an underlying mechanism was not provided.In an isolated rat cervix, WB 4101 concentration-dependently increased GTPγS binding and increased tone, with both being modified by the day of pregnancy . Phentol tissues ; unequiv1-AR agonists methoxamine and the α1A-selective A 61603 facilitated Ca2+-mediated persistent inward currents and produced muscle spasms both in vivo and in vitro, whereas in vivo recorded spasms were inhibited by WB 4101, prazosin, and Rec 15/2739 in the absence of agonists [1A- but not α1B-AR exhibited antidepressant-like behavior in the tail suspension test and forced swim test [Other investigators have explored the possible involvement of IA in synaptic transmission and other CNS functions. In rat cardiac vagal neurons, prazosin reduced the frequency of GABAergic and glycinergic neurotransmission, whereas phenylephrine increased it ; howeveragonists . In contwim test , which wwim test .1-AR. While some in vivo data applying known inverse agonists are compatible with this view, the study designs did not allow unequivocal differentiation between IA and the antagonism of endogenous neurotransmitters in most cases.In conclusion, data from isolated tissues are highly suggestive of the possibility of observing IA with natively expressed α2-AR, in most cases not providing conclusive evidence that the observed effects are mediated by IA. In cultured human meibomian gland epithelial cells, the α2-AR agonists brimonidine and clonidine promoted differentiation and inhibited proliferation, whereas RX 821002 and MK 912 failed to inhibit this and, if anything, acted as partial agonists on differentiation [2-AR agonists clonidine and dexmedetomidine enhanced tumor growth, which was inhibited by yohimbine and rauwolscine; in the absence of clonidine, rauwolscine reduced tumor growth, with yohimbine having a smaller and inconclusive effect [Only a few in vivo reports relate to IA at αntiation . In micee effect .2-AR ligands on the inhibition of food intake in rats by sibutramine or bupropion. Imiloxan, atipamezole, BRL 44408, and RX 821002 alone did not affect the food intake at the chosen doses [2-AR antagonists were studied in conjunction with bupropion [2-AR subtype recognition profiles of the antagonists. In rats with chronic spinal cord injury, clonidine and UK14303 decreased excitatory postsynaptic potentials, whereas RX 821002 increased them [Others have investigated the effects of αen doses . Atipamesed them .The role of IA has been investigated more often in the heart than in any other tissue. Studies were based on isolated tissues or performed in vivo in healthy animals with endogenously expressed receptors ,90,101 o2-selective ICI 118,551 has consistently been reported to be an inverse agonist at β2-AR (see above), several investigators reported the lowering of cAMP formation by ICI 118,551 in most studies with cardiac tissue from mice transgenic for the WT receptor [1/β2-double KO mice transfected with either a β2-AR or β1/β2 chimeric receptor (but not with a β1-AR) [2-AR [Signal transduction in the heart has mostly been studied as cAMP formation. As the βreceptor ,112,114;a β1-AR) ,103; anda β1-AR) ,110,112,a β1-AR) ,114 witha β1-AR) ; howevera β1-AR) . The inf2-AR in comparison to control animals. Initial studies reported greater Ca2+ sparks in the transgenic mice, which was normalized by ICI 118,551 [2+ channel were found to be unaltered and not affected by ICI 118,551 [2+ channel in transgenic mice, they also failed to observe IA by ICI 118,551 in this model [f current was markedly enhanced in the transgenic mice and, in contrast to the Ca2+ channel activity, shifted towards values observed in WT mice by ICI 118,551 [2+ transients in WT mice, but reduce it in transgenic animals [Several investigators have explored spontaneous activity and IA, predominantly by using transgenic mice overexpressing WT β 118,551 . In cont 118,551 . While ois model . That gr 118,551 . Based o 118,551  predicte animals .2-AR [1-AR [2-AR and/or Gi [Many investigators have explored possible IA in cardiac contraction and, more rarely, relaxation . Such st2-AR ,112,114 AR [1-AR , and somnd/or Gi ,103,104.nd/or Gi . Some annd/or Gi  and mostnd/or Gi ,117.2-AR, multiple groups independently reported that ICI 118,551 reduced basal cardiomyocyte contraction [i by pertussis toxin. In line with this, it was also reported that the overexpression of β2-AR in rabbit cardiomyocytes or Gi in rat cardiomyocytes allowed the detection of IA by ICI 118,551 [1/β2 double KO mice transfected with β1-AR, β2-AR, or chimeras thereof [2-AR, the inhibition of basal contraction was observed with ICI 118,551, but not with CGP 20,712 or propranolol; inhibition by ICI was also observed upon transfection with the chimeric receptor, but not with the β1-AR. In contrast to an observation by others [In studies with transgenic expression of the βtraction ,113,114. 