Rehabilitation interventions are frequently cited as key in supporting frail older people’s recovery following periods of decompensation and acute ill-health. Clinicians are required to make decisions about a patient’s potential to respond to rehabilitation. ‘Rehabilitation potential’ decisions can determine access to services. In acute settings clinicians have limited time to assess and work with patients, families and carers. The complexities of ageing, recovery, rehabilitation and frailty may not be fully appreciated. This study aimed to explore multiple perspectives of the concept of rehabilitation potential and how it is assessed in older people living with frailty in the acute healthcare setting.Five focus groups with a purposive sample of 28 participants which included clinicians and members of the public were conducted. Analysis comprised a thematic approach using the Framework method.Rehabilitation potential was found to encapsulate a complex decision-making process where clinicians judged an individual’s ability to benefit from and participate in targeted rehabilitation. They asked, “Will it work?”, “Is it wanted?” and “Is it available?” In order to predict who would benefit from rehabilitation interventions, clinicians assessed a range of holistic clinical and non-clinical factors. An iterative approach to assessment delivered by a multi-disciplinary team, centred around patient and carer needs and wants was needed to accommodate complexity. Participants believed that everyone had some form of potential but this was dependent on availability of rehabilitation resources and conceptualisations of frailty and rehabilitation. Tensions between iterative approaches to rehabilitation potential assessment and the realities of rapid decision making in the acute hospital setting were found.Rehabilitation potential decisions involve a complex process of multidisciplinary decision-making and prognostication on the likely outcome and benefit from rehabilitation programmes. These findings lay the foundation for developing structured approaches to rehabilitation potential decision making tools and guidance. My potential is different from your potential. So I think it is person determined, activity determined.” [Physiotherapist five]Focus group threeCentral to the concept of rehabilitation potential was the notion of ‘will it work’. This theme described how participants made predictions about which patients would benefit from rehabilitation and how benefit was understood and measured. Rehabilitation potential was found to involve a complex process of prognostication and clinical judgement of which individuals would benefit from rehabilitation. Some participants held the belief that everyone had some form of potential, which was highly individualised and influenced by patients’ functional needs and wants. Therefore a unifying definition of rehabilitation potential was deemed to be less clinically useful.“Patients who have an acute event, hip fracture, stroke, they have potential to gain something but there are other patients that have chronic disease like heart failure, they have a sloped line.” Participants’ discussions around measuring rehabilitation benefit and potential lead to interesting and discordant insights into understanding rehabilitation outcomes. Some participants held the view that rehabilitation should always seek improvement with measurable gains in function and independence. Given the fine balance between dependence and independence, small gains were seen to be significant in supporting independent living and quality of life.“In terms of people's potential, I think it is about looking at how big that potential needs to be. So for some people it could be very small steps and it is not necessarily about them being able to do things for themselves that they can't do … can they adapt the way they do things, can they compensate and find different ways of doing things, to be able to have some purpose. [Occupational therapist four]I think that is a really good point … if they’ve got a life limiting illness, for example end stage heart failure, they don’t have the reserve to do lots and lots of rehab. Maybe all they need to be able to do is sit in a chair, have tea and watch TV. [Geriatrician  three]Yes that is rehabilitation; it is helping someone to manage their energy and to adapt to their environment.” [Occupational therapist four]Focus group threeHowever, other participants expressed the view that rehabilitation that sought to maintain, slow or manage the decline of abilities should be of equal value.“How do we distinguish between general decline and when somebody comes out of hospital what their potential is? Because obviously, you've got comorbidities that have an impact on function, it is a fine balance between what they also perceive as their potential. I often try and pin it down a bit more when I am taking their initial histories to okay, literally in the weeks following, the weeks prior to coming into hospital and you're feeling well what were you able to do?” Participants spoke of the challenges they faced in working out if change or improvement was feasible. They reported the need to understand underlying trajectories of diagnoses, disease progression and rehabilitation response.“You need carryover … it’s something you need to happen where we [patient and clinician] agree to a goal and work towards that goal. [Physiotherapist seven]Rehabilitation is not a half hour session on one day, rehabilitation takes days, weeks. [Physiotherapist six]Exactly, it’s iterative.” [Elderly Care Physician two]Focus group fourIterative approaches enabled the multi-disciplinary team to understand how benefit was measured or gains “carried-over” between assessments. This was said to provide invaluable information on the perceived success of rehabilitation programmes.“I just want to be educated … . I wanted to speak to someone that could tell me how I could achieve optimal health and well-being. I knew I couldn't be cured because two consultants had told me of the issues. [Member of public two]It’s the explanation. I was thinking about somebody who wanted to walk but you can’t walk until you’ve sat up. And trying to get that message across, that actually sitting on the side of the bed is the first goal before standing up.” [Occupational therapist three]Focus group twoDissonance was identified between professional and carer participants. Some believed only healthcare professionals could predict benefit, having greater experience of multi-morbidity, rehabilitation response and evidence in comparison to patients and their families. Patient and carer participants vehemently disagreed with this stating that they could understand what was achievable and realistic and hence influence understandings of rehabilitation potential, if adequate support and education were given; thereby empowering them to be equal partners in rehabilitation potential assessments and rehabilitation intervention delivery.They've had this acute event and they have been in bed for a week because they have had really bad pneumonia or whatever and they are already teetering on the edge of not doing much for themselves because they are used other people doing it for them … we haven’t given them a chance and that is constricted by the limitations of the time that you have.” “This theme considered the role of volition and motivation in establishing individuals’ rehabilitation potential. Rehabilitation was viewed as an active partnership which required a willingness to participate in order to gain benefit and desired outcomes. An understanding of an individual’s rehabilitation potential was said to emerge over multiple assessments and through trials of rehabilitation. Participants stated that an iterative approach allowed for complexity and fluctuations in function, which are common in frailty and dementia, to be understood, so that potentially life-changing decisions were not made at a single time point. This was particularly important during the acute phase when individuals were still undergoing medical treatment where assessments during this time were felt to produce an unfair representation of abilities.“There have been some situations when people have said that this particular individual may not be capable of rehabilitation or is at a stage of dementia that actually trying to rehabilitate them would not be appropriate because of lack of capacity, lack of ability and the disease itself actually impacting on that level of rehabilitation. [Nurse one]I am quite sure that this would apply to my mother-in-law who has Alzheimer’s and her brain has shrunken. She is frail and 90 and suffers from hallucinations and delirium. I would certainly say, but I’m still not sure why some effort could not be made to offer something that might enable her to function better. [Member of public four]I agree with you … as a clinician, if someone has dementia, sometimes it depends on the level of dementia, it is difficult for people with cognitive impairment to take this on board.” [Nurse one]Focus group fiveThis approach was said to be challenging in operationalise in the presence of cognitive impairment and communication difficulties.“[Referring to her mother] the hospital was adamant that they weren’t going to let her out until she could walk. We were told she wasn’t very compliant. She was adamant she wouldn’t walk in hospital and we tried very hard to tell the hospital that she would walk if she got out. They sent her home; she got out the ambulance and walked in.” Family members reported experiencing challenges when the notion of rehabilitation potential was linked to motivation or their relative’s involvement in rehabilitation assessments or programmes. This was found to be particularly pronounced in the presence of Alzheimer’s and other dementias when assessments were completed in the ‘artificial’ hospital environment.“I don’t try to assess someone on something that they don’t do regularly before. So, if they don’t drink hot drinks, I wouldn’t drag them to the kitchen. [Occupational therapist one]It’s about the context of it isn’t it because in hospital you are in the routine of the ward, it doesn’t fit with what maybe they are doing at home so they might not engage. [Occupational therapist two]That’s one nice thing about working in the community.” [Physiotherapist three]Focus group oneIndividualised assessments which considered individual patient needs, wants and abilities were believed to enhance motivation and participation. Some participants preferred such approaches over standardised assessments.“It isn’t individualised and so things can drop through … .because there was the tick box system of can she do this can she do that … a couple of questions to me of what is most important to you and I would have said my eyesight and then that should have set off actions to help me.” This view was echoed by carer participants who placed a high value on individualised and person-centred approaches to rehabilitation assessments but often reported that these were not experienced in the acute hospital setting.“Involve the family if it is appropriate, particularly if the person doesn't have the capacity, then the family become more important … you try and build up trust and build a relationship more so than you would normally.” “I would have appreciated being given advice to enable me to do more for myself … they should have listened to me when I said I was allergic to that medication but they didn’t.” Family involvement and support were seen as crucial in determining rehabilitation potential, particularly where patients lacked capacity and insight. Individuals with support from family or friends were viewed as more likely to make sustained gains in rehabilitation and continue with the intervention outside of allocated therapy time.