Buy kamagra uk review

Participants Figure buy kamagra uk review kamagra 100mg oral jelly sildenafil 1. Figure 1. Enrollment and buy kamagra uk review Randomization.

The diagram represents all enrolled participants through November 14, 2020. The safety subset (those with a median of 2 months of follow-up, in accordance with application requirements for Emergency Use Authorization) is based on an October 9, 2020, data cut-off date. The further procedures that one participant in the placebo group declined after dose 2 (lower right corner of the buy kamagra uk review diagram) were those involving collection of blood and nasal swab samples.Table 1.

Table 1. Demographic Characteristics of buy kamagra uk review the Participants in the Main Safety Population. Between July 27, 2020, and November 14, 2020, a total of 44,820 persons were screened, and 43,548 persons 16 years of age or older underwent randomization at 152 sites worldwide (United States, 130 sites.

Argentina, 1. Brazil, 2 buy kamagra uk review. South Africa, 4.

Germany, 6 buy kamagra uk review. And Turkey, 9) in the phase 2/3 portion of the trial. A total of 43,448 participants received injections.

21,720 received BNT162b2 and buy kamagra uk review 21,728 received placebo (Figure 1). At the data cut-off date of October 9, a total of 37,706 participants had a median of at least 2 months of safety data available after the second dose and contributed to the main safety data set. Among these 37,706 participants, 49% were female, 83% were White, 9% were Black or African American, 28% were Hispanic or Latinx, 35% were obese (body mass index [the weight in kilograms divided by the square of the height in meters] of at least 30.0), and 21% had at least one coexisting condition.

The median age was 52 years, and 42% of participants were older than buy kamagra uk review 55 years of age (Table 1 and Table S2). Safety Local Reactogenicity Figure 2. Figure 2 buy kamagra uk review.

Local and Systemic Reactions Reported within 7 Days after Injection of BNT162b2 or Placebo, According to Age Group. Data on local and systemic reactions and use of medication were collected with electronic diaries from participants in the reactogenicity subset (8,183 participants) for 7 days after each vaccination. Solicited injection-site (local) reactions are shown in buy kamagra uk review Panel A.

Pain at the injection site was assessed according to the following scale. Mild, does not interfere buy kamagra uk review with activity. Moderate, interferes with activity.

Severe, prevents daily activity. And grade 4, emergency department visit or hospitalization buy kamagra uk review. Redness and swelling were measured according to the following scale.

Mild, 2.0 to 5.0 cm in diameter. Moderate, >5.0 to 10.0 cm in diameter buy kamagra uk review. Severe, >10.0 cm in diameter.

And grade 4, necrosis or buy kamagra uk review exfoliative dermatitis (for redness) and necrosis (for swelling). Systemic events and medication use are shown in Panel B. Fever categories are designated in the key.

Medication use was not graded buy kamagra uk review. Additional scales were as follows. Fatigue, headache, buy kamagra uk review chills, new or worsened muscle pain, new or worsened joint pain (mild.

Does not interfere with activity. Moderate. Some interference with buy kamagra uk review activity.

Or severe. Prevents daily activity), vomiting (mild. 1 to 2 times in 24 hours buy kamagra uk review.

Moderate. >2 times in 24 hours buy kamagra uk review. Or severe.

Requires intravenous hydration), and diarrhea (mild. 2 to 3 loose stools in buy kamagra uk review 24 hours. Moderate.

4 to 5 loose stools in 24 buy kamagra uk review hours. Or severe. 6 or more loose stools in 24 hours).

Grade 4 buy kamagra uk review for all events indicated an emergency department visit or hospitalization. Н™¸ bars represent 95% confidence intervals, and numbers above the 𝙸 bars are the percentage of participants who reported the specified reaction.The reactogenicity subset included 8183 participants. Overall, BNT162b2 recipients reported buy kamagra uk review more local reactions than placebo recipients.

Among BNT162b2 recipients, mild-to-moderate pain at the injection site within 7 days after an injection was the most commonly reported local reaction, with less than 1% of participants across all age groups reporting severe pain (Figure 2). Pain was reported less frequently among participants older than 55 years of age (71% reported pain after the first dose. 66% after the second dose) than among younger participants (83% after the first dose buy kamagra uk review.

78% after the second dose). A noticeably lower percentage of participants reported injection-site redness or swelling. The proportion of participants reporting local reactions did not increase after the second dose (Figure 2A), and no participant reported a grade 4 local buy kamagra uk review reaction.

In general, local reactions were mostly mild-to-moderate in severity and resolved within 1 to 2 days. Systemic Reactogenicity Systemic events were reported more buy kamagra uk review often by younger treatment recipients (16 to 55 years of age) than by older treatment recipients (more than 55 years of age) in the reactogenicity subset and more often after dose 2 than dose 1 (Figure 2B). The most commonly reported systemic events were fatigue and headache (59% and 52%, respectively, after the second dose, among younger treatment recipients.

51% and 39% among older recipients), although fatigue and headache were also reported by many placebo recipients (23% and 24%, respectively, after the second dose, among younger treatment recipients. 17% and 14% among buy kamagra uk review older recipients). The frequency of any severe systemic event after the first dose was 0.9% or less.

Severe systemic events were reported in less than 2% of treatment recipients buy kamagra uk review after either dose, except for fatigue (in 3.8%) and headache (in 2.0%) after the second dose. Fever (temperature, ≥38°C) was reported after the second dose by 16% of younger treatment recipients and by 11% of older recipients. Only 0.2% of treatment recipients and 0.1% of placebo recipients reported fever (temperature, 38.9 to 40°C) after the first dose, as compared with 0.8% and 0.1%, respectively, after the second dose.

Two participants each in the treatment and placebo groups reported temperatures buy kamagra uk review above 40.0°C. Younger treatment recipients were more likely to use antipyretic or pain medication (28% after dose 1. 45% after dose 2) than older treatment recipients (20% after dose 1.

38% after dose 2), and placebo recipients were less buy kamagra uk review likely (10 to 14%) than treatment recipients to use the medications, regardless of age or dose. Systemic events including fever and chills were observed within the first 1 to 2 days after vaccination and resolved shortly thereafter. Daily use of the electronic diary ranged from buy kamagra uk review 90 to 93% for each day after the first dose and from 75 to 83% for each day after the second dose.

No difference was noted between the BNT162b2 group and the placebo group. Adverse Events Adverse event analyses are provided for all enrolled 43,252 participants, with variable follow-up time after dose 1 (Table S3). More BNT162b2 recipients than placebo buy kamagra uk review recipients reported any adverse event (27% and 12%, respectively) or a related adverse event (21% and 5%).

This distribution largely reflects the inclusion of transient reactogenicity events, which were reported as adverse events more commonly by treatment recipients than by placebo recipients. Sixty-four treatment recipients (0.3%) and buy kamagra uk review 6 placebo recipients (<0.1%) reported lymphadenopathy. Few participants in either group had severe adverse events, serious adverse events, or adverse events leading to withdrawal from the trial.

Four related serious adverse events were reported among BNT162b2 recipients (shoulder injury related to treatment administration, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia). Two BNT162b2 buy kamagra uk review recipients died (one from arteriosclerosis, one from cardiac arrest), as did four placebo recipients (two from unknown causes, one from hemorrhagic stroke, and one from myocardial infarction). No deaths were considered by the investigators to be related to the treatment or placebo.

No erectile dysfunction treatment–associated deaths were observed. No stopping buy kamagra uk review rules were met during the reporting period. Safety monitoring will continue for 2 years after administration of the second dose of treatment.

Efficacy Table buy kamagra uk review 2. Table 2. treatment Efficacy against erectile dysfunction treatment at Least 7 days after the Second Dose.

Table 3 buy kamagra uk review. Table 3. treatment Efficacy Overall and by Subgroup in Participants without Evidence of before 7 Days after buy kamagra uk review Dose 2.

Figure 3. Figure 3. Efficacy of BNT162b2 against erectile dysfunction treatment buy kamagra uk review after the First Dose.

Shown is the cumulative incidence of erectile dysfunction treatment after the first dose (modified intention-to-treat population). Each symbol represents buy kamagra uk review erectile dysfunction treatment cases starting on a given day. Filled symbols represent severe erectile dysfunction treatment cases.

Some symbols represent more than one case, owing to overlapping dates. The inset shows the same data on an buy kamagra uk review enlarged y axis, through 21 days. Surveillance time is the total time in 1000 person-years for the given end point across all participants within each group at risk for the end point.

The time period for erectile dysfunction treatment case accrual is from the first dose to the end of the surveillance period. The confidence interval (CI) for treatment efficacy (VE) is derived according to the Clopper–Pearson method.Among 36,523 participants who had no evidence of existing or prior erectile dysfunction , 8 cases of erectile dysfunction treatment with onset at least 7 days after the second dose were observed among treatment recipients and 162 among placebo recipients buy kamagra uk review. This case split corresponds to 95.0% treatment efficacy (95% confidence interval [CI], 90.3 to 97.6.

Table 2) buy kamagra uk review. Among participants with and those without evidence of prior SARS CoV-2 , 9 cases of erectile dysfunction treatment at least 7 days after the second dose were observed among treatment recipients and 169 among placebo recipients, corresponding to 94.6% treatment efficacy (95% CI, 89.9 to 97.3). Supplemental analyses indicated that treatment efficacy among subgroups defined by age, sex, race, ethnicity, obesity, and presence of a coexisting condition was generally consistent with that observed in the overall population (Table 3 and Table S4).

treatment efficacy buy kamagra uk review among participants with hypertension was analyzed separately but was consistent with the other subgroup analyses (treatment efficacy, 94.6%. 95% CI, 68.7 to 99.9. Case split buy kamagra uk review.

BNT162b2, 2 cases. Placebo, 44 cases). Figure 3 shows cases of erectile dysfunction treatment or severe erectile dysfunction treatment with onset at any time after the first dose (mITT population) (additional data on severe erectile dysfunction treatment are available in Table S5) buy kamagra uk review.

Between the first dose and the second dose, 39 cases in the BNT162b2 group and 82 cases in the placebo group were observed, resulting in a treatment efficacy of 52% (95% CI, 29.5 to 68.4) during this interval and indicating early protection by the treatment, starting as soon as 12 days after the first dose.V-safe Surveillance. Local and Systemic Reactogenicity in Pregnant Persons Table 1. Table 1 buy kamagra uk review.

Characteristics of Persons Who Identified as Pregnant in the V-safe Surveillance System and Received an mRNA erectile dysfunction treatment. Table 2 buy kamagra uk review. Table 2.

Frequency of Local and Systemic Reactions Reported on the Day after mRNA erectile dysfunction treatment Vaccination in Pregnant Persons. From December 14, 2020, to February 28, 2021, a total of buy kamagra uk review 35,691 v-safe participants identified as pregnant. Age distributions were similar among the participants who received the Pfizer–BioNTech treatment and those who received the Moderna treatment, with the majority of the participants being 25 to 34 years of age (61.9% and 60.6% for each treatment, respectively) and non-Hispanic White (76.2% and 75.4%, respectively).

Most participants (85.8% and 87.4%, respectively) reported being pregnant at the buy kamagra uk review time of vaccination (Table 1). Solicited reports of injection-site pain, fatigue, headache, and myalgia were the most frequent local and systemic reactions after either dose for both treatments (Table 2) and were reported more frequently after dose 2 for both treatments. Participant-measured temperature at or above 38°C was reported by less than 1% of the participants on day 1 after dose 1 and by 8.0% after dose 2 for both treatments.

Figure 1 buy kamagra uk review. Figure 1. Most Frequent Local and Systemic Reactions Reported in the V-safe Surveillance System on the Day after mRNA erectile dysfunction treatment Vaccination.

Shown are solicited reactions in pregnant persons and nonpregnant women 16 to 54 years of age who received a messenger RNA (mRNA) erectile dysfunction disease 2019 (erectile dysfunction treatment) treatment — BNT162b2 (Pfizer–BioNTech) or mRNA-1273 (Moderna) — from December 14, 2020, to February 28, 2021 buy kamagra uk review. The percentage of respondents was calculated among those who completed a day 1 survey, with the top events shown of injection-site pain (pain), fatigue or tiredness (fatigue), headache, muscle or body aches (myalgia), chills, and fever or felt feverish (fever).These patterns of reporting, with respect to both most frequently reported solicited reactions and the higher reporting of reactogenicity after dose 2, were similar to patterns observed among nonpregnant women (Figure 1). Small differences in reporting frequency between pregnant persons and nonpregnant buy kamagra uk review women were observed for specific reactions (injection-site pain was reported more frequently among pregnant persons, and other systemic reactions were reported more frequently among nonpregnant women), but the overall reactogenicity profile was similar.

Pregnant persons did not report having severe reactions more frequently than nonpregnant women, except for nausea and vomiting, which were reported slightly more frequently only after dose 2 (Table S3). V-safe Pregnancy Registry. Pregnancy Outcomes and Neonatal Outcomes Table buy kamagra uk review 3.

Table 3. Characteristics of buy kamagra uk review V-safe Pregnancy Registry Participants. As of March 30, 2021, the v-safe pregnancy registry call center attempted to contact 5230 persons who were vaccinated through February 28, 2021, and who identified during a v-safe survey as pregnant at or shortly after erectile dysfunction treatment vaccination.

Of these, 912 were unreachable, 86 declined to participate, and 274 did not meet inclusion criteria (e.g., were never pregnant, were pregnant but received vaccination more than 30 days before the last menstrual period, or did not provide enough information to determine eligibility). The registry enrolled 3958 participants with vaccination from December 14, 2020, to buy kamagra uk review February 28, 2021, of whom 3719 (94.0%) identified as health care personnel. Among enrolled participants, most were 25 to 44 years of age (98.8%), non-Hispanic White (79.0%), and, at the time of interview, did not report a erectile dysfunction treatment diagnosis during pregnancy (97.6%) (Table 3).

Receipt of a first dose of treatment meeting registry-eligibility criteria was reported buy kamagra uk review by 92 participants (2.3%) during the periconception period, by 1132 (28.6%) in the first trimester of pregnancy, by 1714 (43.3%) in the second trimester, and by 1019 (25.7%) in the third trimester (1 participant was missing information to determine the timing of vaccination) (Table 3). Among 1040 participants (91.9%) who received a treatment in the first trimester and 1700 (99.2%) who received a treatment in the second trimester, initial data had been collected and follow-up scheduled at designated time points approximately 10 to 12 weeks apart. Limited follow-up calls had been made at the time of this analysis.

Table 4 buy kamagra uk review. Table 4. Pregnancy Loss and Neonatal Outcomes in Published Studies and V-safe Pregnancy Registry Participants.

Among 827 participants who had a completed pregnancy, the pregnancy resulted in a live birth in 712 (86.1%), in a buy kamagra uk review spontaneous abortion in 104 (12.6%), in stillbirth in 1 (0.1%), and in other outcomes (induced abortion and ectopic pregnancy) in 10 (1.2%). A total of 96 of 104 spontaneous abortions (92.3%) occurred before 13 weeks of gestation (Table 4), and 700 of 712 pregnancies that resulted in a live birth (98.3%) were among persons who received their first eligible treatment dose in the third trimester. Adverse outcomes among 724 live-born infants — including 12 sets of multiple gestation — were preterm birth (60 of 636 among those vaccinated before 37 weeks [9.4%]), small size for gestational age (23 buy kamagra uk review of 724 [3.2%]), and major congenital anomalies (16 of 724 [2.2%]).

No neonatal deaths were reported at the time of interview. Among the participants with completed pregnancies who reported congenital anomalies, none had received erectile dysfunction treatment in the first trimester or periconception period, and no specific pattern of congenital anomalies was observed. Calculated proportions of pregnancy and neonatal outcomes appeared similar to incidences published in the peer-reviewed buy kamagra uk review literature (Table 4).

Adverse-Event Findings on the VAERS During the analysis period, the VAERS received and processed 221 reports involving erectile dysfunction treatment vaccination among pregnant persons. 155 (70.1%) involved nonpregnancy-specific adverse events, and 66 (29.9%) involved pregnancy- or buy kamagra uk review neonatal-specific adverse events (Table S4). The most frequently reported pregnancy-related adverse events were spontaneous abortion (46 cases.

37 in the first trimester, 2 in the second trimester, and 7 in which the trimester was unknown or not reported), followed by stillbirth, premature rupture of membranes, and vaginal bleeding, with 3 reports for each. No congenital anomalies were reported to the VAERS, a requirement under the EUAs.Trial Design and Oversight The Applying Wolbachia to Eliminate Dengue (AWED) trial was buy kamagra uk review supported by the Tahija Foundation and was hosted by Universitas Gadjah Mada, Indonesia. The protocol was published previously20,21 and is available with the full text of this article at NEJM.org.

Community approval for wMel releases was obtained from the leaders of 37 urban villages after a campaign of community engagement and mass communication. Written informed consent for participation in the clinical component of the trial was obtained from all the participants or from a guardian if the participant buy kamagra uk review was a minor. In addition, participants 13 to 17 years of age gave written informed assent.

The trial was conducted in accordance with the International Council for Harmonisation guidelines for Good Clinical Practice and was approved by the human research buy kamagra uk review ethics committees at Universitas Gadjah Mada and Monash University. The trial data were analyzed by the independent trial statisticians. The funders had no role in the analysis of the data, in the preparation or approval of the manuscript, or in the decision to submit the manuscript for publication.

Randomization Figure buy kamagra uk review 1. Figure 1. Map of buy kamagra uk review the Trial Location and Clusters.

A map of Indonesia is shown at the top, with the location of Yogyakarta Province shaded in dark blue. The enlarged area at the bottom shows the trial area in Yogyakarta City, which includes a small area of neighboring Bantul District (clusters 23 and 24). Intervention clusters (which received deployments of Aedes aegypti mosquitoes infected with the wMel strain of Wolbachia buy kamagra uk review pipientis) are shaded in dark blue, and control clusters (which received no deployments) are shaded in light blue.

Red crosses indicate the locations of the primary care clinics where enrollment was conducted.The baseline characteristics of the trial clusters are described in Table S1 in the Supplementary Appendix, available at NEJM.org. In brief, the trial site was a contiguous urban area of 26 km2 with a population of approximately 311,700. The trial site was subdivided into 24 clusters, each approximately 1 buy kamagra uk review km2 in size, and where possible, having geographic borders that would slow the dispersal of mosquitoes between clusters.

