Endobronchial ultrasound-guided transbronchial biopsy has emerged as an excellent tool in diagnosing lung cancer. However, its use to diagnose lymphoma has been questioned, since the gold standard for diagnosing lymphomas is an excisional biopsy of involved lymph nodes. However, the procedure is sometimes risky or difficult. Recent studies have been showing great results using endobronchial ultrasound-guided transbronchial needle aspiration when accompanied by immunohistochemistry and cytology. Here, we present a case of Hodgkin's lymphoma patient that was accurately diagnosed using endobronchial ultrasound-guided transbronchial needle aspiration. Some of the most crucial features of a diagnostic procedure are high sensitivity, specificity, and overall diagnostic yield. Numerous studies have evaluated the effectiveness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and have yielded different results concerning different aspects. A study carried by Tyan et al. yielded that EBUS-TBNA has nearly 89% diagnostic sensitivity . In refeThe patient is a forty-two-year-old man. He is a nonsmoker and with no known underlying medical conditions and had been referred from another healthcare facility to the pulmonary clinic having a history of chronic cough with sudden onset about a month ago. The cough was initially dry but later became productive of a mild-moderate amount of whitish sputum. The patient had about four to five episodes of hemoptysis in small amounts. He has no history of chest pain, wheezing, fever, or night sweating, but reports that he has lost about ten kilograms in four months and suffered a decrease in appetite.The patient's vitals were stable; however, the patient seemed underweight. There was no lymphadenopathy, splenomegaly, hepatomegaly, or skin rash. Other examinations were unremarkable. Laboratory tests are shown in A computed tomography (CT) scan was done at the other hospital, which revealed mediastinal and right hilar lymphadenopathy suspicious for malignancy . Focal aAn EBUS-TBNA was done, and the right lower paratracheal lymph node (Station 4R) was sampled. The pathology revealed “scattered binucleated/multinuclear single large lymphocytes with prominent large macronuclei.” Moreover, a background of polymorphic lymphocytes and occasional bronchial cells were seen . The cytHodgkin's lymphoma is a curable malignancy if diagnosed early, with early intervention. Some of the options that are considered when choosing a diagnostic test include sensitivity, specificity, rate of complications, and overall diagnostic yield. Various studies have confirmed the effectiveness of EBUS-TBNA in diagnosing not only lymphoma but also lung cancer and other types of cancer, giving accurate results.Some clinicians still argue that there is insufficient information to validate the speculated accuracy of EBUS-TBNA. They will opt for surgical excision and core biopsy as a sampling technique as the disease management is significantly based on the pathologic subtype and grade. Therefore, a few samples obtained through EBUS-TBNA may not be adequate. However, there are studies such as that conducted by Nason and colleagues, which shows that the real-time ultrasound incorporated in EBUS-TBNA has facilitated the sampling technique of this diagnostic method, thus rendering this claim unconvincing .Similarly, developing data shows that EBUS-TBNA expertly diagnoses lymphoma when it is coupled with immunohistochemical, flowcytometric, and molecular studies and cytogenic studies. Grosu et al. showed that when EBUS-TBNA is used with immunohistochemistry and cytometry, it can give an overall of about 77% sensitivity and 100% specificity with a higher negative predictive value of 86% . The stuBandyopadhyay and colleagues mentioned that the main disadvantages of EBUS-TBNA included lesser sampling and inferior negative predictivity; however, there is more and more evidence supporting its use . In one The current advances in the minimally invasive diagnostic approach, particularly the EBUS-TBNA, including the on-site assessment, triaging samples, and flowcytometry, among others, have overcome the foregoing limitations that were holding EBUS-TBNA back. Currently, it is an effective tool for diagnosing lymphoma and can be used as the first line in lymphoma suspected cases with isolated mediastinal lymphadenopathy.


Dear Editor,A 61-year-old woman with IgM-monoclonal gammopathy of unknown significance (MGUS) type lambda was transferred to our department in October 2018 showing a severe nephrotic syndrome. Renal function was not impaired. Due to a common variable immunodeficiency (CVID) syndrome with hypogammaglobulinemia (IgA and IgG), the patient received polyvalent human IVIGs in a dose of 20 g every 3 to 4 weeks since 2014. The immunoglobulin preparation used  contains IgG1 67.8%, IgG2 28.7%, IgG3 2.3%, IgG4 1.2% and IgA at a maximum of 25 μg/mL, 250 mmol/L L-proline and water [Current findings showed reduced complement factors  suggesting an immunocomplex-mediated disease. ANA, ds-DNA, cryoglobulins, p- and c-ANCA-antibodies were normal. Serologies for HIV, hepatitis B and C were negative. Ultrasound diagnostics and chest x-ray showed pulmonary and hepatic congestion. Echocardiography was normal. Diuretic treatment was initiated, leading to adequate weight loss. Renal biopsy was performed. Findings were compatible with a membranoproliferative glomerulonephritis (MPGN) of the immune complex type with deposits of IgM matching the serological findings of the paraproteinemia [–0.33 g/LThe preexisting high-risk IgM-MGUS was updated to that of IgM-MGRS –5. AssumSurprisingly, not only nephrological but also hematological results improved enormously to a point that neither criteria for MGRS nor even MGUS were fulfilled .The parallel decrease of IgM, sFLC-lambda and proteinuria suggests a potential role for IVIGs in the pathogenesis of MGUS and the resulting IgM-positive MPGN in this patient. A direct effect of IVIGs is unlikely as the IVIG preparation used was free of IgM. However, IVIGs are known to also contain natural auto-antibodies including IgM type auto-antibodies . In addiWe speculate that IVIGs induced an acute immune response leading to monoclonal IgM production followed by its renal deposition causing glomerular immune reactions. To our knowledge, this is the first case describing a reversible high-risk MGUS and MGUS-associated immune complex-mediated MPGN provoked by the administration of IVIGs. Yet, the precise immune mechanisms underlying this observation remain unclear.


This paper reviews the literature on evaluations of brief intervention training programs for health professionals which address one or more lifestyle factors of chronic disease to identify factors impacting on development and implementation of programs. A search was conducted of the literature evaluating brief intervention training programs from 2000–2019 in the databases: Medline, CINAHL, Psychinfo, Academic Premier, Science Direct, Ovid , Web of Science and Informit. The content analysis and data extraction were aligned to the domains in the Consolidated Framework for Implementation Research (CFIR) to assist in the narrative synthesis. The search identified eight evaluations of programs targeting multiple risk factors, and 17 targeting single risk factors. The behavioural risk factor most commonly addressed was smoking, followed by alcohol and drug use. Programs consisted of face-to-face workshops and/or online or distance learning methods. Facilitators included availability of sustainable funding, adapting the program to suit the organisation’s structural characteristics and adoption of the intervention into routine client care. For Indigenous programs, the use of culturally appropriate images and language, consultation with Indigenous communities, and development of resources specific to the communities targeted were important considerations. The increasing prevalence of chronic disease is a global issue affecting all countries and populations. Tobacco use, foods high in saturated and trans fats, salt, and sugar , physical inactivity, and the harmful consumption of alcohol cause more than two-thirds of all new cases of chronic disease . Whilst Preventive efforts at multiple levels of the health care continuum have helped to combat the risk factors. One approach is building the capacity of health workers to deliver brief interventions (BIs) to their clients presenting with such behavioural risk factors. Provision of brief interventions in the primary care setting has been identified as an evidence-based intervention to prevent, detect and manage chronic disease ,8. HowevThe term ‘Brief Intervention Training’ (BI Training) that is used in this article is widely used, and it means ‘training in the delivery of brief interventions’. This article is a review of literature on programs that train health professionals in delivering brief interventions, with a particular interest in the training programs that are developed for health professionals working with Indigenous populations. This literature review addressed the following question: “What factors impact the development and implementation of training programs for health professionals to deliver brief interventions to their clients, with a focus on programs developed for Indigenous clients?”This review searched electronic databases and other sources from 10 February 2018 to 07 March 2018 initially, and the search was updated on 27 May 2019. In this review we included all types of research studies: case-control, case studies, randomised controlled trials, qualitative and mixed methods studies.Articles were included if they were: evaluations or studies of BI training programs that trained health professionals to deliver BIs to modify one or more health behaviours of general and Indigenous populations, and if they were published from 1 January 2000 to the search date. The review considered a range of locations where the training occurred, including hospitals and community clinics. Articles were excluded if they were: evaluations of delivery of BIs rather than of a training program, conducted as part of a university curriculum or on students , not published in the English language, dissertations, discussion pieces, editorials, and opinion pieces, systematic reviews, and meta analyses.To locate literature that specifically evaluated BI training programs for health professionals which targeted behavioural risk factors of chronic disease, a set of search terms was developed. Trial searches were conducted before finalising the search strategy. The search terms were grouped as follows: group 1 consisted of: evaluat* OR assess* OR analys* OR measur* apprais*, group 2 consisted of: brief intervention OR behaviour* intervention OR motivational interview* OR counsel* OR intervention OR interview*, group 3 consisted of: train* OR program* OR activity OR deliver* OR support OR research OR study, and group 4 consisted of four sections: (a) smok* OR tobacco OR nicotine OR smok* cessation OR smok* control OR tobacco control, (b) nutrition OR diet OR obesity OR weight, (c) physical activity OR exercise, and (d) alcohol OR grog OR substance OR drug*.The search was conducted in two phases. Firstly, eight scientific electronic databases, Medline, CINAHL, Psychinfo, Academic Premier, Science Direct, Ovid , Web of Science and Informit, were searched. Secondly, to identify any grey literature, a web search was undertaken in the same period in the Cochrane database, and the websites and publications of the following organisations: Australian Institute of Health and Welfare (AIHW), The Lowitja Institute, Australian Indigenous Health Infonet, The National Aboriginal Community Controlled Health Organisation (NACCHO), Menzies School of Health Research, and health departments of Australian federal, state and territory governments. The search for grey literature was mainly limited to Australia due to constraints of time and resources.The combined searches of all databases and the web search located 14,972 articles, of which 5776 duplicates were removed. The 9196 articles located from the literature search were screened through a three-step process. Firstly, the lead researcher (SS) assessed the articles by examining the title to verify its fit with the inclusion/exclusion criteria. From the screening of 9196 articles, 245 articles were identified to progress to the next step. Secondly, these 245 articles, based on a screening of their titles and abstracts, were checked against the inclusion criteria. A total of 217 articles were selected from this review process.As the third step, full texts were retrieved for the articles selected in the second step, and the lead researcher (SS) and co-researcher (VM) conducted a review by reading all full text articles. Any disagreements between the lead researcher and the co-researcher on the inclusion/exclusion of articles were referred to a third reviewer (FC). From these processes, 41 articles were identified for inclusion in the literature review. Studies that were reviews of BI training kits, reports of training and development without details of the training component and training conducted as part of a university curriculum or on students were excluded. Sixteen studies were excluded in this process, resulting in the final count of 25 articles for the literature review. The search results are presented in the PRISMA flow diagram .To synthesise and analyse the literature to identify factors impacting on training program implementation, this review applied the five domains of the Consolidated Framework for Implementation Research (CFIR) . CFIR’s CFIR, as a conceptual framework, can guide systematic assessment of multilevel implementation contexts to identify factors that might influence intervention implementation and effectiveness , and to Nearly half of the 25 retrieved studies (12) were conducted in the United States (US), eight in Australia and three in the United Kingdom. Eleven studies specifically looked