118,551 . Similar 118,551 . Others  thereof ,103: Upoy others , the IA y others .2-AR, reductions of the basal cardiomyocyte tone were not detected in cardiomyocytes from WT mice [While these studies demonstrate that IA is detectable for cardiomyocyte contraction if the basal tone of the system is increased by an enhanced expression of receptor or G proteins, the clinically more relevant question is whether this also applies in the absence of such enhancement of the basal tone. In contrast to the above study with transgenic expression of the β WT mice ,114 or,  WT mice ,106. The WT mice . However WT mice . One gro WT mice ,120. In 1-AR gene polymorphism [389 subjects than in those carrying at least one Gly389 allele; in a mixed group of failing and non-failing hearts, carvedilol behaved as a neutral antagonist, whereas bucindolol was neutral in Gly389 carriers, but elicited a negative inotropic response in homozygous Arg389 subjects.Studies on IA in human hearts have involved failing heart samples, mixed groups of failing, and non-failing hearts, or parallel investigations of both. One group reported that metoprolol, but not carvedilol or bucindolol, reduced isoprenaline-induced contraction in failing human hearts to levels lower than the baseline . In a fomorphism . Isopren2-AR for 4 days [i in the heart of the transgenic mice, increased Gs, and further increased GRK2. In WT mice, neither affected Gi, and only ICI 118,551 increased Gs, but ICI 118,551, propranolol, and carvedilol increased GRK2, whereas alprenolol had no effect on any of the three proteins. In line with this pattern of altered protein expression, treatment with ICI 118,551, carvedilol, and propranolol increased the basal tension of isolated atria by 150, 141, and 129 mg compared to 96 mg in non-treated mice; tension in alprenolol-treated animals was 90 mg. The acute addition of ICI 118,551 reduced atrial tension, and this effect was markedly greater than in historical controls [2-AR transgenic mice was reduced to WT levels by all three ligands. The increased GRK2 expression levels in transgenic mice was lowered by treatment with alprenolol or carvedilol, but not with ICI 118,551; in contrast, only carvedilol increased GRK2 expression levels in WT mice. The increase in basal atrial tension in transgenic mice upon treatment with ICI 118,551 or carvedilol [2-AR and antagonism at β1-AR.Applying a very different approach, the group of Bond from Houston, TX, did not acutely add inverse agonists, but rather administered them for multiple days or weeks. In an initial study, alprenolol, carvedilol, ICI 118,551, or propranolol were given to WT and mice with transgenic overexpression of the βr 4 days . ICI 118controls . In a focontrols . Cardiacrvedilol  was not rvedilol . The autrvedilol . Myocard1-AR exhibited a greater spontaneous beating right of isolated right atria [2-AR [2-AR induced conduction blocks in the murine heart; however, it remains unclear whether this can be attributed to IA because ICI 118,551 did not enhance, but rather reverse, this [A possible role of IA at β-AR has also been explored for the regulation of chronotropy and cardiac conduction. Mice with the heart-specific transgenic overexpression of βht atria . The incia [2-AR . A diffese, this .2-AR and a reduced expression of several proteins involved in the regulation of bronchial tone, including Gi, phosphodiesterase 4D, and phospholipase C-β1. However, these findings did not allow a clear conclusion on the possible involvement of IA in the observed effects of ICI 118,551 and nadolol. To obtain further evidence, the asthma model was applied to WT and β2-AR knock-out mice [2-AR to directly compare the acute and chronic effects of nadolol [2-AR protein kinase A site Ser262, whereas prolonged exposure increased it. Chronic exposure to nadolol also increased β2-AR protein levels and decreased receptor degradation, consistent with receptor stabilization by the inverse