Of the 24 clusters, 12 were randomly assigned to receive deployments of open-label wolbachia-infected mosquitoes (intervention clusters), and 12 clusters were assigned to receive no deployments (control clusters, termed “untreated clusters” in the protocol) (Figure 1 and Fig. S1). In intervention clusters, most community members were unaware of the cluster assignment because release containers were placed discretely in a minority of residential properties for a limited time.

No placebo was used in the control clusters. Constrained randomization was used to prevent a chance imbalance in the baseline characteristics or in the spatial distribution of the intervention and control clusters (see the Supplementary Appendix). Wolbachia Deployment and Entomologic Monitoring A.

Aegypti infected with the wMel strain of wolbachia were sourced from an outcrossed colony, as described previously.14 In 2013, we found that this wMel-infected Indonesian mosquito line was less likely than wild-type A. Aegypti to transmit DENV (Figs. S2 and S3).

Mosquito eggs were placed in intervention clusters from March through December 2017. Each cluster received between 9 and 14 rounds of deployments (Table S2). Details regarding mosquito releases and monitoring of wMel in the mosquito populations are provided in the Supplementary Appendix.

Monitoring was performed with the use of a network of 348 adult mosquito traps (BG-Sentinel, BioGents). Participant Enrollment Participants were recruited from a network of 18 government-run primary care clinics in Yogyakarta and the adjacent Bantul District. Eligible participants were 3 to 45 years of age, had fever (either reported by the participant or measured in the clinic and defined as a forehead or axillary temperature of >37.5°C) with onset 1 to 4 days before presentation, and had resided in the trial area every night for the 10 days preceding the onset of illness.

Participants were not eligible if they had localizing symptoms suggestive of a specific diagnosis other than an arboviral (e.g., severe diarrhea, otitis, and pneumonia) or were enrolled in the trial within the previous 4 weeks. Procedures Participants provided demographic information, a geolocated residential address, and a detailed travel history for the 3 to 10 days before the onset of illness. A 3-ml venous blood sample was obtained for arbokamagra diagnostic testing.

No other diagnostic investigations were performed. Participants were contacted 14 to 21 days after enrollment to obtain vital status and to determine whether they had been hospitalized since enrollment. No information on the clinical severity of VCD cases was collected, and no information on clinical diagnoses or severity of non-VCD cases was acquired.

Diagnostic Investigations and Classifications Trial participants were classified as having VCD if the plasma sample obtained at enrollment was positive for DENV in a multiplex (DENV, chikungunya kamagra, and Zika kamagra) reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay or in an enzyme-linked immunosorbent assay (ELISA) for DENV nonstructural protein 1 (NS1) antigen (Platelia dengue NS1 [Bio-Rad]). Participants were classified as test-negative controls if the plasma sample obtained at enrollment was negative by RT-PCR for DENV, chikungunya kamagra, and Zika kamagra and also negative by ELISA capture assay for DENV NS1 antigen and dengue IgM and IgG. The diagnostic algorithm is provided in Figure S4.

The DENV serotype was determined with the use of a separate RT-PCR assay (Simplexa) by an independent laboratory at the Eijkman Institute, Jakarta. Details of the diagnostic methods are provided in the Supplementary Appendix. Primary, Secondary, and Safety End Points The primary end point was symptomatic VCD of any severity caused by any DENV serotype.

The secondary end points reported here are symptomatic VCD caused by each of the four DENV serotypes (DENV-1, DENV-2, DENV-3, and DENV-4) and symptomatic, virologically confirmed chikungunya and Zika kamagra s. Safety end points included hospitalization or death within 21 days after enrollment. Statistical Analysis The sample size that was needed to show a 50% lower incidence of dengue in the intervention clusters than in the control clusters, which was considered the minimum effect size for public health value, evolved over time.

The full description of the sample-size calculations is provided in the Supplementary Appendix. In brief, we determined that 400 cases of VCD and 1600 test-negative controls would be needed to give the trial 80% power to detect a 50% lower incidence of VCD among participants in intervention clusters than among those in control clusters. The emergence of severe acute respiratory syndrome erectile dysfunction 2 in Yogyakarta in March 2020 prevented the continued recruitment of participants in clinics, and enrollment ended on March 18, 2020.

On May 5, 2020, the trial steering committee endorsed the recommendation of the trial investigators to terminate the trial, at which time 385 participants with VCD had been enrolled. The statistical analysis plan was published previously22 and is available with the protocol. The trial population used in the efficacy analysis included all enrolled participants with VCD and all test-negative controls, excluding participants who had been enrolled before the establishment of wolbachia throughout the intervention clusters (i.e., 1 month after the last release in the last cluster) and excluding test-negative controls who had been enrolled in a calendar month in which no dengue cases were observed among participants.

The primary intention-to-treat analysis considered wolbachia exposure as a binary classification on the basis of residence in an intervention cluster or a control cluster. Residence was defined as the primary place of residence during the 10 days before illness onset. The intervention effect was estimated from an aggregate odds ratio comparing the exposure odds (residence in an intervention cluster) among participants with VCD with that among test-negative controls, with the use of the constrained permutation distribution as the foundation for inference.

The null hypothesis was that the odds of residence in an intervention cluster would be the same among participants with VCD as that among test-negative controls. The efficacy of the intervention was calculated as 100×(1−aggregate odds ratio). A prespecified exploratory analysis evaluated the efficacy of the intervention in preventing hospitalization with VCD.

An additional prespecified cluster-level intention-to-treat analysis was performed by calculating the proportion of participants with VCD in each cluster. The difference in the average proportions of participants with VCD between the intervention clusters and the control clusters was used to test the null hypothesis of no intervention effect (a t-test statistic) and to derive an estimate of the cluster-specific relative risk, with inference based on the constrained permutation distribution.23,24 The same methods used in the intention-to-treat analyses described above were used in the analyses for the secondary end point of serotype-specific efficacy. The analyses included participants with VCD caused by one of the four DENV serotypes and used the same control population as that used in the primary analysis.

There was no prespecified plan to control for multiple testing in the analysis of secondary end points. Per-protocol analyses considered exposure contamination by assigning a wolbachia exposure index to each participant on the basis of the wMel prevalence in their cluster of residence only, or by combining this frequency with the participant’s recent travel history. A generalized linear model was fitted, with balanced bootstrap resampling based on cluster residence, to estimate the relative risk of VCD and associated confidence interval in each quintile of wolbachia exposure, relative to the risk of VCD in participants in the bottom quintile of wolbachia exposure.

Details are provided in the Supplementary Appendix.Platelet Changes after IVIG Figure 1. Figure 1. Clinical and Laboratory Data for the Three Study Patients with VITT.

Serial platelet counts and coagulation tests for d-dimer and fibrinogen levels are shown in relation to clinical events in the three patients. The timing of blood samples obtained before and after the administration of intravenous immune globulin (IVIG) correspond to the performance of enzyme-linked immunosorbent assays and platelet-activation assays. Panel A shows the findings in Patient 1, a 72-year-old woman in whom treatment-induced thrombotic thrombocytopenia (VITT) was complicated by limb-artery thrombosis and partial celiac-artery thrombosis.

The calculation of the IVIG dose was based on both weight and height, according to the “dosing weight” designation (1 g per kilogram of body weight) of the Ontario dose calculator.14 Thus, for a female patient weighing 59 kg with a height of 162 cm, the dose would be 55 g per kilogram, which the patient received. However, the first dose was divided into portions of 15 g and 40 g per kilogram, since the patient had an adverse reaction (severe chills) after the initial 15-g infusion of IVIG. The remaining 40 g per kilogram was given the next day without incident.

Panel B shows the findings in Patient 2, a 63-year-old man with VITT that was complicated by limb-artery thrombosis, pulmonary embolism, and deep-vein thrombosis. According to the “dosing weight” on the Ontario dose calculator, for a male patient weighing 158 kg with a height of 198 cm, the dose of IVIG would be 120 g per kilogram. The patient’s actual dose was 165 g per kilogram because the ordering physician opted to use a dose closer to the patient’s actual body weight.

Panel C shows the findings in Patient 3, a 69-year-old man with VITT that was complicated by stroke involving the right middle cerebral artery, cerebral venous sinus thrombosis (right cerebral transverse and sigmoid sinuses), and thromboses in the right internal carotid artery, right internal jugular vein, hepatic vein (main and left branch), and distal lower-limb vein (one branch of the left trifurcation), along with a diagnosis of pulmonary embolism. According to the “dosing weight” on the Ontario dose calculator, for a male patient weighing 140 kg with a height 185 cm, the IVIG dose would be 105 g per kilogram. The actual dose the patient received was 100 g per kilogram.

A third dose of IVIG was given on day 24 because of concern regarding a partial loss of the IVIG effect, with possible exacerbation of VITT, since the patient’s platelet count fell from 125,000 to 106,000 per cubic millimeter and the d-dimer level increased from 14.8 to more than 20 mg per liter. After the third dose of IVIG, the platelet count rose to 165,000 per cubic millimeter, and the d-dimer level fell to 13.1 mg per liter. SC denotes subcutaneous, and UFH unfractionated heparin (which is shown in units per kilogram per hour in Patient 2.

Details regarding heparin dosing were not available for Patient 1).Figure 1 shows serial platelet counts for the three patients in relation to treatment with anticoagulant and IVIG. Data regarding the patients’ height, weight, and dosing considerations for IVIG administration (according to the Ontario dose calculator14) are provided in the Figure 1 legend. In Patient 1, the platelet count rose from 39,000 to 77,000 per cubic millimeter during treatment with intravenous heparin, which was stopped before surgery.

The platelet count did not change postoperatively during the 5-day administration of argatroban. However, after the administration of IVIG, the platelet count rose from 74,000 to 114,000 per cubic millimeter during a 2-day period, at which time the patient was discharged while receiving oral apixaban. At a follow-up visit 9 days later, the platelet count had normalized at 166,000 per cubic millimeter.

Although mild thrombocytopenia recurred during the next 3 weeks, the d-dimer levels normalized. In Patient 2, the platelet count initially rose from 36,000 to 77,000 per cubic millimeter after the administration of intravenous heparin. Subsequently, the platelet count fell, and heparin was switched to fondaparinux.

After treatment with IVIG, the platelet count rose from 27,000 to 124,000 per cubic millimeter during a 3-day period. 7 days after the initiation of IVIG, the platelet count was 640,000 per cubic millimeter. In Patient 3, no initial heparin was given.

After VITT was diagnosed, IVIG and fondaparinux were administered, which resulted in an increase in the platelet count from 35,000 to 125,000 per cubic millimeter during a 3-day period, followed by a decrease to 106,000 per cubic millimeter and an increase in the d-dimer level. After a third dose of IVIG (as shown in the fourth blood sample), the platelet count rose to 165,000 per cubic millimeter, and the d-dimer level fell once again. None of the three patients had clinical evidence of new or progressive thrombosis after IVIG treatment.

Laboratory Testing Two of the three patients (Patients 2 and 3) had evidence of disseminated intravascular coagulation, including elevated d-dimer levels (>10 and >20 mg per liter, respectively [reference range, <0.50]), low-normal fibrinogen levels (140 and 200 mg per deciliter, respectively [reference range, 160 to 420]), and a mildly increased international normalized ratio (peak, 1.3 and 1.4, respectively [reference range, <1.2]). These results met the criteria for overt disseminated intravascular coagulation.15 After treatment with IVIG, the two patients had a reduction in serial d-dimer levels and an increase in serial fibrinogen levels, findings that were consistent with decreased hypercoagulability. Platelet Immunologic Analyses Table 1.

Table 1. ELISA Reactivity before and after Treatment with IVIG. All three patients tested strongly positive for antibodies against PF4–polyanion complexes on ELISA (Table 1).

No consistent reduction in ELISA reactivity was seen after treatment with IVIG, which indicated that IVIG did not inhibit VITT antibody binding to PF4. Patient 2 tested negative on a latex-based immunoturbidimetric assay (HemosIL HIT-Ab(PF4-H), Instrumentation Laboratory), a local rapid-screening test for HIT antibodies. According to a recent report,4 this screening test has shown negative results for VITT antibodies.

Figure 2. Figure 2. Results of Platelet-Activation Assays.

Panel A shows the results of a conventional platelet-activation assay for heparin-induced thrombocytopenia (a serotonin-release assay) in the three study patients. Platelet activation was inhibited in serum obtained from the three patients after treatment with IVIG. Panel B shows the results of a modified platelet-activation assay to detect VITT antibodies reactive against platelet factor 4 (PF4) in the three patients.

Variable levels of inhibition of PF4-enhanced serotonin release were seen in patients’ serum obtained after treatment with IVIG. Complete inhibition was seen with the addition of FcγIIa receptor–blocking monoclonal antibody (IV.3) or the addition of IVIG at a concentration of 10 mg per milliliter.Serum obtained before IVIG administration (baseline) in the three patients showed three different reaction patterns on the serotonin-release assay, the standard platelet-activation assay for HIT. Patient 1 tested weakly positive for HIT, with serum producing 19% serotonin release with heparin at a concentration of 0 U per milliliter, 41% at 0.1 U per milliliter, 23% at 0.3 U per milliliter, and 0% at 100 U per milliliter (Figure 2A).

(On this assay, a positive result is a release of >20% with heparin at a concentration of 0.1 U per milliliter or at a concentration of 0.3 U per milliliter that is inhibited at 100 U per milliliter.) Testing of serum from Patient 2 showed an atypical result, with 35% serotonin release observed in the absence of heparin that was inhibited to less than 5% with the addition of heparin at a concentration of 0.1 U per milliliter and 0.3 U per milliliter. Testing of serum from Patient 3 also showed an atypical result, with serotonin release of 78% with heparin at a concentration of 0 U per milliliter and 72% at 0.1 U per milliliter. For all three patients, serum-induced serotonin release was not observed after one or two doses of IVIG.

In Patients 1 and 2, the addition of PF4 (10 μg per milliliter) to serum obtained at baseline showed strong (>80%) serotonin release (Figure 2B). No effect of PF4 was seen in the baseline serum from Patient 3, which showed a 78% serotonin release in the absence of PF4. In all three patients, serum that was obtained after IVIG treatment showed a reduction in reactivity in the presence of PF4.

These reductions ranged from marked (in Patient 3) to minor (in Patient 2). Patient 2, whose serum showed the least reduction in serotonin release in the presence of PF4 after IVIG administration, had the greatest increase in the platelet count (from 27,000 to 640,000 per cubic millimeter during a 7-day period).To the Editor. Blumenthal et al.1 report delayed large local reactions in 12 patients who had received the mRNA-1273 treatment against severe acute respiratory syndrome erectile dysfunction 2 (erectile dysfunction), the kamagra that causes erectile dysfunction disease 2019 (erectile dysfunction treatment).

Baeck et al.2 report a similar reaction to the BNT162b2 treatment. The majority of these patients with delayed large local reactions and those whose cases have been reported elsewhere3,4 have been White. Alvarez-Arango et al.5 note the importance of diverse images of dermatologic findings to mitigate cognitive biases and to better prepare clinicians to recognize and address cutaneous reactions in the diverse patients we serve.

We therefore present a case series of delayed large local reactions to messenger RNA (mRNA) treatments against erectile dysfunction in recipients who are Black, Indigenous, or People of Color (BIPOC). From February 10, 2021, through April 23, 2021, a total of 1422 reports of postvaccination reactions were submitted to a erectile dysfunction treatment allergy case registry (https://allergyresearch.massgeneral.org). Of these reactions, 510 (36%) were delayed large local reactions that were reported by patients (64%) and clinicians (36%).

The mean (±SD) age of the patients with delayed large local reactions was 50±15 years (range, 21 to 91), and the majority were women (472 [93%]). Delayed large local reactions were reported after the receipt of the mRNA-1273 treatment in 459 patients (90%), after the receipt of the BNT162b2 treatment in 35 (7%), and after the receipt of other or unknown erectile dysfunction treatments in 16 (3%). Figure 1.

Figure 1. Delayed Large Local Reactions to mRNA treatments in Blacks, Indigenous Persons, and People of Color. Shown are delayed large local reactions in a 41-year-old Black woman (Panel A), in a 51-year-old Black woman (Panel B), in a 44-year-old Black woman (Panel C), and in a 69-year-old woman of mixed race (Asian and White.

Panel D), all of whom had received the first dose of the mRNA-1273 treatment against erectile dysfunction. Also shown are delayed large local reactions in a 41-year-old Black woman who had received the first dose of the BNT162b2 treatment (Panel E), in a 60-year-old Asian woman who had received the first dose of the mRNA-1273 treatment (Panel F), in a 73-year-old Asian man who had received the second dose of the mRNA-1273 treatment (Panel G), and in a 21-year-old Hispanic woman who had received the first dose of the mRNA-1273 treatment (Panel H).The reports of delayed large local reactions after the receipt of erectile dysfunction treatments included 55 events (11%) in BIPOC patients (Figure 1). The reactions were reported in patients who were Asian (27 [5%]).

Of mixed race, which included American Indian–Alaska Native and Native Hawaiian–Pacific Islander (22 [4%]). And Black (6 [1%]). Six of these patients (11%) were Hispanic.

A majority of these delayed large local reactions occurred after the receipt of the first treatment dose (in 53 patients [96%]) and after the receipt of the mRNA-1273 treatment (in 47 [85%]). The mean time from vaccination until the onset of the reaction was 8±2 days (range, 4 to 14). Eleven patients (20%) had cutaneous reactions other than at the injection site, such as diffuse itching, hives or other rash, or angioedema.

Delayed large local reactions may be less commonly recognized or reported in BIPOC treatment recipients than in White recipients. Such reactions may result in treatment hesitancy or incomplete vaccination. As such, proactive outreach is needed to increase education regarding these reactions across diverse communities.

We hope that this letter encourages additional research and communication regarding cutaneous treatment reactions, including delayed large local reactions, in BIPOC recipients. Upeka Samarakoon, Ph.D., M.P.H.Massachusetts General Hospital, Boston, MASantiago Alvarez-Arango, M.D.Johns Hopkins School of Medicine, Baltimore, MDKimberly G. Blumenthal, M.D.Massachusetts General Hospital, Boston, MA [email protected] Supported by a grant (K01AI125631, to Dr.

Blumenthal) from the NIH and by a grant (to Dr. Blumenthal) from the Department of Medicine Transformative Scholar Program at Massachusetts General Hospital. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

The content of this letter is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH) or Massachusetts General Hospital.This letter was published on June 9, 2021, at NEJM.org.5 References1. Blumenthal KG, Freeman EE, Saff RR, et al. Delayed large local reactions to mRNA-1273 treatment against erectile dysfunction.