at the broader aspects of program implementation by analysing the factors that supported or hindered the processes of training: the program’s fit with the current practices of trainees, policies and protocols in place within health services to support the training program and the use of systems for recording and reporting BI delivery. Three studies evaluated client/patient satisfaction with the brief intervention they received.Outcome measures in the different papers varied considerably, and they broadly examined the impact on the trainees in the areas of satisfaction with the training and improvements in confidence, motivation, skills and knowledge pre- and post- intervention, cost of the intervention, implementation of brief intervention with clients, trainees’ perceptions of role adequacy and self-efficacy, clients’ satisfaction with the brief intervention provided, reported changes in clients’ engagement in the risk behaviour, access to resources, and exploration of policies and protocols within health services to support the activity. Three studies conducted audits of client clinical charts to determine the quantity and quality of chart recordings of brief interventions ,31,36. IOf the studies identified in this review, there were six programs that had more than 200 trainees , nine programs had between 51 and 200 trainees, 10 programs had under 50 trainees; while one program did not specify the trainee numbers. The program with the largest number of trainees, the ‘Country-wide distance training for delivery of screening and brief intervention for problematic substance use’  conducteThe five domains and the 39 constructs and subconstructs of the CFIR were used to categorise the factors that impacted on the implementation of the different studies . In condThe domain of intervention characteristics relates to the features of the intervention that impact on its adoption and application. These features are classified into eight constructs: Intervention Source, Evidence Strength and Quality, Relative Advantage, Adaptability, Trialability, Complexity, Design Quality and Packaging, and Cost.A construct of this domain that was most frequently addressed in the different studies was ‘Adaptability’, which signifies the ability of an intervention to be tailored to meet local needs. For example, programs that targeted Indigenous clients developed culturally appropriate resources, and programs that trained a mix of health workers made adjustments to the curriculum to suit the trainee population from different disciplines and cultural backgrounds, and with varying levels of education ,30,33,37Programs that used resources developed by educational institutions or universities ,25,40 weThe domain of outer setting incorporates four constructs: patient needs and resources, cosmopolitanism, structural characteristics, and external policies and incentives. The construct that was most often mentioned, in ten studies ,33,36,37The influence of the external policies was evident in the development of some of the Australian programs, which were based on a number of national and state level strategies that broadly advised that any intervention designed to address smoking must be tailored to disadvantaged groups and must encourage behaviour change. The materials and resources used for these programs were perceived to be culturally appropriate to Indigenous populations ,37.The effect of external supports in the form of incentives and funding on the maintenance of a program was discussed in a few studies by ,30,33,37The domain of Inner Setting includes five constructs: Structural Characteristics, Networks and Communications, Culture, Implementation Climate, and Readiness for Implementation. For operational programs conducted over large geographical areas, distance was a major structural characteristic that impacted on the implementation. In the SBIRT  training in the state of New Mexico in the United States , two cliAnother large operational program, the Queensland Smokecheck program , was conThe construct ‘Readiness for implementation’ was referred to eight times. This construct consists of three sub-constructs: Leadership Engagement, Available Resources, and Access to Knowledge and Information. Some of the challenges experienced in the recruitment of training participants for different programs, as reported, for example, in the evaluation of the NSW SmokeCheck Program, were: small staff numbers for some organisations; some organisations did not feel they fitted in with the program; the reluctance on the part of managers and senior health professionals to attend the program; and the lack of managerial support for the implementation of the program . BarrierOut of all five of the CFIR domains, the influence of the characteristics of the trainees on the implementation of the programs has been the least evaluated area. This domain consists of five constructs: Knowledge and Beliefs about the Intervention, Self-efficacy, Individual Stage of Change, Individual Identification with Organization, and Other Personal Attributes. Several programs trained multiple health professionals: nurses, health workers, general practitioners, specialist doctors, and alcohol and community workers. However, none of the studies evaluated how the program’s impact varied according to the professional or personal characteristics of the participants.This domain consists of the following constructs: Planning, Engaging, Executing, and Reflecting and Evaluating. The construct of ‘Planning’ was referred to seven times and ‘Engaging’ was referred to five times. The study by Gonzales et al.  describeThis review identified that the evaluations of large operational programs such as the Queensland and NSW Smokecheck Programs, the South Australian Cancer Council’s Quitskills Program, Brazil’s Country-wide distance training program and the New Mexico SBIRT project had the potential to probe into the multiple factors that impacted on the implementation of these programs ,30,33,37We know from previous studies that the characteristics of the ‘Inner Setting’ significantly influence implementation efforts. Although professional training in the delivery of brief interventions is usually delivered by external providers, its implementation requires active collaboration with different health services. The size and spread of the health service, the structure and duration of the training program, the materials and resources developed, and the program’s requirement to cater for a mix of health professionals are important considerations in its implementation ,42. We aThis review too, based on the number of references to the different CFIR domains, confirmed that the characteristics of the health service  play a significant role in the implementation of the program. Besides establishing partnerships at senior levels with the participating organisations from the start, the importance of extending the program or tailoring the training to suit the managers and supervisors of the organisations was identified as helping to ensure better adoption by the health services . This reIn the area of delivery of brief interventions by health professionals to their clients, the availability of resources  and how they were managed within the organisation, and the program’s fit with the structural characteristics of the organisation were important . BI deliIn addition, a review of previously conducted systematic reviews highlighted similar themes and identified the importance of follow-up training sessions and/or training events spread over a longer time period . Whilst The application of the CFIR in this review has been highly beneficial in guiding the assessment of multilevel implementation contexts to locate factors that influenced implementation and effectiveness of the interventions, particularly in identifying the non-explicit descriptions of barriers and facilitators from the different articles. The studies included in this review differed significantly in terms of the settings, the size and nature of trainee populations, modes of interventions, program content, and outcome measures, and thus provided a comprehensive picture of the intervention environment.However, most studies extracted in this review were about small programs with few participants, delivered across few sites , with a very short period of operation, and usually targeting one health behaviour, and hence conducted little evaluation to gain insights into the factors that impacted on the implementation of the programs. Similarly, although BI programs for multiple health behaviours were reviewed in eight studies, none of the studies specifically identified or described the challenges of conducting multi-behaviour change training or implementation of BIs for multiple risk factors. Whilst key factors that impact on the implementation of brief intervention training programs for the general population were well identified, there was limited information on factors specific to the Indigenous populations. Only a small number of broad factors such as: consulting the communities prior to development of the program, tailoring the program to match the participant population and ensuring the cultural suitability of the programs and resources were identified. Limited research has examined the most effective methods for delivery of BI training to Indigenous health workers who work with Indigenous clients. Similarly lacking is an understanding of the extent of decline in the skills and knowledge that trainees acquired from a BI training program, although two studies reported that participants felt increasingly less legitimate and confident as time elapsed ,33. We aThe Final Report on NSW SmokeCheck stated that ‘the results point to the need for organisational development on the part of health services to ensure that smoking cessation becomes a standard component of Aboriginal Health Workers’ and other health professionals’ clinical and health promotion roles. The report points to the need for health services to provide organisational support to trainees, highlighting the role of health services’ managerial staff in supporting the implementation of BI training programs. This suggests the need for all future BI training programs to incorporate specific training components for managers. The health practitioners’ perceptions about their knowledge and their right to work in the identified area(s) are important in the ongoing support for the program, and the resultant delivery of BIs. Hence, the design of the programs needs to consider the trainees’ fit with the program: their educational and professional backgrounds and build on their role legitimacy and adequacy. This is particularly important consideration for managers, as the responsibility for preventive care is often perceived to be on front line health professionals rather than on the whole health service.To increase the accessibility of the program to health workers located in rural and remote locations, the need for the availability and sustainability of funding is highlighted. It is also important to consider alternate modes of delivering the training such as web-based modules and distance learning. Gaps in health professionals’ knowledge and skills continue to exist even after participation in the training program, and erosion in motivation and skills is likely to happen over time, impacting on their ability to deliver brief interventions. To address these concerns and to address the high turnover of staff members, routine repeat courses and refresher programs suitable to the trainee population need to be available. In the context of BI delivery for Indigenous clients, the role of Aboriginal Health Workers as mediators between service providers and communities needs to be acknowledged in the training program . Whilst The identification of common contextual factors that impacted on the implementation of the program has been difficult due to the varied nature of the studies. However, the descriptions of the development and implementation of the programs do provide some information on the factors that favoured or hindered the different processes. The most commonly discussed CFIR domain in the different evaluations was the influence of the inner setting or the characteristics of the participating organisations. The application of the CFIR has been particularly beneficial in identifying and teasing out the not so obvious descriptions of the contextual factors from the different articles. A highlight of this review is the generation of the knowledge that the literature on BI training programs for health professionals is generally deficient in understanding the complex interplay of contextual factors that impact on the implementation of the programs.Key messages from the review for the development and implementation of future BI training programs include: ensuring supports from management and engagement of workers from the start and incorporating the intervention as a standard component of health professionals’ roles. The availability of ongoing funding and adapting the program to meet the structural characteristics of the organisations are also important. Subsequent to the conduct of the training program, ongoing implementation of the intervention needs to be incorporated into routine practice aligning with the operational procedures of the organisation. This review highlights that healthcare providers can attain brief motivational interview knowledge, skills and confidence relatively quickly and these can be sustained over time, however, further research is needed to determine if BI skills are long lasting. Finally, to comprehensively understand the factors that impact on the implementation of BI training programs, conduct of in-depth qualitative studies to evaluate specific training features and methods that work best is recommended. It is expected that the results of such a study would provide deeper insights into facilitators and barriers of organisational implementation of BI training programs and its ongoing delivery.


