In the PRD group, a shorter LOP compared with the GA group was observed . It was noted that the PRD group had a lower total remifentanil consumption than the SPI group . In ASA I-III patients undergoing ESS, intraoperative monitoring based on state entropy and SPI values can optimize the CSF and reduce TEIBL, whereas monitoring based on state entropy and PRD measurements can optimize the cost effectiveness of anesthetic drugs and the use of the operation room.Inadequate intraoperative analgesia causes the deterioration of the condition of the surgical field (CSF) as a result of hemodynamic instability. Analgesia monitors are used to guide remifentanil) infusion to optimize intraoperative analgesia. The main aim of the current randomized controlled trial was to investigate the potential advantages of intraoperative analgesia monitoring using surgical Pleth index (SPI)- or pupillometry (PRD)-guided remifentanil administration for managing the volume of total intraoperative blood loss (TEIBL), CSF, and length of operation (LOP) in comparison with the standard practice in patients undergoing endoscopic sinus surgery (ESS). The 89 patients in our study were grouped as follows: 30 patients were assigned to the general analgesia (GA) group, 31 patients were assigned to the SPI group, and 28 patients were assigned to the PRD group. The speed of remifentanil infusion was accelerated by 50% when SPI, PRD, or BSS were increased by >15 points, >5%, or >2, respectively, in adjacent groups until their normalization. The SPI group showed significantly lower TEIBL in comparison to the GA group (165.2 ± 100.2 vs. 283.3 ± 193.5 mL;  Endoscopic sinus surgery (ESS) is currently the surgical treatment of choice for sinonasal disease, and its outcome is dependent on the intraoperative condition of the surgical field (CSF) . Marked A wide variety of maneuvers have been proposed to decrease the potential risk of harming the surrounding structures by reducing the amount of total intraoperative blood loss (TEIBL) during ESS performed under general anesthesia. Numerous perioperative regimens, including either premedication or the intraoperative intravenous infusion of beta-blockers ,4,5 or aSurgical maneuvers in the operation field provoke painful afferent stimulation (nociceptive effect), which can induce the release of stress hormones in the absence of sufficient intraoperative analgesia; trigger heart rate and arterial blood pressure increments, resulting in potentially excessive TEIBL; and lead to the administration of recall of awareness tests (ROA attenuates this activity (anti-nociceptive effect)). However, excessively high doses of intravenous intraoperative remifentanil may lead to hemodynamic depression with hazardous bradycardia and hypotension and an increased requirement for intravenous fluids with unwelcome untoward events ,14,15,16Currently, different techniques for monitoring the intraoperative efficacy of analgesia surgical pleth index (SPI), antinociception index (ANI), and pupillary dilatation reflex (PRD) are gaining increasing popularity , as in tThe main aim of the current randomized controlled trial was to investigate the potential advantages of intraoperative analgesia monitoring using SPI- or PRD-guided remifentanil administration for managing the volume of TEIBL, CSF, and LOP in comparison with the standard practice based on the observance of CSF.One hundred patients  score, I–III) with a history of chronic rhinosinusitis who were scheduled to undergo elective ESS without septoplasty with or without polyposis at the Department of Otolaryngology in Regional Hospital no. 5 in Sosnowiec, Poland, met the inclusion criteria for the present comparative analysis.The exclusion criteria were as follows: pregnancy, history of allergy to hypnotics, pre-existing cardiovascular diseases , risk of intraoperative hypotension (low left ventricle ejection fraction < 30%) requiring extensive fluid challenge and the administration of vasoactive drugs that may possibly influence hemodynamic monitoring, low platelet count , any pathology in coagulation tests, medication with drugs interfering with clotting.Randomization was performed by the principal investigator (M.S.) by opening sealed envelopes after each participant provided written informed consent to participate in the study and undergo general anesthesia for ESS. The study protocol was in compliance with the 1964 Helsinki Declaration and was approved by the Local Bioethics Committee at the Medical University of Silesia in Katowice (Poland) on 24 May 2016 . The study was registered in the Clinical Trials Registry .2 was maintained at 35–37 mmHg. The lungs were ventilated using a low flow  and lung-protective strategies with low tidal volumes of 6 mL/kg of ideal body weight.Patients fasted for 12 h before ESS. All the patients received 3.75–7.5 mg of midazolam  in premedication on the day of surgery. Immediately before the surgery, the patients received 10 mL/kg per body weight of Optylite Solution intravenously (i.v.). The patients were preoxygenated with 100% oxygen and intravenously administered fentanyl  in a single dose of 2 µg/kg body weight and propofol  in a single dose of 2.5 mg/kg body weight. When the ciliary reflex disappeared, patients in all groups were paralyzed with a standard intravenous dose of rocuronium  at 0.6 mg/kg body weight, and were intubated after approximately 1 min 20 s with a proper-sized cuffed endotracheal tube 7.0–8.5 in the supine position. During the co-induction of general anesthesia, CO2), fraction of inspired oxygen in the gas mixture (FiO2), and exhaled carbon dioxide concentration (etCO2). The depth of anesthesia was monitored using response and state entropy  and muscle relaxation was monitored using the E-NMT module in all patients, despite their group allocation. Surgical pleth index (SPI) measurements using a Carescape Monitor  in patients allocated to the SPI group only and PRD measurements using NeuroLight Algiscan  in patients allocated to the PRD group only were performed accordingly.Throughout the induction and the surgery itself, standard monitoring procedures for vital parameters were used, including non-invasive arterial pressure (NIBP) measurement every 5 min and measurements of systolic arterial pressure (SAP), mean arterial pressure (MAP), diastolic arterial pressure (DAP), heart rate (HR), standard ECG II, arterial blood saturation  technique. Propofol and remifentanil were administered in a constant intravenous  infusion to separate venous access. An extra dose of rocuronium was always administered when train of poor (TOF). The depth of anesthesia was maintained using propofol at a target SE value of around 40, since the depth of general anesthesia influences patients’ reactions to painful stimuli.After the end of the ESS, in order to avoid unacceptable postoperative pain perception a standard dose of non-steroidal anti-inflammatory drug was administered intravenously according to the guidelines and individual patients’ conditions . At the TEIBL measurements for each patient were performed by the same researcher (I.S.). The blood suction canisters, surgical pads, and irrigation totals were examined to calculate the final blood loss, similar to the technique adopted by DeMaria S et al.  All BBS Upon their admission to the operating theatre, a sensor of entropy EEG  was affixed onto the patients’ foreheads according to the manufacturer’s suggestions, a pulse oximeter was attached to their finger contralateral to that used for venous access, an NIBP cuff was attached to their left arm, and the first values were recorded.The patients were positioned at 15° in the reverse Trendelenburg position to reduce venous congestion. After the induction of TIVA, initial infusion of remifentanil 0.25 µg/kg body weight/minute was started. Randomization was performed simultaneously.On the basis of group allocation, remifentanil infusion was adjusted alongside the maintenance of TIVA as described below.The SPI value was measured online and recorded with a sampling frequency of 1 min. Each time the SPI value was >15 in comparison with the mean SPI value during stage 2, the remifentanil infusion speed was increased by 50% in the sequence 0.25/0.375/0.5/0.675/etc. µg/kg body weight/min. When the MAP was <65 mmHg, an extra fluid challenge of 5 mL/kg body weight was administered.Alternatively, to avoid unnecessary hemodynamic complications in cases with HR < 45/min, MAP < 65 mmHg with no reaction to fluid challenge, BBS < 2, and SPI < baseline value, the remifentanil infusion rate was decreased by 50% alongside the administration of a single 10 mg dose of ephedrine .The PRD was measured and recorded with a sampling frequency of 15 min. Each time the PRD value was >5%, the remifentanil infusion speed was increased by 50% in the sequence 0.25/0.375/0.5/0.675/etc. µg/kg body weight/min. When MAP was <65 mmHg, an extra fluid challenge of 5 mL/kg body weight was administered.Additionally, each time the BBS value was >2, extra PRD measurements were conducted.Alternatively, to avoid unnecessary hemodynamic complications in cases with HR < 45/min, MAP < 65 mmHg with no reaction to fluid challenge, BBS < 2, and PRD < 5%, the remifentanil infusion rate was decreased by 50% with the administration of a single 10 mg dose of ephedrine.BBS values were measured and recorded with a sampling frequency of 5 min. Each time the BBS value was >2, the remifentanil infusion speed was increased by 50% in the sequence 0.25/0.375/0.5/0.675/etc. µg/kg body weight/min.Alternatively, despite the group allocation, to avoid unwelcome bradycardia and hypotension, in cases with HR < 45/min or MAP < 65 mmHg with no reaction to fluid challenge (iv bolus of 5 mL/kg of body weight of Optylite solution), and BBS < 2 the infusion rate of remifentanil was reduced to 50% of the initial infusion speed alongside the administration of a single 10 mg dose of ephedrine.The sequence of events related to the adjustment of remifentanil infusion according to the group allocation  values is shown on the graph .After the induction of TIVA, pledgets impregnated with topical vasoconstrictor were administered to the nasal cavity for the duration of stage 2. All ESS procedures were performed by the same specialist in otolaryngology with over 10 years of experience