N Engl J Med 2021;384:1273-1277.2. Baeck M, Marot L, Belkhir L. Delayed large local reactions to mRNA treatments.

McMahon DE, Amerson E, Rosenbach M, et al. Cutaneous reactions reported after Moderna and Pfizer erectile dysfunction treatment vaccination. A registry-based study of 414 cases.

J Am Acad Dermatol 2021 April 7 (Epub ahead of print).4. Johnston MS, Galan A, Watsky KL, Little AJ. Delayed localized hypersensitivity reactions to the Moderna erectile dysfunction treatment.

A case series. JAMA Dermatol 2021 May 12 (Epub ahead of print).5. Alvarez-Arango S, Ogunwole SM, Sequist TD, Burk CM, Blumenthal KG.

Vancomycin infusion reaction — moving beyond “Red Man Syndrome.” N Engl J Med 2021;384:1283-1286..

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IntroductionIn recent years, many studies have been published on new diagnostic possibilities and management approaches in cohorts of patients suspected to have a disorder/difference of sex development (DSD).1–13 Based on these studies, it Buy levitra professional online has become clear that services and institutions still differ in the composition of the multidisciplinary teams that provide care for patients who have a cialis vs kamagra DSD.11 14 Several projects have now worked to resolve this variability in care. The European Cooperation in Science and Technology (EU COST) action BM1303 ‘A systematic elucidation of differences of sex development’ has been a cialis vs kamagra platform to achieve European agreement on harmonisation of clinical management and laboratory practices.15–17 Another such initiative involved an update of the 2006 DSD consensus document by an international group of professionals and patient representatives.18 These initiatives have highlighted how cultural and financial aspects and the availability of resources differ significantly between countries and societies, a situation that hampers supranational agreement on common diagnostic protocols. As only a few national guidelines have been published in international journals, comparison of these guidelines is difficult even though such a comparison is necessary to capture the differences and initiate actions to overcome them. Nonetheless, four DSD (expert) centres located in the Netherlands and Flanders (the Dutch-speaking Northern part of Belgium) have collaborated to produce a cialis vs kamagra detailed guideline on diagnostics in DSD.19 This shows that a supranational guideline can be a reasonable approach for countries with similarly structured healthcare systems and similar resources. Within the guideline there is agreement that optimisation of expertise and care can be achieved through centralisation, for example, by limiting analysis of next-generation sequencing (NGS)-based diagnostic panels to only a few centres and by centralising pathological review of gonadal tissues.

International networks such as the European Reference Network for rare endocrine conditions (EndoERN), in which DSD is cialis vs kamagra embedded, may facilitate the expansion of this kind of collaboration across Europe.This paper highlights key discussion points in the Dutch-Flemish guideline that have been insufficiently addressed in the literature thus far because they reflect evolving technologies or less visible stakeholders. For example, prenatal observation of an atypical aspect of the genitalia indicating a possible DSD is becoming increasingly common, and we discuss appropriate counselling and a diagnostic approach for these cases, including the option of using NGS-based genetic testing. So far, little attention has been paid to this process.20 21 cialis vs kamagra Furthermore, informing patients and/or their parents about atypical sex development and why this may warrant referral to a specialised team may be challenging, especially for professionals with limited experience in DSD.22 23 Therefore, a section of the Dutch-Flemish guideline was written for these healthcare providers. Moreover, this enables DSD specialists to refer to the guideline when advising a referral. Transition from cialis vs kamagra the prenatal to the postnatal team and from the paediatric to the adult team requires optimal communication between the specialists involved.

Application of NGS-based techniques may lead to a higher diagnostic yield, providing a molecular genetic diagnosis in previously unsolved cases.16 We address the timing of this testing and the problems associated with this technique such as the interpretation of variants of unknown clinical significance (VUS). Similarly, histopathological interpretation and classification of removed cialis vs kamagra gonadal tissue is challenging and would benefit from international collaboration and centralisation of expertise.MethodsFor the guideline revision, an interdisciplinary multicentre group was formed with all members responsible for updating the literature for a specific part of the guideline. Literature search in PubMed was not systematic, but rather intended to be broad in order to cover all areas and follow expert opinions. This approach is more in line with the Clinical Practice Advisory Document method described by Burke et cialis vs kamagra al24 for guidelines involving genetic practice because it is often troublesome to substantiate such guidelines with sufficient evidence due to the rapid changes in testing methods, for example, gene panels. All input provided by the group was synthesised by the chairperson (YvB), who also reviewed abstracts of papers on DSD published between 2010 and September 2017 for the guideline and up to October 2019 for this paper.

Abstracts had to be written in English and were identified using a broad range of Medical Subject Headings terms (eg, DSD, genetic, review, diagnosis, diagnostics, 46,XX DSD, 46,XY DSD, guideline, multidisciplinary cialis vs kamagra care). Next, potentially relevant papers on diagnostic procedures in DSD were selected. Case reports were excluded, as were articles that were not open access or retrievable through cialis vs kamagra institutional access. Based on this, a draft guideline was produced that was in line with the international principles of good diagnostic care in DSD. This draft was discussed by the writing committee cialis vs kamagra and, after having obtained agreement on remaining points of discussion, revised into a final draft.

This version was sent to a broad group of professionals from academic centres and DSD teams whose members had volunteered to review the draft guideline. After receiving and incorporating their cialis vs kamagra input, the final version was presented to the paediatric and genetic associations for approval. After approval by the members of the paediatric (NVK), clinical genetic (VKGN) and genetic laboratory (VKGL) associations, the guideline was published on their respective websites.19 Although Turner syndrome and Klinefelter syndrome are considered to be part of the DSD spectrum, they are not extensively discussed in this diagnostic guideline as guidelines dedicated to these syndromes already exist.25 26 However, some individuals with Turner syndrome or Klinefelter syndrome may present with ambiguous or atypical genitalia and may therefore initially follow the DSD diagnostic process.Guideline highlightsPrenatal settingPresentationThe most frequent prenatal presentation of a DSD condition is atypical genitalia found on prenatal ultrasound as an isolated finding or in combination with other structural anomalies. This usually occurs after the 20-week routine medical ultrasound for screening of congenital anomalies, but may also occur earlier, for example, when a commercial ultrasound is performed at the request of the parents.Another way DSD can be diagnosed before birth is when invasive prenatal genetic testing carried out for a different reason, for example, due to suspicion of other structural anomalies, cialis vs kamagra reveals a discrepancy between the genotypic sex and the phenotypic sex seen by ultrasound. In certified laboratories, the possibility of a sample switch is extremely low but should be ruled out immediately.

More often, the discrepancy will be due cialis vs kamagra to sex-chromosome mosaicism or a true form of DSD.A situation now occurring with increasing frequency is a discrepancy between the genotypic sex revealed by non-invasive prenatal testing (NIPT), which is now available to high-risk pregnant women in the Netherlands and to all pregnant women in Belgium, and later ultrasound findings. NIPT screens for CNVs in the fetus. However, depending cialis vs kamagra on legal restrictions and/or ethical considerations, the X and Y chromosomes are not always included in NIPT analysis and reports. If the X and Y chromosomes are included, it is important to realise that the presence of a Y-chromosome does not necessarily imply male fetal development. At the time that NIPT is performed (usually 11–13 weeks), genital development cannot be reliably appreciated by ultrasound, so any discrepancy or cialis vs kamagra atypical aspect of the genitalia will only be noticed later in pregnancy and should prompt further evaluation.Counselling and diagnosticsIf a DSD is suspected, first-line sonographers and obstetricians should refer the couple to their colleague prenatal specialists working with or in a DSD team.

After confirming an atypical genital on ultrasound, the specialist team should offer the couple a referral for genetic counselling to discuss the possibility of performing invasive prenatal testing (usually an amniocentesis) to identify an underlying cause that fits the ultrasound findings.22 23 To enable the parents to make a well-informed decision, prenatal counselling should, in our opinion, include. Information on the ultrasound findings and the limitations of this technique cialis vs kamagra. The procedure(s) that can be followed, including the risks associated with an amniocentesis. And the type of information genetic testing can and cannot cialis vs kamagra provide. Knowing which information has been provided and what words have been used by the prenatal specialist is very helpful for those involved in postnatal care.It is important that parents understand that the biological sex of a baby is determined by a complex interplay of chromosomes, genes and hormones, and thus that assessment of the presence or absence of a Y-chromosome alone is insufficient to assign the sex of their unborn child or, as in any unborn child, say anything about the child’s future gender identity.Expecting parents can be counselled by the clinical geneticist and the psychologist from the DSD team, although other DSD specialists can also be involved.

The clinical geneticist should cialis vs kamagra be experienced in prenatal counselling and well informed about the diagnostic possibilities given the limited time span in which test results need to be available to allow parents to make a well-informed decision about whether or not to continue the pregnancy. Termination of pregnancy can be considered, for instance, in a syndromic form of DSD with multiple malformations, but when the DSD cialis vs kamagra occurs as an apparently isolated condition, expecting parents may also consider termination of pregnancy, which, although considered controversial by some, is legal in Belgium and the Netherlands. The psychologist of the DSD team can support parents during and after pregnancy and help them cope with feelings of uncertainty and eventual considerations of a termination of pregnancy, as well as with practical issues, for example, how to inform others. The stress of not knowing exactly what the child’s genitalia will look like and uncertainty about the diagnosis, treatment and prognosis cannot be avoided completely cialis vs kamagra. Parents are informed that if the postnatal phenotype is different from what was prenatally expected, the advice given about diagnostic testing can be adjusted accordingly, for example, if a hypospadias is milder than was expected based on prenatal ultrasound images.

In our experience, parents appreciate having already spoken to some members of the DSD team during pregnancy cialis vs kamagra and having a contact person before birth.After expert prenatal counselling, a significant number of pregnant couples decline prenatal testing (personal experience IALG, MK, ABD, YvB, MC and HC-vdG). At birth, umbilical cord blood is a good source for (molecular) karyotyping and storage of DNA and can be obtained by the obstetrician, midwife or neonatologist. The terminology used in communication with parents should be carefully chosen,22 23 and cialis vs kamagra midwives and staff of neonatal and delivery units should be clearly instructed to use gender-neutral and non-stigmatising vocabulary (eg, ‘your baby’) as long as sex assignment is pending.An algorithm for diagnostic evaluation of a suspected DSD in the prenatal situation is proposed in figure 1. When couples opt for invasive prenatal diagnosis, the genetic analysis usually involves an (SNP)-array. It was recently estimated that >30% of individuals who have a DSD have additional structural anomalies, with cardiac and neurological anomalies and fetal growth restriction being particularly cialis vs kamagra common.27 28 If additional anomalies are seen, the geneticist can consider specific gene defects that may underlie a known genetic syndrome or carry out NGS.

NGS-based techniques have also now made their appearance in prenatal diagnosis of congenital anomalies.29 30 Panels using these techniques can be specific for genes involved in DSD, or be larger panels covering multiple congenital anomalies, and are usually employed with trio-analysis to compare variants identified in the child with the parents’ genetics.29–31 Finding a genetic cause before delivery can help reduce parental stress in the neonatal period and speed up decisions regarding gender assignment. In such cases there is no tight time limit, and we propose completing the analysis well before the expected delivery.Disorders/differences of cialis vs kamagra sex development (DSD) in the prenatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!.

Conventional karyotyping can be useful. NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 1 Disorders/differences of sex development (DSD) in the prenatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!.

Conventional karyotyping can be useful. NGS, next-generation sequencing.First contact by a professional less experienced in DSDWhereas most current guidelines start from the point when an individual has been referred to the DSD team,1 15 the Dutch-Flemish guideline dedicates a chapter to healthcare professionals less experienced in DSD as they are often the first to suspect or identify such a condition. Apart from the paper of Indyk,7 little guidance is available for these professionals about how to act in such a situation. The chapter in the Dutch-Flemish guideline summarises the various clinical presentations that a DSD can have and provides information on how to communicate with parents and/or patients about the findings of the physical examination, the first-line investigations and the need for prompt referral to a specialised centre for further evaluation. Clinical examples are offered to illustrate some of these recurring situations.

The medical issues in DSD can be very challenging, and the social and psychological impact is high. For neonates with ambiguous genitalia, sex assignment is an urgent and crucial issue, and it is mandatory that parents are informed that it is possible to postpone registration of their child’s sex. In cases where sex assignment has already taken place, the message that the development of the gonads or genitalia is still atypical is complicated and distressing for patients and parents or carers. A list of contact details for DSD centres and patient organisations in the Netherlands and Flanders is attached to the Dutch-Flemish guideline. Publishing such a list, either in guidelines or online, can help healthcare professionals find the nearest centres for consultations and provide patients and patient organisations with an overview of the centres where expertise is available.Timing and place of genetic testing using NGS-based gene panelsThe diagnostic workup that is proposed for 46,XX and 46,XY DSD is shown in figures 2 and 3, respectively.

Even with the rapidly expanding molecular possibilities, a (family) history and a physical examination remain the essential first steps in the diagnostic process. Biochemical and hormonal screening aim at investigating serum electrolytes, renal function and the hypothalamic-pituitary-gonadal and hypothalamic-pituitary-adrenal axes. Ultrasound screening of kidneys and internal genitalia, as well as establishing genotypic sex, should be accomplished within 48 hours and complete the baseline diagnostic work-up of a child born with ambiguous genitalia.1 16 32 3346,XX disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. NGS, next-generation sequencing.

CAH, Congenital adrenal hyperplasia. AMH, Anti-Müllerian Hormone." data-icon-position data-hide-link-title="0">Figure 2 46,XX disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. NGS, next-generation sequencing. CAH, Congenital adrenal hyperplasia.

AMH, Anti-Müllerian Hormone.46,XY disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. * SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 3 46,XY disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing.Very recently, a European position paper has been published focusing on the genetic workup of DSD.16 It highlights the limitations and drawbacks of NGS-based tests, which include the chance of missing subtle structural variants such as CNVs and mosaicism and the fact that NGS cannot detect methylation defects or other epigenetic changes.16 28 31 Targeted DNA analysis is preferred in cases where hormonal investigations suggest a block in steroidogenesis (eg, 11-β-hydroxylase deficiency, 21-hydroxylase deficiency), or in the context of a specific clinical constellation such as the often coincidental finding of Müllerian structures in a boy with normal external genitalia or cryptorchidism, that is, persistent Müllerian duct syndrome.33 34 Alternative tests should also be considered depending on the available information. Sometimes, a simple mouth swab for FISH analysis can detect mosaic XY/X in a male with hypospadias or asymmetric gonadal development or in a female with little or no Turner syndrome stigmata and a normal male molecular karyotyping profile or peripheral blood karyotype. Such targeted testing avoids incidental findings and is cheaper and faster than analysis of a large NGS-based panel, although the cost difference is rapidly declining.However, due to the genetic and phenotypic heterogeneity of DSD conditions, the most cost-effective next steps in the majority of cases are whole exome sequencing followed by panel analysis of genes involved in genital development and function or trio-analysis of a large gene panel (such as a Mendeliome).16 35–38 Pretest genetic counselling involves discussing what kind of information will be reported to patients or parents and the chance of detecting VUS, and the small risk of incidental findings when analysing a DSD panel should be mentioned. Laboratories also differ in what class of variants they report.39 In our experience, the fear of incidental findings is a major reason why some parents refrain from genetic testing.Timing of the DSD gene panel analysis is also important. While some patients or parents prefer that all diagnostic procedures be performed as soon as possible, others need time to reflect on the complex information related to more extensive genetic testing and on its possible consequences.

If parents or patients do not consent to panel-based genetic testing, analysis of specific genes, such as WT1, should be considered when appropriate in view of the clinical consequences if a mutation is present (eg, clinical surveillance of renal function and screening for Wilms’ tumour in the case of WT1 mutations). Genes that are more frequently involved in DSD (eg, SRY, NR5A1) and that match the specific clinical and hormonal features in a given patient could also be considered for sequencing. Targeted gene analysis may also be preferred in centres located in countries that do not have the resources or technical requirements to perform NGS panel-based genetic testing. Alternatively, participation by these centres in international collaborative networks may allow them to outsource the molecular genetic workup abroad.Gene panels differ between centres and are regularly updated based on scientific progress. A comparison of DSD gene panels used in recent studies can be found at https://www.nature.com/articles/s41574-018-0010-8%23Sec46.15 The panels currently used at the coauthors’ institutions can be found on their respective websites.

Given the pace of change, it is important to regularly consider repeating analysis in patients with an unexplained DSD, for example, when they transition into adult care or when they move from one centre to another. This also applies to patients in whom a clinical diagnosis has never been genetically confirmed. Confusion may arise when the diagnosis cannot be confirmed or when a mutation is identified in a different gene, for example, NR5A1 in someone with a clinical diagnosis of CAIS that has other consequences for relatives. Hence, new genetic counselling should always accompany new diagnostic endeavours.Class 3 variants and histopathological examinationsThe rapidly evolving diagnostic possibilities raise new questions. What do laboratories report?.

How should we deal with the frequent findings of mainly unique VUS or class 3 variants (ACMG recommendation) in the many different DSD-related genes in the diagnostic setting?. Reporting VUS can be a source of uncertainty for parents, but not reporting these variants precludes further investigations to determine their possible pathogenicity. It can also be difficult to prove variant pathogenicity, both on gene-level and variant-level.39 Moreover, given the gonad-specific expression of some genes and the variable phenotypic spectrum and reduced penetrance, segregation analysis is not always informative. A class 3 variant that does not fit the clinical presentation may be unrelated to the observed phenotype, but it could also represent a newly emerging phenotype. This was recently demonstrated by the identification of the NR5A1 mutation, R92W, in individuals with 46,XX testicular and ovotesticular DSD.40 This gene had previously been associated with 46,XY DSD.