Mycoplasma pneumoniae IgM-positive sera, 5 Legionella pneumophila IgM-positive sera, 6 sera of HIV infection patients, 36 rheumatoid factor IgM (RF-IgM)-positive sera, 5 sera from hypertensive patients, 5 sera from diabetes mellitus patients, and 14 sera from novel coronavirus infection disease 19 (COVID-19) patients.We set out to investigate the interference factors that led to false-positive novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgM detection results using gold immunochromatography assay (GICA) and enzyme-linked immunosorbent assay (ELISA) and the corresponding solutions. GICA and ELISA were used to detect SARS-CoV-2 IgM in 86 serum samples, including 5 influenza A virus (Flu A) IgM-positive sera, 5 influenza B virus (Flu B) IgM-positive sera, 5  Mycoplasma pneumoniae IgM-positive sera, 5 Legionella pneumophila IgM-positive sera, 6 sera of HIV infection patients, 36 rheumatoid factor IgM (RF-IgM)-positive sera, 5 sera from hypertensive patients, 5 sera from diabetes mellitus patients, and 14 sera from novel coronavirus infection disease 19 (COVID-19) patients. The interference factors causing false-positive reactivity with the two methods were analyzed, and the urea dissociation test was employed to dissociate the SARS-CoV-2 IgM-positive serum using the best dissociation concentration. The two methods detected positive SARS-CoV-2 IgM in 22 mid-to-high-level-RF-IgM-positive sera and 14 sera from COVID-19 patients; the other 50 sera were negative. At a urea dissociation concentration of 6 mol/liter, SARS-CoV-2 IgM results were positive in 1 mid-to-high-level-RF-IgM-positive serum and in 14 COVID-19 patient sera detected using GICA. At a urea dissociation concentration of 4 mol/liter and with affinity index (AI) levels lower than 0.371 set to negative, SARS-CoV-2 IgM results were positive in 3 mid-to-high-level-RF-IgM-positive sera and in 14 COVID-19 patient sera detected using ELISA. The presence of RF-IgM at mid-to-high levels could lead to false-positive reactivity of SARS-CoV-2 IgM detected using GICA and ELISA, and urea dissociation tests would be helpful in reducing SARS-CoV-2 IgM false-positive results.We set out to investigate the interference factors that led to false-positive novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgM detection results using gold immunochromatography assay (GICA) and enzyme-linked immunosorbent assay (ELISA) and the corresponding solutions. GICA and ELISA were used to detect SARS-CoV-2 IgM in 86 serum samples, including 5 influenza A virus (Flu A) IgM-positive sera, 5 influenza B virus (Flu B) IgM-positive sera, 5  The outbreak of infections by a novel coronavirus (nCoV) strain, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), that began in Wuhan, China, has spread rapidly throughout the country, as well as to other countries around the world. The outlook of prevention and control of novel coronavirus infection disease 19 (COVID-19) is still grim. As of 20 February 2020, the number of confirmed COVID-19 cases exceeded 70,000, and this number has continued to rise steadily, placing enormous emphasis on the timely and accurate diagnosis and treatment of the disease. At present, diagnosis of COVID-19 is mainly based on epidemiological history inquiry, laboratory testing, and chest radiology examination. Among these examinations, detection of nucleic acid from SARS-CoV-2 represents direct evidence for COVID-19 diagnosis 13. DetectThe detection of serum-specific IgM and IgG, especially the former, is routinely used in clinical laboratories to evaluate the acute phase of infection of pathogens in the serum , 6. In m7–Toxoplasma gondii IgG in different detection systems  patients met the diagnostic criteria, and sera were collected within 3 to 7 days after the beginning of the clinical symptoms. In addition to the 36 RF-IgM-positive serum samples, detection levels of RF-IgM in the remaining 50 serum samples were lower than 20.00 IU/ml.This study was approved by the Ethics Committee of Affiliated Hospital of North Sichuan Medical College. Serum from a total of 86 patients with different pathogen infections and related chronic diseases were collected from the Affiliated Hospital of North Sichuan Medical College and Nanchong Central Hospital from 25 January 2020 to 15 February 2020. In accordance with the Notice on the Issuance of Strategic Guidelines for Diagnosis and Treatment of Novel Coronavirus (SARS-CoV-2) Infected Pneumonia . RF-IgM was detected by rate nephelometry assay . HIV combi pertussis toxin) (PT) was detected by electrochemiluminescence assay . HIV infection was confirmed by immunoblotting assay (the confirmed information was fed back by CDC). SARS-CoV-2 nucleic acid was detected using real-time PCR (RT-PCR) . GICA and ELISA were used for SARS-CoV-2 IgM detection . Optical density in ELISA plates was measured using a microplate reader .IgM against Flu A and Flu B, Sera (100 μl) were added into 1-ml sample diluents  and mixed, and then 100 μl of the diluted sample was put into the sample hole of the test card. The liquid was chromatographed upward under the control of the capillary effect; when the liquid was about to reach the upper absorbent paper, 100 μl PBS solution containing 6 mol/liter urea was added into the sample hole of the test card; the results were observed after 20 to 25 min. The SARS-CoV-2 IgM in the sample bound first with the anti-human-IgM labeled by colloidal gold and then with the SARS-CoV-2 recombinant antigen at the test line (T) position to form a complex of SARS-CoV-2 antigen, SARS-CoV-2 IgM, and anti-human IgM labeled by colloidal gold. A complex of goat polyclonal IgG and anti-human IgM labeled by colloidal gold was formed at the control line (C) position. For the positive standard, colloidal gold color reactions occur at both the T-line and C-line positions; for the negative standard, the colloidal gold color reaction occurs only at the C-line position.Sera (8 μl) were added into 800-μl sample diluents (0.02 M PBS) and mixed, and then 100-μl volumes of the diluted sample, the negative control, and the positive control were added to the wells of plates coated with SARS-CoV-2 recombinant antigen, and the plates were incubated at 37°C for 30 min. The plates were washed five times, and 100 μl of PBS solution  was added and incubated at 37°C for 10 min. After three more washes, anti-human IgM horseradish peroxidase (HRP)-labeled antibody was added into the reaction system to form an indirect immune complex. Following five washes to remove unbound substances, the substrate was added for the color reaction. The results were interpreted according to the ratios of the sample optical density value and the cutoff optical density value (S/CO) as follows: positive, S/CO equal to or greater than 1.00; negative, S/CO less than 1.00. The results of affinity index (AI) analyses were expressed as the ratios of the S/CO values determined for different dissociated urea concentrations to that of PBS with 0 mol/liter urea. The AI threshold value was set as the middle value between the highest AI value determined for the false-positive sample results with the outliers removed and the lowest AI value determined for all of the SARS-CoV-2 infection samples. The results were interpreted as follows: positive, AI value of sera greater than or equal to the AI threshold; negative, AI value of sera less than the AI threshold.P value of <0.05 determined by two-tailed tests.Statistical analyses were performed by the use of SPSS, version 19.0 . Fisher’s exact test was used for the specific comparisons of GICA and ELISA results obtained for the detection of SARS-CoV-2 IgM in sera with positive RF-IgM before and after urea dissociation. The specific comparisons between the GICA and ELISA results obtained for the detection of SARS-CoV-2 IgM before and after urea dissociation in all control sera were made using Pearson’s chi-square test. The statistical significance of all tests was defined as a M. pneumoniae IgM-positive sera, 5 L. pneumophila IgM-positive sera, 6 sera from HIV infection patients, 5 sera from hypertensive patients, and 5 sera from diabetes mellitus patients , and the sensitivity was not affected , and the sensitivity was unaffected (The urea dissociation test of ELISA was carried out with PBS containing 0 mol/liter, 1 mol/liter, 2 mol/liter, 4 mol/liter, 6 mol/liter, and 8 mol/liter urea in 22 RF-IgM-positive serum samples and serum from 14 COVID-19 patients that were positive for SARS-CoV-2 IgM in ELISA before urea dissociation. When the dissociation concentration of urea was 4 mol/liter and with the AI calculation method set to 0.371, the results of SARS-CoV-2 IgM analyses in 19 serum samples with positive RF-IgM turned negative, whereas those of SARS-CoV-2 IgM in 14 serum samples from COVID-19 patients remained positive . Throughaffected .M. pneumoniae, and L. pneumophila, including fever, fatigue, and cough. Moreover, the majority of COVID-19 patients have