agonist; it also increased cellular levels of Gαs, but had no effect on Gαi. Overall, these observations in HEK293 cells were consistent with those in the murine asthma model and lend additional support to the involvement of IA in the observed bronchoprotective effects.Although studied to a lesser extent than in the heart, IA at β-AR has also been explored in the airways, largely by two groups of investigators. The Bond group from Houston, TX, initially showed that the treatment of mice with nadolol or ICI 118,551, but not with metoprolol, had a protective effect on the ovalbumin-induced airway hypersensitivity model of asthma . This waout mice . The knoout mice . Finally nadolol . Basal csc) current in Calu-3 human airway adenocarcinoma cells, whereas carvedilol decreased under basal conditions and after stimulation with a cAMP-mimetic [The group of Zaagsma and Meurs from Groningen, The Netherlands, used bovine tracheal smooth muscle strips and found that an 18 h treatment with fenoterol reduced airway contractility; when various antagonists were added after the fenoterol treatment , they restored airway contractility with a rank order of efficacy of pindolol ≥ timolol = propranolol > alprenolol ≥ sotalol > labetalol . Of note-mimetic . The car2+-activated K+ channel iKCa1 to cause hyperpolarization and enhancement of both Ca2+ influx and degranulation. While salbutamol inhibited iKCa1 currents, ICI 118,551 opened such channels [2-AR, but definitive evidence was not provided.Inflammatory cells play important roles in the pathophysiology of obstructive airway disease. IgE-dependent activation of human mast cells opened the intermediate conductance Cachannels . In antichannels . However2-AR, it was reported that CGP 20,712 or the combination of CGP 20,712 with ICI 118,551  reduced cAMP formation in rat pituitary cell aggregates, whereas either compound alone inhibited the stimulatory effects of isoprenaline [Unrelated to airways or βrenaline . The inh2-AR as a model system. The first crystal structures were obtained by locking the receptor into an immobile state, supported by binding to the inverse agonist carazolol [Advances in the structural exploration of receptor conformations and ligand-induced changes thereof since the mid-2000s have enabled an improved understanding of inverse agonism and its relationship to agonism. Much of this work has been done using the βarazolol ,129. Strarazolol  or ‘oppoarazolol ,131,132 arazolol . Structuarazolol  and, morarazolol . Anotherarazolol . An IA-iarazolol .Crystallization data also enables computational prediction of the degree of (inverse) agonism ,139. It NMR spectroscopy has been reported to map three , and mol2-ARs, different Gs protein species select for different receptor activity levels, thereby leading to a different potential for action, and action, of inverse agonists [2-ARs [At βagonists ,84. Moreagonists . The actagonists ,80. Simis [2-ARs —this may2-ARs [s vs. Gi signaling [Receptor expression levels can change the apparent properties of ligands  . Convers2-ARs . Inverse2-ARs  and gene2-ARs  propertiignaling . Similarignaling .Agonists and inverse agonists may be able to stabilize different multimolecular complexes, e.g., receptor monomers vs. dimers . G prote2-AR having been studied the most frequently and b3-AR apparently not having been studied at all. This has led to a heterogenous robustness of the existing evidence, but some common themes have emerged. The detected IA at a given subtype and model system varies between compounds, but some chemical compound classes may intrinsically exhibit greater IA than others. For instance, quinazolines appear to exhibit a greater degree of IA at α1A- and α1B-AR than N-arylpiperazines (The degree of investigation of IA at AR subtypes differs markedly, particularly at the level of endogenously expressed receptors at the tissue level, with βerazines . However1-AR gene polymorphism [1- over β2-AR and biased agonism. Another pathophysiological example is obstructive airway disease, particularly asthma. While the use of β-AR antagonists is classically considered contra-indicated in asthma patients, it has been shown that slow up-titration is well-tolerated in asthmatic patients and may even have beneficial effects [IA is best observed when the tone of the system is increased, for instance, by the overexpression of the receptor, presence of a CAM, or increased expression of the coupled G protein . Accordimorphism ,102. As morphism . However effects . As β-AR effects , it has  effects . However effects .Based on all of the above, the question emerges of whether IA should play a role in drug discovery and provide a development perspective, e.g., as part of a target product profile for new compounds. Whether IA is a potential therapeutic strategy or just a pharmacological curiosity has been debated since the early days of IA research ,158. A p