In diagnostic laboratories, there is usually no capacity or expertise to conduct large-scale functional studies to determine pathogenicity of these unique class 3 VUS in the different genes involved in DSD. Functional validation of variants identified in novel genes may be more attractive in a research context. However, for individual families with VUS in well-established DSD genes such as AR or HSD17B3, functional analysis may provide a confirmed diagnosis that implies for relatives the option of undergoing their own DNA analysis and estimating the genetic risk of their own future offspring. This makes genetic follow-up important in these cases and demonstrates the usefulness of international databases and networks and the centralisation of functional studies of genetic variants in order to reduce costs and maximise expertise.The same is true for histopathological description, germ-cell tumour risk assessment in specific forms of DSD and classification of gonadal samples. Germ-cell tumour risk is related to the type of DSD (among other factors), but it is impossible to make risk estimates in individual cases.41–44 Gonadectomy may be indicated in cases with high-risk dysgenetic abdominal gonads that cannot be brought into a stable superficial (ie, inguinal, labioscrotal) position that allows clinical or radiological surveillance, or to avoid virilisation due to 5-alpha reductase deficiency in a 46,XY girl with a stable female gender identity.45 Pathological examination of DSD gonads requires specific expertise.

For example, the differentiation between benign germ cell abnormalities, such as delayed maturation and (pre)malignant development of germ cells, is crucial for clinical management but can be very troublesome.46 Centralised pathological examination of gonadal biopsy and gonadectomy samples in one centre, or a restricted number of centres, on a national scale can help to overcome the problem of non-uniform classification and has proven feasible in the Netherlands and Belgium. We therefore believe that uniform assessment and classification of gonadal differentiation patterns should also be addressed in guidelines on DSD management.International databases of gonadal tissues are crucial for learning more about the risk of malignancy in different forms of DSD, but they are only reliable if uniform criteria for histological classification are strictly applied.46 These criteria could be incorporated in many existing networks such as the I-DSD consortium, the Disorders of Sex Development Translational Research Network, the European Reference Network on Urogenital Diseases (eUROGEN), the EndoERN and COST actions.15–17 47Communication at the transition from paediatric to adult carePaediatric and adult teams need to collaborate closely to facilitate a well-organised transition from paediatric to adult specialist care.15 48–50 Both teams need to exchange information optimally and should consider transition as a longitudinal process rather than a fixed moment in time. Age-appropriate information is key at all ages, and an overview of topics to be discussed at each stage is described by Cools et al.15 Table 1 shows an example of how transition can be organised.View this table:Table 1 Example of transition table as used in the DSD clinic of the Erasmus Medical CenterPsychological support and the continued provision of information remains important for individuals with a DSD at all ages.15 22 In addition to the information given by the DSD team members, families and patients can benefit from resources such as support groups and information available on the internet.47 Information available online should be checked for accuracy and completeness when referring patients and parents to internet sites.Recommendations for future actionsMost guidelines and articles on the diagnosis and management of DSD are aimed at specialists and are only published in specialist journals or on websites for endocrinologists, urologists or geneticists. Yet there is a need for guidelines directed towards first-line and second-line healthcare workers that summarise the recommendations about the first crucial steps in the management of DSD. These should be published in widely available general medical journals and online, along with a national list of DSD centres.

Furthermore, DSD (expert) centres should provide continuous education to all those who may be involved in the identification of individuals with a DSD in order to enable these healthcare professionals to recognise atypical genitalia, to promptly refer individuals who have a DSD and to inform the patient and parents about this and subsequent diagnostic procedures.As DSD continues to be a rare condition, it will take time to evaluate the effects of having such a guideline on the preparedness of first-line and second-line healthcare workers to recognise DSD conditions. One way to evaluate this might be the development and use of questionnaires asking patients, carers and families and referring physicians how satisfied they were with the initial medical consultation and referral and what could be improved. A helpful addition to existing international databases that collect information on genetic variations would be a list of centres that offer suitable functional studies for certain genes, ideally covering the most frequently mutated genes (at minimum).Patient organisations can also play an important role in informing patients about newly available diagnostic or therapeutic strategies and options, and their influence and specific role has now been recognised and discussed in several publications.17 47 However, it should be kept in mind that these organisations do not represent all patients, as a substantial number of patients and parents are not member of such an organisation.Professionals have to provide optimal medical care based on well-established evidence, or at least on broad consensus. Yet not everything can be regulated by recommendations and guidelines. Options, ideas and wishes should be openly discussed between professionals, patients and families within their confidential relationship.

This will enable highly individualised holistic care tailored to the patient’s needs and expectations. Once they are well-informed of all available options, parents and/or patients can choose what they consider the optimal care for their children or themselves.15 16ConclusionThe Dutch-Flemish guideline uniquely addresses some topics that are under-represented in the literature, thus adding some key aspects to those addressed in recent consensus papers and guidelines.15–17 33 47As more children with a DSD are now being identified prenatally, and the literature on prenatal diagnosis of DSD remains scarce,20 21 we propose a prenatal diagnostic algorithm and emphasise the importance of having a prenatal specialist involved in or collaborating with DSD (expert) centres.We also stress that good communication between all involved parties is essential. Professionals should be well informed about protocols and communication. Collaboration between centres is necessary to optimise aspects of care such as uniform interpretation of gonadal pathology and functional testing of class 3 variants found by genetic testing. Guidelines can provide a framework within which individualised patient care should be discussed with all stakeholders.AcknowledgmentsThe authors would like to thank the colleagues of the DSD teams for their input in and critical reading of the Dutch-Flemish guideline.

Amsterdam University Center (AMC and VU), Maastricht University Medical Center, Erasmus Medical Center Rotterdam, Radboud University Medical Center Nijmegen, University Medical Center Groningen, University Medical Center Utrecht, Ghent University Hospital. The authors would like to thank Kate McIntyre for editing the revised manuscript and Tom de Vries Lentsch for providing the figures as a PDF. Three of the authors of this publication are members of the European Reference Network for rare endocrine diseases—Project ID 739543.IntroductionEndometrial cancer is the most common gynaecological malignancy in the developed world.1 Its incidence has risen over the last two decades as a consequence of the ageing population, fewer hysterectomies for benign disease and the obesity epidemic. In the USA, it is estimated that women have a 1 in 35 lifetime risk of endometrial cancer, and in contrast to cancers of most other sites, cancer-specific mortality has risen by approximately 2% every year since 2008 related to the rapidly rising incidence.2Endometrial cancer has traditionally been classified into type I and type II based on morphology.3 The more common subtype, type I, is mostly comprised of endometrioid tumours and is oestrogen-driven, arises from a hyperplastic endometrium, presents at an early stage and has an excellent 5 year survival rate.4 By contrast, type II includes non-endometrioid tumours, specifically serous, carcinosarcoma and clear cell subtypes, which are biologically aggressive tumours with a poor prognosis that are often diagnosed at an advanced stage.5 Recent efforts have focused on a molecular classification system for more accurate categorisation of endometrial tumours into four groups with distinct prognostic profiles.6 7The majority of endometrial cancers arise through the interplay of familial, genetic and lifestyle factors. Two inherited cancer predisposition syndromes, Lynch syndrome and the much rarer Cowden syndrome, substantially increase the lifetime risk of endometrial cancer, but these only account for around 3–5% of cases.8–10 Having first or second degree relative(s) with endometrial or colorectal cancer increases endometrial cancer risk, although a large European twin study failed to demonstrate a strong heritable link.11 The authors failed to show that there was greater concordance in monozygotic than dizygotic twins, but the study was based on relatively small numbers of endometrial cancers.

Lu and colleagues reported an association between common single nucleotide polymorphisms (SNPs) and endometrial cancer risk, revealing the potential role of SNPs in explaining part of the risk in both the familial and general populations.12 Thus far, many SNPs have been reported to modify susceptibility to endometrial cancer. However, much of this work predated genome wide association studies and is of variable quality. Understanding genetic predisposition to endometrial cancer could facilitate personalised risk assessment with a view to targeted prevention and screening interventions.13 This emerged as the most important unanswered research question in endometrial cancer according to patients, carers and healthcare professionals in our recently completed James Lind Womb Cancer Alliance Priority Setting Partnership.14 It would be particularly useful for non-endometrioid endometrial cancers, for which advancing age is so far the only predictor.15We therefore conducted a comprehensive systematic review of the literature to provide an overview of the relationship between SNPs and endometrial cancer risk. We compiled a list of the most robust endometrial cancer-associated SNPs. We assessed the applicability of this panel of SNPs with a theoretical polygenic risk score (PRS) calculation.

We also critically appraised the meta-analyses investigating the most frequently reported SNPs in MDM2. Finally, we described all SNPs reported within genes and pathways that are likely involved in endometrial carcinogenesis and metastasis.MethodsOur systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) collaboration 2009 recommendations. The registered protocol is available through PROSPERO (CRD42018091907).16Search strategyWe searched Embase, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases via the Healthcare Databases Advanced Search (HDAS) platform, from 2007 to 2018, to identify studies reporting associations between polymorphisms and endometrial cancer risk. Key words including MeSH (Medical Subject Heading) terms and free-text words were searched in both titles and abstracts. The following terms were used.

€œendomet*”,“uter*”, “womb”, “cancer(s)”, “neoplasm(s)”, “endometrium tumour”, “carcinoma”, “adenosarcoma”, “clear cell carcinoma”, “carcinosarcoma”, “SNP”, “single nucleotide polymorphism”, “GWAS”, and “genome-wide association study/ies”. No other restrictions were applied. The search was repeated with time restrictions between 2018 and June 2019 to capture any recent publications.Eligibility criteriaStudies were selected for full-text evaluation if they were primary articles investigating a relationship between endometrial cancer and SNPs. Study outcome was either the increased or decreased risk of endometrial cancer relative to controls reported as an odds ratio (OR) with corresponding 95% confidence intervals (95% CIs).Study selectionThree independent reviewers screened all articles uploaded to a screening spreadsheet developed by Helena VonVille.17 Disagreements were resolved by discussion. Chronbach’s α score was calculated between reviewers and indicated high consistency at 0.92.

Case–control, prospective and retrospective studies, genome-wide association studies (GWAS), and both discovery and validation studies were selected for full-text evaluation. Non-English articles, editorials, conference abstracts and proceedings, letters and correspondence, case reports and review articles were excluded.Candidate-gene studies with at least 100 women and GWAS with at least 1000 women in the case arm were selected to ensure reliability of the results, as explained by Spencer et al.18 To construct a panel of up to 30 SNPs with the strongest evidence of association, those with the strongest p values were selected. For the purpose of an SNP panel, articles utilising broad European or multi-ethnic cohorts were selected. Where overlapping populations were identified, the most comprehensive study was included.Data extraction and synthesisFor each study, the following data were extracted. SNP ID, nearby gene(s)/chromosome location, OR (95% CI), p value, minor or effect allele frequency (MAF/EAF), EA (effect allele) and OA (other allele), adjustment, ethnicity and ancestry, number of cases and controls, endometrial cancer type, and study type including discovery or validation study and meta-analysis.

For risk estimates, a preference towards most adjusted results was applied. For candidate-gene studies, a standard p value of<0.05 was applied and for GWAS a p value of <5×10-8, indicating genome-wide significance, was accepted as statistically significant. However, due to the limited number of SNPs with p values reaching genome-wide significance, this threshold was then lowered to <1×10-5, allowing for marginally significant SNPs to be included. As shown by Mavaddat et al, for breast cancer, SNPs that fall below genome-wide significance may still be useful for generating a PRS and improving the models.19We estimated the potential value of a PRS based on the most significant SNPs by comparing the predicted risk for a woman with a risk score in the top 1% of the distribution to the mean predicted risk. Per-allele ORs and MAFs were taken from the publications and standard errors (SEs) for the lnORs were derived from published 95% CIs.

The PRS was assumed to have a Normal distribution, with mean 2∑βipI and SE, σ, equal to √2∑βi2pI(1−pi), according to the binomial distribution, where the summation is over all SNPs in the risk score. Hence the relative risk (RR) comparing the top 1% of the distribution to the mean is given by exp(Z0.01σ), where Z is the inverse of the standard normal cumulative distribution.ResultsThe flow chart of study selection is illustrated in figure 1. In total, 453 text articles were evaluated and, of those, 149 articles met our inclusion criteria. One study was excluded from table 1, for having an Asian-only population, as this would make it harder to compare with the rest of the results which were all either multi-ethnic or Caucasian cohorts, as stated in our inclusion criteria for the SNP panel.20 Any SNPs without 95% CIs were also excluded from any downstream analysis. Additionally, SNPs in linkage disequilibrium (r2 >0.2) with each other were examined, and of those in linkage disequilibrium, the SNP with strongest association was reported.

Per allele ORs were used unless stated otherwise.View this table:Table 1 List of top SNPs most likely to contribute to endometrial cancer risk identified through systematic review of recent literature21–25Study selection flow diagram. *Reasons. Irrelevant articles, articles focusing on other conditions, non-GWAS/candidate-gene study related articles, technical and duplicate articles. GWAS, genome-wide association study. Adapted from.

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA Statement. PLoS Med 6(6). E1000097.

Doi:10.1371/journal.pmed1000097." data-icon-position data-hide-link-title="0">Figure 1 Study selection flow diagram. *Reasons. Irrelevant articles, articles focusing on other conditions, non-GWAS/candidate-gene study related articles, technical and duplicate articles. GWAS, genome-wide association study. Adapted from.

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA Statement. PLoS Med 6(6). E1000097.

Doi:10.1371/journal.pmed1000097.Top SNPs associated with endometrial cancer riskFollowing careful interpretation of the data, 24 independent SNPs with the lowest p values that showed the strongest association with endometrial cancer were obtained (table 1).21–25 These SNPs are located in or around genes coding for transcription factors, cell growth and apoptosis regulators, and enzymes involved in the steroidogenesis pathway. All the SNPs presented here were reported on the basis of a GWAS or in one case, an exome-wide association study, and hence no SNPs from candidate-gene studies made it to the list. This is partly due to the nature of larger GWAS providing more comprehensive and powered results as opposed to candidate gene studies. Additionally, a vast majority of SNPs reported by candidate-gene studies were later refuted by large-scale GWAS such as in the case of TERT and MDM2 variants.26 27 The exception to this is the CYP19 gene, where candidate-gene studies reported an association between variants in this gene with endometrial cancer in both Asian and broad European populations, and this association was more recently confirmed by large-scale GWAS.21 28–30 Moreover, a recent article authored by O’Mara and colleagues reviewed the GWAS that identified most of the currently known SNPs associated with endometrial cancer.31Most of the studies represented in table 1 are GWAS and the majority of these involved broad European populations. Those having a multi-ethnic cohort also consisted primarily of broad European populations.

Only four of the variants in table 1 are located in coding regions of a gene, or in regulatory flanking regions around the gene. Thus, most of these variants would not be expected to cause any functional effects on the gene or the resulting protein. An eQTL search using GTEx Portal showed that some of the SNPs are significantly associated (p<0.05) with modified transcription levels of the respective genes in various tissues such as prostate (rs11263761), thyroid (rs9668337), pituitary (rs2747716), breast mammary (rs882380) and testicular (rs2498794) tissue, as summarised in table 2.View this table:Table 2 List of eQTL hits for the selected panel of SNPsThe only variant for which there was an indication of a specific association with non-endometrioid endometrial cancer was rs148261157 near the BCL11A gene. The A allele of this SNP had a moderately higher association in the non-endometrioid arm (OR 1.64, 95% CI 1.32 to 2.04. P=9.6×10-6) compared with the endometrioid arm (OR 1.25, 95% CI 1.14 to 1.38.

P=4.7×10-6).21Oestrogen receptors α and β encoded by ESR1 and ESR2, respectively, have been extensively studied due to the assumed role of oestrogens in the development of endometrial cancer. O’Mara et al reported a lead SNP (rs79575945) in the ESR1 region that was associated with endometrial cancer (p=1.86×10-5).24 However, this SNP did not reach genome-wide significance in a more recent larger GWAS.21 No statistically significant associations have been reported between endometrial cancer and SNPs in the ESR2 gene region.AKT is an oncogene linked to endometrial carcinogenesis. It is involved in the PI3K/AKT/mTOR pro-proliferative signalling pathway to inactivate apoptosis and allow cell survival. The A allele of rs2494737 and G allele of rs2498796 were reported to be associated with increased and decreased risk of endometrial cancer in 2016, respectively.22 30 However, this association was not replicated in a larger GWAS in 2018.21 Nevertheless, given the previous strong indications, and biological basis that could explain endometrial carcinogenesis, we decided to include an AKT1 variant (rs2498794) in our results.PTEN is a multi-functional tumour suppressor gene that regulates the AKT/PKB signalling pathway and is commonly mutated in many cancers including endometrial cancer.32 Loss-of-function germline mutations in PTEN are responsible for Cowden syndrome, which exerts a lifetime risk of endometrial cancer of up to 28%.9 Lacey and colleagues studied SNPs in the PTEN gene region. However, none showed significant differences in frequency between 447 endometrial cancer cases and 439 controls of European ancestry.33KRAS mutations are known to be present in endometrial cancer.

These can be activated by high levels of KLF5 (transcriptional activator). Three SNPs have been identified in or around KLF5 that are associated with endometrial cancer. The G allele of rs11841589 (OR 1.15, 95% CI 1.11 to 1.21. P=4.83×10-11), the A allele of rs9600103 (OR 1.23, 95% CI 1.16 to 1.30. P=3.76×10-12) and C allele of rs7981863 (OR 1.16, 95% CI 1.12 to 1.20.

P=2.70×10-17) have all been found to be associated with an increased likelihood of endometrial cancer in large European cohorts.21 30 34 It is worth noting that these SNPs are not independent, and hence they quite possibly tag the same causal variant.The MYC family of proto-oncogenes encode transcription factors that regulate cell proliferation, which can contribute to cancer development if dysregulated. The recent GWAS by O’Mara et al reported three SNPs within the MYC region that reached genome-wide significance with conditional p values reaching at least 5×10–8.35To test the utility of these SNPs as predictive markers, we devised a theoretical PRS calculation using the log ORs and EAFs per SNP from the published data. The results were very encouraging with an RR of 3.16 for the top 1% versus the mean, using all the top SNPs presented in table 1 and 2.09 when using only the SNPs that reached genome-wide significance (including AKT1).Controversy surrounding MDM2 variant SNP309MDM2 negatively regulates tumour suppressor gene TP53, and as such, has been extensively studied in relation to its potential role in predisposition to endometrial cancer. Our search identified six original studies of the association between MDM2 SNP rs2279744 (also referred to as SNP309) and endometrial cancer, all of which found a statistically significant increased risk per copy of the G allele. Two more original studies were identified through our full-text evaluation.