had preexisting diseases such as diabetes, hypertension, and other endocrine and metabolic diseases (SARS-CoV-2 infection patients have many clinical symptoms similar to those of patients infected with common respiratory tract pathogens such as Flu A, Flu B, diseases , 17. TheRF is an autoantibody against the FC segment of denatured IgG, the main type of which is IgM. It is the main factor that causes the interference in immune responses –20. When–A mid-to-high level of RF-IgM can cause false-positive results of SARS-CoV-2 IgM detection by GICA and ELISA. Therefore, when serum is RF-IgM positive, it is difficult to determine the real SARS-CoV-2 IgM status. This study attempted to eliminate or reduce the interference by urea dissociation. The main rationale for the selection of the time point used for addition of urea solution in the GICA method was as follows: first, after a certain reaction time, the specific antigen antibody may bond more firmly, thus making the procedure of urea dissociation more challenging; second, at that time point, the amount of liquid content in the sample well was small, with little change in urea concentration in the dissociation solution added later, thereby ensuring the dissociation effect. According to our previous study , the ureIn conclusion, when GICA and ELISA are used to detect SARS-CoV-2 IgM, the level of RF-IgM in the serum should be evaluated, and the urea dissociation test should be carried out to avoid the risk of false-positive results. At the same time, the results of this study suggest that the urea dissociation test cannot completely eliminate interference from RF-IgM. Therefore, when SARS-CoV-2 IgM results are still positive after urea dissociation, RT-PCR should be used for nucleic acid detection. In addition, it should be emphasized that serological tests represent a method that is complementary to nucleic acid detection. The preferred method for detection of acute disease is via molecular testing, rather than testing for IgM, precisely because of the possibility of inaccurate results. On the basis of our research results, we suggest that all of the methods mentioned above should be used to eliminate or reduce the impact of cross-reaction when using GICA and ELISA methods to detect SARS-CoV-2 IgM, which will help in the preliminary screening of suspected and high-risk groups, as well as in the assessment, prevention, and control of the SARS-CoV-2 epidemic and the formulation of appropriate prevention systems.


ARID1A, SMARCA2, SMARCA4, SMARCB1/INI1, SMARCC1, SMARCC2 and PBRM1 mutations in a TCGA data set of sq-BLCA (n = 45) revealed that ARID1A was the most frequently altered SWI/SNF gene (15%) while being associated with protein downregulation. Genetic alterations and loss of ARID1A were confirmed by Targeted Next Generation Sequencing (NGS) (3/6) and immunohistochemistry (6/116). Correlation with further mutational data and PD-L1 expression revealed co-occurrence of ARID1A loss and TP53 mutations, while positive correlations with other driver mutations such as PIK3CA were not observed. Finally, a rare number of sq-BLCA samples were characterized by both ARID1A protein loss and strong PD-L1 expression suggesting a putative benefit upon immune checkpoint inhibitor therapy. Hence, for the first time, our data revealed expression loss of SWI/SNF subunits in sq-BLCA, highlighting ARID1A as a putative target of a small subgroup of patients eligible for novel therapeutic strategies.Dysfunction of the SWI/SNF complex has been observed in various cancers including urothelial carcinomas. However, the clinical impact of the SWI/SNF complex in squamous-differentiated bladder cancers (sq-BLCA) remains unclear. Therefore, we aimed to analyze potential expression loss and genetic alterations of (putative) key components of the SWI/SNF complex considering the co-occurrence of genetic driver mutations and PD-L1 expression as indicators for therapeutic implications. Assessment of  TP53 mutations or non-muscle-invasive bladder cancers (NMIBCs) including activating FGFR3 mutations or PIK3CA alterations ; c.1753C>T (p.Gln585Ter/COSM1133047): n = 2, breast carcinoma [H_KU-1186-1186_A2_core], Burkitt lymphoma BL-6; c.4005-2A>G (COSM6925751): n = 1, transitional cell bladder carcinoma [P-0003024-T01-IM3]). Two of the three mutations are also (redundantly) listed in the cBioPortal database v3.4.13 . The mutation c.4005-2A>G affects the canonical splice site and leads to loss of the acceptor splice site according to distinct prediction tools. All three mutations are, therefore, most likely deleterious and probably lead to a nonsense-mediated decay of the truncated protein and, therefore, to a protein loss. To our knowledge, none of the three mutations has been previously described in the literature, but all three mutations are annotated in the COSMIC database v92 (ARID1A-mutated cancers may cooperate with immune checkpoint blockade therapy [ARID1A-mutated cancer (1/3) was identified to be potentially eligible for atezolizumab first line therapy  or uterine corpus endometrioid carcinomas (34%) [ARID1A mutations are inactivating truncating mutations [ARID1A gene alterations in urothelial carcinomas [ARID1A mutations in ovarian clear cell carcinoma [ARID1A mutated carcinomas are associated with poor prognosis, and for instance, in breast cancer patients, inactivated ARID1A suggests a tumor suppressive function [To date, dysfunction of the components of the SWI/SNF complex has been shown for various cancer entities  includinas (34%) . Most ARutations —e.g., 63rcinomas  or over arcinoma . ARID1A function ,49. ARID1A with a frequency of 26% in urothelial bladder cancer [ARID1A mutations in 15% of sq-BLCA of the TCGA data set. The pathological/functional significance of identified missense mutations remains elusive; however, by stratifying the mutations we significantly observed reduced ARID1A protein levels for both—i.e., for nonsense mutations as well as for the combined group of nonsense and missense mutations. Further mechanisms potentially involved in gene silencing such as epigenetic silencing or mutations in non-coding regions as well as post-transcriptional or translational modifications [ARID1A mutations correlated with loss of protein expression—i.e., 73% of tumors with heterozygous ARID1A mutations lacked protein expression [ARID1A in both pure and mixed SCC samples which were characterized by ARID1A protein loss. Interestingly, we found that protein loss of the BAF-specific subunit ARID1A was closely associated with expression loss of the commonly shared and central subunits SMARCA4 and SMARCC1, as well as with the BAF/PBAF-associated factor SMARCC2. In turn, ARID1A expression correlates with all analyzed components potentially involved in assembly of the BAF complex [SMARCA2-mutated cells depends on the residual SMARCA4-containing complex activity in specific tumor entities [Recently, we revealed frequent genetic alterations of genes encoding for SWI/SNF subunits including r cancer . Most ofications  might bepression —suggesti complex ,12 suggeentities . Thus, fARID1A mutations are associated with mismatch repair deficiency and normal p53 expression [PIK3CA and ARID1A mutations has been shown before [PIK3CA mutations; however, none of the tumors lacking ARID1A expression showed evidence for any of the analyzed driver mutations . Thus, a hypothesized causal and functional link between both events  seems unlikely in squamous bladder cancer. In turn, ARID1A loss occurred in a TP53-deficient genetic background suggesting a regulation of potentially different biological processes to those described to date [Besides involvement of ARID1A in SW/SNF-mediated chromatin remodeling, ARID1A is thought to contribute to DNA damage repair, especially DNA double strand break (DSB) repair . It has pression . Coexistn before , whereas to date , but affARID1A mutation in combination with immune cytokine CXCL13 expression predicts response to immune checkpoint inhibitors in metastasized bladder cancers [ARID1A mutations and increased PD-L1 expression as previously reported [ARID1A mutations may benefit from ICI treatment. In addition, Fukumoto and colleagues showed that inhibition of histone deacetylase 6 (HDAC6) contributes to growth suppression of ARID1A-mutated tumors, while synergistic effects were shown in combination with anti-PDL1 therapy [ARID1A mutation.However, accumulating studies propose the involvement of functional ARID1A loss in synthetic lethality, which contributes to the response to various classical ,21 and n cancers . As we a cancers , ARID1A reported  could no therapy . Althoug therapy , current therapy ,27. ThusIn conclusion, we provide, for the first time, data describing expression loss of components of the SWI/SNF-complex in sq-BLCA including pure SCC, highlighting ARID1A as an interesting target for a small subgroup of patients which may benefit from novel therapeutics in an ARID1A mutated background.