in this field (P.W), who performed either sphenoethmoidectomy with medial antrostomy (the most severe procedure), total ethmoidectomy with medial antrostomy, anterior ethmoidectomy with medial antrostomy, or isolated antrostomy (the least severe procedure) using powered and manual instrumentation. When the patients showed bleeding that did not respond to topical vasoconstriction, bipolar cautery was administered and standard nasal dressings were placed within the middle meatus, as required.CSF estimations were performed every 5 min by the operator on the basis of the Boezaart bleeding score (BBS) ; 1, slight bleeding, no suctioning required; 2, slight bleeding, occasional suctioning required; 3, slight bleeding, frequent suctioning required and bleeding threatens the surgical field a few seconds after suction is removed; 4, moderate bleeding, frequent suctioning required and bleeding threatens the surgical field directly after suction is removed; 5, severe bleeding, constant suctioning required and bleeding appears faster than can be removed by suction, with the surgical field being severely threatened and surgery usually not possible) .The time of surgery was counted from the moment of first insertion into the nasal cavity until the last withdrawal of the endoscope from the nasal cavity.n = 135 per 1.5 years), a confidence level of 95%, and a margin of error of 5%. Statistical calculations were performed using MS Excel, STATISTICA 13, and Stat Soft Poland. The measured data were characterized using the mean and standard deviation (X ± SD), as well as median with interquartile range (M (IQR)). The normality of distribution was assessed using the Shapiro–Wilk W test. The significance of the differences between means was tested using a one-way ANOVA, and for skewed distributions the compatibility in groups was examined using the Kruskal–Wallis test. To explore differences between multiple groups, the appropriate post hoc tests were used. For nominal data, we used percentages. The relationships between nominal variables were verified by the χ2 test of independence. Statistical significance was set at p < 0.05.The sample size was estimated at 100 considering the total number of surgeries performed  women and 56 (62.9%) men, who were grouped as follows: GA, 30 patients (33.7%); SPI, 31 patients (34.8%); and PRD, 28 patients (31.5%). The detailed patient characteristics are shown in All operated patients were divided into four categories depending on the severity of the surgery performed: sphenoethmoidectomy with medial antrostomy (the most severe procedure), total ethmoidectomy with medial antrostomy, anterior ethmoidectomy with medial antrostomy, or isolated antrostomy (the least severe procedure). This classification provided the best representation of the difficulty and duration of the procedure, thus allowing the best assessment of the major factors influencing the bleeding. Another criterion of similar importance for the final result was the distinction between single- and double-sided procedures. This system of division allowed for the statistical estimation of homogeneity among the three groups tested  with respect to the surgical procedure performed .There were no significant differences in terms of the number of surgical procedures carried out. This allowed us to eliminate the possibility of the unwanted influence of the type of surgical procedure performed on intraoperative bleeding. No statistically significant intergroup differences were observed in the percentages of surgical procedures performed .The GA group showed a significantly higher intraoperative blood loss, length of surgery, propofol consumption, and maximum speed of remifentanil infusion, while the SPI group showed a higher total remifentanil consumption and higher minimum and mean speeds of remifentanil infusion . A compaObtaining a “dry” surgical field—assessed, for example, using the BBS—has become a matter of great concern for patients undergoing ESS, as excessive intraoperative bleeding in the surgical field can lead to a number of unwelcome untoward life-threatening complications, such as the disruption of neighboring structures  as a result of bleeding impairing visibility ,17,18. FFor PRD, the intraoperative guidance of opioid titration was based on objective measurements of pupil sizes and pupillary reflexes using portable infrared pupillometers reflecting the reactions of the human pupils to drugs and nociceptive stimulation. During the session, the patient’s eye was flooded with infrared light and the reflected images were measured on an infrared sensor, with the variations in pupil size, alongside the pupillary light reflex and pupillary reflex dilatation, being calculated by the instrument and displayed on a screen immediately after each time-stamped measurement. The monitoring of the quality of intraoperative analgesia using pupillometry has proven to be useful in the management of pain because it allows for the assessment of the effect of opioids and the titration of anesthetics ,29, and Karkanevatos et al.  analyzedIn turn, Sabourdin et al.  performeIn our study, despite the group allocation, we employed state entropy (SE) to achieve similar conditions for all subjects in terms of central nervous system suppression, which was achieved using propofol infusion. The depth of anesthesia markedly influences the intraoperative pain perception. SE within a range of 40–60 is known to reflect the proper surgical depth of anesthesia, and the target SE in our study was set at around 40  to provide comparable conditions for all subjects in the study. Although the mean SE in the PRD group was significantly higher than that in the SPI and GA groups , the three different anesthetic regimens could be reliably compared, since such differences showed little clinical relevance and because the majority of studies in the recent literature pay no attention to the depth of anesthesia in individual subjects undergoing ESS.We hypothesized that intraoperative surgical manipulations lead to afferent nociceptive stimulation, resulting in increased blood pressure and heart rate and eventually excessive bleeding impairing the CSF, the intensity of which would vary depending on the stage of ESS , with varied hemodynamic changes occurring according to the intensity of the surgical maneuvers performed.p < 0.05) and no significant difference from the PRD group. In our study, the online observation of SPI value changes alongside the online adjustment of remifentanil infusion speed in the case of a delta SPI increase >15 points over the baseline level supposedly resulted in the effective suppression of afferent nociceptive stimulation before the increase in heart rate and systolic blood pressure resulted in excessive blood loss. In contrast to SPI monitoring, PRD assessments could not have been performed online due to the manufacturer’s indications. Therefore, nociceptive afferent stimulation in the PRD group led to some hemodynamic decompensation, resulting in increased blood loss. However, this was subsequently suppressed by accelerating the FMFNT infusion after PRD measurement (sensitivity > 5%), and no statistically significant difference was noted between the PRD and GA groups.In the current study, the final analysis showed a statistically significant difference between the SPI and GA groups in terms of TEIBL (p = 0.111), the authors underlined the limited application of their anesthetic regimen to patients with ASA I-II status due to the subsequent risk of myocardial depression, whereas the current analysis also included 14 ASA III patients.According to the literature, the values of TEIBL and CSF vary according to the anesthetic regimen used. Lee et al.  comparedVery impressive TEIBL values were also achieved by Cardesín A et al. , with paThe overall cumulative dose of remifentanil and propofol given failed to reach statistical significance in the SPI guidance and optimized the intraoperative use of TIVA without sparring effect and influence on LOP. In the PRD group, the LOP was significantly shorter (63.1 ± 26.7 min) than that in the control group (82.6 ± 33.1 min). The introduction of PRD-guided remifentanil administration in our study resulted in a shorter LOP than that in the study conducted by Lee J et al. , who comp < 0.05), and they were also far from the definition of controlled hypotension, whereas the CSF and TEIBL values were surprisingly even more acceptable. Blood pressure reductions, which constitute an independent risk factor for the occurrence of myocardial ischemia in high-risk patients, were not as low in the SPI group as in the PRD and control groups . Thus, the anesthetic regimen used in the current study consisting of SPI-guided remifentanil infusion provided patient safety with a satisfactory TEIBL.Interestingly, the novel approach to the intraoperative monitoring of analgesia during ESS adopted in the current study appeared to be safer for patients in the SPI group compared with the control group in view of the fact that profound hypotension was reported to lead to severe postoperative complications, such as the impairment of cerebrovascular autoregulation and heart function, multi-organ failure, personality changes, and death ,35,36,37In the study of Nair S et al. , the autOur study has several limitations. Although the anesthetic regimen of SPI-guided remifentanil infusion is usually based on the assumption that any SPI value > 50 or intraoperative delta SPI > 10 constitutes an indication of the acceleration of remifentanil infusion , we adopOur results are similar to observations made by other researchers. This procedure may impose either a substantial cost or constitute a risk of potential cardiovascular complications while excluding numerous ASA III patients, whose population is growing. We recommend the introduction of adequacy of anesthesia (AoA) monitoring based on SE and SPI to optimize the CSF and reduce the total estimated intraoperative blood loss in a wider group of patients, who may otherwise receive either premedication with clonidine or an expensive intravenous infusion of esmolol. The introduction of intraoperative monitoring based on state entropy and PRD measurements will help us to optimize resources related to the cost-effectiveness of drugs and the use of an operation room.