“Some of it is about what we are prepared to invest in. So if we say everybody can make some improvement in their life, how much energy are we as a service going to put into the person or are we only bothered if it’s going to save some other resources for health or social care in the short term or preventatively in the long-term. Or do we see some value for that person … I find it difficult as a therapist because no matter how disabled you are at the time; you can probably improve. [Occupational therapist four]I am with you on that. But I think it goes round to be more business orientated than what we were initially established to be … I think we are losing that if the patient is a number … they should be classed as a person, looking at all aspects of that persons’ life.” [Physiotherapist five]It’s difficult though isn’t it? There aren’t infinite resources and I do believe, even as an OT that we’ve got to use resources wisely. How do you determine who’s got potential, where is the money going to be best spent, where are the efforts going to be best used?” [Occupational therapist five]Focus group threeAvailability of rehabilitation resources was found to be a critical component of rehabilitation potential. This theme described the challenges participants faced in accessing the type, intensity and availability of rehabilitation services available to patients and the ethical dilemmas in working with limited resources. Participants spoke of their belief that everyone should be given fair access to rehabilitation, regardless of age and diagnosis but that they faced dilemmas when working in systems where resources were limited. Some participants reported instances where they had not referred individuals whom they deemed unlikely to make significant gains to or participate in rehabilitation programmes but that they felt ambivalent about this.“It’s a lot of responsibility to make those decisions, especially with closed decisions between care home or last attempt for home.” This view was echoed by members of the public who judged that everyone should have fair access to rehabilitation and that some kind of benefit was, in most cases, achievable. However, rehabilitation that met individuals’ needs was not always readily available or provided at optimal intensity. Professional participants reported that this placed them under a great deal of pressure and led to ethical dilemmas when allocating rehabilitation in resource-limited systems which had fixed and frequently outdated notions and models of rehabilitation.“Is there a need for this service? Is there an evidence-base and how much does it cost? We have to weigh up with the pot of money we’ve got for the system and it goes on those things that are proven to work, where we know we are going to get the best bangs for our buck.” This view was expanded further through discussion with a commissioner who discussed how money was allocated within a pressured system.“Is it available? Yes, we are in a rationed system, but we should at least be open and honest and transparent. So, if we are saying we aren’t going to do it because it’s not available, let’s not say we’re not going to do it because the person can’t possibly benefit from it.” One geriatrician proposed that greater transparency was required in the decision-making process and how this was communicated with other healthcare professionals, patients, families and their carers.In some cases, this led to the patients being prematurely labelled as having no rehabilitation potential due to narrow understandings of what rehabilitation could achieve and a lack of in-depth assessments in the acute setting.This study found that the term rehabilitation potential was poorly defined in clinical practice and meant different things to different participants at different times. It involved predicting who would benefit from and participate with rehabilitation programmes and was driven by three main questions:” will it work?”, “is it wanted?” and “is it available?” Assessments of rehabilitation potential were found to be understood through holistic assessments completed over multiple time points by an experienced multi-disciplinary team with a focus on what was important to the patient.Assessments of rehabilitation potential have frequently taken a binary approach – patients either have or don’t have rehabilitation potential , 19, 39.Predicting recovery in older people living with frailty, and rehabilitation potential following a period of acute ill health, was found to be challenging. Cameron and Kurle  suggesteThis study found that motivation was a critical component of rehabilitation potential assessments. Motivation for rehabilitation influences participation and success in terms of physical function . It has Trials of rehabilitation which assessed patient participation, motivation and response were found to inform decisions on rehabilitation potential. This was found to be challenging amongst those with permanent or temporary cognitive impairment. In relation to people living with dementia, low rehabilitation potential and motivation have been suggested as significant factors for poor rehabilitation response and rehabilitation outcomes . GoodwinThis study suggests that clinicians also take into account the availability of rehabilitation resources when making decisions about rehabilitation potential in frail older people. These findings are consistent with other studies into rehabilitation potential in stroke, Acquired Brain Injury , 46 and Participants in this study spoke of the ethical dilemmas they encountered in navigating decision-making in frailty rehabilitation. This study found that participants respected decision-making capabilities of autonomous individuals but spoke of the challenges they faced when dealing with individuals with either permanent or temporary cognitive impairment. The importance of justice also featured strongly. Participants wrestled with the desire for equality of access to rehabilitation for their patients, regardless of age, cognition, degree of frailty or burden of comorbidity, but this was tempered by the knowledge that resources were limited and had to be rationed where need and benefit were perceived to be the greatest . Age-basStrengths of this study include the diversity of participants recruited to the focus groups, which increased the generalisability and transferability of the findings through wider insights into rehabilitation potential in different healthcare systems. However, the sample was biased towards professional participants which may have affected the strength of patient and carer representation in the data. Including the voice of patients and families, ensured that their important perspectives were included but we were unable to recruit any participants with cognitive or communication impairment. Transferability of findings could have been enhanced further by identifying professional participants years in practice and time working with geriatric patients.Skilled facilitation is an essential prerequisite for successful focus groups  and can The opportunistic recruitment of Elderly Care Physicians from the Netherlands, whilst working in different models of healthcare, revealed that rehabilitation potential was a concept not isolated to the UK and so the inclusion of Dutch participants increased the generalisability and transferability of the findings through wider insights into rehabilitation potential in different healthcare systems. Additionally, it provided the opportunity for deviant accounts and constructs of rehabilitation potential to be explored.This study suggests that rehabilitation potential encapsulates complex decision-making processes where clinicians, in partnership with patients, make clinical judgements on an individual’s ability to benefit from and participate in targeted rehabilitation programmes. Participants believed that everyone had some form of rehabilitation potential, but this was dependant on their conceptual understanding of rehabilitation and the availability of current rehabilitation interventions to meet individual needs. There was a sense that rehabilitation of sufficient intensity, duration and specialisation was not available to meet all patients’ needs. Ethical dilemma’s associated with resource availability and allocation featured strongly in participants’ responses and the challenges they faced in navigating these in the hospital setting and rationing of resources.This study provides a structure for rehabilitation potential decisions - “Will it work?”, “Is it wanted?” and “Is it available?” –and lays the foundation for guidelines or assessment tools which make such decisions more transparent and consistent. Future research should focus on the development of such structured approaches to decision-making about rehabilitation and analysing their effect on clinical practice and outcomes for patients.


In animal models flux via AR in hearts is increased by diabetes and ischemia and its inhibition protects diabetic and non-diabetic hearts from ischemia-reperfusion injury. In mouse models of diabetic atherosclerosis, human AR expression accelerates progression and impairs regression of atherosclerotic plaques. Genetic studies have revealed that single nucleotide polymorphisms (SNPs) of the ALD2 (human AR gene) is associated with diabetic complications, including cardiorenal complications. This Review presents current knowledge regarding the roles for AR in the causes and consequences of diabetic cardiovascular disease and the status of AR inhibitors in clinical trials. Studies from both human subjects and animal models are presented to highlight the breadth of evidence linking AR to the cardiovascular consequences of diabetes.Diabetes is a leading cause of cardiovascular morbidity and mortality. Despite numerous treatments for cardiovascular disease (CVD), for patients with diabetes, these therapies provide less benefit for protection from CVD. These considerations spur the concept that diabetes-specific, disease-modifying therapies are essential to identify especially as the diabetes epidemic continues to expand. In this context, high levels of blood glucose stimulate the flux  As the number of people with diabetes has increased, consequent increases in diabetic complications has been observed  events were not reduced , diabetes and cardiovascular disease are risk factors for severe adverse clinical outcome in COVID19 patients . EmerginIn this review, we will focus on aldose reductase (AR), its possible link to the cardiovascular complications of diabetes mellitus and the potential impact of pharmacological inhibition of AR on cardiovascular complications of diabetes.via the polyol pathway, cytoplasmic redox state, activity of specific isoforms of protein kinase C, in the glucosamine biosynthesis pathway, and production of glycating species are observed (One of the key mechanisms by which chronic hyperglycemia(CH) exerts its deleterious effects on CV tissue involves nonenzymatic glycation reactions of reducing sugars with free amino groups of proteins, DNA, and lipids. Amadori products formed by this reaction leads to the formation of advanced glycation end products (AGEs) –48. Thesobserved , 53–61.The present review mainly focuses on aldose reductase (AR), the first enzyme of the polyol pathway that regulates the uptake of excess glucose by the cardiovascular cells.Aldose reductase , a monomeric enzyme of ~35,900 Daltons, belongs to the aldo-keto reductase superfamily –67. The mK values for the above substrates are in the range of 8 to 50 µmol/L. For glucose, Inagaki et al. , approximately 18 kilobases (kb) long and includes ten exons coding for 316 amino acids, has been mapped to locus q35 on human chromosome 7 T polymorphisms are closely linked. Majority of studies have demonstrated an association between polymorphisms in the ALD2 gene and the increased risk for rapid onset or increased prevalence of diabetic complications. The “Z-2” (AC)23 microsatellite polymorphism has been associated with high expression levels of AR  for cytosolic NAD+  generation of intermediates to facilitate production of advanced glycation end product precursors –127, (b)ectively , 135. Thectively , 137, mavia its ability to regulate HDAC3 degradation and consequent activation of PPARγ.In addition to the enzymatic activity, two recent studies have revealed other functions for AR. First, our studies  showed tSecond, AR actions independent of its enzymatic activity were revealed in a study by Shimizu et al. . Using pAdding to the AR functional conundrum are data from mice devoid of AR . These AThough the physiological function of AR in normal cellular and organ physiology is unclear, the pathogenic role of AR as a key player mediating diabetic complications is well established. This review will focus on the pathogenic role of AR in diabetic cardiovascular complications.The presence