These data revealed the oncogenic of lnc‐ATB and provided a novel biomarker for OC diagnosis. Furthermore, these findings indicated the mechanism of lnc‐ATB functioning in the progression of OC, which provided a new target for OC therapy.Ovarian cancer (OC) remains one of the most lethal gynecological malignancies. The unfavourable prognosis is mainly due to the lack of early‐stage diagnosis, drug resistance and recurrence. Therefore, it needs to investigate the mechanism of OC tumorigenesis and identify effective biomarkers for the clinical diagnosis. It is reported that long noncoding RNAs (lncRNAs) play important roles during the tumorigenesis of OC. Therefore, the present study aimed to study the role and clinical significance of LncRNAs ATB (lnc‐ATB) in the development and progression of OC. In our research, lnc‐ATB expression in OC tissues was elevated compared with adjacent normal tissues and high expression of lnc‐ATB was associated with poor outcomes of OC patients. The silencing of lnc‐ATB blocked cell proliferation, invasion and migration in SKOV3 and A2780 cells. RNA immunoprecipitation and RNA pull‐down results showed that lnc‐ATB positively regulated the expression of EZH2 via directly interacting with EZH2. Besides, the overexpression of EZH2 partly rescued lnc‐ATB silencing‐inducing inhibition of cell proliferation, invasion and migration. Chromatin immunoprecipitation assay results demonstrated that the silencing of lnc‐ATB reduced the occupancy of  These findings revealed that lnc‐ATB exerted as an oncogene and provided the mechanism by which lnc‐ATB promotes the progression of ovarian cancer, which shed a new light for OC therapy.Enhancer of zeste homolog 2 (EZH2) is a histone H3 lysine 27‐specific methyltransferase (H3K27me) of the polycomb repressive complex 2 (PRC2).22.1A total of 80 pairs of OC tissues and adjacent non‐tumour tissues were extracted from patients who had undergone surgical resections or biopsies at Shengli Oilfield Central Hospital. No patients received hormone therapy, chemotherapy or radiotherapy before the current study. All specimens were evaluated by at least two pathologists according to the WHO classification. Each patient signed an informed consent form. This study was approved by the Ethics Committee of Shengli Oilfield Central Hospital. Fresh tissue samples were immediately placed in a liquid nitrogen tank for follow‐up experiments.2.22. Negative control (NC) and Lnc‐ATB siRNAs were synthesized by Sangon . The sequences against Lnc‐ATB and NC were as follows: si‐lnc‐ATB#1, 5'‐CUGUGUAGUUGUUUGUUAACU‐3'; si‐lnc‐ATB#2, 5'‐GCUGUGCAGUCUCAGGUUAGG‐3'; NC siRNA sense, 5'‑AGCAUGCAU GAGUACCCAGCC‑3'. The open reading frame of EZH2 was inserted into pcDNA3.1 (pcDNA3.1‐EZH2) for EZH2 overexpression. Cells were transfected with siRNAs or pcDNA3.1‐EZH2 by using RNAiMAX or Lipofectamine 3000  according to the manufacturer's instruction. After transfection for the indicated time, the cells were harvested for further experiments.The normal human ovarian epithelial cell , ovarian cancer cell lines SKOV3 (BNCC310551), A2780 (BNCC341157), IGROV1 (BNCC342341) and ES‐2 (BNCC100168) were purchased from BeNa Culture Collection . Ovarian cell line OV2008 (CL1349) was obtained from the Institute of Biochemistry and Cell Biology of the Chinese Academy of Sciences . Cells were incubated with RPMI‐1640 medium containing 10% foetal bovine serum, 1% penicillin/streptomycin at 37°C in a humidified chamber supplemented with 5% CO2.3Cells were seeded into 96‐well plates at the density of 3000 cells/well after the IncRNA‐ATB siRNA and NC siRNA transfection. After 0, 24, 48, 72 and 96 hours, 20 μL of CCK8 reagent was added into each well. After 2 hours at 37°C, the absorbance was measured at a wavelength of 490 nm on an automatic microplate reader (Dynex Technologies). Three independent experiments were repeated.2.4For the colony formation assay, 300 cells were seeded into 6‐well plates