However, these were not included here as they did not meet our inclusion criteria—one due to small sample size, the other due to studying rs2279744 status dependent on another SNP.36 37 Even so, the two studies were described in multiple meta-analyses that are listed in table 3. Different permutations of these eight original studies appear in at least eight published meta-analyses. However, even the largest meta-analysis contained <2000 cases (table 3)38View this table:Table 3 Characteristics of studies that examined MDM2 SNP rs2279744In comparison, a GWAS including nearly 13 000 cases found no evidence of an association with OR and corresponding 95% CI of 1.00 (0.97 to 1.03) and a p value of 0.93 (personal communication).21 Nevertheless, we cannot completely rule out a role for MDM2 variants in endometrial cancer predisposition as the candidate-gene studies reported larger effects in Asians, whereas the GWAS primarily contained participants of European ancestry. There is also some suggestion that the SNP309 variant is in linkage disequilibrium with another variant, SNP285, which confers an opposite effect.It is worth noting that the SNP285C/SNP309G haplotype frequency was observed in up to 8% of Europeans, thus requiring correction for the confounding effect of SNP285C in European studies.39 However, aside from one study conducted by Knappskog et al, no other study including the meta-analyses corrected for the confounding effect of SNP285.40 Among the studies presented in table 3, Knappskog et al (2012) reported that after correcting for SNP285, the OR for association of this haplotype with endometrial cancer was much lower, though still significant. Unfortunately, the meta-analyses which synthesised Knappskog et al (2012), as part of their analysis, did not correct for SNP285C in the European-based studies they included.38 41 42 It is also concerning that two meta-analyses using the same primary articles failed to report the same result, in two instances.38 42–44DiscussionThis article represents the most comprehensive systematic review to date, regarding critical appraisal of the available evidence of common low-penetrance variants implicated in predisposition to endometrial cancer.

We have identified the most robust SNPs in the context of endometrial cancer risk. Of those, only 19 were significant at genome-wide level and a further five were considered marginally significant. The largest GWAS conducted in this field was the discovery- and meta-GWAS by O’Mara et al, which utilised 12 096 cases and 108 979 controls.21 Despite the inclusion of all published GWAS and around 5000 newly genotyped cases, the total number did not reach anywhere near what is currently available for other common cancers such as breast cancer. For instance, BCAC (Breast Cancer Association Consortium) stands at well over 200 000 individuals with more than half being cases, and resulted in identification of ~170 SNPs in relation to breast cancer.19 45 A total of 313 SNPs including imputations were then used to derive a PRS for breast cancer.19 Therefore, further efforts should be directed to recruit more patients, with deep phenotypic clinical data to allow for relevant adjustments and subgroup analyses to be conducted for better precision.A recent pre-print study by Zhang and colleagues examined the polygenicity and potential for SNP-based risk prediction for 14 common cancers, including endometrial cancer, using available summary-level data from European-ancestry datasets.46 They estimated that there are just over 1000 independent endometrial cancer susceptibility SNPs, and that a PRS comprising all such SNPs would have an area under the receiver-operator curve of 0.64, similar to that predicted for ovarian cancer, but lower than that for the other cancers in the study. The modelling in the paper suggests that an endometrial cancer GWAS double the size of the current largest study would be able to identify susceptibility SNPs together explaining 40% of the genetic variance, but that in order to explain 75% of the genetic variance it would be necessary to have a GWAS comprising close to 150 000 cases and controls, far in excess of what is currently feasible.We found that the literature consists mainly of candidate-gene studies with small sample sizes, meta-analyses reporting conflicting results despite using the same set of primary articles, and multiple reports of significant SNPs that have not been validated by any larger GWAS.

The candidate-gene studies were indeed the most useful and cheaper technique available until the mid to late 2000s. However, a lack of reproducibility (particularly due to population stratification and reporting bias), uncertainty of reported associations, and considerably high false discovery rates make these studies much less appropriate in the post-GWAS era. Unlike the candidate-gene approach, GWAS do not require prior knowledge, selection of genes or SNPs, and provide vast amounts of data. Furthermore, both the genotyping process and data analysis phases have become cheaper, the latter particularly due to faster and open-access pre-phasing and imputation tools being made available.It is clear from table 1 that some SNPs were reported with wide 95% CI, which can be directly attributed to small sample sizes particularly when restricting the cases to non-endometrioid histology only, low EAF or poor imputation quality. Thus, these should be interpreted with caution.

Additionally, most of the SNPs reported by candidate-gene studies were not detected by the largest GWAS to date conducted by O’Mara et al.21 However, this does not necessarily mean that the possibility of those SNPs being relevant should be completely dismissed. Moreover, meta-analyses were attempted for other variants. However, these showed no statistically significant association and many presented with high heterogeneity between the respective studies (data not shown). Furthermore, as many studies utilised the same set of cases and/or controls, conducting a meta-analysis was not possible for a good number of SNPs. It is therefore unequivocal that the literature is crowded with numerous small candidate-gene studies and conflicting data.

This makes it particularly hard to detect novel SNPs and conduct meaningful meta-analyses.We found convincing evidence for 19 variants that indicated the strongest association with endometrial cancer, as shown in table 1. The associations between endometrial cancer and variants in or around HNF1B, CYP19A1, SOX4, MYC, KLF and EIF2AK found in earlier GWAS were then replicated in the latest and largest GWAS. These SNPs showed promising potential in a theoretical PRS we devised based on published data. Using all 24 or genome-wide significant SNPs only, women with a PRS in the top 1% of the distribution would be predicted to have a risk of endometrial cancer 3.16 and 2.09 times higher than the mean risk, respectively.However, the importance of these variants and relevance of the proximate genes in a functional or biological context is challenging to evaluate. Long distance promoter regulation by enhancers may disguise the genuine target gene.

In addition, enhancers often do not loop to the nearest gene, further complicating the relevance of nearby gene(s) to a GWAS hit. In order to elucidate biologically relevant candidate target genes in endometrial cancer, O’Mara et al looked into promoter-associated chromatin looping using a modern HiChIP approach.47 The authors utilised normal and tumoural endometrial cell lines for this analysis which showed significant enrichment for endometrial cancer heritability, with 103 candidate target genes identified across the 13 risk loci identified by the largest ECAC GWAS. Notable genes identified here were CDKN2A and WT1, and their antisense counterparts. The former was reported to be nearby of rs1679014 and the latter of rs10835920, as shown in table 1. Moreover, of the 36 candidate target genes, 17 were found to be downregulated while 19 were upregulated in endometrial tumours.The authors also investigated overlap between the 13 endometrial cancer risk loci and top eQTL variants for each target gene.47 In whole blood, of the two particular lead SNPs, rs8822380 at 17q21.32 was a top eQTL for SNX11 and HOXB2, whereas rs937213 at 15q15.1 was a top eQTL for SRP14.

In endometrial tumour, rs7579014 at 2p16.1 was found to be a top eQTL for BCL11A. This is particularly interesting because BCL11A was the only nearby/candidate gene that had a GWAS association reported in both endometrioid and non-endometrioid subtypes. The study looked at protein–protein interactions between endometrial cancer drivers and candidate target gene products. Significant interactions were observed with TP53 (most significant), AKT, PTEN, ESR1 and KRAS, among others. Finally, when 103 target candidate genes and 387 proteins were combined together, 462 pathways were found to be significantly enriched.

Many of these are related to gene regulation, cancer, obesity, insulinaemia and oestrogen exposure. This study clearly showed a potential biological relevance for some of the SNPs reported by ECAC GWAS in 2018.Most of the larger included studies used cohorts primarily composed of women of broad European descent. Hence, there are negligible data available for other ethnicities, particularly African women. This is compounded by the lack of reference genotype data available for comparative analysis, making it harder for research to be conducted in ethnicities other than Europeans. This poses a problem for developing risk prediction models that are equally valuable and predictive across populations.

Thus, our results also are of limited applicability to non-European populations.Furthermore, considering that non-endometrioid cases comprise a small proportion (~20%) of all endometrial cancer cases, much larger cohort sizes are needed to detect any genuine signals for non-endometrioid tumours. Most of the evaluated studies looked at either overall/mixed endometrial cancer subtypes or endometrioid histology, and those that looked at variant associations with non-endometrioid histology were unlikely to have enough power to detect any signal with statistical significance. This is particularly concerning because non-endometrioid subtypes are biologically aggressive tumours with a much poorer prognosis that contribute disproportionately to mortality from endometrial cancer. It is particularly important that attempts to improve early detection and prevention of endometrial cancer focus primarily on improving outcomes from these subtypes. It is also worth noting that, despite the current shift towards a molecular classification of endometrial cancer, most studies used the overarching classical Bokhman’s classification system, type I versus type II, or no histological classification system at all.

Therefore, it is important to create and follow a standardised and comprehensive classification system for reporting tumour subtypes for future studies.This study compiled and presented available information for an extensively studied, yet unproven in large datasets, SNP309 variant in MDM2. Currently, there is no convincing evidence for an association between this variant and endometrial cancer risk. Additionally, of all the studies, only one accounted for the opposing effect of a nearby variant SNP285 in their analyses. Thus, we conclude that until confirmed by a sufficiently large GWAS, this variant should not be considered significant in influencing the risk of endometrial cancer and therefore not included in a PRS. This is also true for the majority of the SNPs reported in candidate-gene studies, as the numbers fall far short of being able to detect genuine signals.This systematic review presents the most up-to-date evidence for endometrial cancer susceptibility variants, emphasising the need for further large-scale studies to identify more variants of importance, and validation of these associations.

Until data from larger and more diverse cohorts are available, the top 24 SNPs presented here are the most robust common genetic variants that affect endometrial cancer risk. The multiplicative effects of these SNPs could be used in a PRS to allow personalised risk prediction models to be developed for targeted screening and prevention interventions for women at greatest risk of endometrial cancer..

IntroductionIn recent years, many studies have been published on new diagnostic possibilities and management approaches in cohorts of patients suspected to have a disorder/difference of sex development (DSD).1–13 Based on these studies, Buy levitra professional online it has become clear that services and institutions still differ in the composition of the multidisciplinary teams that provide care for patients buy kamagra uk review who have a DSD.11 14 Several projects have now worked to resolve this variability in care. The European Cooperation in Science and Technology (EU COST) action BM1303 buy kamagra uk review ‘A systematic elucidation of differences of sex development’ has been a platform to achieve European agreement on harmonisation of clinical management and laboratory practices.15–17 Another such initiative involved an update of the 2006 DSD consensus document by an international group of professionals and patient representatives.18 These initiatives have highlighted how cultural and financial aspects and the availability of resources differ significantly between countries and societies, a situation that hampers supranational agreement on common diagnostic protocols. As only a few national guidelines have been published in international journals, comparison of these guidelines is difficult even though such a comparison is necessary to capture the differences and initiate actions to overcome them. Nonetheless, four DSD (expert) buy kamagra uk review centres located in the Netherlands and Flanders (the Dutch-speaking Northern part of Belgium) have collaborated to produce a detailed guideline on diagnostics in DSD.19 This shows that a supranational guideline can be a reasonable approach for countries with similarly structured healthcare systems and similar resources.

Within the guideline there is agreement that optimisation of expertise and care can be achieved through centralisation, for example, by limiting analysis of next-generation sequencing (NGS)-based diagnostic panels to only a few centres and by centralising pathological review of gonadal tissues. International networks such as the European Reference Network for rare endocrine conditions (EndoERN), in which DSD is embedded, may facilitate the expansion of this kind of collaboration across Europe.This paper highlights key discussion buy kamagra uk review points in the Dutch-Flemish guideline that have been insufficiently addressed in the literature thus far because they reflect evolving technologies or less visible stakeholders. For example, prenatal observation of an atypical aspect of the genitalia indicating a possible DSD is becoming increasingly common, and we discuss appropriate counselling and a diagnostic approach for these cases, including the option of using NGS-based genetic testing. So far, little attention has been paid to this process.20 21 Furthermore, informing patients and/or their parents about atypical sex development and why this may warrant referral to buy kamagra uk review a specialised team may be challenging, especially for professionals with limited experience in DSD.22 23 Therefore, a section of the Dutch-Flemish guideline was written for these healthcare providers.

Moreover, this enables DSD specialists to refer to the guideline when advising a referral. Transition from the buy kamagra uk review prenatal to the postnatal team and from the paediatric to the adult team requires optimal communication between the specialists involved. Application of NGS-based techniques may lead to a higher diagnostic yield, providing a molecular genetic diagnosis in previously unsolved cases.16 We address the timing of this testing and the problems associated with this technique such as the interpretation of variants of unknown clinical significance (VUS). Similarly, histopathological interpretation and classification of removed gonadal tissue is challenging and would benefit from international collaboration and centralisation of expertise.MethodsFor the guideline revision, an buy kamagra uk review interdisciplinary multicentre group was formed with all members responsible for updating the literature for a specific part of the guideline.

Literature search in PubMed was not systematic, but rather intended to be broad in order to cover all areas and follow expert opinions. This approach is more in line with the Clinical buy kamagra uk review Practice Advisory Document method described by Burke et al24 for guidelines involving genetic practice because it is often troublesome to substantiate such guidelines with sufficient evidence due to the rapid changes in testing methods, for example, gene panels. All input provided by the group was synthesised by the chairperson (YvB), who also reviewed abstracts of papers on DSD published between 2010 and September 2017 for the guideline and up to October 2019 for this paper. Abstracts had to be written in English and were identified using a broad range of Medical Subject Headings terms (eg, buy kamagra uk review DSD, genetic, review, diagnosis, diagnostics, 46,XX DSD, 46,XY DSD, guideline, multidisciplinary care).

Next, potentially relevant papers on diagnostic procedures in DSD were selected. Case reports were excluded, as were articles that were not open access or retrievable through institutional access buy kamagra uk review. Based on this, a draft guideline was produced that was in line with the international principles of good diagnostic care in DSD. This draft buy kamagra uk review was discussed by the writing committee and, after having obtained agreement on remaining points of discussion, revised into a final draft.

This version was sent to a broad group of professionals from academic centres and DSD teams whose members had volunteered to review the draft guideline. After receiving and incorporating their input, the final version was presented to the paediatric and genetic associations buy kamagra uk review for approval. After approval by the members of the paediatric (NVK), clinical genetic (VKGN) and genetic laboratory (VKGL) associations, the guideline was published on their respective websites.19 Although Turner syndrome and Klinefelter syndrome are considered to be part of the DSD spectrum, they are not extensively discussed in this diagnostic guideline as guidelines dedicated to these syndromes already exist.25 26 However, some individuals with Turner syndrome or Klinefelter syndrome may present with ambiguous or atypical genitalia and may therefore initially follow the DSD diagnostic process.Guideline highlightsPrenatal settingPresentationThe most frequent prenatal presentation of a DSD condition is atypical genitalia found on prenatal ultrasound as an isolated finding or in combination with other structural anomalies. This usually occurs after the 20-week routine medical ultrasound for screening of congenital anomalies, but may also occur earlier, for example, when a commercial ultrasound is performed at the request of the parents.Another way DSD can be diagnosed before birth is when invasive prenatal genetic testing carried out for a different reason, for example, due to suspicion of other structural buy kamagra uk review anomalies, reveals a discrepancy between the genotypic sex and the phenotypic sex seen by ultrasound.

In certified laboratories, the possibility of a sample switch is extremely low but should be ruled out immediately. More often, the discrepancy will be due to sex-chromosome mosaicism or a true form of DSD.A situation now occurring with increasing frequency is a discrepancy between the genotypic sex revealed by non-invasive buy kamagra uk review prenatal testing (NIPT), which is now available to high-risk pregnant women in the Netherlands and to all pregnant women in Belgium, and later ultrasound findings. NIPT screens for CNVs in the fetus. However, depending on legal restrictions and/or ethical considerations, the X and Y chromosomes buy kamagra uk review are not always included in NIPT analysis and reports.

If the X and Y chromosomes are included, it is important to realise that the presence of a Y-chromosome does not necessarily imply male fetal development. At the time that NIPT is performed (usually 11–13 weeks), genital development cannot be reliably appreciated by ultrasound, so any discrepancy or atypical aspect of the genitalia will only be noticed later in pregnancy and should prompt further evaluation.Counselling and diagnosticsIf a buy kamagra uk review DSD is suspected, first-line sonographers and obstetricians should refer the couple to their colleague prenatal specialists working with or in a DSD team. After confirming an atypical genital on ultrasound, the specialist team should offer the couple a referral for genetic counselling to discuss the possibility of performing invasive prenatal testing (usually an amniocentesis) to identify an underlying cause that fits the ultrasound findings.22 23 To enable the parents to make a well-informed decision, prenatal counselling should, in our opinion, include. Information on the buy kamagra uk review ultrasound findings and the limitations of this technique.

The procedure(s) that can be followed, including the risks associated with an amniocentesis. And the type of information genetic testing can buy kamagra uk review and cannot provide. Knowing which information has been provided and what words have been used by the prenatal specialist is very helpful for those involved in postnatal care.It is important that parents understand that the biological sex of a baby is determined by a complex interplay of chromosomes, genes and hormones, and thus that assessment of the presence or absence of a Y-chromosome alone is insufficient to assign the sex of their unborn child or, as in any unborn child, say anything about the child’s future gender identity.Expecting parents can be counselled by the clinical geneticist and the psychologist from the DSD team, although other DSD specialists can also be involved. The clinical geneticist should be experienced in prenatal counselling and well informed about the diagnostic possibilities given the limited time span in which test results buy kamagra uk review need to be available to allow parents to make a well-informed decision about whether or not to continue the pregnancy.

Termination of pregnancy can be considered, for instance, in a syndromic form of DSD with multiple malformations, buy kamagra uk review but when the DSD occurs as an apparently isolated condition, expecting parents may also consider termination of pregnancy, which, although considered controversial by some, is legal in Belgium and the Netherlands. The psychologist of the DSD team can support parents during and after pregnancy and help them cope with feelings of uncertainty and eventual considerations of a termination of pregnancy, as well as with practical issues, for example, how to inform others. The stress buy kamagra uk review of not knowing exactly what the child’s genitalia will look like and uncertainty about the diagnosis, treatment and prognosis cannot be avoided completely. Parents are informed that if the postnatal phenotype is different from what was prenatally expected, the advice given about diagnostic testing can be adjusted accordingly, for example, if a hypospadias is milder than was expected based on prenatal ultrasound images.