and activity of AR in cardiac myocytes of rats and rabbits has been demonstrated in several studies, e.g., , 143–147via a histocompatibility gene promoter  was expressed promoter . These tpromoter . These hpromoter . AR inhipromoter . Studiespromoter Figure 2promoter . Increaspromoter . Attenuapromoter . Since MR hearts . These s+/NADH and increased protein kinase C α/β activity. These data  using the α-myosin heavy chain (MHC) promoter . Cardiomin vivo I/R injury model revealed that AR null mice was protected, in part, due to short term activation of the β-catenin pathway and subsequent increases in mesenchymal markers and fibrosis provoking genes  from human atherosclerotic plaques Ldlr (−/−)Apoe    and apolpoe−/−)   mice propoe−/−)  . Subsequ−/−Apoe mice and in human atherosclerotic carotid artery, AR is expressed in endothelial cells and this endothelial AR leads to endothelial dysfunction and increased expression of VCAM-1 and MMP-2  proliferation caused by balloon injury in animal models of restenosis. Studies have shown that AR inhibition prevents SMC growth in in animal models of restenosis –190. Stutivation . In additivation , as welltivation , and G1/tivation . These stivation –190.in vivo. Hydantoin class of ARIs inhibit both aldehyde and AR with comparable efficacies (AR inhibitors (ARIs) have been extensively reviewed in the literature, e.g., , 83, 192ficacies , thus lificacies , 197.The number of patents filed over the last 5 years demonstrates that, after decades of uncertainty, scientific interest in AR and its inhibitors has resurged. During the last 5 years, a number of synthetic compounds have been designed and patented as AR inhibitors, mainly belonging to the carboxylic-type class. Inspired by the well-known inhibitor zopolrestat, Mylari and co-workers designed a novel class of carboxylic acid inhibitors and its water-soluble formulations –201 to oInitial studies on AR inhibition attenuating injury and improving functional recovery after I/R in both diabetic and nondiabetic hearts generated considerable interest toward testing these molecules for diabetic heart disease , 204, anvia AR unambiguously confirm pathogenic role for AR in mediating diabetic complications. Importantly, data on genetic polymorphisms of ALD2 from around the globe indicate an association between “high AR” alleles and diabetic complications. The preclinical and clinical data reviewed above indicate that inhibiting AR could play a key role in our therapeutic strategy to prevent/arrest progression of diabetic cardiovascular complications. Recent development of potent AR inhibitors and new formulations has set the stage for successful clinical testing of these molecules in patients with diabetic cardiovascular complications.The DCCT, UKPDS, and prior ARI studies have indicated that relatively long clinical trials with focused recruitment strategies and end points will be needed to demonstrate efficacy on microvascular and macrovascular complications of diabetes. Focus on prevention or slowing of cardiovascular disease progression in diabetic patients should be the primary goal, not rapid reversal of disease endpoints. Despite developmental setbacks over the last two decades, preclinical and clinical evidence linking progression of diabetic cardiovascular complications and elevated flux SJ, MS, and RR wrote the first draft of the manuscript and completed all of the editing. GY and RR prepared figures. SJ, MS, GY, AS, and RR provided critical comments on the manuscript and edited the manuscript. All authors contributed to the article and approved the submitted version.AS and RR are supported, in part, by funds from the Diabetes Research Program, NYU Grossman School of Medicine and grants from the U.S. Public Health Service . SJ was supported by a training grant for medical students . RR is a consultant for Applied Therapeutics and receives funding from them for ARI studies.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


R2 = 1) was observed between the AR and spiked-in leukemia cells. On real patient data, AR kinetics was in line with the clinical evolution for five out of six patients. In conclusion, we present a convenient flow cytometry data analysis approach for the follow-up of hematological malignancies. Further evaluation and validation on more patient samples and different flow cytometry panels is required before implementation in clinical practice.Standardization, data mining techniques, and comparison to normality are changing the landscape of multiparameter flow cytometry in clinical hematology. On the basis of these principles, a strategy was developed for measurable residual disease (MRD) assessment. Herein, suspicious cell clusters are first identified at diagnosis using a clustering algorithm. Subsequently, automated multidimensional spaces, named “Clouds”, are created around these clusters on the basis of density calculations. This step identifies the immunophenotypic pattern of the suspicious cell clusters. Thereafter, using reference samples, the “Abnormality Ratio” (AR) of each Cloud is calculated, and major malignant Clouds are retained, known as “Leukemic Clouds” (L-Clouds). In follow-up samples, MRD is identified when more cells fall into a patient’s L-Cloud compared to reference samples (AR concept). This workflow was applied on simulated data and real-life leukemia flow cytometry data. On simulated data, strong patient-dependent positive correlation ( Multiparameter flow cytometry (MFC) is a powerful technology for cell phenotyping, capable of analyzing multiple parameters on millions of single cells in a short period of time . This teThe immunophenotypic follow-up of acute myeloid leukemia (AML) is a difficult topic, mainly given the important heterogeneity of the disease ,7,8. MulIn this study, we aimed to propose an original and more reproducible analysis strategy for the development of promising MFC biomarkers for disease-based MRD assessment. This strategy was applied to data from AML patients for creating patient-specific MRD models.For creating good models, the performance of a model must be optimized in regard to its objective. The objective of the present approach was to obtain a strategy that confers a very high positive predictive value (PPV) for relapse. Importantly, the interest of a model with high PPV would take the position of a first-line classification tool for MRD—positive tests would not require further testing for evaluating disease persistence, whereas negative tests would require further investigations.This study received the approval of the ethics committee of the University Hospital, CHU UCL Namur, Belgium (CE-164/2018)). Retrospective bone marrow MFC data from 6 AML patients at diagnosis (6 FCS (flow cytometry standard) files) and follow-up (46 FCS files) were used, as well as 20 reference patients (control group), thus yielding a total of 72 FCS files, from which an additional 36 simulated MRD FCS files were generated. All FCS files are available in open source in the k-nearest neighbor (KNN)-based algorithm using the Euclidean distances of transformed raw data (patent no. US10133962B2). For contour gating, kernel density estimation is used through the use of the “reference image” tool of the Infinicyt software. It allows delineating the position of a clustered cell population in two-dimensional spaces on the basis of density calculations. In this study, the largest possible kernel density estimation functions available were used (probability model with a resolution of 64 bins) according to the Infinicyt software.The algorithm presented in this study was developed using the Infinicyt software . Two data analysis methods were used consecutively: clustering and contour gating. In the Infinicyt software, clustering is based on cell density and a On the basis of the consecutive use of these two data analysis methods, three new concepts were described: the “Cloud”, the “Leukemic Cloud” or “L-Cloud”, and the “Abnormality Ratio” or “AR” . Briefly(a)From a diagnostic AML sample, clustering is used on MFC data to obtain cell clusters.(b)Suspicious cell cluster(s) are then identified on the basis of their aberrant immunophenotypic profile. These are usually CD45 low, with low SSC , and are(c)Once suspicious cell clusters are identified, “Cloud(s)” are created. A “Cloud” is created by the Boolean intersection of the contour gates of 45 bi-parametric plots .(d)Once a Cloud is created at diagnosis, its Abnormality Ratio (AR) can be calculated. The AR is calculated as follows: AR =  of patient sample)/ of control group sample). Note: If # Cloud cells = 0, use 1.(e)4 cells  at diagnosis will define a “Leukemic Cloud” or “L-Cloud”. Of note, if multiple Clouds of at least 5 × 103 cells have an AR of >1000 , all should be considered as L-Clouds. The Cloud with the highest AR and at least 1 × 104 cells will be considered the “the major L-Cloud”. MRD assessment at follow-up will be done through the AR calculation at follow-up of L-Clouds.The Cloud with the highest AR, formed by a cell cluster of at least 1 × 10The following workflow (AR/L-Cloud workflow) was then designed :(a)From * Cell cluster used to define the L-Cloud).For the theoretical evaluation, the “L-Cloud specificity” was defined by the number of cells of the reference samples falling outside an L-Cloud divided by the number of cells of the reference samples analyzed. “L-Cloud sensitivity” was defined by the number of cells from the “L-Cloud cell cluster”* falling into the L-Cloud divided by the number of cells contained into this same cluster.) out of the cell cluster defining the major L-Cloud of each AML patient. We thus obtained six FCS files, each containing 1 × 104 cells from the “major L-Cloud cell cluster”* (AML-FCS). (*Cell cluster used to define the major L-Cloud).Using the diagnostic FCS files of the six AML patients and the AR/L-Cloud workflow detailed above, 1 × 10Simulation of MRD samples6 cells were sampled (by bootstrapping in R (R-3.5.2)) and saved in a separate FCS file. We thus obtained one FCS file with a mixture of 1 million normal cells (NORM-FCS). Thereafter, simulated MRD was created by computationally spiking a decreasing number of randomly selected cells from the “major L-Cloud cell cluster”*  to the NORM-FCS file, that is, ≈0.5%, 0.1%, 0.05%, 0.01%, 0.005%, and 0.001% simulated MRD. All these simulated follow-up data were saved into separate FCS files, thus obtaining 36 FCS files. (*These cells were different than the cells of the AML-FCS files).First, the FCS files of the 20 reference samples were merged, and then 1 × 10Evaluation procedureL-Clouds were created using the AML-FCS files.Performance characteristics (specificity and sensitivity) of the different L-Clouds were calculated using the AML-FCS files and the NORM-FCS file.The AR was calculated for each of the 36 simulated follow-up data and compared to the expected theoretical results for each patient.For this endpoint, the AML-FCS files and the NORM-FCS file were used.Evaluation procedureUsing the Infinicyt software and the L-Clouds (based on the AML-FCS files), a forward selection was performed on the basis of the specificity value (using the NORM-FCS file) for all steps except the first one. First, the contour gate of the bi-parametric FSC-A/SSC-A graph was selected; the contour gates related to the other parameters were then introduced one at a time. At each step, the improvement in specificity was calculated for each remaining parameter and the one giving the highest improvement was selected. The process was repeated until all parameters were introduced. At this stage, the L-Cloud was not optimized in terms of sensitivity/specificity—no criteria were used to limit the inclusion of parameters and no backwards deletion was performed.For this endpoint, the diagnostic and follow-up MFC data of the 6 AML patients were used, as well as all the data from the 20 reference patients. Using the proposed AR/L-Cloud workflow, AR was calculated at diagnosis and for each follow-up time point. AR results were also evaluated with regard to clinical aspects (treatments) and compared with morphological (remission/blast percentage) and molecular information when available.R2 = 1). The mean sensitivity for the L-Clouds was 66.28%, whereas the specificity ranged from 99.9502% (patient 5) to 99.9999% (patient 4). The specificity had a