after the transfection of LncRNA‐ATB or NC siRNAs. After 10 d, cells were fixed with methanol for 10 minutes at room temperature and stained with 0.5% crystal violet solution (Beyotime Institute of Biotechnology) for 30 minutes at room temperature. Colonies were observed under an Olympus microscope, and the number of colonies was recorded.2.54) in 200 μL of serum‐free RPMI‐1640 medium, whereas, RPMI‐1640 containing 10% FBS was added to the lower chamber. After 36 hours, migrated or invasive cells were fixed with methanol and stained with 1% crystal violet for 20 minutes. The numbers of migrated or invasive cells were calculated from five random fields by using a light microscope . Experiments were carried out independently in triplicate. For cell invasion assay, the upper chamber was pre‐coated with Matrigel (Millipore).Transwell chamber inserts (8.0 mm) were used for cell migration and invasion assays according to the manufacture's protocol. Briefly, the upper chamber was seeded with NC siRNA or LncRNA‐ATB siRNA‐transfected cells , and the concentration of proteins was calculated by a BCA protein assay kit (Beyotime Institute of Biotechnology). An equal amount of proteins (20 μg/lane) was subjected to 12% SDS‐PAGE, followed by an electrophoretic transfer onto a polyvinylidene fluoride membrane. After being blocked with 5% non‐fat milk dissolved in Tris‐buffered saline containing 0.1% Tween‐20 (TBST) for 1 hour at room temperature, membranes were incubated with rabbit polyclonal antibodies against EZH2  or β‐actin  overnight at 4°C. The next morning, membranes were washed with TBST three times and probed with horseradish peroxidase‐conjugated (HRP) goat anti‐rabbit IgG H & L secondary antibody  for 1 hour at 37°C. After being washed with TBST, immunoreactive bands were developed by enhanced chemiluminescence (Beyotime Institute of Biotechnology) and the grey values of each blot were calculated by ImageJ version 1.50 . The relative expression of the target protein was calculated by normalization to β‐actin.2.72) for 20 minutes at room temperature. Then, 107 cells were lysed with 2 mL nuclear separation buffer and 6 mL H2O on ice for 20 minutes. After being centrifuged, the nuclear fraction was resuspended with 1 mL RIP buffer and homogenized 20 minutes. Streptavidin‐agarose beads (Sigma) were incubated with the supernatant for 1 hour and incubated with 5× loading buffer at 95°C for 5 minutes. The specificity of the RNA pull‐down was assessed using Western blot analysis.Biotin‐labelled RNAs were synthesized using Biotin RNA labelling Mix (Roche) and T7 RNA polymerase (Promega), treated with RNase‐free DNase I (Promega) and purified with RNeasy Mini Kit (Qiangen). Next, 3 μg of biotin‐labelled RNAs was mixed with RNA structure buffer  according to the manufacturer's protocol. The RNA concentration and quality were determined by A260/A280 by using a Nanodrop Spectrophotometer (IMPLEN GmbH). The first stranded cDNA was transcribed by using Super M‐MLV reverse transcriptase (BioTeke Corporation). RT‐qPCR was carried out by using Maxima SYBR Green/ROX qPCR Master Mix (Thermo Fisher Scientific) in an ABI 7500 Real‐Time PCR system (Applied Biosystems). PCR reaction conditions were as follows: 95°C for 50 seconds, followed by 40 cycles of 95°C for 15 seconds and 60°C for 45 seconds. The primers for RT‐qPCR were listed as follows: LncRNA‐ATB forward primer; 5′‐ggcaggtagaaaagtcggct‐3′, reverse primer: 5′‐tggaaagagtgggaaggatt‐3′; β‐actin forward primer: 5′‐cttagttgcgttacaccctttcttg‐3′, reverse primer: 5′‐ctgtcaccttcaccgttccagttt‐3′. The relative expression of target genes was normalized to 2.9RNA immunoprecipitation was carried out by using the EZ‐Magna RIP RNA‐binding protein immunoprecipitation kit  according to the protocol. Cells were transfected with NC siRNA or LncRNA‐ATB siRNA and then lysed by RIP buffer. The collected supernatant was divided into two equal parts. A portion of the supernatant was analysed by Western blot analysis and RT‐qPCR to examine endogenous protein content. The other was treated with RIP buffer containing magnetic beads conjugated with anti‐EZH2 antibody or rabbit immunoglobulin G  at 4°C overnight. After instantaneous centrifugation, the supernatant was discarded. After six washes, the eluted samples were digested with 0.5 mg/mL proteinase K at 55°C for 30 minutes to detach the protein, and Trizol‐chloroform was employed to extract the