To investigate the changes in the lumbar intervertebral foramen (LIVF) dimensions from neutral supine to direct anterior approach (DAA)‐specific hyperextension supine position through a standardized three‐dimensional (3D) reconstruction computerized tomography (CT) method.A total of 35 healthy volunteers (18 men and 17 women) were included in this retrospective study. The mean age of enrolled subjects was 28.9 ± 5.0 years. In September 2018, all the individuals underwent a 3D CT scan of the lumbar spine in neutral and 30° hyperextension supine positions, which mimicked the patient’s position in DAA total hip arthroplasty (THA). The dimensions of the LIVF, including foraminal area, height, and width, were measured on 3D reconstructed CT models at all lumbar foraminal levels. Foraminal area was defined as the area bounded by the adjacent superior and inferior vertebral pedicles, the posterosuperior boundary of the inferior vertebral body, the surface of the intervertebral disc posteriorly, the posteroinferior boundary of the superior vertebral body, and the surface of the ligamentum flavum anteriorly. Foraminal height was defined as the longest distance between the border of the superior and the inferior pedicle. Foraminal width was defined as the shortest distance between the posteroinferior edge of the superior vertebrae and the opposing boundary. Subgroup analysis and multiple linear regression were used to evaluate the relationship between percentage changes of the LIVF dimensions and side, sex, and age.P < 0.05). From neutral to hyperextension supine position, the foraminal area reduced by 20.1% at lumbar 1–2 (L1–2), 22.6% at L2–3, 19.9% at L3–4, 18.1% at L4–5, and 12.0% at lumbar 5–sacral 1 (L5–S1) level, respectively; the foraminal height reduced by 9.5% at L1–2, 10.5% at L2–3, 9.5% at L3–4, 9.6% at L4–5, and 6.1% at L5–S1 level, respectively; the foraminal width reduced by 12.8% at L1–2, 14.5% at L2–3, 13.0% at L3–4, 10.4% at L4–5, and 8.4% at L5–S1 level, respectively. The changes in LIVF dimensions were biggest at L2–3 level and smallest at L5–S1 level. Subgroup analysis showed that there were no significant differences in the percentage changes of LIVF dimensions between the sexes and sides (P > 0.05). Multiple linear analysis showed that the percentage changes of LIVF dimensions were not related to side, sex, and age (P > 0.05).The LIVF dimensions varied significantly between the two positions at all levels (The dimensions of the LIVF showed significant decrease at all levels in the DAA‐specific hyperextension supine position compared with the neutral supine position, and the percentage changes of LIVF dimensions were not influenced by side, sex, and age. Total hip arthroplasty (THA) is a reliable and effective surgical intervention for patients with end‐stage hip joint diseaseHowever, we questioned whether this procedure is harmless to the patients. In our experience, some patients have complained about lumbar pain after the DAA THA, although it was relieved later. A recent publication reported that the hyperextension impact could lead to a chance fracture. This indicates that position‐related complications do exist in DAA THAet al.1–5) levels from neutral to extension standing position in patients with low back pain, while they did not find changes in LIVF dimensions at the lumbar 5–sacral 1 (L5–S1) level. In another in vivo dynamic study, Zhong et al.5–S1, and that the foraminal height remained constant throughout the activity. However, another study by Singh et al.5–S1 but decreased significantly from upright sitting to extension standing position at all levels, including L5–S1.Previous studies have elucidated the dimensional changes of LIVF from flexion to extension in standing or sitting position. Ren 2–3 level and smallest at the L5–S1 level. Similarly, Schmid et al.5–S1. Furthermore, Schmid et al.et al.In addition, they found that the decrease in the foraminal area was biggest at the L1–2 to L5–S1 on both sides were measured with the three‐dimensional (3D) reconstruction computed tomography (CT) images at a standardized mid‐pedicle plane, which usually corresponds to the narrowest cross‐section area of the LIVFKnowing the dimensional changes of LIVF from neutral to hyperextension supine position may provide valuable information to understand the potential nerve root complications after DAA THA. In this study, the LIVF dimensions from LWe hypothesized that the LIVF dimensions would decrease with the hyperextension of the lumbar spine in supine position, and the changes in LIVF dimensions would not be influenced by side, sex, and age.A total of 35 healthy volunteers (18 men and 17 women) with a mean age of 28.9 ± 5.0 years were enrolled in this study. Inclusion criteria included the following PICOS principle: (i) Healthy subjects who has no previous spinal diseases and surgical history; (ii) underwent lumbar spine 3D CT in hyperextension position; (iii) underwent lumbar spine 3D CT in neutral supine position; (iv) foraminal area, height, and width at all lumbar foraminal levels; and (v) a retrospective study. Exclusion criteria were: (i) current or prior lower back pain or radiculopathy; (ii) history of spinal surgery; and (iii) anatomic abnormalities or other spinal disorders.Our study was approved by the institutional review board of our institute, and informed consent was obtained from all participants.1–2 to L5–S1 were evaluated on both sides. The subjects were first scanned in conventional neutral supine position. Then we placed a position mat under the pelvis at the level of ASIS so that the hip was hyperextended at 30° during CT scanning, to mimic the hyperextension supine position in the DAA THA  in September 2018. In all subjects, five foramina from Let al.All image data were saved in DICOM format, and were subsequently imported to Mimics 19.0  for preprocessing. Several previous studies have used 3D CT scans for the measurement of LIVF dimensionsThe foraminal area was defined as the outline of the LIVFForaminal height was defined as the longest distance between the boundary of the superior and inferior pedicleForaminal height was defined as the distance between the posteroinferior edge of the superior vertebrae and the anterior boundary of the superior articular processt‐test was used to compare the percentage changes of LIVF dimensions between right and left sides, and the independent t test was used to compare the percentage changes between sexes. Multiple linear regression was used to evaluate the relationship between the percentage changes of LIVF dimensions and the subjects’ age and sexes. A P‐value less than 0.05 was considered significant difference.All parameters were expressed with mean ± SD. All statistical analysis was performed with SPSS 21.0 software . Two of the authors performed blinded measurements. One of the authors repeated measurements with 4‐week intervals. The reliability of intrarater and interrater measurements were assessed using intraclass correlation coefficients (ICCs), which can be interpreted as: <0.40 poor; 0.40–0.59 fair; 0.60–0.74 good; 0.75–1.00 excellentThe intraclass correlation was found to be 0.92 for foraminal area, 0.94 for foraminal height and 0.97 for foraminal width. The interclass correlation was 0.88 for foraminal area, 0.90 for foraminal height, and 0.91 for foraminal width. All measurements showed excellent ICCs.P < 0.05; Table 2 (20.1%) at L1–2, 38.5 ± 12.3 mm2 (22.6%) at L2–3, 32.0 ± 14.5 mm2 (19.9%) at L3–4, 25.7 ± 10.3 mm2 (18.1%) at L4–5, and 15.3 ± 6.8 mm2 (12.0%) at L5–S1 level, respectively.The foraminal area varied significantly between the two positions at all levels (P < 0.05)  at L2–3, 1.9 ± 0.8 mm (9.5%) at L3–4, 1.8 ± 0.8 mm (9.6%) at L4–5, and 1.0 ± 0.6 mm (6.1%) at L5–S1 level, respectively.The foraminal height varied significantly between the two positions at all levels (5) Table , Fig. 3BP < 0.05)  at L2–3, 1.3 ± 0.9mm (13.0%) at L3–4, 1.0 ± 0.6 mm (10.4%) at L4–5 and 0.9 ± 0.7 mm (8.4%) at L5–S1 level, respectively.The foraminal width varied significantly between the two positions at all levels (5) Table , Fig. 3CP > 0.05) (Tables P > 0.05)  and the side and sex  Tables  and 3. T5) Table .2–3 level, and smallest at L5–S1 level. In addition, the percentage changes were not influenced by side, sex, and age.In the current study, we investigated the LIVF dimensions including foraminal area, height, and width on the standardized mid‐pedicle slice and compared the parameters measured in conventional neutral supine and hyperextension supine position. The results confirmed our initial hypothesis that the LIVF dimensions were significantly decreased at all intervertebral foraminal levels with the hyperextension of the lumbar part. The changes in LIVF dimensions were largest at Lin vivo studies have reported position‐dependent morphologic changes of LIVF. Generally, the LIVF dimensions increase in flexion and decrease in extensionSeveral 1–L5 levels5–S1 level, which was similar to the results in Singh’s and Schmid’s study5–S1 level in our study. These differences might be attributed to the different imaging modalities and measurement methods. Moreover, putting the mat under the subjects could place them in passive hyperextension position, and the kinematics in such a position might differ from the active extension position reported in previous studies.This study first investigated the changes in LIVF dimensions when subjects were placed in DAA‐specific hyperextension supine position. Our results showed similar decrease of the foraminal area to the previous studies at L2–3 level, which was coincident with Ren’s study5–S1 level, which was possibly due to different biomechanics at L5–S1 level compared to the upper levels. The sacrum is markedly curved and tilted backwards, and the first sacral vertebra articulates with the fifth lumbar vertebra at specific lumbosacral joint angle5–S1 intervertebral foramen is thought to be less mobile compared to upper levels in extension of the lumbar spine2 nerve root but common in L5 nerve root due to the increased ratio of the nerve root diameter to the foraminal area being lower compared to upper levels4–5 and L5–S1 levels.In our study, the changes in LIVF dimensions were largest at L2–L5 levels, we did not detect a significant difference in LIVF dimensions between the sexes and sides at all levels. The results of the regression analysis showed no influence of side, sex, and age on the percentage changes in LIVF dimensions.Although the percentage changes of foraminal width were slightly higher for the male subjects from LSome limitations to our study should be considered. First, the subjects involved in our study were mainly young and healthy volunteers; therefore, the changes might be different in older people and patients with lumbar spine diseases. Second, the patients were under general anesthesia during the operation, and the muscle relaxation effect possibly influenced the LIVF dimensions. The subjects in the current study were scanned in a conscious state, which might not accurately reflect the intraoperative changes of LIVF dimensions. The exact changes during the operation should be further investigated in future studies. Despite these limitations, our study still demonstrates a decrease in LIVF dimensions with the hyperextension of the lumbar spine in supine position.2–3 level and the smallest at L5–S1 level. The changes in dimensions were not influenced by side, sex, and age. This study demonstrated the position‐dependent change of LIVF comparing the neutral supine position with the DAA‐specific hyperextension supine position. This is of great value for understanding and preventing the potential risk of nerve root injury during DAA THA.In this study, we observed that the LIVF dimensions, including area, height, and width, decreased significantly with extension of the spine in supine position. The biggest decrease of foraminal dimensions was at L