major impact on AR outcome, ranging for example from 2.38 (patient 5) to 720.28 (patient 4) for the 0.1% MRD simulation.Results related to the theoretical evaluation of the AR/Cloud concepts (endpoint 1) are given in For patient 1, a decrease of AR was observed after induction therapy, yet remained >5, although morphological remission was obtained and MLL fusion transcripts became undetectable. At follow-up 6, 2 months after allogeneic stem cell transplantation (ASCT), the AR was 15, which can be considered quite high after curative therapy. At follow-up 7, relapse was characterized by 35% of blasts in morphological assessment and an AR of 463.2.For patient 2, AR also declined after therapy. The 1 log reduction of AR between follow-ups 3 and 4 while the patient was off-treatment may have represented long-lasting effects of chemotherapy or recovered anti-tumor immunity, although none of this was demonstrated. After ASCT, an AR < 1 was observed for the two major malignant cell clusters identified at diagnosis in this patient .For patient 3, a sharp decrease in AR was observed after induction therapy. AR was < 1 at the second follow-up. An increase of AR was, however, observed at follow-ups 3 and 4, before decreasing again after the initiation of anti-Wilm’s tumor 1 (WT1) vaccination.For patient 4, a decline in AR until follow-up 4 was observed. After ASCT, the AR fluctuated. For patients 3 and 4, the AR increase before consolidation therapy (AR > 20) may have contributed to the hypothesis that consolidation therapy (anti-WT1 vaccination for patient 3 and ASCT for patient 4) was essential to the patients’ respective treatments.For patient 5, the AR decreased after the first induction therapy and became <1 after the second induction therapy. The AR << 1 could be explained by the aplastic status of the bone marrow as assessed by morphological examination.For patient 6, a decrease in AR was observed and became < 1 at follow-up 3, although, again, the patient was off-therapy between follow-ups 2 and 3. AR increased to 14 at follow-up 6 in spite of 2 induction cures, which appeared quite high. Molecular relapse was objectivized at follow-up 7 through an increase of nucleophosmin 1 (NPM1) transcripts. At follow-up 8, morphological relapse was frank, with 96% of blasts. However, AR remained low, suggesting the emergence of a different clone  than that of the initial diagnosis. This observation may question the involvement of the consolidation therapy in this “immunophenotypic shift”.MRD monitoring through MFC is challenging, especially in AML, and obtaining consensus about how to proceed is difficult ,11,14,154 cells were tagged as “Leukemic Clouds” or “L-Clouds”  at diagnosis indicates that the AR could be very useful for MRD assessment. A moderate AR  indicates that the AR could be moderately useful for follow-up, whereas low AR (< 1000) indicates that the AR will be of limited use for follow-up. The strategy presented in this study began with an unsupervised data analysis approach (clustering), thereby identifying cell clusters. The position of these clusters in the multidimensional space could then be modeled. We chose a non-parametric approach based on a combination of two-dimensional kernel density estimation models. This choice was made to avoid the use of 10-dimensional black box data analysis approaches , as these latter approaches do not allow easy expert supervision. The created models were dubbed as “Clouds”. In order to avoid time-consuming efforts, not every cell cluster needed to be modeled as a Cloud , but only suspicious cell clusters, chosen on the basis of expert selection. From these models/Clouds, the most interesting for MRD assessment were selected (L-Clouds). The AR concept that we developed was obtained by dividing the number of patient cells  falling into a Cloud, by the number of cells from a control group/reference samples  falling into the same Cloud. Departing from diagnostic patient samples, Clouds with the highest AR and formed by cell clusters of at least 1 × 10uds” see . This cuA first point highlighted by the AR is that the higher the AR at diagnosis, the higher the specificity of the L-Cloud, and the lower the amount of normal  cells into this L-Cloud. In this study, important differences in the L-Cloud specificities were observed. This means that some L-Clouds define a multidimensional region where almost no normal cells were found (patients 3 and 4), whereas other L-Clouds are barely specific and identify a region where many normal cells are found (patients 5 and 6). Specificity in this regard is synonymous of “the degree of aberrancy in regard to normality”, with high specificity meaning high degree of aberrancy. The AR is the “clinically user-friendly” translation of this specificity. It can be rapidly and easily quantified at diagnosis. A lack of specificity of an L-Cloud could be improved by using more immunological markers in extended mutliparametric flow cytometry assays to identify more aberrations. However, over-extended multiparametric flow cytometry assays (> 10/12 colors) would probably be counterproductive with regard to standardization (for the moment). For future application, we could therefore recommend performing multiple well-developed standardized multiparametric assays at diagnosis and selecting the one for follow-up that highlights malignant cell clusters with high specificity on the basis of the AR concept. On the basis of these elements, the “perfect L-Cloud” would correspond to an “empty space” for all reference control samples (= 100% specificity) and would encompass all malignant cells for a given patient. However, according to the results of this study, “perfect L-Clouds” do not exist, which is in line with the theory of leukemia-associated immunophenotypes (LAIPs) showing variable specificities and sensitivities with respect to normality for each LAIP . The second notable element about the AR is that an AR of 1 means that there are, proportionally, as many cells falling into the L-Cloud from a patient sample as the mean of reference samples. An AR of 2 means that there are two times more cells from a patient sample falling into the L-Cloud than the mean of reference samples. Given the interindividual variability among reference samples see , an AR aThe comparison of the AR/L-Cloud approach with other already published flow cytometry MRD approaches is summarized in Regarding the limitations of the proposed strategy, the lack of sensitivity for detecting MRD must be considered and will be linked to multiple well-known causes ,16,17,18Another limitation is the choice of the reference control samples, which is an important part of the proposed strategy that impacts the specificity of the L-Cloud and thereby the sensitivity for MRD detection. In this study, the reference samples were chosen on the basis of the absence of evidence of underlying disease. Such reference samples should include “normal” and “regenerative” bone marrow samples. Ideally, international guidelines regarding the use of “reference bone marrow samples” should be established and/or commercial assays must be developed and validated using a fixed “reference database” that is unique for each technically and clinically validated assay.Finally, this study is a monocentric pilot study based on retrospective data, with all well-known limitations associated with retrospective design. Further prospective, adequately powered studies are required to better evaluate the potential of the proposed methodology.This study is a pilot study underpowered for a validation of the concept. Additional optimization work is still to be done. For example, we did not evaluate the variability among experts for the identification of the suspicious cell clusters at diagnosis. Although this step remains partly subjective among experts, improving objectivity in this field is possible. We used fixed clustering and contour gating algorithms of the Infinicyt software and did not compare them to other clustering and contour gating methods . Moreover, the proposed classification algorithm has yet not been compared towards more conventional classification algorithms . However, as mentioned before, such algorithms are often considered “black box algorithms”, hampering their use in clinical practice, as they do not allow easy biological supervision. Continuous improvement in assay standardization and increasing the amount of cells to be acquired needs to also be part of further evaluation.Interestingly, the AR concept could also be developed for a “follow-up-based DfN approach”, (in contrast to a diagnostic-based DfN approach) where clustering analysis is performed directly on follow-up samples. Clouds may then be created for each suspicious cell cluster at follow-up. AR of the Clouds can then be calculated, and analogically to L-Clouds, AR thresholds for these Clouds could be defined as predictors of relapse in clinical studies. Although probably complementary to diagnostic-based approaches, more difficulties will probably be linked to this kind of DfN approach: (a) normality appears more difficult to define (than pathology); (b) a large amount of cells must be acquired to obtain significant cell clusters, allowing the creation of significant Clouds; and (c) such an approach would require more computational power.This study highlighted the major interest of implementing new data analysis concepts and tools in clinical hematology MFC ,22,23. T


Background: brain-derived neurotrophic factor (BDNF) may play a role during neurorehabilitation following ischemic stroke. This study aimed to elucidate the possible role of BDNF during early recovery from ischemic stroke assisted by motor training. Methods: fifty patients were included after acute recovery from ischemic stroke: 21 first received classical rehabilitation followed by ‘motor rehabilitation using motion sensors and augmented reality’ (AR-rehabilitation), 14 only received AR-rehabilitation, and 15 were only observed. Serum BDNF levels were measured on the first day of stroke, on the 14th day, before AR-based rehabilitation , and after the AR-based rehabilitation . Motor impairment was quantified clinically using the Fugl–Meyer scale (FMA); functional disability and activities of daily living (ADL) were measured using the Modified Rankin Scale (mRS). For comparison, serum BDNF was measured in 50 healthy individuals. Results: BDNF levels were found to significantly increase during the phase with AR-based rehabilitation. The pattern of the sequentially measured BDNF levels was similar in the treated patients. Untreated patients had significantly lower BDNF levels at the endpoint. Conclusions: the fluctuations of BDNF levels are not consistently related to motor improvement but seem to react to active treatment. Without active rehabilitation treatment, BDNF tends to decrease. In 2015, neurological disorders accounted for 10.2% of lost disability-adjusted life-years (DALYs) and 16.8% of deaths globally . In RussStroke causes motor-function deficits that significantly reduce the patient’s mobility, activities of daily living (ADL), and participation in social activities, resulting in a decreased quality of life (QoL) . TraininBrain-derived neurotrophic factor (BDNF) is one of the most extensively studied neurotrophic factors of the mammalian brain. It was discovered in 1982 by Barde and colleagues  and beloThe aim of this study was to explore the putative role of BDNF in rehabilitation following ischemic stroke—specifically, to assess the dynamics of serum BDNF induction by the stimulation of the motor cortex by Augmented Reality (AR)-biofeedback motion training in the early recovery period.Thirty-five ischemic stroke patients over the age of 18 (20 men and 15 women) who had received AR-based rehabilitation from January to December 2019 at the Siberian State Medical University (SSMU), Tomsk, Russia, were recruited. The study was approved by the Ethics Committee of the SSMU, Russia , and all participants gave informed consent. Patients with first-in-life stroke, as clinically manifested and identified according to the WHO clinical criteria, were included. Ischemic stroke of the middle cerebral artery was confirmed by Magnetic Resonance Imaging (MRI) or computerized tomography (CT) scans. Patients with previous neurological disease, chronic degenerative or inflammatory