VEGF-A knockdown (KDVEGF) in diabetic mice and in endothelial nitric oxide synthase knockout mice (−/−eNOS). Diabetes was induced with streptozotocin using the Animal Models of Diabetic Complications Consortium (AMDCC) protocol. Induction of podocyte KDVEGF led to diffuse glomerulosclerosis, foot process effacement, and GBM thickening in both diabetic mice with intact eNOS and in non-diabetic −/−:VEGFKDeNOS mice. KDVEGF diabetic mice developed mild proteinuria and maintained normal glomerular filtration rate (GFR), associated with extremely high NO and thiol urinary excretion. In −/−:VEGFKDeNOS (+dox) mice severe diffuse glomerulosclerosis was associated with microaneurisms, arteriolar hyalinosis, massive proteinuria, and renal failure. Collectively, data indicate that combined podocyte VEGF-A and eNOS deficiency result in diffuse glomerulosclerosis in mice; compensatory NO and thiol generation prevents severe proteinuria and GFR loss in KDVEGF diabetic mice with intact eNOS, whereas KDVEGF induction in −/−:VEGFKDeNOS mice causes massive proteinuria and renal failure mimicking DKD in the absence of diabetes. Mechanistically, we identify KDVEGF-induced abnormal S-nitrosylation of specific proteins, including β3-integrin, laminin, and S-nitrosoglutathione reductase (GSNOR), as targetable molecular mechanisms involved in the development of advanced diffuse glomerulosclerosis and renal failure.Vascular endothelial growth factor-a (VEGF-A) and nitric oxide (NO) are essential for glomerular filtration barrier homeostasis, and are dysregulated in diabetic kidney disease (DKD). While NO availability is consistently low in diabetes, both high and low VEGF-A have been reported in patients with DKD. Here we examined the effect of inducible podocyte  Diabetic kidney disease (DKD) is a major complication of both type 1 and type 2 diabetes that leads to renal failure, and the single most frequent cause of end-stage renal disease (ESRD) worldwide . An incoVEGF-A gain-of-function in diabetic mice leads to the development of Kimmelstiel-Wilson-like nodular glomerulosclerosis and massive proteinuria  and nitric oxide (NO) are essential for glomerular filtration barrier homeostasis, and both are disregulated in diabetic nephropathy . Unlike teinuria . Similare models . Moreovediabetes . These fdiabetes . Endotheult mice . Short tneurisms , and VEGse model .VEGF-A knockdown (KDVEGF) in diabetic mice and in −/−:VEGFKDeNOS mice. We determined that in the setting of NO deficiency, caused either by diabetic milieu or eNOS knockout, KDVEGF results in diffuse glomerulosclerosis and proteinuria, mimicking human diabetic diffuse glomerulosclerosis of increasing severity. This phenotype is linked to the generation of NO and thiol mediated by changes in S-nitrosoglutathione reductase (GSNOR) and β3-integrin S-nitrosylation that impairs their activity.Here we examined the effect of podocyte KDVEGF in eNOS KO mice (−/−:VEGFKDeNOS) by crossbreeding podocin-rtTA:tet-O-siVEGF mice (siVEGF) , and we backcrossed them >8 generations to a stable FVB background. In this study −/−:VEGFKDeNOS mice were fed standard or doxycycline-containing chow (Harlan-Teklad) for 1 month.We generated doxycycline-inducible podocyte (siVEGF)  with eNOeNOS−/−  (eNOS KOsiVEGF mice (KDVEGF) by intraperitoneal streptozotocin (STZ) using the low dose AMDCC  protocol, as previously described (KDVEGF (DM-KDVEGF) and non-diabetic (non-DM-KDVEGF) mice were fed standard (−dox) or doxycycline containing chow (+dox) for 12 weeks to induce VEGF-A knockdown. At the end of the study 24 h urine was collected in metabolic cages; blood and kidney samples were obtained under anesthesia, as we previously described , and BP was measured under anesthesia and analyzed using PowerLab/8SP system  as previously described . Plasma Kidneys were processed for light microscopy and TEM or frozen in isopentane, mounted in OCT (Sakura). Histology was assessed by hematoxylin/eosin and periodic acid–Schiff’s reagent (PAS) stains. TEM was performed using standard techniques, as previously described . A renalImmunohistochemistry (IHC) was performed in frozen kidney sections using primary antibodies against laminin, nephrin, podocin, and S-nitroso-cysteine and appropriate Cy2 and Cy3 fluorescent-tagged secondary antibodies (Jackson ImmunoResearch Laboratories), visualized by confocal microscopy , as previously described . QuantitImmunoblotting was performed using the following primary antibodies: podocin , nephrin , laminin , β3-integrin , VEGF receptor 2 ; actin (A2066. Sigma) or tubulin (Sigma) were used as a loading control. Signals were visualized by chemiluminescence, and quantified using ImageJ software .In situ Proximity Link Assays (PLA) were performed to identify specific S-nitrosylated proteins in kidney frozen sections using laminin rabbit polyclonal antibody  or β3-integrin antibody  and S-nitrosocysteine mouse monoclonal antibody (AG Scientific) and Duolink II fluorescence protocol  , as previously described . Ascorba Sweden) , as prev Sweden) .p < 0.05) was determined using Prism 8 software by unpaired t test with Welch’s correction and one-way Brown-Forsythe ANOVA to compare two or multiple experimental groups, respectively. Mann-Whitney test was used to analyze non-parametric variables.Data are expressed as mean ± SEM unless otherwise stated. Statistical significance (KDVEGF − dox mice (KDVEGF induction with doxycycline for 12 weeks prevented the development of glomerular hypertrophy in DM-KDVEGF + dox mice (KDVEGF (+dox) mice (KDVEGF (+dox) revealed diffuse glomerulosclerosis  mice  was simiox) mice , as quanclerosis  with lim−/−:VEGFKDeNOS (− dox) mice (KDVEGF (+dox) for 4 weeks in −/−:VEGFKDeNOS mice caused severe diffuse glomerulosclerosis (−/−:VEGFKDeNOS (+dox) mice. Significant tubulo-interstitial damage consisting of tubular atrophy and basement membrane thickening, tubular proteinaceous casts, and interstitial lymphocytic infiltrates were also observed in −/−:VEGFKDeNOS (+dox) (−/−:VEGFKDeNOS (−dox) kidneys (KDVEGF (+dox) kidneys (−/−:VEGFKDeNOS (−dox) kidneys, the severity and extension of the changes observed in −/−:VEGFKDeNOS (+dox) kidneys were obvious as demonstrated by highly significant score differences in all parameters.Glomerular histology was mostly normal in uninduced ox) mice , althougclerosis . Extensiclerosis , whereas (+dox)  but were kidneys  or in di kidneys . A semi-KDVEGF (+dox) mice (−/−:VEGFKDeNOS (−dox) kidneys showed normal glomeruliar filtration barrier ultrastructure (−/−:VEGFKDeNOS mice with podocyte KDVEGF (+dox) revealed extensive foot process effacement, GBM thickening, severe mesangial sclerosis, and endotheliosis (KDVEGF (+dox) kidneys  mice . eNOS−/−tructure . In contheliosis , a more  kidneys .KDVEGF in −/−:VEGFKDeNOS (+dox) and diabetic mice resulted in nephrin downregulation, assessed by immunoblotting and immunohistochemistry (−/−:VEGFKDeNOS and diabetic mice subjected to KDVEGF (+dox) (KDVEGF resulted in β3-integrin upregulation in −/−:VEGFKDeNOS (+dox) kidneys, whereas β3-integrin protein expression was not altered in diabetic mice with intact eNOS  . Podocytact eNOS . Collectact eNOS .KDVEGF in −/−:VEGFKDeNOS (+dox) mice caused massive albuminuria >30-fold higher than that measured in uninduced genetically identical mice −/−:VEGFKDeNOS (−dox), (−/−eNOS mice (data not shown). In contrast, mice with intact eNOS developed mild proteinuria when podocyte KDVEGF (+dox) was induced  mice , as reported in KDVEGF mice with intact eNOS  mice (KDVEGF) or intact eNOS (KDVEGF)  mice , red barVEGF-A and urinary excretion are similarly elevated in −/−:VEGFKDeNOS mice, irrespective of podocyte KDVEGF  than in non-diabetic mice (white bar), but KDVEGF did not significantly decrease plasma NO in any experimental group  in diabetic mice, irrespective of podocyte KDVEGF  and in DM-KDVEGF (+dox) kidneys, as detected by biotin-shift assay (BST) (−/−:VEGFKDeNOS − dox) or intact eNOS (KDVEGF − dox), but increased ∼2.5 fold when KDVEGF was induced in −/−:VEGFKDeNOS (+ dox) mice (KDVEGF (DM-KDVEGF −dox or + dox), than in non-diabetic mice (−/−:VEGFKDeNOS − dox or KDVEGF − dox) (−/−:VEGFKDeNOS (+ dox) mice and ∼5-fold in diabetic DM-KDVEGF mice than in non-diabetic mice (S-nitrosoglutathione (GSNO) is the major source of cellular NO not generated by NOS . GSNO rediabetes . In contay (BST) , This SNox) mice . In cont − dox) . Urine Gtic mice . The remKDVEGF (+dox) alters S-nitrosylation of glomerular proteins in −/−:VEGFKDeNOS mice. Using immunohistochemistry we determined that S-nitrosylated proteins localized to glomeruli are significantly increased in −/−:VEGFKDeNOS kidneys with KDVEGF (+dox) as compared to uninduced −/−:VEGFKDeNOS (− dox) kidneys . Glomerular laminin S-nitrosylation (SNO-laminin) was increased significantly in −/−:VEGFKDeNOS mice with KDVEGF (+dox) as compared to uninduced −/−:VEGFKDeNOS (− dox) mice (−/−:VEGFKDeNOS (+ dox) mice .Specific S-nitrosylated proteins were detected ox) mice . Consistin situ PLA we detected β3-integrin S-nitrosylation in glomeruli (−/−:VEGFKDeNOS (+dox) kidneys as compared to uninduced −/−:VEGFKDeNOS (−dox) kidneys (−/−:VEGFKDeNOS (+dox) mice, a phenotype that mimics human advanced DKD with low VEGF.Next, we examined β3-integrin, a transmembrane protein critically involved in maintaining glomerular filtration barrier integrity , whose alomeruli . Quantit kidneys . CollecteNOS knockout, podocyte VEGF-A knockdown results in diffuse glomerulosclerosis and proteinuria of increasing severity, leading to renal failure in −/−:VEGFKDeNOS mice. We show that podocyte KDVEGF and −/−eNOS induce severe diffuse glomerulosclerosis in the absence of diabetic milieu. Podocyte KDVEGF in diabetic mice prevents diabetes-induced glomerulomegaly but causes diabetic diffuse glomerulosclerosis. Mechanistically, we show that compensatory local NO and thiols generation prevent severe proteinuria and GFR loss in diabetic mice with intact eNOS, and we identify abnormal S-nitrosylation of specific proteins, including GSNOR, laminin, and β3-integrin, as novel molecular pathways potentially involved in advanced diffuse glomerulosclerosis.This study demonstrates that in the setting of bioavailable NO deficiency, caused by diabetic milieu or by KDVEGF abrogates VEGF-A-mediated glomerular hypertrophy, leading to diffuse glomerulosclerosis with modest albuminuria and normal creatinine clearance. In contrast, −/−:VEGFKDeNOS mice have a decreased ability to increase NO when podocyte KDVEGF is induced, despite similarly elevated circulating VEGF-A, thereby becoming more susceptible than diabetic mice to deleterious effects of local KDVEGF, resulting in mesangiolysis, extensive podocyte foot process effacement, GBM thickening, and a notably severe diffuse glomerulosclerosis phenotype reminiscent of advanced diabetic diffuse glomerulosclerosis  and leading to renal failure, consistent with the more severe morphologic phenotype.High circulating VEGF-A in diabetic mice stimulates NOS leading to NO production, protecting the integrity of the glomerular endothelium and attenuating functional abnormalities of the glomerular filtration barrier . VEGF-A clerosis . MoreoveVEGF knockdown results in decreased glomerular size in non-diabetic mice . This phenotype is partially similar to that described in diabetic VEGF-A knockout mice  mice is associated with increased S-nitrosylation of glomerular proteins. As opposed to loss of laminin S-nitrosylation in the setting of excess VEGF-A (VEGF-A knockdown increased laminin S-nitrosylation in −/−:VEGFKDeNOS (+dox) mice associates with severe diffuse glomerulosclerosis, suggesting that laminin nitrosylation might prevent the development of glomerular nodules, probably by regulating the secretion or polymerization of 521-laminin heterotrimers  and diabetic KDVEGF (+ dox) mice. Consistent with GSNOR de-nitrosylation, we detected several fold increase in urine NO, GSH-, and Cys-thiols excretion in −/−:VEGFKDeNOS (+dox) and DM-KDVEGF (+dox) diabetic mice. The precise cellular origin of urine NO and thiols  remains to be determined. We posit that GSNOR de-nitrosylation underlies the compensatory mechanism providing an alternative NO source in diabetic and −/−:VEGFKDeNOS (+dox) mice (KDVEGF (+dox) mice, but does not prevent the development of diffuse glomerulosclerosis. The SNO-GSNOR mediated alternate source of NO supports renal function in −/−:VEGFKDeNOS (− dox) mice, but it fails to do so when podocyte KDVEGF is induced (+ dox), leading to massive proteinuria and renal failure, as well as severe diffuse glomerulosclerosis, suggesting incomplete compensation or an additional KDVEGF related pathway, including iNOS activation, which we have not evaluated. GSNOR function is influenced by subcellular localization and modulated by VEGF and NOS signaling  mice . This coignaling .KDVEGF increases β3-integrin S-nitrosylation in −/−eNOS glomeruli might be linked to diffuse glomerulosclerosis. Laminin-521, the mature GBM laminin, binds αvβ3-integrin through interaction between α5-laminin and β3-integrin, transducing FGF and VEGF signals (KDVEGF decreases αvβ3-integrin activity in non-diabetic kidneys and cultured podocytes (KDVEGF increases glomerular β3-integrin S-nitrosylation in −/−:VEGFKDeNOS (+dox) mice, likely decreasing β3-integrin signaling. Decreased β3-integrin inside-out activation disrupts nephrin-VEGFR2-β3 integrin signaling in podocytes (−/−:VEGFKDeNOS (+ dox) mice.  mice. . Whetherx) mice.  and incrx) mice.  