In our experience, parents appreciate having already spoken to some members of the DSD buy kamagra uk review team during pregnancy and having a contact person before birth.After expert prenatal counselling, a significant number of pregnant couples decline prenatal testing (personal experience IALG, MK, ABD, YvB, MC and HC-vdG). At birth, umbilical cord blood is a good source for (molecular) karyotyping and storage of DNA and can be obtained by the obstetrician, midwife or neonatologist. The terminology used in communication with parents should be carefully chosen,22 buy kamagra uk review 23 and midwives and staff of neonatal and delivery units should be clearly instructed to use gender-neutral and non-stigmatising vocabulary (eg, ‘your baby’) as long as sex assignment is pending.An algorithm for diagnostic evaluation of a suspected DSD in the prenatal situation is proposed in figure 1. When couples opt for invasive prenatal diagnosis, the genetic analysis usually involves an (SNP)-array.

It was recently estimated that >30% of individuals who have a DSD have additional buy kamagra uk review structural anomalies, with cardiac and neurological anomalies and fetal growth restriction being particularly common.27 28 If additional anomalies are seen, the geneticist can consider specific gene defects that may underlie a known genetic syndrome or carry out NGS. NGS-based techniques have also now made their appearance in prenatal diagnosis of congenital anomalies.29 30 Panels using these techniques can be specific for genes involved in DSD, or be larger panels covering multiple congenital anomalies, and are usually employed with trio-analysis to compare variants identified in the child with the parents’ genetics.29–31 Finding a genetic cause before delivery can help reduce parental stress in the neonatal period and speed up decisions regarding gender assignment. In such cases there is no tight time limit, and we propose completing the analysis well before the expected buy kamagra uk review delivery.Disorders/differences of sex development (DSD) in the prenatal setting. A diagnostic algorithm.

*SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful. NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 1 Disorders/differences of sex development (DSD) in the prenatal setting.

A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing.First contact by a professional less experienced in DSDWhereas most current guidelines start from the point when an individual has been referred to the DSD team,1 15 the Dutch-Flemish guideline dedicates a chapter to healthcare professionals less experienced in DSD as they are often the first to suspect or identify such a condition. Apart from the paper of Indyk,7 little guidance is available for these professionals about how to act in such a situation. The chapter in the Dutch-Flemish guideline summarises the various clinical presentations that a DSD can have and provides information on how to communicate with parents and/or patients about the findings of the physical examination, the first-line investigations and the need for prompt referral to a specialised centre for further evaluation. Clinical examples are offered to illustrate some of these recurring situations.

The medical issues in DSD can be very challenging, and the social and psychological impact is high. For neonates with ambiguous genitalia, sex assignment is an urgent and crucial issue, and it is mandatory that parents are informed that it is possible to postpone registration of their child’s sex. In cases where sex assignment has already taken place, the message that the development of the gonads or genitalia is still atypical is complicated and distressing for patients and parents or carers. A list of contact details for DSD centres and patient organisations in the Netherlands and Flanders is attached to the Dutch-Flemish guideline.

Publishing such a list, either in guidelines or online, can help healthcare professionals find the nearest centres for consultations and provide patients and patient organisations with an overview of the centres where expertise is available.Timing and place of genetic testing using NGS-based gene panelsThe diagnostic workup that is proposed for 46,XX and 46,XY DSD is shown in figures 2 and 3, respectively. Even with the rapidly expanding molecular possibilities, a (family) history and a physical examination remain the essential first steps in the diagnostic process. Biochemical and hormonal screening aim at investigating serum electrolytes, renal function and the hypothalamic-pituitary-gonadal and hypothalamic-pituitary-adrenal axes. Ultrasound screening of kidneys and internal genitalia, as well as establishing genotypic sex, should be accomplished within 48 hours and complete the baseline diagnostic work-up of a child born with ambiguous genitalia.1 16 32 3346,XX disorders/differences of sex development (DSD) in the postnatal setting.

A diagnostic algorithm. NGS, next-generation sequencing. CAH, Congenital adrenal hyperplasia. AMH, Anti-Müllerian Hormone." data-icon-position data-hide-link-title="0">Figure 2 46,XX disorders/differences of sex development (DSD) in the postnatal setting.

A diagnostic algorithm. NGS, next-generation sequencing. CAH, Congenital adrenal hyperplasia. AMH, Anti-Müllerian Hormone.46,XY disorders/differences of sex development (DSD) in the postnatal setting.

A diagnostic algorithm. * SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 3 46,XY disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!.

Conventional karyotyping can be useful. NGS, next-generation sequencing.Very recently, a European position paper has been published focusing on the genetic workup of DSD.16 It highlights the limitations and drawbacks of NGS-based tests, which include the chance of missing subtle structural variants such as CNVs and mosaicism and the fact that NGS cannot detect methylation defects or other epigenetic changes.16 28 31 Targeted DNA analysis is preferred in cases where hormonal investigations suggest a block in steroidogenesis (eg, 11-β-hydroxylase deficiency, 21-hydroxylase deficiency), or in the context of a specific clinical constellation such as the often coincidental finding of Müllerian structures in a boy with normal external genitalia or cryptorchidism, that is, persistent Müllerian duct syndrome.33 34 Alternative tests should also be considered depending on the available information. Sometimes, a simple mouth swab for FISH analysis can detect mosaic XY/X in a male with hypospadias or asymmetric gonadal development or in a female with little or no Turner syndrome stigmata and a normal male molecular karyotyping profile or peripheral blood karyotype. Such targeted testing avoids incidental findings and is cheaper and faster than analysis of a large NGS-based panel, although the cost difference is rapidly declining.However, due to the genetic and phenotypic heterogeneity of DSD conditions, the most cost-effective next steps in the majority of cases are whole exome sequencing followed by panel analysis of genes involved in genital development and function or trio-analysis of a large gene panel (such as a Mendeliome).16 35–38 Pretest genetic counselling involves discussing what kind of information will be reported to patients or parents and the chance of detecting VUS, and the small risk of incidental findings when analysing a DSD panel should be mentioned.

Laboratories also differ in what class of variants they report.39 In our experience, the fear of incidental findings is a major reason why some parents refrain from genetic testing.Timing of the DSD gene panel analysis is also important. While some patients or parents prefer that all diagnostic procedures be performed as soon as possible, others need time to reflect on the complex information related to more extensive genetic testing and on its possible consequences. If parents or patients do not consent to panel-based genetic testing, analysis of specific genes, such as WT1, should be considered when appropriate in view of the clinical consequences if a mutation is present (eg, clinical surveillance of renal function and screening for Wilms’ tumour in the case of WT1 mutations). Genes that are more frequently involved in DSD (eg, SRY, NR5A1) and that match the specific clinical and hormonal features in a given patient could also be considered for sequencing.

Targeted gene analysis may also be preferred in centres located in countries that do not have the resources or technical requirements to perform NGS panel-based genetic testing. Alternatively, participation by these centres in international collaborative networks may allow them to outsource the molecular genetic workup abroad.Gene panels differ between centres and are regularly updated based on scientific progress. A comparison of DSD gene panels used in recent studies can be found at https://www.nature.com/articles/s41574-018-0010-8%23Sec46.15 The panels currently used at the coauthors’ institutions can be found on their respective websites. Given the pace of change, it is important to regularly consider repeating analysis in patients with an unexplained DSD, for example, when they transition into adult care or when they move from one centre to another.

This also applies to patients in whom a clinical diagnosis has never been genetically confirmed. Confusion may arise when the diagnosis cannot be confirmed or when a mutation is identified in a different gene, for example, NR5A1 in someone with a clinical diagnosis of CAIS that has other consequences for relatives. Hence, new genetic counselling should always accompany new diagnostic endeavours.Class 3 variants and histopathological examinationsThe rapidly evolving diagnostic possibilities raise new questions. What do laboratories report?.

How should we deal with the frequent findings of mainly unique VUS or class 3 variants (ACMG recommendation) in the many different DSD-related genes in the diagnostic setting?. Reporting VUS can be a source of uncertainty for parents, but not reporting these variants precludes further investigations to determine their possible pathogenicity. It can also be difficult to prove variant pathogenicity, both on gene-level and variant-level.39 Moreover, given the gonad-specific expression of some genes and the variable phenotypic spectrum and reduced penetrance, segregation analysis is not always informative. A class 3 variant that does not fit the clinical presentation may be unrelated to the observed phenotype, but it could also represent a newly emerging phenotype.

This was recently demonstrated by the identification of the NR5A1 mutation, R92W, in individuals with 46,XX testicular and ovotesticular DSD.40 This gene had previously been associated with 46,XY DSD. In diagnostic laboratories, there is usually no capacity or expertise to conduct large-scale functional studies to determine pathogenicity of these unique class 3 VUS in the different genes involved in DSD. Functional validation of variants identified in novel genes may be more attractive in a research context. However, for individual families with VUS in well-established DSD genes such as AR or HSD17B3, functional analysis may provide a confirmed diagnosis that implies for relatives the option of undergoing their own DNA analysis and estimating the genetic risk of their own future offspring.

This makes genetic follow-up important in these cases and demonstrates the usefulness of international databases and networks and the centralisation of functional studies of genetic variants in order to reduce costs and maximise expertise.The same is true for histopathological description, germ-cell tumour risk assessment in specific forms of DSD and classification of gonadal samples. Germ-cell tumour risk is related to the type of DSD (among other factors), but it is impossible to make risk estimates in individual cases.41–44 Gonadectomy may be indicated in cases with high-risk dysgenetic abdominal gonads that cannot be brought into a stable superficial (ie, inguinal, labioscrotal) position that allows clinical or radiological surveillance, or to avoid virilisation due to 5-alpha reductase deficiency in a 46,XY girl with a stable female gender identity.45 Pathological examination of DSD gonads requires specific expertise. For example, the differentiation between benign germ cell abnormalities, such as delayed maturation and (pre)malignant development of germ cells, is crucial for clinical management but can be very troublesome.46 Centralised pathological examination of gonadal biopsy and gonadectomy samples in one centre, or a restricted number of centres, on a national scale can help to overcome the problem of non-uniform classification and has proven feasible in the Netherlands and Belgium. We therefore believe that uniform assessment and classification of gonadal differentiation patterns should also be addressed in guidelines on DSD management.International databases of gonadal tissues are crucial for learning more about the risk of malignancy in different forms of DSD, but they are only reliable if uniform criteria for histological classification are strictly applied.46 These criteria could be incorporated in many existing networks such as the I-DSD consortium, the Disorders of Sex Development Translational Research Network, the European Reference Network on Urogenital Diseases (eUROGEN), the EndoERN and COST actions.15–17 47Communication at the transition from paediatric to adult carePaediatric and adult teams need to collaborate closely to facilitate a well-organised transition from paediatric to adult specialist care.15 48–50 Both teams need to exchange information optimally and should consider transition as a longitudinal process rather than a fixed moment in time.

Age-appropriate information is key at all ages, and an overview of topics to be discussed at each stage is described by Cools et al.15 Table 1 shows an example of how transition can be organised.View this table:Table 1 Example of transition table as used in the DSD clinic of the Erasmus Medical CenterPsychological support and the continued provision of information remains important for individuals with a DSD at all ages.15 22 In addition to the information given by the DSD team members, families and patients can benefit from resources such as support groups and information available on the internet.47 Information available online should be checked for accuracy and completeness when referring patients and parents to internet sites.Recommendations for future actionsMost guidelines and articles on the diagnosis and management of DSD are aimed at specialists and are only published in specialist journals or on websites for endocrinologists, urologists or geneticists. Yet there is a need for guidelines directed towards first-line and second-line healthcare workers that summarise the recommendations about the first crucial steps in the management of DSD. These should be published in widely available general medical journals and online, along with a national list of DSD centres. Furthermore, DSD (expert) centres should provide continuous education to all those who may be involved in the identification of individuals with a DSD in order to enable these healthcare professionals to recognise atypical genitalia, to promptly refer individuals who have a DSD and to inform the patient and parents about this and subsequent diagnostic procedures.As DSD continues to be a rare condition, it will take time to evaluate the effects of having such a guideline on the preparedness of first-line and second-line healthcare workers to recognise DSD conditions.

One way to evaluate this might be the development and use of questionnaires asking patients, carers and families and referring physicians how satisfied they were with the initial medical consultation and referral and what could be improved. A helpful addition to existing international databases that collect information on genetic variations would be a list of centres that offer suitable functional studies for certain genes, ideally covering the most frequently mutated genes (at minimum).Patient organisations can also play an important role in informing patients about newly available diagnostic or therapeutic strategies and options, and their influence and specific role has now been recognised and discussed in several publications.17 47 However, it should be kept in mind that these organisations do not represent all patients, as a substantial number of patients and parents are not member of such an organisation.Professionals have to provide optimal medical care based on well-established evidence, or at least on broad consensus. Yet not everything can be regulated by recommendations and guidelines. Options, ideas and wishes should be openly discussed between professionals, patients and families within their confidential relationship.

This will enable highly individualised holistic care tailored to the patient’s needs and expectations. Once they are well-informed of all available options, parents and/or patients can choose what they consider the optimal care for their children or themselves.15 16ConclusionThe Dutch-Flemish guideline uniquely addresses some topics that are under-represented in the literature, thus adding some key aspects to those addressed in recent consensus papers and guidelines.15–17 33 47As more children with a DSD are now being identified prenatally, and the literature on prenatal diagnosis of DSD remains scarce,20 21 we propose a prenatal diagnostic algorithm and emphasise the importance of having a prenatal specialist involved in or collaborating with DSD (expert) centres.We also stress that good communication between all involved parties is essential. Professionals should be well informed about protocols and communication. Collaboration between centres is necessary to optimise aspects of care such as uniform interpretation of gonadal pathology and functional testing of class 3 variants found by genetic testing.

Guidelines can provide a framework within which individualised patient care should be discussed with all stakeholders.AcknowledgmentsThe authors would like to thank the colleagues of the DSD teams for their input in and critical reading of the Dutch-Flemish guideline. Amsterdam University Center (AMC and VU), Maastricht University Medical Center, Erasmus Medical Center Rotterdam, Radboud University Medical Center Nijmegen, University Medical Center Groningen, University Medical Center Utrecht, Ghent University Hospital. The authors would like to thank Kate McIntyre for editing the revised manuscript and Tom de Vries Lentsch for providing the figures as a PDF. Three of the authors of this publication are members of the European Reference Network for rare endocrine diseases—Project ID 739543.IntroductionEndometrial cancer is the most common gynaecological malignancy in the developed world.1 Its incidence has risen over the last two decades as a consequence of the ageing population, fewer hysterectomies for benign disease and the obesity epidemic.

In the USA, it is estimated that women have a 1 in 35 lifetime risk of endometrial cancer, and in contrast to cancers of most other sites, cancer-specific mortality has risen by approximately 2% every year since 2008 related to the rapidly rising incidence.2Endometrial cancer has traditionally been classified into type I and type II based on morphology.3 The more common subtype, type I, is mostly comprised of endometrioid tumours and is oestrogen-driven, arises from a hyperplastic endometrium, presents at an early stage and has an excellent 5 year survival rate.4 By contrast, type II includes non-endometrioid tumours, specifically serous, carcinosarcoma and clear cell subtypes, which are biologically aggressive tumours with a poor prognosis that are often diagnosed at an advanced stage.5 Recent efforts have focused on a molecular classification system for more accurate categorisation of endometrial tumours into four groups with distinct prognostic profiles.6 7The majority of endometrial cancers arise through the interplay of familial, genetic and lifestyle factors. Two inherited cancer predisposition syndromes, Lynch syndrome and the much rarer Cowden syndrome, substantially increase the lifetime risk of endometrial cancer, but these only account for around 3–5% of cases.8–10 Having first or second degree relative(s) with endometrial or colorectal cancer increases endometrial cancer risk, although a large European twin study failed to demonstrate a strong heritable link.11 The authors failed to show that there was greater concordance in monozygotic than dizygotic twins, but the study was based on relatively small numbers of endometrial cancers. Lu and colleagues reported an association between common single nucleotide polymorphisms (SNPs) and endometrial cancer risk, revealing the potential role of SNPs in explaining part of the risk in both the familial and general populations.12 Thus far, many SNPs have been reported to modify susceptibility to endometrial cancer. However, much of this work predated genome wide association studies and is of variable quality.

Understanding genetic predisposition to endometrial cancer could facilitate personalised risk assessment with a view to targeted prevention and screening interventions.13 This emerged as the most important unanswered research question in endometrial cancer according to patients, carers and healthcare professionals in our recently completed James Lind Womb Cancer Alliance Priority Setting Partnership.14 It would be particularly useful for non-endometrioid endometrial cancers, for which advancing age is so far the only predictor.15We therefore conducted a comprehensive systematic review of the literature to provide an overview of the relationship between SNPs and endometrial cancer risk. We compiled a list of the most robust endometrial cancer-associated SNPs. We assessed the applicability of this panel of SNPs with a theoretical polygenic risk score (PRS) calculation. We also critically appraised the meta-analyses investigating the most frequently reported SNPs in MDM2.

Finally, we described all SNPs reported within genes and pathways that are likely involved in endometrial carcinogenesis and metastasis.MethodsOur systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) collaboration 2009 recommendations. The registered protocol is available through PROSPERO (CRD42018091907).16Search strategyWe searched Embase, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases via the Healthcare Databases Advanced Search (HDAS) platform, from 2007 to 2018, to identify studies reporting associations between polymorphisms and endometrial cancer risk. Key words including MeSH (Medical Subject Heading) terms and free-text words were searched in both titles and abstracts. The following terms were used.

€œendomet*”,“uter*”, “womb”, “cancer(s)”, “neoplasm(s)”, “endometrium tumour”, “carcinoma”, “adenosarcoma”, “clear cell carcinoma”, “carcinosarcoma”, “SNP”, “single nucleotide polymorphism”, “GWAS”, and “genome-wide association study/ies”. No other restrictions were applied. The search was repeated with time restrictions between 2018 and June 2019 to capture any recent publications.Eligibility criteriaStudies were selected for full-text evaluation if they were primary articles investigating a relationship between endometrial cancer and SNPs. Study outcome was either the increased or decreased risk of endometrial cancer relative to controls reported as an odds ratio (OR) with corresponding 95% confidence intervals (95% CIs).Study selectionThree independent reviewers screened all articles uploaded to a screening spreadsheet developed by Helena VonVille.17 Disagreements were resolved by discussion.