diseases, or malignancies were not included.Patients were recruited for participation after discharge from the Tomsk Regional Stroke Center (Tomsk RSC) (Days 14–16) and received AR-based rehabilitation during a 10 day course in the last part of the early recovery period (Days 60–90).The inclusion criteria for motor rehabilitation using motion sensors and augmented reality (AR-based rehabilitation) were unilateral stroke; an age between 18 and 80 years; mild-to-moderate upper limb hemiparesis  ; a ModifBlood samples were collected by antecubital venipuncture from 50 individuals with no history of stroke, and the composition of this group was comparable to that of the stroke patients with respect to gender, age, and the presence of risk factors. The patients were examined in an outpatient unit.Point 1—first day of stroke.Point 2—discharge from the Tomsk RSC .Point 3—after traditional rehabilitation/before AR-based rehabilitation  (not in the group C-OPO).Point 4—after AR-based rehabilitation .The study population was categorized into two groups. The group A-Rehab-Traditional-AR included 21 patients who received a 28 day rehabilitation course involving traditional exercise programs in the Siberian Federal Scientific Clinical Center of the Federal Medical-Biological Agency (within 16–60 days of the stroke) before AR-based rehabilitation (within 60–90 days). The group B-Rehab-AR consisted of 14 patients who only received AR-based rehabilitation within the early recovery period (Days 60–90). The group C-outpatient observation (OPO) comprised 15 patients who were under outpatient observation (OPO) after an acute period of ischemic stroke and did not receive any rehabilitation treatment. Details of the applied rehabilitation techniques are provided in To stimulate the motor cortex, we chose a method of influencing sensory systems using biological feedback. Sensory cortex stimulation was performed using augmented reality, which is good in terms of patient safety . We creaIn order to assess the impact of visual stimuli on motor function, we developed specialized software .The program consists of three modules: 1. RehabDT, which collects and analyses data from video capture sensors on the patient’s body; 2. RehabAR, which visualizes the obtained data for the patient on augmented reality glasses and analyzes the motor quality within the Accuracy, Statics, Capture and Balance Domains; and 3. RehabCS, which processes and stores the motion capture data. Details are provided in The AR protocol involved a 10-day course of motor-training sessions held on a consecutive daily basis once in the morning. The time to complete one motor domain was 20 min. The rest time between tasks within the domain, at the request of the patient, was 1–2 min; that between the four motor tasks was 5 min. The patients followed the augmented reality (AR)-based training protocol under the supervision of a kinesiotherapist.® tubes with a clot activator (CAT) to isolate the serum , which was separated by centrifugation at 2000 RCF at 4 °C for 20 min. The serum samples were stored at −80 °C until analysis. The mature BDNF concentration was determined with the MAGPIX multiplex analyzer  using xMAP® Technology in the Mental Health Research Institute based at The Core Facility “Medical Genomics”, Tomsk NRMC. The collected information was processed by the Luminex xPONENT® software, with the subsequent export of data to MILLIPLEX® Analyst 5.1.After patients provided informed consent, blood was collected into BD VacutainerEssential patient characteristics were obtained from the patients’ medical files and/or standard clinical interviews. We used the clinical evaluation of motor impairment and Activities of Daily Living (ADL) as the primary outcome of this study into AR-based rehabilitation. These were measured on two standardized clinical-rating scales: the Fugl–Meyer scale (FMA) was used as an instrument for quantitatively evaluating post-stroke motor disorders ,32, and Variability of movements when following a given trajectory;Total number of completed movements (completed task) during one motor session;Maximum duration of a tasks series in one approach without a rest;Variance of the displacement for the central point of the body during the walk before crossing the obstacles;Height of raising the leg on the affected side when stepping through virtual barrier.Gait and movements of upper extremity changes during AR-rehabilitation were assessed using author parameters’ quality of movements:The direct effects of AR-based rehabilitation were also evaluated by calculating the quality of movement during the first, fifth, and tenth training sessions, and interpreting detailed information obtained with parameters for assessing the quality of movements during the tasks in motor domains .p > 0.05). Quantitative data without a normal distribution were analyzed with non-parametric tests. The chi-square (χ2) test was used to assess the differences in the sizes of distributions of qualitative data. Differences in the parameters between groups were assessed with the non-parametric Mann–Whitney U test; for related samples, we used the Wilcoxon Rank-Sum test. The Bonferroni test was used as a lead for multiple post hoc comparisons. A p value less than 0.05 was considered statistically significant.All data was analyzed with the SPSS statistical package (20.0 Version). The results are expressed as percentages for categorical variables or as medians (Me) and interquartile ranges (IQR). The Shapiro–Wilk test was used to analyze the normality of distribution of the variables (The differences between serum BDNF at Points 2 and 4 (ΔBDNFobserved = BDNF day82 − BDNF day14) and that at Points 3 and 4 (ΔBDNFobserved = BDNF day82 − BDNF day45) were used to estimate the synaptic-plasticity-related and activity-dependent increases in BDNF during the motor training. The difference between the initial and 14-day serum BDNF  was used to estimate the peak neuroplasticity in response to ischemic brain damage (spontaneous plasticity).Fifty ischemic stroke patients and an equal number of healthy individuals were recruited in this study. Their demographic data are presented in The serum BDNF levels measured in the patients from the groups A-Rehab-Traditional-AR, B-Rehab-AR, and C-OPO are shown in 2-4) < 0.001, A-C) = 0.049, Probability B-Rehab-AR vs. C-OPO (PB-C) = 0.021, In 2-3) = 0.010) as well as in B-Rehab-AR (P2-3 = 0.016), they were significantly lower at the end of this period  = 0.049 at Point 3) in the last patient group. This indicates that the BDNF levels decreased less in patients who received active treatment during this period.It should be noted that the absolute BDNF level fluctuations between Points 2 and 3 were dissimilar between the patients of A-Rehab-Traditional-AR, who received active treatment with traditional rehabilitation approaches, and B-Rehab-AR, who were under outpatient observation during this time . Althoug3-4) = 0.012 and P3-4 = 0.017, accordingly). An increase in serum BDNF levels during the activity-dependent stimulation of the motor cortex by the AR-biofeedback-motion training in A-Rehab-Traditional-AR and B-Rehab-AR is also observed when considering the increase in levels before and after AR-based rehabilitation  and each other (PA-B = 0.10 in Point 4).In both A-Rehab-Traditional-AR and B-Rehab-AR, the BDNF levels significantly increased during AR rehabilitation  (A-Ctrl = 0.001 at Point 1) and not significantly different to those in B-Rehab-AR (PA-B = 0.21 at Point 1). A comparison between the BDNF levels as measured in 50 ischemic stroke patients and the same number of comparable healthy individuals is shown in 2-3 < 0.001) was absent in B-Rehab-AR (P2-3 = 0.30), as shown in 2-3 = 0.06, The analysis of motor recovery according to FMA demonstrated similar and significant improvements of motor functions in the upper and low extremities and balance in the three groups at Day 14 , Table 3 = 0.01) . In termA-B = 0.45), despite significantly lower values of ΔBDNF Day 82–Day 45 and the level of BDNF at Point 4 in A-Rehab-Traditional-AR being significantly lower than that in B-Rehab-AR (PA-B = 0.02). A detailed analysis of the FMA scores revealed a number of features as shown in 3-4 = 0.080). However, balance function in A-Rehab-Traditional-AR, which did not recover well after traditional approaches, showed a significant improvement according to FMA-Balance .During AR-based rehabilitation treatment, the changes in serum BDNF levels were accompanied by an improvement of motor function, as quantified with the Fugl–Meyer rating scale (FMA) , and a r2-4 = 0.750, The clinical assessment of motor recovery in C-OPO at Point 4 found no significant change in clinical condition according to total FMA score from the 14th day to the end of the early recovery period (PComparison of the movement parameters concerning the variability of movements during the 1–10 training sessions did not reveal any significant differences between A-Rehab-Traditional-AR and B-Rehab-AR . During In the present study, we tried to elucidate the relationship between serum BDNF levels and motor recovery in response to AR-based rehabilitation over a 60–90-day post-stroke period, which is still considered to belong to the plastic window for stroke recovery ,36. Our BDNF gene, which suggest that BDNF primarily shapes the functioning of local ipsilesional circuits [After ischemic stroke, patients show spontaneous motor recovery, which is most profound over the first 30 days but continues over the subsequent 30–90 days . There acircuits . Finallycircuits . Lu et acircuits ,50. The circuits . Of notecircuits . BDNF macircuits .The ischemic damage to brain tissue and destruction of neural networks probably induces a reorganization of the neuronal connections within the motor cortex ,54. SponIn individual assessments of the movements of the paralyzed limb, we found significant improvement of their quality. This improvement of motor control is considered to represent a beneficial effect of the AR-rehabilitation program. However, along with the obvious motor recovery, we also found compensatory mechanisms primarily concerning the balance function. The stability in an upright position was achieved by sufficient support by the affected leg. Stroke patients reduced the height of raising their leg during walking on the spot on a flat horizontal surface during first days of training which resulted in decreasing the dispersion of the movements of the central point of the body . The resThe members of A-Rehab-Traditional-AR achieved the same level of motor recovery and functional outcomes at the end of study as those of B-Rehab-AR. However, serum BDNF levels in B-Rehab-AR were higher than those in A-Rehab-Traditional-AR at Point 4, despite the lack of traditional rehabilitation between Points 2 and 3. Therefore, the results of our study reveal clinical and laboratory benefits for modern rehabilitation approaches. For more details about motor recovery, we refer to Korelova et al. . During BDNF has been shown to be involved in various brain pathologies and mental disorders. This includes post-stroke depression, which is a common complication of stroke and may impair the outcomes of rehabilitation , such asOur study has several limitations. The number of participants was rather low, particularly those in the groups B-Rehab-AR and C-OPO. This would have increased the influence of individual response types and decreased the likelihood of finding significant differences. Moreover, we only measured BDNF levels and only after the ischemic stroke incident had occurred. Lower levels of BDNF are correlated with an increased risk of stroke and a poorer prognosis ,69,77, aIschemic stroke results in a reduction of peripheral BDNF levels, which is partly compensated by rehabilitation treatment. AR-based rehabilitation also improves the clinical condition. Without treatment, serum BDNF levels fall significantly and the patients show no clinical or functional improvement. The fluctuations of the serum BDNF levels are independent of the actual clinical condition of the patients. We hypothesize that the BDNF levels depend upon at least two independent processes. Active training in motor tasks is accompanied by an increase of the serum BDNF levels, which may be related to the consolidation of the learned motor skills.