A number of commentators have acknowledged the decline of gayborhoods and the concomitant emergence of non-heteronormative diasporas in societies where sexual and gender diversity is normalized Ghaziani . Academi To help develop a more sophisticated conceptualization of post-places, I turn to the post-phenomenological perspectives provided by Gilles Deleuze and Félix Guattari, drawing particularly from their anti-climactic notions of plateaus and afterglows. Theorizing post-places may be useful for scholars interested in gayborhoods as a substantive topic area, but may also be transferred more generally to any instance where emplaced materiality gives way to more virtual and imagined forms of spatial affect, such as Hadrian’s Wall and other ruinous sites producing geographical arrangements within its perimeter that do not necessarily pertain elsewhere, at least not with as much potency. A gayborhood is born as it becomes distinctively LGBTQ+ and declines or ‘dies’ as its physical or imagined differences dissolve. However, from a post-phenomenological perspective a gayborhood can have an afterlife even if its physical presence is lost. This is because gayborhoods, like most meaningful places, produce intense affective experiences that leave their marks in the minds and bodies of humans, as well as in the heterogeneous bodies that constitute the non-human environment. Deleuze and Guattari : 80 streHow might afterglows continue to affect bodies and perpetuate the afterlife of a post-place? At a conscious level, people may compare contemporary sites within an LGBTQ + diaspora to their memories of the erstwhile gayborhood. Stone  shows thworse, suggesting that afterglows may even reverse or invert the powers of a particular physical place. Then again, afterglows like habits may be able to carry across some of the positive affect from a place into a post-placed diaspora. Such speculations are best put to the empirical test.A comparative analysis of gayborhoods with different historical and geographical trajectories, such as that conducted by Gorman-Murray and Nash , suggestPlateaus and afterglows add to a discursive repertoire which already abounds with metaphoric attempts to capture the ambulance, ambiguity, and ambivalence of contemporary LGBTQ + topologies. The notion of a diaspora, so eloquently employed by Bitterman , makes lIn contrast to the diaspora, Doan : 5 proviThe plateau comes closest to the analogy of archipelagos proposed by Ghaziani , especiaOn the topic of future research, there are plenty of theoretical, practical, and political questions that invite further exploration. How affectively intense does a gayborhood (or other place) need to be in order to generate an afterglowing post-place? Do all places leave an afterglow, or is it only those that reach a certain threshold of affective intensity? If the latter, is there a typical threshold that affect needs to reach or does this vary greatly between contexts? Deleuze and Guattari  write ofPractical questions for non-academic stakeholders also abound. Should town planners, place marketers, and policy-makers attempt to anticipate post-places when designing places? Should they seek to nurture afterglows as valuable urban assets when gayborhoods and other once-significant spaces are displaced by gentrification? Or, are afterglows dangerous sources of attachment and resistance that should be avoided by those who wish capitalist accumulation and alteration to advance unabated? Place marketing studies of historical sites certainly suggest that afterglows can be valuable  places. These notions extend the power of place across space but also time, beyond the ostensible ‘death’ of a place as a physical site that can be visited and experienced in the phenomenological first-hand. While phenomenology focuses on the physical and representational aspects of places-as-environments, the post-phenomenological approach developed here may be applied also to places that are physically diminished, such as ruins (e.g. Warnaby et al.


Tailored texting interventions for smoking cessation are increasingly popular given the ubiquitousness of smart phones. Because high development costs and limited expertise may pose substantial barriers to designing and implementing these programs at the local level, utilization of existing programs at the national level is a promising strategy. In 2011, Austin Public Health focused on promoting smoking cessation among Austin/Travis County residents. Their strategy involved marketing and linking their citizens to a federally-funded, evidence-based smoking cessation program via texting. The target audience was low income, 18–24 year olds. Their marketing strategies included radio ads, digital ads, social media ads, and direct outreach at events in Austin, Texas. During the period between April 2016 and July 2017, 1,022 people signed up for the program. The quit rate was comparable to other texting programs which were tailored at the local level, and the program was cost-effective, costing $12,704.56 per life-year added, averting $99.38 per person in medical costs, discounted at 3%. As technological improvements in smart phones have accelerated, tailored texting interventions for smoking cessation have become more popular . A key aIn cost-effectiveness analysis, program development is not included in costs. This is because development costs would not have to be replicated if the program were continued. The cost of extending the program is what is relevant in cost effectiveness . At the In contrast to other programs, Austin Public Health chose to utilize an existing federal program, the National Cancer Institute (NCI)'s SmokefreeTXT. This free federal program was created to provide adults  with 24/7 support for smoking cessation, including encouraging messages, advice, and tips to help smokers quit smoking and stay quit. Using the existing text-based development and operation, and thereby not having to design and implement an individualized texting program allowed the Austin team to devote their energies to marketing the program. They placed ads on the radio, the internet, and in social media. They also direct marketed at various events around town. The purpose of this report is to assess this program from the perspective of cost-effectiveness analysis.Given the high costs and poor health outcomes for smokers, smoking cessation programs generally have been found to be cost-effective , 5. SmokThere are a few cost effectiveness studies of smoking cessation programs which were text- or computer-based. In a randomized controlled trial in the UK, Wu et al.  evaluatehttps://smokefree.gov/tools-tips/text-programs). When an individual signs up, they are asked to enter a desired quit date. NCI begins sending text messages 2 weeks before the quit date and continues to send messages for 6 weeks after it. Users receive from one to five messages a day, approximately 130 messages in total. NCI continues to send follow-up texts 1, 3, and 6 months after the program ends. Automated messages include clinical content, assessments, and user-initiated feedback.SmokeFreeTXT is a free program from the National Cancer Institute designed for smokers ages 13 and up and lasting 6–8 weeks  .Table 2.The benefits were life-years added. The averted medical costs were the medical costs saved by not smoking by age. The method for estimating averted medical costs and life years added are described below. The program costs were those of SmokefreeTXT, as described below in In order to estimate benefits, one must be able to estimate life-years added by the program. Markov chain models are the standard method for estimating life-years added. The idea is to compare the life-years obtained, hypothetically, for a population of smokers with and without SmokefreeTXT. If the additional life-years are greater with SmokefreeTXT, those are part of the benefits of the program.In our Markov Chain, mortality rates varied by age. Following Guerriero et al. , Table 1Finally, we conducted a Monte Carlo sensitivity analysis to test the sensitivity of our analysis to changes in the cost of the program, the effect size, the background quit rate, and the relapse rate.Our Markov chain also allowed costs of smoking to vary by age. Overall, there were 9.5 additional life-years per 1,000 smokers in the intervention versus no intervention. The life-years were discounted at 3%. Note that the actual undiscounted number of life-years added was 4 times higher. Our Markov Chain results show that the intervention led to $99.38 of averted medical costs per enrollee, discounted at 3%. Note that the averted costs were much higher, but as shown in SmokefreeTXT added 9.5 life-years per 1,000 smokers enrolled, costing $12,704.56 per life-year added. This is in line with, but higher, than published results for the most similar program identified [see e.g., , adding 9.5 discounted life-years per 1,000. The quit rate was comparable to other texting programs which were tailored at the local level, and the program was cost-effective, costing $12,704.56 per life-year added.The fact that the national program SmokefreeTXT was able to offer a competitive program in terms of effectiveness and cost-benefit analysis in a local market is positive for other entities seeking to lower smoking prevalence in a cost-efficient manner. Small entities with little expertise in text messaging do not need to incur the expense of creating another texting intervention. They can simply locally market the text messaging service available at the national level. This will lower costs due to scale economies, and improve effectiveness due to increased expertise.More generally, technological improvements such as smart phones afford the possibility of partnerships to form between local communities and higher levels of government. Programs can be developed and shared with local governments and local health departments, taking advantage of expertise and scale economies.Our Monte Carlo model revealed that local marketing of SmokefreeTXTs was robust to variations in parameters in terms of cost-effectiveness. In the one-way sensitivity analysis, the results were sensitive to effect sizes.There were several limitation to our analysis. First, we do not have demographic data on participants. Second, we did not include NCI's programming costs because we do not have an estimate. However, we believe the cost per enrollee must be low given that this program is used nationally.Henry.S.Brown@uth.tmc.edu.The datasets for this study will not be made publicly available because the authors do not own the data. They were shared by the National Cancer Institute. Requests to access these datasets should be directed to HB, The study was submitted to UTHealth's IRB committee and was determined to be exempt.HB led the team, wrote the first draft, and performed the analysis. SS and AL wrote sections of the paper and helped us analyze the National Cancer Institute data as well as cost data. KW advised on the methods and wrote and edited several rounds, as did UP.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.