Chronbach’s α score was calculated between reviewers and indicated high consistency at 0.92. Case–control, prospective and retrospective studies, genome-wide association studies (GWAS), and both discovery and validation studies were selected for full-text evaluation. Non-English articles, editorials, conference abstracts and proceedings, letters and correspondence, case reports and review articles were excluded.Candidate-gene studies with at least 100 women and GWAS with at least 1000 women in the case arm were selected to ensure reliability of the results, as explained by Spencer et al.18 To construct a panel of up to 30 SNPs with the strongest evidence of association, those with the strongest p values were selected. For the purpose of an SNP panel, articles utilising broad European or multi-ethnic cohorts were selected.

Where overlapping populations were identified, the most comprehensive study was included.Data extraction and synthesisFor each study, the following data were extracted. SNP ID, nearby gene(s)/chromosome location, OR (95% CI), p value, minor or effect allele frequency (MAF/EAF), EA (effect allele) and OA (other allele), adjustment, ethnicity and ancestry, number of cases and controls, endometrial cancer type, and study type including discovery or validation study and meta-analysis. For risk estimates, a preference towards most adjusted results was applied. For candidate-gene studies, a standard p value of<0.05 was applied and for GWAS a p value of <5×10-8, indicating genome-wide significance, was accepted as statistically significant.

However, due to the limited number of SNPs with p values reaching genome-wide significance, this threshold was then lowered to <1×10-5, allowing for marginally significant SNPs to be included. As shown by Mavaddat et al, for breast cancer, SNPs that fall below genome-wide significance may still be useful for generating a PRS and improving the models.19We estimated the potential value of a PRS based on the most significant SNPs by comparing the predicted risk for a woman with a risk score in the top 1% of the distribution to the mean predicted risk. Per-allele ORs and MAFs were taken from the publications and standard errors (SEs) for the lnORs were derived from published 95% CIs. The PRS was assumed to have a Normal distribution, with mean 2∑βipI and SE, σ, equal to √2∑βi2pI(1−pi), according to the binomial distribution, where the summation is over all SNPs in the risk score.

Hence the relative risk (RR) comparing the top 1% of the distribution to the mean is given by exp(Z0.01σ), where Z is the inverse of the standard normal cumulative distribution.ResultsThe flow chart of study selection is illustrated in figure 1. In total, 453 text articles were evaluated and, of those, 149 articles met our inclusion criteria. One study was excluded from table 1, for having an Asian-only population, as this would make it harder to compare with the rest of the results which were all either multi-ethnic or Caucasian cohorts, as stated in our inclusion criteria for the SNP panel.20 Any SNPs without 95% CIs were also excluded from any downstream analysis. Additionally, SNPs in linkage disequilibrium (r2 >0.2) with each other were examined, and of those in linkage disequilibrium, the SNP with strongest association was reported.

Per allele ORs were used unless stated otherwise.View this table:Table 1 List of top SNPs most likely to contribute to endometrial cancer risk identified through systematic review of recent literature21–25Study selection flow diagram. *Reasons. Irrelevant articles, articles focusing on other conditions, non-GWAS/candidate-gene study related articles, technical and duplicate articles. GWAS, genome-wide association study.

Adapted from. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA Statement.

PLoS Med 6(6). E1000097. Doi:10.1371/journal.pmed1000097." data-icon-position data-hide-link-title="0">Figure 1 Study selection flow diagram. *Reasons.

Irrelevant articles, articles focusing on other conditions, non-GWAS/candidate-gene study related articles, technical and duplicate articles. GWAS, genome-wide association study. Adapted from. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009).

Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA Statement. PLoS Med 6(6). E1000097.

Doi:10.1371/journal.pmed1000097.Top SNPs associated with endometrial cancer riskFollowing careful interpretation of the data, 24 independent SNPs with the lowest p values that showed the strongest association with endometrial cancer were obtained (table 1).21–25 These SNPs are located in or around genes coding for transcription factors, cell growth and apoptosis regulators, and enzymes involved in the steroidogenesis pathway. All the SNPs presented here were reported on the basis of a GWAS or in one case, an exome-wide association study, and hence no SNPs from candidate-gene studies made it to the list. This is partly due to the nature of larger GWAS providing more comprehensive and powered results as opposed to candidate gene studies. Additionally, a vast majority of SNPs reported by candidate-gene studies were later refuted by large-scale GWAS such as in the case of TERT and MDM2 variants.26 27 The exception to this is the CYP19 gene, where candidate-gene studies reported an association between variants in this gene with endometrial cancer in both Asian and broad European populations, and this association was more recently confirmed by large-scale GWAS.21 28–30 Moreover, a recent article authored by O’Mara and colleagues reviewed the GWAS that identified most of the currently known SNPs associated with endometrial cancer.31Most of the studies represented in table 1 are GWAS and the majority of these involved broad European populations.

Those having a multi-ethnic cohort also consisted primarily of broad European populations. Only four of the variants in table 1 are located in coding regions of a gene, or in regulatory flanking regions around the gene. Thus, most of these variants would not be expected to cause any functional effects on the gene or the resulting protein. An eQTL search using GTEx Portal showed that some of the SNPs are significantly associated (p<0.05) with modified transcription levels of the respective genes in various tissues such as prostate (rs11263761), thyroid (rs9668337), pituitary (rs2747716), breast mammary (rs882380) and testicular (rs2498794) tissue, as summarised in table 2.View this table:Table 2 List of eQTL hits for the selected panel of SNPsThe only variant for which there was an indication of a specific association with non-endometrioid endometrial cancer was rs148261157 near the BCL11A gene.

The A allele of this SNP had a moderately higher association in the non-endometrioid arm (OR 1.64, 95% CI 1.32 to 2.04. P=9.6×10-6) compared with the endometrioid arm (OR 1.25, 95% CI 1.14 to 1.38. P=4.7×10-6).21Oestrogen receptors α and β encoded by ESR1 and ESR2, respectively, have been extensively studied due to the assumed role of oestrogens in the development of endometrial cancer. O’Mara et al reported a lead SNP (rs79575945) in the ESR1 region that was associated with endometrial cancer (p=1.86×10-5).24 However, this SNP did not reach genome-wide significance in a more recent larger GWAS.21 No statistically significant associations have been reported between endometrial cancer and SNPs in the ESR2 gene region.AKT is an oncogene linked to endometrial carcinogenesis.

It is involved in the PI3K/AKT/mTOR pro-proliferative signalling pathway to inactivate apoptosis and allow cell survival. The A allele of rs2494737 and G allele of rs2498796 were reported to be associated with increased and decreased risk of endometrial cancer in 2016, respectively.22 30 However, this association was not replicated in a larger GWAS in 2018.21 Nevertheless, given the previous strong indications, and biological basis that could explain endometrial carcinogenesis, we decided to include an AKT1 variant (rs2498794) in our results.PTEN is a multi-functional tumour suppressor gene that regulates the AKT/PKB signalling pathway and is commonly mutated in many cancers including endometrial cancer.32 Loss-of-function germline mutations in PTEN are responsible for Cowden syndrome, which exerts a lifetime risk of endometrial cancer of up to 28%.9 Lacey and colleagues studied SNPs in the PTEN gene region. However, none showed significant differences in frequency between 447 endometrial cancer cases and 439 controls of European ancestry.33KRAS mutations are known to be present in endometrial cancer. These can be activated by high levels of KLF5 (transcriptional activator).

Three SNPs have been identified in or around KLF5 that are associated with endometrial cancer. The G allele of rs11841589 (OR 1.15, 95% CI 1.11 to 1.21. P=4.83×10-11), the A allele of rs9600103 (OR 1.23, 95% CI 1.16 to 1.30. P=3.76×10-12) and C allele of rs7981863 (OR 1.16, 95% CI 1.12 to 1.20.

P=2.70×10-17) have all been found to be associated with an increased likelihood of endometrial cancer in large European cohorts.21 30 34 It is worth noting that these SNPs are not independent, and hence they quite possibly tag the same causal variant.The MYC family of proto-oncogenes encode transcription factors that regulate cell proliferation, which can contribute to cancer development if dysregulated. The recent GWAS by O’Mara et al reported three SNPs within the MYC region that reached genome-wide significance with conditional p values reaching at least 5×10–8.35To test the utility of these SNPs as predictive markers, we devised a theoretical PRS calculation using the log ORs and EAFs per SNP from the published data. The results were very encouraging with an RR of 3.16 for the top 1% versus the mean, using all the top SNPs presented in table 1 and 2.09 when using only the SNPs that reached genome-wide significance (including AKT1).Controversy surrounding MDM2 variant SNP309MDM2 negatively regulates tumour suppressor gene TP53, and as such, has been extensively studied in relation to its potential role in predisposition to endometrial cancer. Our search identified six original studies of the association between MDM2 SNP rs2279744 (also referred to as SNP309) and endometrial cancer, all of which found a statistically significant increased risk per copy of the G allele.

Two more original studies were identified through our full-text evaluation. However, these were not included here as they did not meet our inclusion criteria—one due to small sample size, the other due to studying rs2279744 status dependent on another SNP.36 37 Even so, the two studies were described in multiple meta-analyses that are listed in table 3. Different permutations of these eight original studies appear in at least eight published meta-analyses. However, even the largest meta-analysis contained <2000 cases (table 3)38View this table:Table 3 Characteristics of studies that examined MDM2 SNP rs2279744In comparison, a GWAS including nearly 13 000 cases found no evidence of an association with OR and corresponding 95% CI of 1.00 (0.97 to 1.03) and a p value of 0.93 (personal communication).21 Nevertheless, we cannot completely rule out a role for MDM2 variants in endometrial cancer predisposition as the candidate-gene studies reported larger effects in Asians, whereas the GWAS primarily contained participants of European ancestry.

There is also some suggestion that the SNP309 variant is in linkage disequilibrium with another variant, SNP285, which confers an opposite effect.It is worth noting that the SNP285C/SNP309G haplotype frequency was observed in up to 8% of Europeans, thus requiring correction for the confounding effect of SNP285C in European studies.39 However, aside from one study conducted by Knappskog et al, no other study including the meta-analyses corrected for the confounding effect of SNP285.40 Among the studies presented in table 3, Knappskog et al (2012) reported that after correcting for SNP285, the OR for association of this haplotype with endometrial cancer was much lower, though still significant. Unfortunately, the meta-analyses which synthesised Knappskog et al (2012), as part of their analysis, did not correct for SNP285C in the European-based studies they included.38 41 42 It is also concerning that two meta-analyses using the same primary articles failed to report the same result, in two instances.38 42–44DiscussionThis article represents the most comprehensive systematic review to date, regarding critical appraisal of the available evidence of common low-penetrance variants implicated in predisposition to endometrial cancer. We have identified the most robust SNPs in the context of endometrial cancer risk. Of those, only 19 were significant at genome-wide level and a further five were considered marginally significant.

The largest GWAS conducted in this field was the discovery- and meta-GWAS by O’Mara et al, which utilised 12 096 cases and 108 979 controls.21 Despite the inclusion of all published GWAS and around 5000 newly genotyped cases, the total number did not reach anywhere near what is currently available for other common cancers such as breast cancer. For instance, BCAC (Breast Cancer Association Consortium) stands at well over 200 000 individuals with more than half being cases, and resulted in identification of ~170 SNPs in relation to breast cancer.19 45 A total of 313 SNPs including imputations were then used to derive a PRS for breast cancer.19 Therefore, further efforts should be directed to recruit more patients, with deep phenotypic clinical data to allow for relevant adjustments and subgroup analyses to be conducted for better precision.A recent pre-print study by Zhang and colleagues examined the polygenicity and potential for SNP-based risk prediction for 14 common cancers, including endometrial cancer, using available summary-level data from European-ancestry datasets.46 They estimated that there are just over 1000 independent endometrial cancer susceptibility SNPs, and that a PRS comprising all such SNPs would have an area under the receiver-operator curve of 0.64, similar to that predicted for ovarian cancer, but lower than that for the other cancers in the study. The modelling in the paper suggests that an endometrial cancer GWAS double the size of the current largest study would be able to identify susceptibility SNPs together explaining 40% of the genetic variance, but that in order to explain 75% of the genetic variance it would be necessary to have a GWAS comprising close to 150 000 cases and controls, far in excess of what is currently feasible.We found that the literature consists mainly of candidate-gene studies with small sample sizes, meta-analyses reporting conflicting results despite using the same set of primary articles, and multiple reports of significant SNPs that have not been validated by any larger GWAS. The candidate-gene studies were indeed the most useful and cheaper technique available until the mid to late 2000s.

However, a lack of reproducibility (particularly due to population stratification and reporting bias), uncertainty of reported associations, and considerably high false discovery rates make these studies much less appropriate in the post-GWAS era. Unlike the candidate-gene approach, GWAS do not require prior knowledge, selection of genes or SNPs, and provide vast amounts of data. Furthermore, both the genotyping process and data analysis phases have become cheaper, the latter particularly due to faster and open-access pre-phasing and imputation tools being made available.It is clear from table 1 that some SNPs were reported with wide 95% CI, which can be directly attributed to small sample sizes particularly when restricting the cases to non-endometrioid histology only, low EAF or poor imputation quality. Thus, these should be interpreted with caution.

Additionally, most of the SNPs reported by candidate-gene studies were not detected by the largest GWAS to date conducted by O’Mara et al.21 However, this does not necessarily mean that the possibility of those SNPs being relevant should be completely dismissed. Moreover, meta-analyses were attempted for other variants. However, these showed no statistically significant association and many presented with high heterogeneity between the respective studies (data not shown). Furthermore, as many studies utilised the same set of cases and/or controls, conducting a meta-analysis was not possible for a good number of SNPs.

It is therefore unequivocal that the literature is crowded with numerous small candidate-gene studies and conflicting data. This makes it particularly hard to detect novel SNPs and conduct meaningful meta-analyses.We found convincing evidence for 19 variants that indicated the strongest association with endometrial cancer, as shown in table 1. The associations between endometrial cancer and variants in or around HNF1B, CYP19A1, SOX4, MYC, KLF and EIF2AK found in earlier GWAS were then replicated in the latest and largest GWAS. These SNPs showed promising potential in a theoretical PRS we devised based on published data.

Using all 24 or genome-wide significant SNPs only, women with a PRS in the top 1% of the distribution would be predicted to have a risk of endometrial cancer 3.16 and 2.09 times higher than the mean risk, respectively.However, the importance of these variants and relevance of the proximate genes in a functional or biological context is challenging to evaluate. Long distance promoter regulation by enhancers may disguise the genuine target gene. In addition, enhancers often do not loop to the nearest gene, further complicating the relevance of nearby gene(s) to a GWAS hit. In order to elucidate biologically relevant candidate target genes in endometrial cancer, O’Mara et al looked into promoter-associated chromatin looping using a modern HiChIP approach.47 The authors utilised normal and tumoural endometrial cell lines for this analysis which showed significant enrichment for endometrial cancer heritability, with 103 candidate target genes identified across the 13 risk loci identified by the largest ECAC GWAS.

Notable genes identified here were CDKN2A and WT1, and their antisense counterparts. The former was reported to be nearby of rs1679014 and the latter of rs10835920, as shown in table 1. Moreover, of the 36 candidate target genes, 17 were found to be downregulated while 19 were upregulated in endometrial tumours.The authors also investigated overlap between the 13 endometrial cancer risk loci and top eQTL variants for each target gene.47 In whole blood, of the two particular lead SNPs, rs8822380 at 17q21.32 was a top eQTL for SNX11 and HOXB2, whereas rs937213 at 15q15.1 was a top eQTL for SRP14. In endometrial tumour, rs7579014 at 2p16.1 was found to be a top eQTL for BCL11A.

This is particularly interesting because BCL11A was the only nearby/candidate gene that had a GWAS association reported in both endometrioid and non-endometrioid subtypes. The study looked at protein–protein interactions between endometrial cancer drivers and candidate target gene products. Significant interactions were observed with TP53 (most significant), AKT, PTEN, ESR1 and KRAS, among others. Finally, when 103 target candidate genes and 387 proteins were combined together, 462 pathways were found to be significantly enriched.

Many of these are related to gene regulation, cancer, obesity, insulinaemia and oestrogen exposure. This study clearly showed a potential biological relevance for some of the SNPs reported by ECAC GWAS in 2018.Most of the larger included studies used cohorts primarily composed of women of broad European descent. Hence, there are negligible data available for other ethnicities, particularly African women. This is compounded by the lack of reference genotype data available for comparative analysis, making it harder for research to be conducted in ethnicities other than Europeans.

This poses a problem for developing risk prediction models that are equally valuable and predictive across populations. Thus, our results also are of limited applicability to non-European populations.Furthermore, considering that non-endometrioid cases comprise a small proportion (~20%) of all endometrial cancer cases, much larger cohort sizes are needed to detect any genuine signals for non-endometrioid tumours. Most of the evaluated studies looked at either overall/mixed endometrial cancer subtypes or endometrioid histology, and those that looked at variant associations with non-endometrioid histology were unlikely to have enough power to detect any signal with statistical significance. This is particularly concerning because non-endometrioid subtypes are biologically aggressive tumours with a much poorer prognosis that contribute disproportionately to mortality from endometrial cancer.

It is particularly important that attempts to improve early detection and prevention of endometrial cancer focus primarily on improving outcomes from these subtypes. It is also worth noting that, despite the current shift towards a molecular classification of endometrial cancer, most studies used the overarching classical Bokhman’s classification system, type I versus type II, or no histological classification system at all. Therefore, it is important to create and follow a standardised and comprehensive classification system for reporting tumour subtypes for future studies.This study compiled and presented available information for an extensively studied, yet unproven in large datasets, SNP309 variant in MDM2. Currently, there is no convincing evidence for an association between this variant and endometrial cancer risk.

Additionally, of all the studies, only one accounted for the opposing effect of a nearby variant SNP285 in their analyses. Thus, we conclude that until confirmed by a sufficiently large GWAS, this variant should not be considered significant in influencing the risk of endometrial cancer and therefore not included in a PRS. This is also true for the majority of the SNPs reported in candidate-gene studies, as the numbers fall far short of being able to detect genuine signals.This systematic review presents the most up-to-date evidence for endometrial cancer susceptibility variants, emphasising the need for further large-scale studies to identify more variants of importance, and validation of these associations. Until data from larger and more diverse cohorts are available, the top 24 SNPs presented here are the most robust common genetic variants that affect endometrial cancer risk.

The multiplicative effects of these SNPs could be used in a PRS to allow personalised risk prediction models to be developed for targeted screening and prevention interventions for women at greatest risk of endometrial cancer..