immunoprecipitated RNA. Purified RNA was used for RT‐qPCR analysis.2.10ChIP was carried out by using EZ‐Magna ChIP TMA kits (Millipore) according to the manufacture's protocol. Cells were cross‐linked with 1% formaldehyde for 10 minutes and quenched with 125 mmol/L glycine for 5 minutes. Fixed cells were resuspended with cell lysis buffer  with the mixture of protease inhibitors for 10 minutes on ice. After washes, the lysates were resuspended with sonication buffer and cracked with ultrasound to cut chromatin fragments into 200‐1000 bp. Protein A Agarose/Salmon Sperm DNA was added into the supernatant diluted with ChIP Dilution Buffer. After centrifugation, the supernatant was extracted and incubated with antibodies against EZH2, H3K27me3 , or IgG for immunoprecipitation overnight. DNA fragments in the immunoprecipitated complex were calculated by RT‐qPCR analysis. The input was used as the control and the relative signals in target groups were compared with the signal of the control IgG group.2.112O2 solution and captured with an inverted microscope . EZH2‐positive cells were stained in brown or dark nankeen.The sections of the tumour and adjacent non‐tumour tissues were fixed in 4% cold paraformaldehyde and cut into 3‐5 μm thickness. Sections were treated with 3% hydrogen peroxide in methanol at room temperature for 20 minutes for the blockage of the activity of endoperoxidase. After 3% BSA blockage, sections were incubated with rabbit polyclonal anti‐EZH2 antibody  at 4°C overnight. The next morning, the sections were incubated with goat anti‐rabbit IgG H & L (HRP) secondary antibody  for 1 hour at 37°C. After being washed with PBS, signals from five non‐overlapped high‐powered fields were developed with diaminobenzidine‐H2.12t test. Kaplan‐Meier survival analysis was used to evaluate overall survival, and differences in survival between the curves were analysed with the two‐sided log‐rank test. Data among multiple groups were compared using one‐way analysis of variance. The Pearson correlation was used to analyse the relationship between Lnc‐ATB and EZH2. A value of P < .05 was considered statistically significant.Data were presented as mean ± standard deviation (SD). Each experiment was repeated at least three times. All statistical analysis was performed with SPSS 18.0 . The comparison of the expression level of LncRNA‐ATB between OC and adjacent non‐tumour tissues was performed by using Student's 33.1P < .01, Figure P < .01, Figure t test. As shown in Figure P = .0467). These results showed that lnc‐ATB is highly expressed in OC tissues and cells, and the up‐regulation expression predicts poor outcome of OC patients.To explore the potential function of lnc‐ATB in the progression of ovarian cancer, we determined lnc‐ATB expression levels in 80 pairs of ovarian tumour and adjacent non‐tumour tissues by RT‐qPCR. Compared with adjacent non‐tumour tissues, lnc‐ATB expression levels in OC tissues were significantly enhanced (3.2P < .01), suggesting lnc‐ATB was successfully knocked down. As shown in Figure P < .01, Figure To further identify the biological functions of lnc‐ATB in OC, we transfected SKOV3 and A2780 cells with synthesized NC or lnc‐ATB siRNAs and performed CCK‐8, colony formation, and Transwell assays. RT‐qPCR results showed that the transfection of lnc‐ATB siRNAs (si‐lnc‐ATB #1 or si‐lnc‐ATB #2) into SKOV3 and A2780 cells significantly inhibited the expression of lnc‐ATB compared with NC siRNA transfection in Figure 3.3http://pridb.gdcb.iastate.edu/RPISeq/) and found the relationship between lnc‐ATB and the sequence of EZH2. RIP assay results showed that the enrichment level of lnc‐ATB in the EZH2 antibody group was higher than that in control group, further verifying the binding relationship between EZH2 and lnc‐ATB  and suppressor of zeste 12 (SUZ12).CDX1, FOXC1, LATS2, CDH1 and DAB2IP genes, leading to the trimethylation of H3K27 and the inhibition of tumour suppressors CDX1, FOXC1, LATS2, CDH1 and DAB2IP expression. That is to say, lnc‐ATB promotes OC progression by the blockage of CDX1, FOXC1, LATS2, CDH1 and DAB2IP via EZH2‐mediated epigenetic silencing (Figure In summary, lnc‐ATB is overexpressed in OC, and high expression of lnc‐ATB is correlated with the progression of OC. Besides, lnc‐ATB directly binds to EZH2 and mediates its accumulation at the promoter region of g Figure . These fAll authors declare no conflicts of interest in this work.