Based on the continuous increase of donor risk, with a majority of organs classified as marginal, quality assessment and prediction of liver function is of utmost importance. This is also caused by the notoriously lack of effective replacement of a failing liver by a device or intensive care treatment. While various parameters of liver function and injury are well-known from clinical practice, the majority of specific tests require prolonged diagnostic time and are more difficult to assess ex situ. In addition, viability assessment of procured organs needs time, because the development of the full picture of cellular injury and the initiation of repair processes depends on metabolic active tissue and reoxygenation with full blood over several hours or days. Measuring injury during cold storage preservation is therefore unlikely to predict the viability after transplantation. In contrast, dynamic organ preservation strategies offer a great opportunity to assess organs before implantation through analysis of recirculating perfusates, bile and perfused liver tissue. Accordingly, several parameters targeting hepatocyte or cholangiocyte function or metabolism have been recently suggested as potential viability tests before organ transplantation. We summarize here a current status of respective machine perfusion tests, and report their clinical relevance. Machine perfusion technology is increasingly applied in solid organ transplantation to improve the outcomes through a reduction of ischemia-reperfusion injury (IRI) with less complications and better graft survival ,2. The pThe term viability carries several definitions in the literature since the earlier days around 1600, when scientists focused on motility to define cellular viability. In biology, viability involves multiple cellular functions dedicated for a single cell or an organism to live, grow, and develop . A more With an increasing number of candidates, improved medical management and surgical technology, and an aging population with more comorbidities, the quality of donors has decreased. Currently, the cumulative donor–recipient risk accepted by a team, varies among centers and relies on different levels of experience ,27. MostAs a first step towards the development of a biomarker, it is therefore important to understand the initial trigger of IRI and the downstream consequences. Looking at different cellular compounds, mitochondria appear at front as instigators of the IRI cascade . During The TCA is blocked through the functional relation with complex II, the lower temperature during ischemia, and the lack of energy to fuel the enzymatic activity ,41. At sROS release appears immediately within the first few minutes after reoxygenation ,43,44,45Liver viability assessment starts at the time of donor offer, where the surgeon draws the initial picture during the first conversation with the involved donor coordinator prior to macroscopic examination. With the delivery of the donor past medical history, results of donor blood tests, including liver transaminases, parameters of coagulation, cholestasis, hypoxia and electrolytes, the viability testing begins . In someMachine perfusion technology currently evolves significantly, and two main concepts are presently introduced in clinical practice. First, perfusion instead or after limited cold ischemia during transport of the liver and second, an endischemic approach of various machine perfusion concept after initial cold ischemia and transport to the recipient center. Both, normothermic machine perfusion (NMP) or hypothermic machine perfusion (HMP) are beneficial for organ assessment because the recirculation of an oxygenated perfusate uncovers various molecules, released from all liver cells into the perfusate at all temperatures.Routine blood gas or biochemical analysis were transferred into the field of organ preservation and have been performed either from the cold storage solution or machine perfusates ,57,58,59Although this technology is also not new, it was recently implemented to quantify molecules used for viability assessment during HOPE treatment ,38. OtheLivers with more than 108 cells per gram weight are the metabolic power house in our bodies and accomplish more than 500 functions . PerfusaHibernators induce changes in their cellular respiration through mitochondria, which further highlights their relevance. Of note, hibernating animals are naturally protected from IRI during periods of arousal, when returning to normal cellular functions and temperature ,70. BaseNormothermic machine perfusion (NMP) is nominated by many as the best perfusion approach to assess organ viability ,73. VariTwo main groups of parameters, selected as “viability criteria,” are in clinical use during NMP to differentiate between liver cells (hepatocytes) and the biliary tree. Additional parameters of perfusion quality, metabolic, and excretory organ function are used to explore how viable a specific organ appears. In 2020, Raigani et al. have demonstrated the median costs of $28,099 USD needed to identify a potentially transplantable liver with NMP in the US .Parameters of perfusion quality are routinely considered as surrogate marker for liver function. Vascular resistance contributes to perfusion flows, which are also dependent on perfusion pressure. An increased vascular resistance has been linked with a generally impaired liver function . Livers The level of transaminases measured in perfusate is another unspecific parameter with many confounders. Prolonged perfusion first, induces hemolysis and leads to additional AST release from erythrocytes. In contrast, a very advanced-injured liver does not release more transaminases into perfusate, due to the “empty hepatocytes,” interpreted as “false low.” Cut-off values are largely missing and those suggested by various groups appear arbitrary. Clinically applied AST and ALT thresholds range from 6000 to 9000 U/L  21,60,7. Ceresa Although lactate is the most prominent parameter, used to assess the viability during NMP, the predictive value is limited. The key question here is to understand, why we fail to distinguish between viable and non-viable livers based on perfusate lactate measurements? During warm or cold ischemia, mitochondria experience hypoxia and respiratory failure with subsequent switch to anaerobic glycolysis. Lactate is produced from pyruvate by lactate dehydrogenase under anaerobic conditions (hypoxia).Importantly, lactate metabolism or clearance to glucose or glycogen requires oxygen and ATP . During Although ex situ perfusion circuits include only the liver, lactate is also released from erythrocytes, particularly when the perfusion duration is prolonged (more than 24 h) . An addiNext, the same group presented a cohort study of 12 livers. Grafts were divided into a lactate clearing (LC)- and a non-LC group, where lactate levels showed constant fluctuations until the end of 6 h NMP . AuthorsBased on a clinical experience with their viability criteria in 5 human liver transplantations, the Birmingham group started a new clinical trial, using lactate clearance in combination with other parameters to confidentially decide if livers qualify for transplantation. Within the VITTAL trial, 31 human livers underwent NMP and 22 grafts were transplanted, based on the following criteria: the achievement of lactate clearance to <2.5 mmol/L, combined with a perfusate pH of >7.3, the evidence of bile production, a homogenous liver perfusion, glucose metabolism and portal vein flow of ≥500 mL/min, and hepatic artery flow rates of ≥150 mL/min (≥2 of the criteria are required to achieve “viability”) . Of noteIn contrast, Reiling et al. applied a threshold of ≤2.0 mmol/L for perfusate lactate, required within the first 2 h of NMP . FinallyAnother challenge is the timing, when to best measure lactate during perfusion. The various timepoint when to decide to accept a liver or not with 2, 2.5, 3, or 4 h of NMP appear randomly selected due to a lack of sufficient data. Interestingly, in their initial paper published in 2016, the group from Birmingham suggested to quantify lactate after 3 h of NMP, then moving to 2.5 h and in their recent VITTAL trial the latest recommendation was 4 h of NMP ,14,80.Following initial lactate clearance, Ceresea et al. have used a second threshold of increasing lactate to ≥4 mmol/L during later perfusion as “warning sign” and discarded 2 livers . Two humNext, individual testing of dialysis components in sophisticated perfusion devices used for prolonged NMP could not achieve lower lactate levels of less than 2.5 mmol/L. These findings underline the fact that even metabolically severely impaired livers have a remaining ability to clear a certain amount of lactate. A study by Watson et al. investigated perfusion characteristic during NMP of 22 transplanted livers. Lactate declined to ≤2.5 mmol/L in all but 5 human livers within two hours. Interestingly, the only liver that suffered a PNF after transplantation, reached this threshold within 90 min of NMP ,60.Despite the frequent use of lactate as the “key parameter” to select viable livers, it is a rather unreliable and unspecific marker to test the quality of a specific organ. Of note, Nasralla et al. have observed a PNF in the perfusion arm of their randomized controlled trial, despite sufficient lactate clearance during NMP according to the above mentioned criteria .In this context, the molecule lactate may be more beneficial in predicting organ function when measured more frequently using the area under the curve (AUC), instead of single values. Additionally, each viability parameter, including lactate should be quantified in a more systematic, prospective approach and in a higher number of cases. Third, measured values might be of more relevance when normed to the liver weight and the amount of circulating perfusate. Although lactate represents the anaerobic glycolysis, other markers including cumulative purine metabolites and succinate may provide a more specific picture of oxidative mitochondrial function.Along with advanced donor liver injury or ischemia times, and subsequent tissue hypoxia and anaerobic metabolism, a low perfusate pH is usually seen during NMP. The majority of case series recommend to maintain a physiological pH range between 7.3 and 7.45 ,74,80,81To mobilize energy from long-term storages, cells switch to anaerobe metabolism when ischemia occurs. The lack of ATP leads to more glycogenolysis, which can be measured through elevated glucose levels in perfusates during NMP. Reiling et al. have included the perfusate glucose concentration at 4 h of NMP in their criteria  59]..59].The stimulation of gluconeogenesis, while blocking glycogenolysis was recently suggested as supportive test ,58,60. HViable livers also metabolize glucose in response to insulin administration, another surrogate for mitochondrial function. The group from Zurich is therefore in favor of such responsive tests to external triggers (such as inulin or vasoactive drugs) instead