β3-integx) mice.  probablyx) mice. . Thus, w failure .Collectively, these findings suggest that S-nitrosylation contributes to the tight regulation of glomerular homeostasis by modulating several important signaling pathways in DKD models. Our findings support a model whereby laminin S-nitrosylation is instrumental to prevent glomerular nodule development, while GSNOR denitrosylation and increased β3-integrin S-nitrosylation lead to diffuse glomerulosclerosis in the setting of low podocyte VEGF-A.−/−:VEGFKDeNOS mice, perform a broad molecular phenotyping, confirm in cultured glomerular cell types the S-nitrosylation abnormalities identified in −/−:VEGFKDeNOS + dox kidneys and assess SNO-protein dysregulation in diabetic mice. Such additional studies will provide insight into how S-nitrosylation modulates several signaling pathways that are critical for glomerular homeostasis in DKD.Further studies are needed to address several limitations of this study: evaluate diabetic KDVEGF in −/−:VEGFKDeNOS mice causes renal failure, massive proteinuria, and severe diffuse glomerulosclerosis in the absence of diabetes. KDVEGF in diabetic mice with intact eNOS prevents diabetes-induced glomerulomegaly, causes diabetic diffuse glomerulosclerosis, and compensatory NO generation attenuates proteinuria and prevents GFR loss. Together, these models are reminiscent of human DKD phenotypes associated with low VEGF-A expression (KDVEGF in −/−:VEGFKDeNOS mice induces increased glomerular β3-integrin S-nitrosylation, likely disrupting nephrin-VEGFR2-β3-integrin signaling (In summary, pression . Mechaniignaling . Our obs


Shape from focus is an accurate, but relatively time-consuming, 3D profilometry technique . This is the case because a large amount of data that needs to be captured and processed to obtain 3D measurements. In this paper, we propose a two-step shape-from-focus measurement approach that can improve the speed with 40%. By using a faster profilometry technique to create a coarse measurement of an unknown target, this coarse measurement can be used to limit the data capture to only the required frames. This method can significantly improve the measurement and processing speed. The method was tested on a 40 mm by 40 mm custom target and resulted in an overall 46% reduction of measurement time. The accuracy of the proposed method was compared against the conventional shape from focus method by comparing both methods with a more accurate reference. With the industrial integration of additive manufacturing into the standard production process comes the need for proper metrology on additive manufactured parts. Many techniques exist to recover the shape from an unknown object. Most techniques are developed for inspection and metrology of finished parts. To improve the quality of additive manufactured products it is of interest to develop these shape recovery techniques for use in at-line or even on-line metrology. In terms of precision and repeatability compared to other techniques like stereo vision or laser triangulation, shape from focus (SFF), otherwise known as depth from focus (DFF), is a good candidate for micrometer precision measurements ,2,3. AddThe following sections will first present the traditional method of shape from focus, i.e., the capturing of images and the processing of these images to generate a depth map. Next, the proposed method, combining coarse topography methods with SFF to speedup the SFF measurement process, will be discussed. Then last, the measurement results will be presented and discussed in the results and conclusion.For use as an on-line metrology technique, it is crucial that the measurement process is sufficiently fast, depending on the speed of the manufacturing process, in order not to slow down the manufacturing. As explained in ETL’s have an advantage over translation stages in terms of speed. The measurements in this paper were made with the Optotune EL-10-30C . With atThe relatively small FOV is thus required for μm accuracy measurements. For the purpose of this paper, we used a target with a size of 40 mm by 40 mm . In ordeTo create the depth-maps from the original images, we have used the Modified Gray Level Variance (GLVM) implementation in Matlab by Pertuz  and testSince the pixels sharpness value follows a Gaussian profile , it is pAs described above, the conventional method for shape from focus has a lot of benefits for use in additive manufacturing but is slower than other topography methods because of the large amount of data capturing and processing needed for it. By comparison, for stereovision, a minimum of two images is required to produce a disparity map albeit with more complex processing. For laser triangulation, all processing complexity can be accounted for by calibration which results in a direct conversion from the reflected laser line to the actual height of an object. By limiting the amount of data to capture and process, SFF’s measurement speed can be improved invariant of the hardware used. This can be done by limiting the data capture to the depth range of the object’s section that is in the field of view of the system. So, instead of capturing images across the whole 2.5 mm range, data capture is limited to a smaller range, e.g., 1 mm. For unknown objects, it is impossible to predetermine this smaller range with the SFF system alone. Another topography method capable of creating depth-maps much faster but also coarser can be used to get a rough estimate of the object’s profile. The lower accuracy of the coarse depth map can then be translated to a margin around the estimated depth range to reduce the possibility of incorrect measurements.A possible topography method to use for the purpose of creating rough depth-maps is Laser triangulation (LT) also known as Sheet of Light (SoL) or laser ranging sensors , but anyL and x and x and mined by (1)x=Lx′If we take The complete measurement system is thus composed of two individual measurement systems. One LT system for coarse measurements and one SFF system for precision measurements. The translation stages are common to both systems . As SFF The measurement principle is very simple . InitialOnce the section is scanned using SFF with the limited range, the reduced data-set is processed with the exact same focus measure algorithm. Next, the translation stages move the target, so another section of it is visible for the SFF system and the process restarts from selecting the same section on the coarse depth map generated by the LT system.This approach combines the benefits of the precision method with the speed of any other method. Additionally, developing the coarse method like LT to have a similar resolution as the SFF system would require an equally small FOV and therefore an increase in measurement time. The addition of extra components to a measurement setup also requires extra investment. However, the additional cost of the extra components is estimated to be small compared to the total measurement cost of measuring for prolonged periods of time. The cost of the laser triangulation system is in the order of magnitude of 10,000 euro. Whereas the measurement cost of running this equipment is estimated to be a minimum of 100 euro per hour. After already 200 h of measurement time, the extra investment cost would already be earned back. Adding a second measurement system for improvement of the original system, can in certain situations be a limitation. e.g., in mobile applications, adding the second measurement system introduces a lot of extra complexity. This method was specifically developed to be used for at-line or on-line metrology purposes, where the added complexity is not an issue.The gain in measurement time with this proposed two-step approach is dependent on two important parameters. Firstly due to the lower accuracy of the coarse measurement, a margin must be applied to the boundaries set to limit the capturing range. For example, if the coarse measurement has a depth resolution of 50 μm the margin should ideally be at least 50 μm above and 50 μm below. If we apply this to the example given above the actual measurement range is 1.1 mm instead of 1 mm. So with the margin applied the total amount of images to be captured is 66 for 1 mm. A larger margin leads to less gain in measurement time.The second important parameter is the ratio between the measurement range of the SFF system and the number of subimages of the full target that need to be measured across the full range. If a relatively flat object is measured, the gain in measurement time will be large because most of the subframes of the depth map will require a limited set of images to be created. If a very rough object is measured that requires every subframe to be measured across the entire measurement range, then there is no gain in measurement time.The reduction in measurement time would not be beneficial if it would also mean a reduction in measurement accuracy. To validate this, we performed reference measurements with a Keyence VK-X1000 using its shape from focus option. The reference measurements have an accuracy of approximately 500 nm and took about 3 h to complete due to the much higher resolution of the Keyence VK-X1000. The measurements of our system were then compared with these reference measurements using the software CloudCompare . For theFrom We have introduced a two-step approach to improve the measurement speed of shape from focus. We have shown that, by applying coarse depth information to shape from focus, the measurement time for stitched measurements can be reduced by limiting the measurement ranges of the individual sub-frames. This approach has led to an overall improvement in the measurement time of 43% on a test target. It has been shown that the proposed method does not impact the accuracy of the measurement. The method is independent of the hardware used. The total time reduction is, however, dependent on multiple parameters. First of all, the added margin to the limits set by the coarse measurement. The applied margin is limited by the accuracy of the fast 3D profilometry technique. Using a more accurate system for the coarse measurements allows us to use narrower margins and therefore a bigger reduction in measurement time. Secondly, the measurement time reduction is dependent on the ratio between the field of view of the shape from focus system and the height ranges of the target within this field of view. If the target has height variations over the full shape from focus range in every section to be imaged, the total reduction in measurement time can be zero. However, the field of view and measurement range of the shape from focus system could also be adapted or optimized for specific parts to provide the maximum reduction. Lastly, due to the lower resolution of the laser triangulation scan some objects of the target might go undetected. So those features will not be included while determining the measurement range for the shape from focus scan which might result in errors.A possible improvement for this method would be to use the measurement from the LT system as an initial value on a point basis when improving the accuracy by Gaussian fitting on the measurement points. The LT measurement could also be used to determine the validity of the depth estimation by shape from focus. To further improve upon SFF as a technique it should be possible to speed up processing significantly with the use of GPU. Using higher speed cameras and a different way of controlling the ETL can possibly also lead to additional gains in measurement time.