Introduction: Plasma androgen receptor (AR) copy number (CN) status identifies castration-resistant prostate cancer (CRPC) patients with worse outcome on abiraterone/enzalutamide. However, the impact of AR CN changes on clinical outcome in CRPC is unknown.Materials and Methods: Plasma samples from 73 patients treated with abiraterone or enzalutamide were collected at baseline and at the time of progression disease (PD). Droplet digital polymerase chain reaction was used to assess AR CN status.Results: We showed that 11 patients (15.1%) changed AR CN status from baseline to PD . Patients changing AR CN status from normal at baseline to gain at PD had intermediate median overall survival (OS) of 20.5 months (95% CI = 8.0–44.2) between those who remained AR CN normal from baseline to PD (27.3 months [95% CI = 21.9–34.4]) and those who remained AR CN gain from baseline to PD . Patients changing AR CN from normal at baseline to gain at PD had a median progression-free survival (PFS) of 9.2 months (95% CI = 2.0–14.7), patients who remained AR CN normal had a median PFS of 9.1 months (95% CI = 7.2–10.1), and patients who remained AR CN gain had a median PFS of 5.4 . Both OS and PFS were not significantly different between patients with AR CN that changes from normal to gain and patients with stable AR CN normal.Conclusions: We showed that CRPC patients changing AR CN status from baseline to progression time point had intermediate OS and we suggested that AR CN evaluation at baseline could be the most informative for clinical outcome of CRPC patients treated with abiraterone or enzalutamide. Larger prospective studies are warranted. Abiraterone acetate and enzalutamide belong to therapies introduced in the past years for patients with metastatic castration-resistant prostate cancer (CRPC), improving patient survival and quality of life –4. DurinAR has been well-investigated and is considered to be one of the main mechanisms of hormone-sensitive to hormone-resistant transition  has a key role in prostate cancer development and progression , 11. Copansition . Plasma ocetaxel . In thisFrom August 2012 to June 2016, CRPC patients with histologically confirmed diagnosis of prostate adenocarcinoma were enrolled. Patients were treated with abiraterone or enzalutamide in pre- or post-chemotherapy settings. Treatment was continued until evidence of disease progression or unacceptable toxicity. The choice of therapy was at the discretion of the treating physician.18F-fluorocholine positron emission tomography/computed tomography (FCH-PET/CT) was performed after 12 ± 4 weeks of treatment.Serum prostate-specific antigen (PSA), alkaline phosphatase (ALP), serum lactate dehydrogenase (LDH), cell blood count to determine neutrophil to lymphocyte ratio were measured within 1 week of starting therapy and once per month thereafter. Radiographic disease was assessed with computed tomography (CT) and bone scans at the time of screening and once every 12 weeks during treatment. Progression disease (PD) was assessed considering radiographic evidence of new lesions by bone scintigraphy and/or new or enlarging soft tissue lesions by CT or magnetic resonance imaging, per the Prostate Cancer Clinical Trials Working Group 3 guidelines . The stuAR CN analysis with a multiplex digital droplet polymerase chain reaction (Biorad) assay using three reference genes: NSUN3, ElF2C1, and AP3B1 and ZXDB at Xp11.21 as a control gene not involving the whole arm of the chromosome, as previously described  tubes, maintained at room temperature, processed within 30 min and stored at −80°C. Circulating DNA was extracted from 1 or 2 ml of plasma using QIAamp Circulating Nucleic Acid Kit (Qiagen). Total extracted DNA was quantified with the Quant-iT high sensitivity PicoGreen double-stranded DNA Assay Kit (Invitrogen). We performed plasma escribed .P-values were two-sided and a p < 0.05 was considered as statistically significant. Statistical analyses were performed with SAS statistical software, version 9.4 .PFS was defined as the time elapsed between the date of start of therapy and the date of radiological/clinical or biochemical progression or last tumor evaluation. OS was defined as the time elapsed between the date of start of therapy and the date of death from any cause or the date of last follow-up. PFS and OS were estimated using Kaplan–Meier method and compared using logrank test. AR CN detection in both baseline and progression samples. Of these, 35 (48%) and 38 (52%) received abiraterone or enzalutamide pre- and post- chemotherapy, respectively. When comparing the baseline patient characteristics according to therapy, post-chemotherapy setting displayed a higher Gleason score, a greater incidence of bone and visceral metastases as well as higher levels of ALP and LDH  of 15 with AR CN gain at baseline showed no changes in AR CN status in their PD sample  between patients with stable AR CN normal that presented a median OS of 27.3 months (95% CI = 21.9–34.4) and patients with stable AR CN gain with a median OS of 9.1 . The two patients changing AR CN from gain to normal presented an OS of 8.5 and 17.4 months, respectively. No significantly worse OS was observed for patients changing AR CN from normal to gain compared to patients with stable AR CN normal , patients with stable AR CN normal presented a median PFS of 9.1 months (95% CI = 7.2–10.1) and patients with stable AR CN gain had a median PFS of 5.4 . The two patients changing AR CN from gain to normal presented a PFS of 8.5 and 3.8 months, respectively. No significantly worse PFS was observed for patients changing AR CN from normal to gain compared to patients with stable AR CN normal (p = 0.551) (Patients changing = 0.551) .AR CN changes and PSA change was performed and we did not found a statistically significant correlation, as shown in AR CN from gain to normal. Interestingly, we found that all patients changing AR CN status from normal to gain (8) did not show PSA decline.Correlation analysis between AR CN changes from baseline to progression time point on clinical outcome of CRPC patients. We identified a low conversion rate of AR CN status, suggesting that, for most of patients, AR CN does not change under the pressure of abiraterone and enzalutamide. These results confirm those found by Romanel et al.  was very low, additional validation is needed. Similarly, only 2 of the 15 AR CN gain patients became normal at PD, so it does not allow to identify the role of AR CN conversion in this setting of patients. Moreover, since both PFS and OS were not significantly different between patients with AR CN that changes from normal to gain and patients with stable AR CN normal, we hypothesized that the difference on clinical outcome depends on AR CN status at baseline. For this reason, we suggested that baseline assessment could be the most relevant time point to consider for AR CN status in therapeutic decision making.We hypothesized that this could be challenging for physicians in helping treatment decision and possibly substituting therapy if AR gene  during therapies  from normal DNA present in cfDNA that potentially affects the detection of AR gain in patients with a low proportion of ctDNA. Larger prospective biomarkers study is warranted.The present study represents the first evidence of the impact of plasma The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by COMITATO ETICO della Romagna. The patients/participants provided their written informed consent to participate in this study.Conceptualization: GG and VC. Methodology, writing—original draft preparation, and writing—review and editing: GG. Software: SG. Validation: UD, VC, and ES. Formal analysis: ES. Investigation: CL. Resources: GS. Data curation: AA. Visualization: CC. Supervision: UD. Project administration: VC. All authors have read and agreed to the published version of the manuscript.GG has received travel support from Sanofi. VC has received speaker honoraria or travel support from Astellas, Janssen-Cilag, and Sanofi-Aventis, and has received consulting fee from Bayer. CL has received honoraria for consulting (advisory board) from Bristol-Myers Squibb and Janssen-Cilag. UD has served as consultant/advisory board member for Astellas, Bayer, BMS, Ipsen, Janssen, Merck, Pfizer, Sanofi, and has received travel support from BMS, Ipsen, Janssen, Pfizer, and has received research funding from AstraZeneca, Roche, Sanofi (Inst). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer FM declared past co-authorships with the authors to the handling editor.