of simple measurement of single factors. Such challenging tests provide better information particularly when combined with other analyses compared to lactate alone ,64.Both, healthy hepatocytes and cholangiocytes, contribute to the production and composition of bile in the liver . The larThe group from Groningen suggested a minimal target bile flow of 10 mL in the first 2.5 h . HoweverThe majority of studies, which aimed to assess liver viability, focused on hepatocytes. In context of the ITBL incidence, ranging between 2.6 and 33.3% in the last 10 years of DCD liver transplantation, the interest in cholangiocyte function is increasing ,87,88. AThree different cut-offs for bile pH during NMP were suggested in the last 3 years. In their second and main systematic liver viability analysis, the group of Chris Watson has included 47 human livers. Three out of 16 transplanted livers, did not achieve a biliary pH of >7.4 and developed an ITBL . Based oAlmost each group, or center and surgeon apply not only different perfusion techniques, but also various criteria or parameter thresholds. For example, in Birmingham, livers are routinely assessed macroscopically in the recipient center and undergo NMP, in context of a clinical study and provided the team in favor of this perfusion technology agrees. Specific criteria are then used to accept a liver for transplantation within the first 4 h of NMP . The lacSuch examples of relatively small cohort studies with different perfusion conditions applied during NMP, various molecules tested in perfusate and bile, multiple cut-offs and timepoints suggested for the measurement of individual parameters, impressively demonstrate the enormous variations and confounders in this field. In addition, the work load ahead of us is obvious to identify the most accurate parameter threshold to support a confident decision during NMP. In 2018, Peter Friend already summarized the current state of viability assessment during NMP as follows: “Data from much larger numbers of transplants done with normothermic perfusion  would be required to determine specific markers of viability.” .2) with an artificial and high dissolved oxygen concentrations at 8–10 °C ..38].Based on the tight connection between FMN release and IRI, both starting from the same pocket in complex I, FMN release could also be a useful marker for viability during other perfusion approaches. Wang et al. have now demonstrated the impact of FMN as a biomarker during normothermic kidney perfusion and normothermic regional perfusion (NRP) in DCD donors . PerfusaDuring ischemia the electron transport across mitochondrial complexes is impaired and next to succinate, another molecule, NADH accumulates. The metabolic reaction of NADH to donate protons for the H+ gradient and electrons, both for the ATP production is linked within the same area in complex I. An improved complex I function through HOPE treatment, leads therefore to increased NADH metabolization. Similarly, to FMN, the molecule NADH has autofluorescence abilities and is used for viability assessment. Already in 2013, the link between perfusate NADH concentration and mitochondrial metabolism was demonstrated . ConfirmMultiple parameters to assess viability during machine perfusion have been suggested within the last 5 years. Today there is no widely accepted marker, which is reliable to provide enough confidence to accept a liver . Two pot


BCR-ABL1 fusion transcript is the minimal residual disease marker in chronic myeloid leukemia; 2% of patients show unusual breakpoints generating atypical transcripts, not quantifiable by standardized real-time PCR (RT–PCR). Response monitoring is performed by non-quantitative NESTED PCR, useless for evaluating patients’ molecular remission, excluding them from treatment-free-remission protocols. Droplet digital PCR (ddPCR) is highly sensitive technology, allowing an absolute quantification independent of standard curves. Based on this, we have developed assays able to evaluate the molecular response in atypical patients. We designed new ddPCR-based molecular assays able to quantify atypical BCR-ABL1 transcripts, with a detection limit of 0.001%, validated in a cohort of 65 RNA from 11 patients. Fifty samples were identified congruently by ddPCR and NESTED PCR , while 11 positive samples were detected only by ddPCR. Our results highlight ddPCR usefulness, primarily when the BCR–ABL1/ABL1 level is less than 1.5% and NESTED PCR results are often inaccurate. Furthermore, we identified 3 patients who maintained a deep molecular response for at least one year, who could be considered good candidates for treatment-free remission approaches. Here, we describe a new promising molecular approach, highly sensitive, to monitor atypical BCR–ABL1 patients, paving the foundation to include them in treatment-free remission protocols. BCR gene and on exon 2 of the ABL1 gene  [Chronic myeloid leukemia (CML) is characterized by a BCR–ABL1 fusion protein, originating from the translocation between chromosome 9 and 22 ), which is also the molecular marker for the evaluation of the minimal residual disease (MRD) in CML [scripts) . Recentlscripts) , also suDroplet digital PCR (ddPCR) has recently emerged as a possible alternative or complement to RT-PCR to monitor low levels of disease ,8. ddPCRIn the present study, we developed a method for the evaluation of molecular response in CML patients characterized by atypical breakpoints based on ddPCR in order to improve the prognostic information that could allow TKI discontinuation and/or guide the therapeutic choice.After obtaining informed consent, peripheral blood (PB) and bone marrow (BM) were collected at diagnosis and during follow-up from 11 CML patients: 3 patients with e13a3, 2 with e14a3, and 6 with e19a2. A total of 65 RNA samples (13 BM and 52 PB) were collected from three Italian diagnostic laboratories. The mean time from diagnosis was 26 months, ranging from 1 to 104 months of follow-up. Total RNA was reverse transcribed to complementary DNA using M-MLV reverse transcriptase, RNAse inhibitor, and random hexamer primers , following the manufacturer’s recommendations.The study was approved by the ethics committee of San Luigi Gonzaga Hospital .BCR–ABL1 was sequenced by the Sanger method, using the primers described in van Dongen et al. [To assess the type of transcripts, n et al. .Monitoring of the patients’ follow-up was routinely performed in each laboratory with NESTED PCR, as described by van Dongen et al. .BCR–ABL1 breakpoints , by using Primer Express 3.0 . Primer efficiency was calculated for each transcript with RT–PCR  by using serial dilutions of cDNA from positive patients at diagnosis. The specificity of each amplicon was evaluated by analyzing the melting curve. Furthermore, we checked that selected primers and probes, listed in BCR–ABL1 transcripts (e13a2 and e14a2). The ABL1  gene was used as an internal control.Different primers and MGB-probes were designed, flanking the BCR–ABL1 fusion and ABL1 transcripts were tested in a multiplex, where probes for BCR–ABL1 detection were labeled with FAMTM, while the probe for ABL1 detection was labeled with VIC® fluorochrome in the same well. Each replicate was partitioned into ~20,000 droplets by a droplet generator  and each droplet was amplified by using ddPCR™ Supermix for Probes  and the thermal cycling conditions suggested by the manufacturer. Final concentrations of custom primers and probes are listed in ABL1 assay was diluted following the manufacturer’s indications. Each sample was then loaded onto the QX200™ Droplet Reader , and ddPCR data were analyzed with QuantaSoft™ analysis software .The BCR–ABL1/ABL1. The limit of detection (LoD) of each assay was calculated mixing the RNA of samples without BCR–ABL1 translocation with an increasing amount of RNA from patients with atypical transcripts .Each sample was analyzed in triplicate, and 100 ng of initial RNA were loaded for each well. The target concentration in each sample was expressed as a percentage of 2 = 0.9988, 0.9879 and 0.9984 for e13a3, e14a3 and e19a2, respectively) and efficiency . Furthermore, the curves obtained showed very high linearity , with high specificity.Among the designed primers, we selected the best sets based on the evaluation of the efficiency. Selected primers showed high linearity  of TKI treatment . Patient 5 showed BCR–ABL1 levels from 0.08% to 0.52% during all the time of TKI administration ; Patient 8 acquired T315I mutation; all the other patients showed a reduction in BCR–ABL1 levels that remained detectable by ddPCR during the entire follow-up, while NESTED PCR failed to detect several of these cases (Among the e19a2 group, only Patient 7 achieved a se cases c.The data indicated that our ddPCR assays were more effective than NESTED PCR in defining the molecular response in these patients, managing to identify three patients who have achieved and maintained a DMR for at least one year.BCR–ABL1 levels represent the molecular marker for the evaluation of MRD, defining the depth of molecular remission, and guiding clinical decisions [The introduction of TKI has completely changed CML management, helping to improve the response rate, survival, and quality of life of patients . BCR–ABLecisions . DiffereBCR–ABL1 levels in CML patients with atypical transcripts. Despite the fact that NESTED PCR and Sanger sequencing remain useful to diagnose and identify the BCR–ABL1 transcripts, we demonstrate that our ddPCR assays are effective in defining the molecular response in these patients, improving clinical information and guiding therapeutic decisions. Our assay shows good efficiency and a very low LoD, allowing us to also identify positive samples when the BCR–ABL1 level was so low that NESTED PCR was inaccurate. In particular, NESTED PCR was imprecise when the transcript level was lower than 1%, and the positivity could only be detected with a second PCR step, suggesting that it is a not suitable technique for a precise MRD assessment. By contrast, ddPCR results can be considered more reliable because positive samples showed a percentage of BCR–ABL1/ABL1 greater than LoD identified in the setting analysis.We describe a new method based on ddPCR for the absolute quantification of Recent studies have shown that discontinuing TKI treatment in patients who have achieved a stable DMR could decrease the cost of therapy and altogether reduce the treatment side effects, increasing the quality of life of CML patients .Despite the fact that current guidelines do not recommend discontinuation for patients with atypical transcripts, our group has previously described 7 cases that have successfully discontinued the treatment due to severe comorbidities , also suBCR–ABL1 fusion transcripts in CML patients that helps in the definition of MRD levels to better delineate a therapeutic strategy and the optimal time for discontinuation.In conclusion, we have described a new highly sensitive and specific method for molecular monitoring of atypical