C. briggsae mutations orthologous to alleles of importantC. elegans genes. Both Cel-glp-4(bn2) andCbr-glp-4(v473) aretemperature-sensitive, causing sterility at 25°C. By contrast,Cel-fog-1(q253)is stronglyts, but its orthologCbr-fog-1(v442)causes a loss-of-function at all temperatures. Finally, theC. elegansglp-1allelesbn18ande2141are tssterile. However, theirC. briggsae orthologs,Cbr-glp-1(v429)andCbr-glp-1(v438)respectively, are wild-type at all temperatures. Thus, atsmutation in one species provides clues about how to designts alleles in another, but all theoretical outcomes are possible.To learn if orthologous mutations are temperature-sensitive in related species, we studied four C. eleganshas severaltsalleles of critical genes that are helpful for genetic and developmental studies. To determine whether the temperature-sensitive behavior of mutations inC. elegansand C. briggsaeis evolutionarily conserved, we constructed orthologs of fourC. elegans germlinetsmutations inC. briggsae using CRISPR-Cas9  or TALEN  mediated gene editing.Temperature-sensitive mutations have a wild-type phenotype at the normal (or permissive) temperature and a mutant phenotype at the restrictive temperature, and are versatile tools for studying gene function. The temperature-sensitive proteins may exhibit altered stability, failure to fold or aggregate, resistance to proteolysis, or be cleared more quickly because of partial unfolding, since any of these factors might reduce function at unfavorable temperatures .glp-4gene encodes a Valyl Aminoacyl tRNA Synthetase, essential for populating the germline with sufficient numbers of cells for gametogenesis . At the restrictive temperature of 25°C,C. elegans glp-4(bn2ts) mutants are sterile, because they produce very few germ cells, all of which arrest at meiotic prophase (Beanan and Strome 1992). By contrast, they are self-fertile hermaphrodites at the permissive temperature of 15°C. There is 87% sequence identity between Cel-GLP-4 and Cbr-GLP-4, and even higher amino acid sequence conservation (96%) within 50 amino acids of thebn2allele. This allele alters the Gly 296 residue to aspartic acid, and the orthologous CRISPR mutation inC. briggsaechanges Gly 293 to aspartic acid. This ortholog,C. briggsaeglp-4(v473) I, is also temperature-sensitive ; much like itsC. elegansortholog, it results in sterility and germ cells that fail to differentiate into gametes only when grown at 25°C . Thus,Cbr-glp-4(v473ts)provides a valuable new germline-proliferation-defectivetsallele forC. briggsae.TheC. elegans . Infog-1mutants, germ cells that would normally develop into sperm instead become oocytes. Furthermore,fog-1is required for spermatogenesis in bothXOmales andXXhermaphrodites. TheC. elegansfog-1alleleq253tsis a replacement of Thr 366 by Ile . It is strongly temperature sensitive, causingXXanimals to become self-sterile at 25°C but not at the permissive temperature of 15°. Although Cel-FOG-1 and Cbr-FOG-1 share only 54% sequence identity, they have higher conservation near the site ofq253. TheCbr-fog-1(v442) Iallele has an orthologous change (Thr 391 to Ile) that we made using TALEN gene editing. In contrast toC. elegansq253ts, theCbr-fog-1(v442) allele causesa loss of function at all temperatures . TheXXhermaphrodites made only oocytes  and theXOmales produced oocytes at both permissive and non-permissive temperatures. As inC. elegans,this mutation is semidominant in males , which implies conservation of howfog-1is regulated in this sex. Since the homozygotes are self-sterile, we balancedCbr-fog-1(v442)withunc-40(v270).FOG-1 is a Cytoplasmic Polyadenylation Element Binding (CPEB) protein that controls the sperm fate inC. elegansglp-1allelesbn18ande2141arestrongly temperature-sensitive, blocking germline proliferation at restrictive temperatures and causing sterility .C. elegans glp-1(e2141ts) is a missense allele that changes arginine 974 to cysteine, and is orthologous toCbr-glp-1(v438), which we made using CRISPR/Cas9. Although theC. briggsaeallele changes arginine 955 to cysteine, it is notts, since the mutants appear wild type at both permissive and restrictive temperatures .GLP-1 is a notch receptor protein that regulates the mitotic proliferation of germ cells . TheCel-glp-1(bn18ts) withC. briggsae. Thebn18ts allelereplaces alanine 1034 with threonine, and is orthologous toCbr-glp-1(v429), an alanine 1020 to threonine substitution that we made using CRISPR-Cas9. Unlikebn18ts, Cbr-glp-1(v429)is not sterile at either the restrictive or permissive temperatures, but instead develops like the wild type.We also comparedC. elegans glp-1(ts)alleles are sterile at the non-permissive temperature, neither of theC. briggsaeorthologues showed sterility or defective germline development. However, a loss of function allele located nearby in the transcript does exhibit a Glp phenotype.Cbr-glp-1(v439) is a frameshift mutation caused by the deletion of nucleotide 2867 T in the coding sequence, near the site ofv438. These mutant worms are sterile and display the Glp-1 defective phenotype at all temperatures . Thus, theglp-1 loss-of-function phenotypeis conserved betweenC. briggsae and C. elegans but not the temperature-sensitivity of key alleles.AlthoughC. eleganstsalleles we studied had similar behavior inC. briggsae. However, the other alleles were onlytsin one species. Thus, mutations orthologous to knowntsalleles can be temperature-sensitive in other species, and provide a promising guide for generating such alleles, but their behavior often differs. Although high levels of structural conservation might suggest that mutations will behave similarly in both species, we found it hard to predict which alleles will bets without experimental tests. We suspect thatC. elegansandC. briggsae sometimes differ because some genetic backgrounds are more sensitive to perturbation than others.Taken together, our findings show that one of the fourReagents


Pulmonary sarcomatoid carcinoma (PSC) is a rare and aggressive disease without standardized treatment strategies. The efficacy of second-line or beyond immune checkpoint inhibitors (ICIs) has been proven in recent studies, whereas the evidence for first-line immunotherapy for PSC is still limited to case reports and remains poorly understood.This was a multicenter, retrospective analysis of 21 patients with a histological diagnosis of PSC who received ICI as first-line therapy from January 2019 to March 2022. The expression of PD-L1 was evaluated by immunohistochemistry (IHC) using the monoclonal antibody 22C3. Low and high PD-L1 expressions were defined using the tumor proportion score (TPS), with cutoffs of 1 and 50%, respectively.P = 0.86 and P = 0.34, respectively) and different immunotherapies . No serious adverse events (grade ≥ 3) were noted.All eight patients had PD-L1 positivity who underwent PD-L1 expression assessment, and six patients  had high PD-L1 expression. Among the 21 PSC patients, seven received tislelizumab, six received camrelizumab, four received sintilimab, three received pembrolizumab, and one received durvalumab. Among them, 18 PSCs received combination therapy, whereas another three PSCs received immunotherapy alone. Out of the 21 PSC patients, 12 (57.1%) achieved a partial response (PR), and five patients had stable disease (SD) as the best response, whereas four PSCs experienced dramatic progressive disease (PD). The median progression-free survival (PFS) was 9.2  months, and the median OS was 22.8  months. Among the three treatment groups , the median PFS was 8.0, 9.4, and 9.6 months, and the median OS was 19.0, 22.8, and 30.6 months, respectively. There was no difference in PFS and OS between the three treatment regimen groups (First-line immunotherapy has promising therapeutic potential in the treatment of PSC. More studies are warranted to confirm these findings. Pulmonary sarcomatoid carcinoma (PSC), a rare and aggressive disease, accounts for less than 1% of non-small cell lung cancer (NSCLC) . No stanStudies have shown higher frequencies of genetic mutations and PD-L1–positive expression in PSC than in conventional NSCLC, and PD-L1 positivity might lead to survival benefits from immunotherapy or even a favorable response in those harboring actionable mutations , 8, 9. IThe low number of patients who have undergone immunotherapy as a first-line treatment strategy makes it challenging to evaluate the specific safety and efficacy of first-line immunotherapy for PSC. The purpose of this paper is to report the largest study of first-line immunotherapy for PSC treatment to date.A multicenter, retrospective study was conducted at two tertiary medical institutions in the Nanchang region of China, namely The First and Second Affiliated Hospital of Nanchang University in China. The patients diagnosed with advanced PSC (III/IV) who received first-line immunotherapy from January 2019 to March 2022 were enrolled. Patients with pulmonary interstitial disease, systemic immunosuppression, autoimmune disease, or second primary malignancy were excluded from this study. Written informed consent was not required, as this was a retrospective review study. The last follow-up time was 30 April 2022. Each