Mindreading is contingent upon interpersonal context. Little is known about how competitive contexts influence mindreading skills. The idea was that the capacity to think about mental states would decline when individuals experiencing failure in competition. This study aims to assess effects of a competitive experience (a computer competitive PC game) on a sample of healthy subjects (119 participants). The sample was divided into two sub-samples. The experimental group underwent an experience of failure, consisting in a PC game of logic against a hypothetical opponent. The control group was required instead only to discuss past personal experiences of competitive interactions. The Metacognitive Assessment Interview was administered to each sub-sample for evaluating mindreading capacities. Self-report tests were additionally provided for evaluation of trait-based dispositions: self-esteem, perfectionism, narcissism. Results supported our hypothesis: induction of sense of failure compromises ability to describe one’s own mental states and mental states of others. This effect was more pronounced in the domain of self-reflection. Results remained significant after controlling for self-esteem, perfectionism, and narcissism. We discuss possible clinical implications of these findings and the importance of evaluating mindreading capacities under the pressure of social rank as well as of other social motive. When humans are under pressure of competition, they have increased need to be aware of their inner experiences and to make accurate guesses about the mental states of others. They need to recognize if they are afraid of losing, if they still have resources, if the task is important enough or, alternatively, if they are devoting too much time and effort to a task that is less relevant than it seems. At the same time, they need to form an accurate and possibly realistic picture of what is passing through the mind of the others. Being aware of one’s own feelings and what has elicited them helps decision-making, while realizing what is passing through the mind of others and the motive driving overt behavior is necessary for adjusting own action so as to maximize the chances that one’s own personal goal will be fulfilled and that relationships will be as smooth and stable as possible.Some authors have noted that mindreading is relevant in the competition context . ChimpanUnfortunately, the pressure of competition may narrow our capacity to make sense of mental states, so we may have limited abilities in the very moment we need them. Fear of failure may steer our attention to signals of incapacity in the self or of criticism in the others. Shame about feeling inferior may let us forget the many moments in which we succeeded, or simply discard relevant needs, such as relaxing, searching for social sharing, and playing. Under the background of these reflections, what do we currently know about the effects of competition on capacities to make sense of mental states?The human capacity to recognize and reflect upon mental states has been variously defined as mindreading, mentalization, metacognition, and theory of mind .Being aware of the differences, we henceforth use the term mindreading because it encompasses different domains of awareness and reflection on both one’s own and others mental states. In this study we use the term mindreading as it is possibly the more inclusive term referring to the capacity for mentalistic reasoning. This capacity includes: naming and distinguishing the feeling one is experiencing, describing the complexity of one’s own thoughts in the situation. It also includes the awareness that one’s ideas are open to question and do not necessarily reflect reality. Another aspect is the capacity to understand what the others think and feel and what drives their behavior on the basis of cues, such as facial expressions, behavior, and personal history .Poor mindreading may manifest itself under specific types of social interaction experienced as problematic. As we earlier observed, mindreading is particularly necessary when humans are in the heat of personally relevant interactions. As an example, a child driven by attachment needs to express distress in a way that will move the caregiver to care of her. Clinical observations made the point that in persons with some psychiatric disorders, mindreading is compromised exactly when it is most needed, that is in the heat of interactions driven by primary social needs, such as attachment. These persons actually get confused about what they feel and form negative and rigid representations, about intentions, thoughts, and feelings of the others , with thUnderstanding under what conditions mindreading capacities are compromised is relevant in order to know how to protect individuals against such a decline or in order to predict where this momentary collapse will happen and deal with it. Historically, the major focus has been on the relationship between activation of attachment and decline in mindreading in a series of psychiatric condition, ranging from borderline personality disorders to post-traumatic disorders and psychosis . SupportIn the clinical fields some authors have noted that mindreading may not just be compromised in the context of disturbed attachment. Other evolutionary selected motives may be at the roots of state-dependent failure in making sense of mental states  noted thAmong these motives, social rank, that is competition or antagonism, seems to be a key factor underlying momentary mindreading failures. Humans are continuously facing competitive contexts, driven by social rank , 2005. EThe influence of competition and social rank on mindreading has undergone some research scrutiny. First, establishing social rank is relevant, as humans need to know the positions others occupy in the hierarchy. Actually, individuals have a bias toward faster attribution of rank when they think the other is above them, and then their defense system is more quickly turned on as a response to possible threats . Zink etIn fact, Consistently, Attention to the link between mindreading and social rank has been given by clinicians as well. The connections between activation of the social rank motive and variations in mindreading have been hypothesized and investigated. Research have highlighted that social rank may bias our perceptions of others and that under the activation of this social motive capacities for understanding mental states may be narrower than when other motives  are active . There asecond-person approach emphasizes that experiencing and interacting with others are crucial primary ways of evaluating levels of mindreading. Recent studies have also drawn attention to the fact that tasks which involve engagement in direct personal interactions may affect mindreading more than off line tasks  and neuroimage measures of mental states. What is missing is an assessment of mindreading capacities as emerging from the individual’s subjective experience. In other words, how does the immediacy of competitive interactions affect the way subjects attribute mental states to themselves and to each other. Moreover, it is necessary to measure mindreading in real interactions among individuals, rather than solely in the laboratory. This Our research question was: when primed with a competitive situation where they were convinced they failed, will individuals have reduced general capacities to understand their own mental states and those of others? Specifically, we assessed mindreading in two different situations: an online situation where participants were directly involved in a game focused on winning or losing; an indirect situation where participants were asked to describe the mental states during a past experience of competition. We therefore focused on analysis of discourse as emerging in a semi-structured interview where the object of the reflections was not the mental state of the opponent in a game, but the overall capacity to ascribe mental states to self and others.Our hypothesis was that when primed with the idea of having failed a task where they faced a more successful opponent, individuals would display reduced capacity for mindreading both as regarding both self and others. We expected to find significantly lower mindreading levels in the group primed with an experience of failure than in the control group who did not participate in the competitive induction.We also considered that some trait-based dispositions – in particular self-esteem, perfectionism, narcissism – may make some subgroups more prone to the effect of social rank, so we controlled for their effect on mindreading. Specifically, we controlled whether persons low in self-esteem, high in perfectionism, or high in narcissism can have a more pronounced impact on experiences of failures on their mindreading capacity.A sample of 136 individuals from the population of Psychology students resident in Turin and surrounding areas were administered a series of self-report tests on a voluntary basis. Of this initial sample, 119 participants (65 men and 54 women) were available for the second phase of the test. A pseudo-random matching procedure was used for the allocation of the participants to the groups. First, couples of participants were formed that were matched on sex, age, and education. Then, within each pair, participants were randomly allocated to the experimental or to the control group. The average age of the sample was 26.2 ± 8.4 years and the age range was 18–63 years.In a first session of the experiment, participants were recruited among the student population of Turin by last year students working for their final project. Those who accepted to participate were lead to a quiet room and asked to complete a series of paper and pencil self-administered questionnaires, which tested self-esteem, perfectionism, and grandiose and vulnerable narcissistic traits. The sample was then divided into two sub-samples matched by gender, age, and education.n = 66) and recall of past experiences of failing a competition . In order to evoke a sense of failure, we created a tweaked version of a very common game, known as “Minesweepers” or “Flowery Meadows,” involving logical and deductive skills. The aim of the game is to open the highest possible number of “mine-free” cells , while taking into account the numbers which flash up on the clicked cells as one proceeds. These numbers represent the number of mines still concealed in the eight cells adjacent to the flashing number. In our version, it was impossible to win the task. Our goal was to induce a state of distressing arousal in the participants of the experimental group, as a consequence of losing the game.In a second session of the experiment about 1 month later, the participants were called back to a laboratory room of the University, in order to complete one of two experimental conditions: induction of an experience of failure , and the average score of players at the same level of computer game expertise as the participant. This last bar displayed slightly higher levels than that of the opponent, creating the impression that one had lost against an average adversary and not against a top-player .Finally, at the end of this second session, the Metacognitive Assessment Interview was administered. The participants of the experimental group who had undergone the induction, that is the experience of losing the game, were interviewed with the MAI immediately after the game, and the interview made specific reference to their subjective experience during the task. The control group did not play any game and was simply asked to talk about past experiences of failing a competition.Metacognition Assessment Interview   .Rosenberg Self-Esteem Scale , were entered together in the first block of the analysis to control for their effect on mindreading, and participation in the competitive induction procedure  was entered in the second block. All the analyses were performed with SPSS 20.0 .Correlation analyses showed that participating in the induction procedure was associated to lower total scores and Self scores of the MAI. As regard correlations of MAI and underlying traits, grandiose narcissism as assessed with the NPI was associated to lower mindreading, both the Total score and Self and Others sub-scales. Mindreading was not associated with any of the other traits, that is Self Esteem (SES), perfectionism (MPS), and Vulnerable Narcissism (HSNS) , 2.Then, a hierarchical multiple linear regression analysis was performed with the MAI total score as the dependent variable. The trait-like control variables , entered in the first block, accounted for 11.9% of the variance of mindreading, with grandiose narcissistic traits showing the greatest effect. Consistent with the hypothesis, the induction accounted for an additional 5.0% of the variance of mindreading after controlling for all the baseline variables .In order to investigate whether being primed with an experience of failure affected the capacity to understand both ones’ own and others’ mental states, the same analysis was repeated with the MAI Self score and with the MAI Other score as the dependent variables. The trait-like control variables accounted for 7.1% of the variance of Self mindreading and of the 12.9% of the variance of other mindreading, and again overt narcissistic traits showed the greatest effect. However, after controlling for all the baseline variables, the induction accounted for an additional 10.1% of the variance of Self mindreading only, while the effect on Other mindreading was not significant . The tolWe investigated the influence of social rank motive in humans. Our idea was that humans tend to display a reduced capacity to reflect and describe their own mental states and those of others when primed with a sense of failure vs. when they just have to recall past experiences of failure. Our goal was to understand whether actually experiencing failure affected mindreading when participants had to report narratives focused on personal experiences of competition. This is