The aim of the present analysis is to compare the quantitative angiographic aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) among three balloon-expandable valves.Quantitative videodensitometric aortography is an objective, accurate, and reproducible tool for adjudication of AR following TAVI.This is a retrospective corelab analysis, independent from industry, of aortograms from patients treated with TAVI using the balloon-expandable Myval transcatheter heart valve (THV) , Sapien 3, and XT THVs . The study comprised of 108 analyzable aortograms from consecutive patients in a multicenter European registry who underwent Myval THV implantation. The results of quantitative assessment of AR in the Sapien 3 THV (n = 397) and Sapien XT THV (n = 239) were retrieved from a published pooled database.The Myval THV had the lowest proportion of patients with moderate or severe angiographic quantitative AR (2.8%) compared to the Sapien 3 THV  and Sapien XT THV . Furthermore, the Myval THV had the lowest mean angiographic quantitative AR (6.3 ± 6.3%), followed by Sapien 3 THV (7.6 ± 7.1%) and Sapien XT THV (8.8 ± 7.5%), and it was significantly lower than that of the Sapien XT THV (p = 0.006), but not significantly different from Sapien 3 THV (p = 0.246).The Myval THV, in comparison with other BEV’s analyzed in our database, showed a lower occurrence of moderate or severe AR after TAVI. These results should be confirmed in prospective cohorts of randomized patients with head-to-head THV comparisons. Moderate or severe aortic regurgitation (AR) following transcatheter aortic valve implantation (TAVI) has been associated with increased short- and long-term mortality . In the Quantitative videodensitometric aortography is an objective, accurate, and reproducible tool for adjudication of AR following TAVI 678. The 67This is a retrospective corelab analysis, independent from industry, of aortography from patients treated with TAVI using the Myval THV, Sapien 3 THV, and Sapien XT THV. The CAAS A-valve 2.0.2  was used for assessment of quantitative angiographic AR. This method relies on the angiographic radiopaque density changes after contrast injection in the ascending aorta and its regurgitation (and subsequently density increase) in the left ventricular outflow tract (LVOT) 678. The 67Continuous variables were reported as mean ± standard deviations. Comparison of LVOT-AR was performed using one-way analysis of variance and 2-by-2 comparisons using the post-hoc Bonferroni test. Stratification of continuous variable regurgitation into categorical variables was performed according to the following pre-determined threshold criteria: 1) none or trace regurgitation (LVOT-AR <6%); 2) mild 6% to ≤17%); and 3) moderate or severe(>17%) [%; and 3)The cumulative frequency curves of LVOT-AR after TAVI for the three BEVs are shown in Panel The Myval THV, in comparison with other BEV’s analyzed in our database, showed a lower occurrence of moderate or severe AR after TAVI. This could be explained as follow: firstly, the internal skirt of the Myval THV on the valve frame prevents the bioprosthetic valve from inadvertent damage caused by native calcium spicules and also minimizes propensity for AR. Additionally, the external skirt further contributes to minimizing AR by facilitating the plugging of micro-channels at the THV anchor site. Finally, the Myval THV has additional intermediate and extra-large sizes to traditional sizes . The availability of nine THV size matrix might eliminate the need for potentially risky under- or oversizing, hence reducing AR after THV implantation. Our findings should be confirmed in prospective cohorts of randomized patients with head-to-head THV comparisons.in-vitro, in-vivo, and in the clinical setting [67ClinicalTrials.gov NCT04275726, EudraCT number 2020-000137-40) [The present study has several limitations. First, aortograms were not repeated in the follow-up, since the purpose of the present study was to investigate the acute performance of AR following TAVI using a guidance solely based on aortography. Second, the gold standard for AR assessment is still echocardiography. However, the quantitative videodensitometric aortographic assessment of AR following TAVI by the CAAS A-Valve software has been extensively vetted and validated  setting 678 and ietting 67. Finally0137-40) . This tr