patient’s relevant clinical data were collected from hospital electronic medical records, including sex, age, smoking status, Eastern Cooperative Oncology Group (ECOG) score, histology, clinical stage, and distant metastasis. The best tumor response was evaluated according to RECIST version 1.1. Progression-free survival (PFS) was the time from the date of immunotherapy to the date of disease progression or death. Overall survival (OS) was the time from the date of immunotherapy to death from any cause or the last follow-up.The expression of PD-L1 protein was evaluated by immunohistochemistry (IHC) performed on 4-µm formalin-fixed paraffin-embedded (FFPE) tissue sections using a Dako PD-L1 22C3 pharmDx kit . PD-L1 protein expression was determined by using the tumor proportion score (TPS), and the cutoffs for low and high expressions were 1 and 50%, respectively .p < 0.05 was considered statistically significant.Kaplan–Meier curves were drawn to analyze the survival of PSC patients. The corresponding 95% confidence interval (95% CI) was calculated. Statistical tests were performed in IBM SPSS version 25 . In the end, 21 PSC patients who were treated with first-line immunotherapy were enrolled. The clinical characteristics are summarized in PD-L1 expression was assessed by IHC in the eight samples available. Six patients  had high expression (TPS > 49%) and the others had low expression (TPS 1–49%) , camrelizumab , sintilimab , and pembrolizumab . Of the seven patients who received tislelizumab combined with anlotinib treatment, two achieved partial response (PR) as the best response, one of them with tumor shrinkage of approximately 72%, and four achieved stable disease (SD), whereas rapid progression occurred in another patient for PFS of 1.7 months and OS of 5.4 months , sintilimab , or durvalumab . Both patients treated with the pembrolizumab combination achieved PR , and another did not have PD-L1 testing since there was no gene mutation. Two were treated with camrelizumab monotherapy. The OS was 12.6 months in one patient (PD-L1 95%) and more than 25.4 months in the other. Sintilimab monotherapy was adopted as a first-line treatment for one CS patient with PD-L1 expression of 20%, who had a PFS of more than 5 months and whose OS was not reached.The median follow-up time for this cohort was 8.5 (range: 0.3–30.6) months, and only seven of the 21 PSC patients (33.3%) were deceased at the last follow-up time. In the whole sample, the median PFS was 9.2  months , the median PFS was 8.0, 9.4, and 9.6 months, and the median OS was 19.0, 22.8, and 30.6 months, respectively. Nevertheless, there was no difference in PFS and OS between the three treatment regimens groups  was 57.2%, and a disease control rate (DCR) of 81.0% was achieved Table 2.Five patients (23.8%) experienced adverse events Table 2,Continuing efforts to find novel therapeutic strategies for PSC are imperative. Although the efficacy of immunotherapy after disease progression has been demonstrated , first-lImmunotherapy has substantially contributed to the treatment of conventional NSCLC and has improved patient outcomes –19, provAlong with accumulating research on immune therapies in PSC, the efficacy of first-line treatment has been gradually unveiled. Pembrolizumab monotherapy treatment in three PSC patients showed a response, with a PFS of more than 11.0 months . SimilarStudies have shown that harboring the BRAF V600E mutation was associated with greater clinical benefit from ICIs and significantly prolonged PFS in NSCLC . SimilarDisease progression is inevitable, and little is known about what contributes to dramatic progress without any response to immunotherapy; however, we cannot ignore the four patients who showed progress in our study with advanced IVB stages at immunotherapy initiation.KRAS and TP53 mutations have been demonstrated to be associated with high PD-L1 expression in NSCLC –26. FurtA phase Ib trial (NCT03628521) regarding combined sintilimab and anlotinib as first-line therapy in patients with advanced NSCLC saw decent success, with a median PFS of 15.0 months . AnotherThe limitations of this study are its small sample size, and we did not find an exact predictive factor or mechanism of dramatic progression. Additionally, this study had different treatment regimens and several immunotherapies with limited numbers of people on each treatment, and although the results showed no differences between groups, a larger sample of studies is needed to support this. Although remarkable outcomes have been obtained, they may suffer from selection bias (a low rate of incidence). Several clinical trials including first-line toripalimab combined therapy (NCT04725448) in the treatment of patients with advanced PSC are in progress. We hope that those studies can reveal more detail about the value of immunotherapy and help guide treatment decisions. One challenge is to be able to predict which patients are most likely to derive benefit from immune therapies and the mechanism of progression at initial treatment. Considering the rarity and complexity of PSC, clinical studies involving multiple centers, even globally, are needed to improve prognosis.Our study sheds light on the promising therapeutic potential of first-line immunotherapy in the treatment of PSC. Given these findings, a prospective study is warranted to explore the efficacy of immunotherapy with or without chemotherapy, and it is necessary to determine the reason for the dramatic progression at initial immunotherapy treatment.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.This study was reviewed and approved by the institutional ethics committee of the Second Affiliated Hospital of Nanchang University and the Medical Research Ethics Committee of the First Affiliated Hospital of Nanchang University.AL and YL co-designed the research. ZZ, XQ, and FL made a significant contribution to the data integration and analysis. ZZ provided patients’ information and data analysis. XQ drew up the manuscript. FL and YW processed the figures and tables. YYu, CF, XZ, and SY collected the outcome. RC, BY, TWand YYi followed up on the case. All authors contributed to the article and approved the submitted version.This study was supported by grants from the National Natural Science Foundation of China , the Surface project of the Natural Science Foundation of Jiangxi Province , Technology Supporting Program of Jiangxi Province (No.2015BBG70236), The Key Project of Education Department of Jiangxi Province (No.GJJ170012), and The Graduate Student Innovation Special Fund Project of Jiangxi Province (No. YC2022-s207).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Ramadan fasting was the only time-restricted eating regimen trialled in this population with no strong evidence of a significant effect on insulin levels.  As the systematic review retrieved only one study investigating time-restricted eating to reduce insulin in patients with PCOS, there is no evidence to suggest that this intervention is effective. From the narrative review, based on studies in other patient groups, time-restricted eating could improve insulin resistance in those with PCOS; however, well-designed studies are required before this intervention can be recommended. Polycystic ovarian syndrome (PCOS) affects up to 10% of premenopausal women and is characterised by multiple ovarian cysts, hyperandrogenism causing hirsutism, hyperinsulinemia, insulin resistance, obesity, infertility, and mood disturbances . Both phThe majority of women with PCOS have insulin resistance, independent of weight –20. ThisHyperinsulinemia is linked with persistent hyperandrogenism, as well as its clinical manifestations, by directly driving excessive androgen production . Due to Dietary interventions in PCOS are varied with many diets being unsustainable and most largely ineffective. Dietary regimens including energy  restriction , 28, MedTime-restricted eating involves a period of fasting, thereby allowing a decrease in insulin levels, an improvement in insulin sensitivity, and an improvement in glucose regulation. The short-term putative benefits of time-restricted eating include increased cell metabolic and oxidative stress resistance . A perioFasting-induced fuel switching has the potential to overcome the issues seen in patients with PCOS, as seen in other populations with underlying insulin resistance, including metabolic syndrome, obesity, and type 2 diabetes –44. TimeThis systematic review followed PRISMA reporting guidelines . This rePopulation: Females above the age of eighteen years, diagnosed with polycystic ovarian syndrome using Rotterdam criteria.Intervention: Any time-restricted feeding regimen, alone or in combination . To include 16 : 8 method, 18 : 6 method, 5 : 2 diet, alternate day fasting, intermittent fasting, Ramadan or other religious fasting methods deemed suitable.Comparator: Comparison to usual ad libitum diet or no dietary or fasting intervention, standard treatment-as-usual, and pharmacological therapy.Outcomes: Metabolic parameters which represent effect on insulin levels, C peptide concentrations, glucagon, insulin-like growth factor 1 (IGF-1), glycated haemoglobin (HbA1c), homeostatic model assessment for insulin resistance (HOMA-IR), fasting blood glucose, sex hormone binding globulin (SHBG), or oral glucose tolerance test (OGTT).The PICO model was employed to expand the return from the review and applicability of data collected.A preliminary scoping review was conducted to identify the nature and extent of the research available. A systematic search strategy was constructed with oversight of a medical librarian DM. Five search strategies were created for Medline, CINAHL , EMBASE, WOS (Web of Science), and Cochrane Library, the details of which are found in Timeline: Published before 10th of May 2021 when final searches were run.Patients: Female patients with a diagnosis of polycystic ovarian syndrome by Rotterdam criteria.Inclusion: All study designs considered which were published in peer-reviewed medical journals. Studies involving time-restricted eating, Ramadan fasting, and diets with any fasting regimen were considered, in addition to studies where time-restricted eating/intermittent fasting combined with concurrent medication use , metformin, spironolactone, etc.). Studies must have baseline and postintervention measures of outcomes. Pilot studies were assessed for inclusion if clear outcome effects were detailed. Only studies involving humans were included.Exclusion: Conference papers, unpublished reports, letters to the editor, papers not in English were excluded. Studies considering administration of supplements, studies without a control group, studies without a baseline compared to postintervention measures, and nonhuman, preclinical, and animal studies were also excluded.Results of included studies were extracted by two independent reviewers (R.F. and R.G.). Study characteristics were collected including details of participants, study methodology, intervention details, and effect on insulin and other metabolic parameters. Analysis to assess study quality and risk of bias was conducted in accordance with Cochrane Handbook for Systematic Reviews of Interventions.The studies included in the review were inherently heterogeneous due to varying interventions and outcomes. As a result, a descriptive presentation of the studies was used without pooling of outcomes for analysis.The one study included was a nonrandomised controlled study with a Ramadan fasting regimen. This study recruited women with a PCOS diagnosis. The details of the study, population characteristics, and outcomes were extracted and reviewed.Due to the lack of studies identified for inclusion and heterogeneity of study designs, it was not possible to conduct a meta-analysis.p=0.543), insulin (p=0.818), FSH, LH, testosterone, or adrenaline after undergoing Ramadan fasting. Significant effects of Ramadan fasting on reducing cortisol (p=0.049) and noradrenaline levels (p=0.047) were shown. Overall there was no benefit of Ramadan fasting shown in this study on insulin levels or glucose haemostasis [One small study was identified which looked at 40 women with PCOS, 20 of whom completed Ramadan fasting for a mean of 26 days and were compared to a nonfasting control group. Details of the length of fasting times were not included but rather details of eating patterns before sunrise, after sunset, and between sunset and sunrise. There were no significant differences in levels of beta-endorphin . The overall risk of bias was deemed to be low.A systematic review of the literature found that the effects of time-restricted eating on insulin levels in patients with PCOS has not been investigated to date, and therefore there is no evidence to suggest that this intervention would be effective in reducing insulin in patients with PCOS. The systematic review retrieved just one study  which inp=0.017), area under the curve for insulin (AUCIns) (p=0.007), ratio of AUCIns/AUCGlu (p=0.001), HOMA-IR (p=0.0025), SHBG (p < 0.001), body weight (p < 0.001), BMI (p < 0.001), body fat mass (p < 0.001), percentage of free androgen index (p=0.001), CRP (p=0.040), ALT (p=0.027), and IGF-1 (p=0.006). There were no significant differences in fasting glucose, area under the curve for glucose (AUCGlu), lipid profiles, and gonadal parameters including luteinizing hormone (LH), follicular stimulating hormone (FSH), and LH/FSH ratio or total testosterone. Overall, this study suggested that 16 : 8 time-restricted regimen improved parameters of glucose haemostasis and weight [The systematic review had excluded two studies investigating the effects of time-restricted eating as they were noncontrolled. The first of these  investigd weight  in womenp=0.439), BMI (p=0.646), fasting blood glucose (p=0.183), insulin (p=0.474), HOMA-IR (p=0.364), HOMA-B (p=0.736), QUICKI (p=0.308), or lipid profiles. There were significant decreases in C-reactive protein levels (p=0.072), nitric oxide (NO) levels (p=0.003), and total glutathione levels (p=0.011). This study corroborated the systematic review finding that Ramadan fasting exerted no benefit on parameters of glucose haemostasis but had modest benefits on markers of inflammation and cardiovascular health [The second study  investigulin p=0.4, HOMA-IThere is some evidence from small studies in other patient groups that Ramadan fasting may have positive benefits on insulin levels and glucose haemostasis. Ramadan improved HbA1c levels in 29 patients with type 2 diabetes  and was β cell responsiveness, independent of weight loss [In studies on time-restricted eating reporting weight loss , it is dght loss . HoweverLi et al. observed significant results in a short, time-restricted eating regimen suggesting that improvements in hyperinsulinemia and insulin resistance can be seen without energy restriction . This isThe optimum length of a time-restricted eating intervention to have a significant effect on insulin levels is undecided. Initially switching from standard dietary pattern to intermittent fasting, hunger, irritability, and reduced concentration ability while adapting to the new dietary regimen is expected . These iLi et al.  allowed Time-restricted eating reportedly causes a shift in fuel source from glucose to fatty acids during the fasting period . TypicalTypical ad libitum eating (with short fasting periods) might perturb normal glucose metabolism. Eating habits have largely changed with modern lifestyle. A longitudinal study of dietary habit changes over a 40-year timespan in USA showed higher daily energy intake, later breakfast and lunch times, and shorter time between dinner and a postdinner snack, with a significant increase in snacking among women in particular . There aIncreased recruitment of insulin receptors, internalised by the effects of persistent hyperinsulinemia as demonstrated in Upregulation of insulin receptor expression which is downregulated by hyperinsulinemia.Lowering insulin requirements with fasting. Fasting overcomes the issues seen in patients with PCOS including saturation of defected insulin receptors, beta cell dysfunction, and reduced hepatic insulin clearance –72.Reduced leptin levels and increased adiponectin with an overall improved balance improving insulin resistance , 73, 74.On a molecular level, the biochemical effects of time-restricted eating in PCOS are thought to include the following:α, and NRF2), AMP kinase, and deacetylases such as sirtuins (SIRTs) [On a cellular level, time-restricted eating reportedly contributes to the fluctuating ratios of NAD+ to NADH, ATP to AMP, and acetyl CoA to CoA. These result in downstream activation of proteins including transcription factors  , 40, as  (SIRTs) , 40. SIRFasting reportedly results in downregulation of the insulin-IGF-1 signalling pathway and reduced circulating amino acids causing reduced mTOR activity with subsequent inhibition of protein synthesis. All of the above processes allow activation of cellular repair and maintenance processes, stress resistance and mitochondrial biogenesis, cellular proteostasis, and autophagy with overall improved cell survival. The AMP to ATP ratio is increased by fasting, activating AMPK, which triggers repair and halts anabolic processes .A prospective randomised intervention study with crossover design would be best to determine the effect of a time-restricted eating pattern on insulin levels, androgens, fertility, and satiety. We suggest that a controlled feasibility study should be conducted to investigate the feasibility, safety, compliance, and acceptance of time-restricted eating in patients with PCOS, as well as its effects on insulin, androgens, and satiety, and have registered a study to investigate these outcomes (NCT05126199).The systematic review found no studies investigating the effect of time-restricted eating on insulin levels in patients with PCOS, with the exception of one study on Ramadan fasting which showed no effect. Although a narrative review discussed an uncontrolled study which showed improvement in glucose homeostasis, weight, and androgens with 16 : 8 time-restricted eating in PCOS, overall we conclude that there is insufficient evidence that time-restricted eating works to reduce insulin levels in PCOS, and, pending further studies, the intervention should not be recommended in this group.