an aspect of mindreading which, to the best of our knowledge, has not been previously investigated.Our hypothesis was that the capacity to reflect on mental states, or mindreading, would be lower in participants undergoing an induction of failure , as compared to participants who only had to reflect about a past experience of failure without actually experiencing it (offline experience of the control group). Results supported our hypothesis: inducing a sense of failure lead to lower ability to describe both one’s own and others’ mental states in a semi-structured interview (MAI), and this effect was particularly evident with regard to self-reflection. Our results are consistent with earlier findings which have demonstrated that mindreading capacity is diminished during competitive interactions . What thWhen participants are primed to experiencing failure in the moment, that is failing systematically a game against an opponent, their capacity to form a larger and nuanced understanding of what passes through their mind and in others’ minds is reduced. Why so? It is likely that when they actual fail, their attention is focused on personal flaws or on the idea the others will judge them, and so they neglect other aspects of their subjective experience, such as their vulnerabilities, when faced an on line failure, participants may be driven by defensive purposes, so they may be less prone to disclose a wide range of thoughts and emotions, as they depict the other as superior, spiteful, critical or rejecting. In the same time, when reflecting about the others they may catch a range of thoughts and emotions, though these are likely mostly concerned about how others are evaluating their performance. In other terms, failing a task peculiarly affects capacities for self-reflection and overall understanding of mental states in human interactions, while the specific capacities to understand the others is less impaired, probably because the person is paying much attention to signs of criticism or rejection.On the other hand, we are not in a position to say whether simply remembering failure was associated to impaired mindreading as we have not normative score for the MAI. In order to better understand if simply focusing on failure has detrimental effects on mindreading, we would have needed to compare this condition with other conditions of success and of being driven by other motives, such as, for example, attachment, sexuality or exploration.There are different possible explanations for this finding. One is that when people focus on their experience of defeat they lose the capacity to form a bigger picture of what is passing through their own and others’ minds. Their attention is concentrated on personal flaws or on the idea the others will judge them, despise them or reject them, and so they neglect other aspects of their subjective experience, such as their vulnerabilities, their involvement in the task, the relevance of the task for their personal life, or the presence of other aspects of their experience which are not connected to task performance. At the same time, when faced with failure, participants may be driven by defensive purposes, so they may be less prone to disclose a wide range of thoughts and emotions, as they depict the other as superior, spiteful, critical, or rejecting. Overall, these results highlight the importance of taking into account the online interpersonal contex in which mindreading assessment takes place.We also controlled for potential confounds, as the literature shows that mindreading could be affected by trait-based sensitivity to issues of social rank, e.g., low self-esteem, high maladaptive perfectionism, and both overt and vulnerable narcissism . Our secEven though these trait-based dispositions, especially grandiose narcissisms, affected mindreading, our results show that experiencing failure significantly narrowed the ability to reason about one’s own mind, even after controlling for all these variables.If supported by future studies, these results may have relevant implications. In the clinical field, it might be necessary to make clients aware of their sensitivity to failure and of how their ability to reflect on mental states might suffer when they are prey to feelings and ideas of failure or criticism or rejection. Particularly in clinical settings and when evaluating psychiatric populations, it is essential to remain aware of the emotions being activated during clinical interactions which may evoke or be associated with competitive experiences. The data emerging from this study underline the importance of ongoing assessment of the patient’s active emotional state and especially whether a competitive mental state is being activated. It also supports the idea that failure in mindreading is not just connected to problems in the attachment domain, but depends also on the activation of social rank motive . It lookEven though our results are promising, there are many limitations which need to be considered. For one, the sample was small, which decreases statistical power and increases the likelihood of a type II error . In particular, we could expect that with a bigger sample size some trait-based dispositions, such as grandiose and vulnerable narcissism, would become significantly related in the condition of online defeat.Second, our sample was made up of western Caucasian, mostly well-educated and young participants, therefore our results cannot be generalized to people from other ethnicities, lower levels of education or older age group. Third, many other variables may have influenced results, for example psychological symptoms, tendency to worry, poor emotion regulation, and so forth. Moreover, we did not assess attachment history, so it remains necessary to control for its influence. We assume that social rank may predict mindreading capacity even after controlling for attachment history, as mindreading and attachment are different systems with different evolutionary purposes, but this is a matter for future research. Overall, there is a need to extend our findings controlling for variables we did not consider here. Fourth, our study only explored the effect of experiences of failure. We are not in a position to predict whether the reverse is true, i.e., whether or how experiences of success influence mindreading. All possibilities are open: mindreading capacities may remain unaffected by experiences of success, or people may instead experience a benefit and become more open and capable of reflecting upon their own mental states and those of others; it is also possible that success may have a detrimental effect on mindreading as people may remain entrenched in the social rank motive and lose the capacity to grasp the bigger picture of what they and others may think and feel. Fifth, our was a study with a community sample, so results cannot be generalized to people with mental health problems, such as depression, anxiety, PTSD, or personality disorders. Many have noted that these populations tend to have diminished capacities for mindreading . MindreaThese limitations notwithstanding, our study yields further support to earlier findings that, when caught by social rank, humans become less able in mindreading and noted how self-reflection is particularly affected. More studies are needed to explore how the social rank motive affects mindreading, under what conditions and in which sub-populations. This would pave the way for a deeper understanding of how humans make decisions under these circumstances and of how to counteract the detrimental effect of experiences of failure.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committee of IUSTO, Università Pontificia Salesiana di Torino, Italy. The patients/participants provided their written informed consent to participate in this study.LC designed the research, analyzed the data, and wrote the manuscript. GD and AS designed the research and wrote the manuscript. AC performed the research. GN analyzed the data and prepared the figures. CC designed the research, recruited the participants, analyzed the data, and wrote the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Glossopharyngeal neuralgia (GN) is a nerve compression syndrome that presents with episodes of unilateral sharp, stabbing pain in the distribution of the ninth cranial nerve. This syndrome may present with cardiac and autonomic manifestations - a condition termed vagoglossopharyngeal neuralgia (VGPN). Most cases of VGPN arise from neurovascular insult at the cerebellopontine angle. Conservative treatment for VGPN includes antiepileptic medications. Surgical treatments include trigeminal tractotomy-nucleotomy, Gamma Knife® stereotactic radiosurgery, radiofrequency thermocoagulation, rhizotomy, and, as shown in this paper, endoscopic microvascular decompression (E-MVD). In this article, we present two cases. Case 1 demonstrates a 53-year-old male with right-sided GN symptoms that began to experience syncopal episodes 10-years after the initial presentation. Case 2 presents a 61-year-old female with a history of Ehlers-Danlos syndrome, and the malignant vasovagal syndrome that became associated with painful, shooting left anterior neck spasms consistent with GN. Both patients underwent E-MVD, leading to complete relief of neuralgia and cardiac symptoms. Our outcomes support previously published reports of successful treatment of VGPN using microvascular decompression (MVD) and describe a purely endoscopic surgical technique. MVD is the preferred treatment option for VGPN with evident neurovascular insult. Glossopharyngeal neuralgia (GN) is a nerve compression syndrome with an incidence of 0.8/100,000 and typically presents with episodes of unilateral sharp, stabbing pain in the distribution of the ninth cranial nerve, including the throat, jaw, ear, and tongue . ConservCase 1Case 1 demonstrates a 53-year-old male with right-sided GN symptoms that began to experience syncopal episodes 10-years after initial presentation. The patient underwent extensive medical and cardiac workup prior to surgical consideration. He was diagnosed with supraventricular tachycardia and underwent cardiac ablation, but continued to experience syncopal episodes despite the resolution of his tachyarrhythmia. Preoperative MRI was unrevealing for neurovascular compression. Ultimately, he underwent a right retrosigmoid craniotomy for E-MVD. During the procedure, it was noted  is fixed into place with the aid of a Mitaka Pneumatic Arm , allowing for bimanual dexterity and enhanced surgical ergonomics throughout the case. Fixed endoscope stabilization prevents unintended injury of surrounding neurovascular structures. As previously described, a strict triangle technique is used, with the endoscope fixed at the apex of the visualization triangle both proximally at the dura and distally at the petrous temporal bone and jugular foramen. At the entrance of the cerebellar convexity dura, the endoscope must be at the apex at "2 o’clock", and the instruments can be passed underneath the endoscope along the cerebellar folia surface at "5 o’clock" and "7 o’clock" [This triangle method allows for sharp dissection at the root entry zone of the glossopharyngeal and vagal nerves and excellent visualization of the neurovascular conflict. Once the arachnoid has been dissected off the nerves, polytetrafluoroethylene (PTFE) is used to decompress the neurovascular conflict. Dynamic retraction is used through the entirety of the case, avoiding the use of fixed brain retractors. Following decompression, the surgical field is filled with saline, and the dura is closed in a watertight fashion.PathogenesisWhile the pathogenesis of VGPN remains debated, one commonly accepted cause is the neurovascular insult of the ninth and tenth nerve rootlets as they emerge from the brainstem at the root entry zone (REZ) . As the The mechanism of how pain in the glossopharyngeal distribution and vagal symptoms overlap remains unclear. One proposed mechanism is that rootlet adhesions between the ninth and tenth nerves disturb the carotid sinus nerve of Hering, which stimulates the motor vagal nucleus enough to promote syncope . Others Treatment optionsConservative treatment of VGPN involves the use of antiepileptic medications, such as carbamazepine, oxcarbamazepine, valproic acid, lamotrigine, and levetiracetam, to control pain . Beta-agThe trigeminal tractotomy-nucleotomy procedure involves the destruction of the trigeminal tractus of the medulla at the level of the inferior olive . While iMVD is the preferred treatment for GN and VGPN with neurovascular insult. This is commonly due to arterial compression along with central myelin of the ninth nerve and rostral fascicles of the tenth nerve. The posterior inferior cerebellar artery (PICA) is a common culprit vessel in GN and VGPN; other cerebellar arteries may be implicated . VasculaIn our practice, the use of a fully endoscopic approach allows for the continued use of a minimally invasive retrosigmoid approach while achieving improved visualization of the entire course of the ninth nerve compared to the microscopic approach. The use of the endoscope for GN has been described, noting improved visualization of neurovascular conflict compared to microscopic approaches -20. The Another surgical option to consider includes intraoperative rhizotomy of the ninth and tenth nerves. This procedure should only be indicated for patients without a clear neurovascular insult. While it is still a destructive procedure, unlike thermocoagulation, unwanted outcomes such as pharyngeal discomfort, dysphagia, and hoarseness may be mitigated if rhizotomy of tenth nerve fibers can be avoided . In combWe presented two cases demonstrating safe and successful management of VGPN with E-MVD after the failure of medical therapy. These outcomes support previously published case reports of successful treatment of VGPN using MVD. The use of the endoscope allows panoramic visualization of neurovascular conflict and improved surgical maneuverability compared to that of the microscopic approach.