Actinic reticuloid (AR)—a subtype of chronic actinic dermatitis—clinically and histopathologically shows lymphoma-like features. We report a male patient initially diagnosed with erythrodermic cutaneous T cell lymphoma (CTCL) who developed severe broadband photosensitivity. Clinical evaluation, histopathology, and phototesting were consistent with AR. The patient was treated with cyclosporine 150–300 mg/d. Under this therapy, he developed several times primary cutaneous anaplastic large cell lymphomas (C-ALCL) which in part tended to regress spontaneously under cyclosporine reduction. The association between cyclosporine treatment and development of C-ALCL and other CD30+ lymphoproliferative disorders has previously been reported in patients with atopic dermatitis, psoriasis, and transplant patients. In conclusion, the present case highlights the difficulties arising in the distinction between AR and CTCL and shows that long-term cyclosporine treatment may cause C-ALCL development in AR as well. It has been suggested that photosensitive disorders, including persistent light reaction, photosensitive atopic dermatitis, chronic photosensitivity dermatitis, and actinic reticuloid (AR), should be considered as one entity, so called chronic actinic dermatitis (CAD) , 2. This2 daily.We report a male patient with a history of atopic dermatitis and polyvalent type 1-hypersensitivity since childhood. When he was 46 years old, he had erythroderma, palmoplantar hyperkeratosis, alopecia, and lymphadenopathy. The histologic picture of several skin biopsies showed features of CTCL. Lymph node as well as bone marrow biopsy did not demonstrate evidence for lymphoma manifestation. He was initially treated with high-dose corticosteroids and extracorporeal photopheresis (11 cycles) followed by 9 cycles with liposomal-pegylated doxorubicin. Since he did not adequately respond to doxorubicin, his therapy was switched to bexarotene 150 mg/m2 UV-A; PUVA 180, Waldmann, Villingen-Schwenningen, Germany) did not reveal evidence for airborne contact dermatitis or photocontact allergy [At the age of 48 years, he noticed increasing UV sensitivity and worsening of his skin condition, in particular within the sun-exposed skin regions. Notably, he had less skin problems during winter. Clinically, he showed a similar picture as mentioned above. However, the grade of infiltration and induration of skin lesions had significantly increased including impressive tumor-like aggregated papules and nodes mainly affecting the sun-exposed areas . Histolo2) and UV-A (0.9 J/cm2) based on previously established lower reference limits of 33 mJ/cm2 and 12.6 J/cm2, respectively [After a brief warm-up period, the MED for broadband UV-B (280–320 nm) and broadband UV-A (320–400 nm) was determined with a compact previously commercially available phototest device . As generally recommended, phototesting was performed on healthy buttock skin . Twenty-d UV-A 0. J/cm2 baAt the age of 58 years, he re-attended our department because of new reddish ulcerated nodular lesions (3 × 5 cm in diameter) behind the left ear. Histology and immunohistochemistry was consistent with a CD30+ lymphoproliferative disorder. Given the large and polymorphic lymphocytes and the >90% CD30 positivity, a primary C-ALCL was favored. TCR rearrangement was positive. Tests for EBV were negative. Complete work-up including flow cytometry of peripheral blood, bone marrow biopsy, and thoracic/abdominal/pelvic computed tomography showed no evidence for systemic disease. The lesion could only be excised incompletely. Hence, postsurgery radiotherapy was performed. Five months later, he also developed reddish, partly ulcerated nodules on the scalp as well as upper right arm. Again, histology and immunohistochemistry confirmed the diagnosis of C-ALCL . Interesn = 231) with CAD, the development of genuine lymphomas was not significantly increased compared with the healthy population [As demonstrated by the present case, the action spectrum of CAD and AR is usually very broad, including UV-B, UV-A, and visible wavelength. Even though not tested in our photodermatology unit, our patient had a history for also being highly sensitive to visible light. The clinical and histopathologic features of AR are similar in nature to those of delayed-type hypersensitivity reaction of the allergic contact dermatitis type. For instance, the observation of increased numbers of cutaneous CD8+ T cells in AR indicates a delayed-type immunologic reaction against a cutaneous antigen  likely induced by UV radiation , 2. To dpulation  suggestepulation . The lonApart from the fact that AR is a serious mimicker of CTCL, the present case also highlights that patients who are under cyclosporine treatment for inflammatory skin disorders or other conditions are prone to develop C-ALCL. Most patients in such a clinical constellation had atopic dermatitis or psoriasis . MoreoveKirby et al.  describeIn conclusion, the present case highlights the difficulties arising in the distinction between AR and CTCL and shows that long-term cyclosporine treatment may cause C-ALCL development in AR as well.