Dolutegravir is being scaled up globally as part of antiretroviral therapy (ART), but for people with HIV and tuberculosis co‐infection, its use is complicated by a drug–drug interaction with rifampicin requiring an additional daily dose of dolutegravir. This represents a disadvantage over efavirenz, which does not have a major drug–drug interaction with rifampicin. We sought to describe HIV clinic practices for prescribing concomitant dolutegravir and rifampicin, and characterize virologic outcomes among patients with tuberculosis co‐infection receiving dolutegravir or efavirenz.Within the four sub‐Saharan Africa regions of the International epidemiology Databases to Evaluate AIDS consortium, we conducted a site survey (2021) and a cohort study (2015–2021). The cohort study used routine clinical data and included patients newly initiating or already receiving dolutegravir or efavirenz at the time of tuberculosis diagnosis. Patients were followed from tuberculosis diagnosis until viral suppression (<1000 copies/ml), a competing event  or administrative censoring at 12 months.n = 465), the cumulative incidence of viral suppression was 58.9% , switching ART regimen was 4.1% (95% CI: 2.6–6.2%) and loss to program/death was 23.4% (95% CI: 19.7–27.4%). Patients receiving dolutegravir had improved viral suppression compared with patients receiving efavirenz who had a tuberculosis diagnosis before site dolutegravir availability  and after site dolutegravir availability .In the survey, 86 of 90 (96%) HIV clinics in 18 countries reported prescribing dolutegravir to patients who were receiving rifampicin as part of tuberculosis treatment, with 77 (90%) reporting that they use twice‐daily dosing of dolutegravir, of which 74 (96%) reported having 50 mg tablets available to accommodate twice‐daily dosing. The cohort study included 3563 patients in 11 countries, with 67% newly or recently initiating ART. Among patients receiving dolutegravir (At a programmatic level, dolutegravir was being widely prescribed in sub‐Saharan Africa for people with HIV and tuberculosis co‐infection with a dose adjustment for the drug–drug interaction with rifampicin. Despite this more complex regimen, our cohort study revealed that dolutegravir did not negatively impact viral suppression. GlobFor patients with tuberculosis co‐infection, the use of dolutegravir is complicated by a drug–drug interaction with rifampicin , which iWe sought to (1) describe HIV clinic practices for prescribing concomitant dolutegravir and rifampicin and (2) characterize virologic outcomes among patients with tuberculosis co‐infection receiving dolutegravir and make comparisons with patients receiving efavirenz.2The data for this study came from the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium, which collects routine clinical data from HIV care and treatment sites in 44 countries across seven geographical regions. This study, which focused on the four sub‐Saharan Africa regional cohorts  for drug‐susceptible tuberculosis . AdditioTo reduce potential misclassification of ART regimen at tuberculosis diagnosis, we excluded patients with conflicting ART regimen start dates (e.g. same start date for efavirenz and dolutegravir), likely resulting from data entry errors, as well as patients with a documented change in ART regimen (e.g. from dolutegravir to efavirenz) within 1 month after their tuberculosis diagnosis. ART regimens were defined as first‐ and second‐line regimens recommended by the World Health Organization (WHO) , consist2.4Our exposure was receiving either a dolutegravir‐ or efavirenz‐containing regimen at the time of tuberculosis diagnosis or initiating ART with such a regimen within 2 months after tuberculosis diagnosis. Patients receiving efavirenz comprised the control groups for comparison with dolutegravir and were stratified by timing of tuberculosis diagnosis, either before the introduction of dolutegravir at their site  or after the introduction of dolutegravir at their site  Figure . The incOur outcome was viral suppression, which was defined as the earliest documentation of a viral load (VL) measurement <1000 copies/ml during follow‐up. VL was based on documentation of a quantitative HIV RNA test using local site protocols and procedural standards. A threshold of 1000 copies/ml was chosen to reflect variation across sites in specimens used and assay lower limits of detection. Based on site testing capacity , we assuCompeting events were switching to a new ART regimen and loss to program or death, as these events could either modify the risk or prevent the occurrence of the viral suppression outcome. Switching to a new ART regimen was based on medication records, indicating the discontinuation of efavirenz or dolutegravir, that is switch from efavirenz to dolutegravir, a PI or another NNRTI, or switch from dolutegravir to an NNRTI or a PI. Reasons for regimen switches were not documented but were likely related to issues specific to the patient (e.g. tolerability) or program . Loss to program included loss to follow‐up (i.e. no record for ≥6 months immediately before administrative censoring at 12 months after tuberculosis diagnosis), known facility transfer or other documented reason for leaving care, with the last recorded date of contact used to determine the timing of this outcome. Determination of death was based on a site's usual practices for ascertainment.3 or CD4+ percentage <14, or WHO Clinical Stage 4 event), initial NRTI backbone, time of ART initiation, CD4 count closest to date of tuberculosis diagnosis (within 12 months before or 2 months after), most recent VL in the previous 12 months among those on ART for >6 months at tuberculosis diagnosis and site of tuberculosis disease . Documentation of an HRZE regimen included both patients with a proxy diagnosis and patients who initiated HRZE within 1 month of a documented tuberculosis diagnosis. As the collection and completeness of data on tuberculosis medications varied by site, we limited this variable to sites with ≥1 patient documented to receive HRZE.Baseline variables were age group, sex, underweight , documentation of a prior AIDS diagnosis  and Mann–Whitney U tests (numeric variables) to compare DTG with C‐EFV and H‐EFV.Patients were followed from their date of tuberculosis diagnosis until documentation of viral suppression, a competing event  or administrative censoring at 12 months after tuberculosis diagnosis. If the viral suppression outcome was documented on the same day as a competing event, the patient was considered to have the former outcome.p<0.05) in bivariate analyses, except for CD4 count, which was expected to be influenced by the decreasing use of CD4 testing over time ), eight (2%) were at sites reporting only once‐daily dosing and 25 (5%) were at sites that did not participate in the survey.Patients were categorized into the following exposure groups: DTG (3) versus DTG group (median 107 cells/mm3); however, patients in the DTG group less often had a CD4 test (34% vs. 41%). Although ART‐experienced patients in the DTG group were more likely than EFV groups to have a baseline VL test (81% vs. 59%), there were no significant differences in viral suppression. Documentation of HRZE was significantly lower in the DTG group (61%) compared with both EFV groups (73–75%).When comparing patient characteristics of DTG with both EFV groups, there were significant differences in age group, sex and site of tuberculosis disease, and when comparing DTG with the H‐EFV group, there were also significant differences in timing of ART initiation and CD4 count Table . CompareAt the end of 12‐month follow‐up, the cumulative incidence of viral suppression was 58.9% for DTG, 49.6% for C‐EFV and 44.9% for H‐EFV; the cumulative incidence of switching ART regimen was 4.1% for DTG, 10.0% for C‐EFV and 5.7% for H‐EFV; and the cumulative incidence of loss to program or death was 23.4% for DTG, 28.6% for C‐EFV and 28.8% for H‐EFV  . TherefoIn the cohort study, a large proportion (91%) of patients receiving dolutegravir who had VL ascertained in the 12 months after tuberculosis diagnosis had viral suppression, which was lower (59%) for the entire sample that fully considered loss to program or death, which could preclude VL testing, and patients who did not have VL testing for other reasons. For both samples, dolutegravir was significantly associated with improved viral suppression compared with efavirenz. When stratifying by subgroup, there were some differences in statistical significance for comparisons, but overall, results were similar in magnitude. In the INSPIRING trial, 48‐week viral suppression (<50 copies/ml) was similar in magnitude for both the dolutegravir (75%) and efavirenz (82%) arms among participants newly initiating ART; however, this trial was not powered to statistically compare viral suppression between treatment arms . Real‐woThe finding that viral suppression with dolutegravir was at least as good as (and possibly better) compared with efavirenz is supportive of HIV treatment programs already routinely prescribing dolutegravir to patients with tuberculosis co‐infection. In some settings, efavirenz remains preferred for patients initiating ART at the time of tuberculosis diagnosis to avoid the drug–drug interaction with rifampicin  and our The results from our cohort study should be interpreted in the context of some limitations. We attempted to adjust for potential confounders in regression analyses, which we considered to be patient characteristics that were significantly different between exposure groups. Nevertheless, because of the observational study design, unobserved confounders may be present. The comparison of DTG with H‐EFV allowed for potentially less selection bias than the comparison with C‐EFV, as dolutegravir was not yet available when these patients had a tuberculosis diagnosis. However, follow‐up in the H‐EFV group began as early as 2015 and thus, the lower viral suppression in this group may have been related to changes in VL testing availability and practices over time, including the use of targeted rather than routine VL monitoring . DespiteAs we leveraged routine clinical data, misclassification of some variables and missing data related to erroneous or incomplete documentation is anticipated. For the inclusion criteria, it may be possible that a tuberculosis diagnosis was incorrectly documented. It may also be possible that some patients had drug resistant tuberculosis and were not receiving rifampicin; however, such treatment is often provided off‐site in our setting . To examWe did not have information on dosing frequency of antiretroviral drugs, so we could not compare outcomes by dolutegravir dosing. Few patients in the DTG group were at sites that reported not using twice‐daily dosing, precluding a robust subgroup analysis. The necessity of dolutegravir 50 mg twice daily for all patients receiving concomitant rifampicin remains unresolved , 32, 33;5We documented the widespread programmatic implementation of dolutegravir for patients with tuberculosis co‐infection at HIV clinics in sub‐Saharan Africa and use of the recommended twice‐daily dosing to counteract the drug–drug interaction with rifampicin. Despite this more complex regimen, dolutegravir did not negatively impact viral suppression.The authors declare that they have no competing interests.MLR and DN conceived the study. MLR, EB, MY, LF, KKW‐K, NSS and DN contributed to the study design. EB, DM‐N, RDW, CS‐W, CC, WRM, GM, CK, TT, JAM, PL, AD, CT, IR, OCE and LD contributed to data collection. MLR analysed the data and wrote the manuscript. All authors participated in the interpretation of the results, revision of the manuscript, and have read and approved the final manuscript.Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Cancer Institute, the National Institute of Mental Health, the National Institute on Drug Abuse, the National Heart, Lung, and Blood Institute, the National Institute on Alcohol Abuse and Alcoholism, the National Institute of Diabetes and Digestive and Kidney Diseases, the Fogarty International Center and the National Library of Medicine: Central Africa, U01AI096299; East Africa, U01AI069911; Southern Africa, U01AI069924; West Africa, U01AI069919. Informatics resources are supported by the Harmonist project, R24AI24872.The International Epidemiology Databases to Evaluate AIDS (IeDEA) is supported by the U.S. National Institutes of Health's National Institute of Allergy and Infectious Diseases, the This work is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. National Institutes of Health.Appendix S1. Members of the contributing IeDEA regions.Click here for additional data file.Appendix S2. Site survey of dolutegravir use among patients with tuberculosis co‐infection.Click here for additional data file.Supplemental Table 1. Characteristics of sites included in survey of dolutegravir use in tuberculosis co‐infection.Supplemental Table 2. Cumulative incidence of viral suppression redefining viral suppression from <1000 copies/mL to <400 copies/mL .Supplemental Table 3. Hazards regression models for the associations between dolutegravir and efavirenz groups with viral suppression redefined from <1000 copies/mL to <400 copies/mL .Supplemental Table 4. Cumulative incidence of viral suppression stratified by number of viral load tests in the 12 months after tuberculosis diagnosis .Supplemental Table 5. Hazards regression models for the associations between dolutegravir and efavirenz groups stratified by number of viral load tests in the 12 months after tuberculosis diagnosis .Supplemental Table 6. Cumulative incidence of viral suppression stratified by baseline recent viral load among patients initiating antiretroviral therapy >6 months before tuberculosis diagnosis .Supplemental Table 7. Hazards regression models for the associations between dolutegravir and efavirenz groups stratified by baseline recent viral load among patients initiating antiretroviral therapy >6 months before tuberculosis diagnosis .Click here for additional data file.