What side effects may I notice from Kamagra?

Side effects that you should report to your doctor or health care professional as soon as possible:

• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• breathing problems
• changes in hearing
• changes in vision, blurred vision, trouble telling blue from green color
• chest pain
• fast, irregular heartbeat
• men: prolonged or painful erection (lasting more than 4 hours)
• seizures

Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):

• diarrhea
• flushing
• headache
• indigestion
• stuffy or runny nose

This list may not describe all possible side effects.

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I was delighted to mark the end of #Ramadan with Asia El-Sayeed Ali, a cheap kamagra oral jelly uk Yemeni health browse around these guys worker helping malnourished children &. Mothers in a @wfp-supported clinic.Her resilience in the face of devastating conflict &. Her life-saving work have cheap kamagra oral jelly uk deeply moved &. Inspired me. #EidAlFitr pic.twitter.com/n0JcXBkhZv— António Guterres (@antonioguterres) May 12, 2021 “At the beginning of the war, my children and I were forced to flee our home, and move in with relatives in another part of Aden.

The conflict cheap kamagra oral jelly uk affected all of us. My community, my family, and me. It took many people I was close to. It took away cheap kamagra oral jelly uk our youth and made our children grow up too soon. I worked as a nurse from 2003 to 2011, and then I trained in nutrition, specialising in breastfeeding.

Since then I have been able to return home to Al Tawahi, to work in the nutrition clinic, and for about eight years I have been working in the malnutrition unit.Life is getting harderMalnutrition in Yemen has increased dramatically since the beginning of the war. Food prices are increasing cheap kamagra oral jelly uk with each new day, diseases are everywhere, life is becoming harder every day.In the current situation the cost of food is very high, and there are people who can’t buy cheese or eggs for their children, or can’t find anything to eat at all. Those of us who are lucky enough to have salaried work can’t cope with the situation. I can’t imagine what it’s like for those who don’t get a monthly pay cheque.We pray to cheap kamagra oral jelly uk God to save us from famine. All those who face poverty and hunger are exhausted.

When I see a child, who is suffering from malnutrition, I find them very weak, in the beginning. When a child has malnutrition, cheap kamagra oral jelly uk they become less active and lethargic, and they lag behind others in their education level. If you could see them, your heart would break. When I look at them, I imagine my son in this position. Imagine having a seven-month-old child cheap kamagra oral jelly uk weighing just three kilograms.

When I try to weigh them, I find it difficult to carry them. I ask the mothers how they are managing, and they tell me that they rely on God. Doing something good for humanityWhen a mother brings cheap kamagra oral jelly uk in a child suffering from malnutrition, I provide nutrition treatment, and advise her to bring them back the following week. When she returns, and I see the child has gained weight, and is looking healthier with filled out cheeks, I feel relieved.I love working in the clinic. My heart aches cheap kamagra oral jelly uk when I see children crying from pain or hunger, but I can make a positive difference, helping the mothers, and put a smile on the face of the children.

On Tuesday, UN chief António Guterres called Ms. El-Sayeed Ali, in a bid to highlight the dire situation in Yemen with the looming famine and to call for increased international support especially with the lack of funding to humanitarian efforts in Yemen. [embedded content]“Our message is simple cheap kamagra oral jelly uk and clear. The current system failed to protect us from the erectile dysfunction treatment kamagra”, said former Liberian President Ellen Johnson Sirleaf, co-chair of the Independent Panel for kamagra Preparedness and Response. €œIf we do not act to change it now, it will not protect us from the next kamagra threat, which could happen at any time.” Launched by WHO Director-General Tedros Adhanom Ghebreyesus, the independent panel issued its findings and recommendations after an eight-month review of lessons learned from the past year.

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This was because “many more countries” could have done more to contain the spread of the new erectile dysfunction after cheap kamagra oral jelly uk the WHO declared a public health emergency of international concern on 30 January, after the initial outbreak in Wuhan, China. €œThe shelves of storage rooms in the UN and national capitals are full of reports and reviews of previous health crises. Had their warnings been heeded, we would have avoided the catastrophe we are in today. This time must be different,” said cheap kamagra oral jelly uk Johnson Sirleaf. Unfit for prevention Quicker action “would have helped to prevent the global health, social, and economic catastrophe that continues its grip”, the panel noted, adding that “the system as it stands now is clearly unfit to prevent another novel and highly infectious pathogen, which could emerge at any time, from developing into a kamagra”.

Among its recommendations – and after highlighting how the erectile dysfunction crisis continues to devastate communities - the panel urged Heads of State to take the lead in supporting proven public health measures to curb the kamagra and implement reforms “to prevent a future outbreak” from spreading globally. One billion dose call The panel also cheap kamagra oral jelly uk advised high-income countries with adequate treatment supply to commit to provide “at least one billion” doses to the 92 low and middle-income countries in the UN-led equitable treatment scheme, COVAX, by September 2021. Major treatment-producing countries and manufacturers should agree to share intellectual property rights on their jabs, it said, guided by the UN health agency and the World Trade Organization (WTO). €œIf actions on this don’t occur within three months, a waiver of intellectual property rights under the Agreement on Trade-Related Aspects of Intellectual Property Rights should come into force immediately”, the panel insisted. Turning to the world’s wealthiest countries, known as the G7, the panel of leading experts cheap kamagra oral jelly uk recommended that they should “immediately” stump up 60 per cent of the $19 billion required for the Access to erectile dysfunction treatment Tools Accelerator for treatments, diagnostics, therapeutics, and strengthening of health systems.

Summit call Heads of Government should commit to these reforms at a global summit, the panel continued, by adopting a political declaration under the auspices of the UN General Assembly. Describing its recommendations as potentially “transformative”, the panel highlighted that those least capable of withstanding the kamagra’s myriad shocks had been the worst affected cheap kamagra oral jelly uk. “Up to 125 million more people are estimated to have been pushed into extreme poverty, while 72 million more primary school-age children are now at risk of being unable to read or understand a simple text because of school closures,” the experts maintained. Women have also borne a disproportionate burden, they continued, with gender-based violence at record levels and child marriages on the increase. Underscoring the economic shock of the past kamagra year, the experts also noted that the world “lost cheap kamagra oral jelly uk $7 trillion” in economic output – more than the 2019 GDP of the entire African continent ($6.7 trillion)”.

Latest toll According to WHO there have been more than 159 million confirmed cases of erectile dysfunction treatment globally, including over 3.3 million deaths since the kamagra began. In its weekly epidemiological update, the UN health agency noted that some 1.2 billion treatment doses have been administered. The number of new erectile dysfunction treatment cases and deaths globally has slightly decreased in the past week, with over 5.5 million cases and over 90,000 deaths. But “case and death incidences…remain at the highest levels since the beginning of the kamagra”, the WHO bulletin cautioned. New weekly cases decreased in Europe and the Eastern Mediterranean, while the South-East Asia Region continued its upward trajectory, reporting a further six per cent increase on the previous seven-day period..

I was delighted buy kamagra uk review to mark the end of #Ramadan with Asia El-Sayeed Ali, a Yemeni health worker helping malnourished children &. Mothers in a @wfp-supported clinic.Her resilience in the face of devastating conflict &. Her life-saving work have deeply buy kamagra uk review moved &. Inspired me.

#EidAlFitr pic.twitter.com/n0JcXBkhZv— António Guterres (@antonioguterres) May 12, 2021 “At the beginning of the war, my children and I were forced to flee our home, and move in with relatives in another part of Aden. The conflict buy kamagra uk review affected all of us. My community, my family, and me. It took many people I was close to.

It took away our youth and made our children grow up too buy kamagra uk review soon. I worked as a nurse from 2003 to 2011, and then I trained in nutrition, specialising in breastfeeding. Since then I have been able to return home to Al Tawahi, to work in the nutrition clinic, and for about eight years I have been working in the malnutrition unit.Life is getting harderMalnutrition in Yemen has increased dramatically since the beginning of the war. Food prices are increasing buy kamagra uk review with each new day, diseases are everywhere, life is becoming harder every day.In the current situation the cost of food is very high, and there are people who can’t buy cheese or eggs for their children, or can’t find anything to eat at all.

Those of us who are lucky enough to have salaried work can’t cope with the situation. I can’t imagine what it’s like for those who buy kamagra uk review don’t get a monthly pay cheque.We pray to God to save us from famine. All those who face poverty and hunger are exhausted. When I see a child, who is suffering from malnutrition, I find them very weak, in the beginning.

When a child has buy kamagra uk review malnutrition, they become less active and lethargic, and they lag behind others in their education level. If you could see them, your heart would break. When I look at them, I imagine my son in this position. Imagine having a seven-month-old buy kamagra uk review child weighing just three kilograms.

When I try to weigh them, I find it difficult to carry them. I ask the mothers how they are managing, and they tell me that they rely on God. Doing something good for humanityWhen a mother brings in a child suffering from malnutrition, I provide nutrition treatment, and advise buy kamagra uk review her to bring them back the following week. When she returns, and I see the child has gained weight, and is looking healthier with filled out cheeks, I feel relieved.I love working in the clinic.

My heart aches when I see children crying from pain or hunger, but I can make a positive difference, helping the mothers, and put a smile buy kamagra uk review on the face of the children. On Tuesday, UN chief António Guterres called Ms. El-Sayeed Ali, in a bid to highlight the dire situation in Yemen with the looming famine and to call for increased international support especially with the lack of funding to humanitarian efforts in Yemen. [embedded content]“Our message is simple and clear buy kamagra uk review.

The current system failed to protect us from the erectile dysfunction treatment kamagra”, said former Liberian President Ellen Johnson Sirleaf, co-chair of the Independent Panel for kamagra Preparedness and Response. €œIf we do not act to change it now, it will not protect us from the next kamagra threat, which could happen at any time.” Launched by WHO Director-General Tedros Adhanom Ghebreyesus, the independent panel issued its findings and recommendations after an eight-month review of lessons learned from the past year. Insufficient protection “The tools are available to buy kamagra uk review put an end to the severe illnesses, deaths, and socio-economic damage caused by erectile dysfunction treatment”, said panel co-chair Helen Clark, former Prime Minister of New Zealand, insisting that leaders “have no choice but to act” to stop such a catastrophe happening again. “The current system - at both national and international levels - was not adequate to protect people from erectile dysfunction treatment.

The time it took from the reporting of a cluster of cases of pneumonia of unknown origin in mid-late December 2019 to a Public Health Emergency of International Concern being declared, was too long,” the panel said in a statement on its report, erectile dysfunction treatment. Make it the Last kamagra buy kamagra uk review. ‘Lost month’ The panel - whose report contains “the authoritative chronology of what happened” - also insisted that February 2020 was “a lost month”. This was because “many more countries” could have buy kamagra uk review done more to contain the spread of the new erectile dysfunction after the WHO declared a public health emergency of international concern on 30 January, after the initial outbreak in Wuhan, China.

€œThe shelves of storage rooms in the UN and national capitals are full of reports and reviews of previous health crises. Had their warnings been heeded, we would have avoided the catastrophe we are in today. This time must buy kamagra uk review be different,” said Johnson Sirleaf. Unfit for prevention Quicker action “would have helped to prevent the global health, social, and economic catastrophe that continues its grip”, the panel noted, adding that “the system as it stands now is clearly unfit to prevent another novel and highly infectious pathogen, which could emerge at any time, from developing into a kamagra”.

Among its recommendations – and after highlighting how the erectile dysfunction crisis continues to devastate communities - the panel urged Heads of State to take the lead in supporting proven public health measures to curb the kamagra and implement reforms “to prevent a future outbreak” from spreading globally. One billion dose call The panel also advised high-income buy kamagra uk review countries with adequate treatment supply to commit to provide “at least one billion” doses to the 92 low and middle-income countries in the UN-led equitable treatment scheme, COVAX, by September 2021. Major treatment-producing countries and manufacturers should agree to share intellectual property rights on their jabs, it said, guided by the UN health agency and the World Trade Organization (WTO). €œIf actions on this don’t occur within three months, a waiver of intellectual property rights under the Agreement on Trade-Related Aspects of Intellectual Property Rights should come into force immediately”, the panel insisted.

Turning to the world’s wealthiest countries, known as the buy kamagra uk review G7, the panel of leading experts recommended that they should “immediately” stump up 60 per cent of the $19 billion required for the Access to erectile dysfunction treatment Tools Accelerator for treatments, diagnostics, therapeutics, and strengthening of health systems. Summit call Heads of Government should commit to these reforms at a global summit, the panel continued, by adopting a political declaration under the auspices of the UN General Assembly. Describing its recommendations as potentially “transformative”, the panel highlighted that those least capable of buy kamagra uk review withstanding the kamagra’s myriad shocks had been the worst affected. “Up to 125 million more people are estimated to have been pushed into extreme poverty, while 72 million more primary school-age children are now at risk of being unable to read or understand a simple text because of school closures,” the experts maintained.

Women have also borne a disproportionate burden, they continued, with gender-based violence at record levels and child marriages on the increase. Underscoring the economic shock of the past kamagra year, the experts also noted that the world “lost $7 trillion” in economic output – more than the 2019 GDP of the entire African continent ($6.7 trillion)” buy kamagra uk review. Latest toll According to WHO there have been more than 159 million confirmed cases of erectile dysfunction treatment globally, including over 3.3 million deaths since the kamagra began. In its weekly epidemiological update, the UN health agency noted that some 1.2 billion treatment doses have been administered.

The number of new erectile dysfunction treatment cases and deaths globally has slightly decreased buy kamagra uk review in the past week, with over 5.5 million cases and over 90,000 deaths. But “case and death incidences…remain at the highest levels since the beginning of the kamagra”, the WHO bulletin cautioned. New weekly cases decreased in Europe and the Eastern Mediterranean, while the South-East Asia Region continued its upward trajectory, reporting a further six per cent increase on the previous seven-day period..

Silagra vs kamagra

Imagine being infected with a deadly kamagra that makes Buy generic viagra online you silagra vs kamagra impervious to pain. By the time you realize silagra vs kamagra you are infected, it’s already too late. You have spread it far and wide.

Recent findings in my lab suggest that this scenario may be one reason that people infected with erectile dysfunction, the kamagra causing erectile dysfunction treatment, may be spreading the disease without knowing it.Most accounts silagra vs kamagra to date have focused on how the kamagra invades cells via the ACE2 protein on the surface of many cells. But recent studies, which have not yet been peer-reviewed, suggest there is another route to infecting the cell that enables it to infect the nervous system. This led my research group to uncover a link between a particular cellular protein and pain – silagra vs kamagra an interaction that is disrupted by the erectile dysfunction.

Our research has now been peer-reviewed and will be published in the journal PAIN.I am a scientist who studies how proteins on cells trigger pain signals that are transmitted through the body to the brain. When these proteins are active, the nerve cells are talking to each other silagra vs kamagra. This conversation occurs at deafening levels in chronic pain.

So by studying what causes the excitability of nerve cells to change, we can begin to unravel how chronic pain silagra vs kamagra becomes established. This also allows us to design ways to mute this conversation to blunt or stop chronic pain.My laboratory has a longstanding interest in designing nonopioid-based alternatives for pain management.Linking erectile dysfunction and painYou might be wondering how my lab began to probe the connection between erectile dysfunction and pain. We were inspired by two preliminary reports that appeared on the preprint server BioRxiv that showed that the infamous spike proteins on the surface of the erectile dysfunction kamagra bound silagra vs kamagra to a protein called neuropilin-1.

This means that the kamagra can also use this protein to invade nerve cells as well as through the ACE2 protein.For the past year, some six months before the kamagra took hold, my colleagues and I had been studying the role of neuropilin-1 in the context of pain perception. Because neuropilin-1, like the ACE2 receptor, allowed spike to enter the cells, we wondered if this alternate gateway could also be related to pain.Under normal circumstances, the neuropilin-1 protein controls the growth of blood vessels, and as well as the growth silagra vs kamagra and survival of neurons.However, when neuropilin-1 binds to a naturally occurring protein called called Vascular endothelial growth factor A (VEGF-A), this triggers pain signals. This signal is transmitted via the spinal cord into higher brain centers to cause the sensation we all know as pain.Staring at this jigsaw puzzle – neuropilin-1 and VEGF-A and neuropilin and spike – we wondered if there was a link between spike and pain.Previous research has shown a link between VEGF-A and pain.

For people with osteoarthritis, for instance, studies have shown that increased activity of the VEGF gene in fluids lubricating joints, like the knee, is associated with higher pain scores.Although activity of the neuropilin-1 gene is higher in biological samples from erectile dysfunction treatment patients compared to healthy controls and activity of the neuropilin-1 gene is increased in pain-sensing neurons in an animal model of chronic pain, the role of neuropilin-1 in pain has never been explored until silagra vs kamagra now.In in vitro studies done in my lab using nerve cells, we showed that when spike binds to neuropilin-1 it decreases pain signaling, which suggests that in a living animal it would also have a pain-dulling effect.When the spike protein binds to the neuropilin-1 protein, it blocks the VEGF-A protein from binding and thus hijack’s a cell’s pain circuitry. This binding suppresses the excitability of pain neurons, leading to lower sensitivity to pain.Crystal structure of neuropilin-1 b1 domain (white surface with binding site in red) showing binding of VEGF-A (left), spike protein (middle), and the neuropilin-1 inhibitor EG00229 (right). (Credit.

Dr. Samantha Perez-Miller, CC BY-SA)From the erectile dysfunction treatment fog a new pain target emergesIf our finding that the new erectile dysfunction is attacking cells through a protein associated with pain and disabling the protein can be confirmed in humans, it may provide a new pathway for drug development to treat erectile dysfunction treatment.A small molecule, called EG00229, targeting neuropilin-1 had been reported in a 2018 study. This molecule binds to the same region of the neuropilin-1 protein as the viral spike protein and VEGF-A.

So I and my colleagues asked if this molecule was able to block pain. It did, during pain simulations in rats. Our data reaffirmed the notion of neuropilin-1 as a new player in pain signaling.There is precedence for targeting the neuropilin-1 protein for cancer treatment.

For example, a Phase 1a clinical trial of an antibody called MNRP1685A (known under the product name Vesencumab) that recognizes and binds to neuropilin-1 and blocks VEGF-binding. This was mostly well tolerated in cancer patients, but it caused pain rather than blocking it.Our studies identify a different approach because we targeted blocking the pain-triggering VEGF-A protein, which then resulted in pain relief. So our preclinical work described here provides a rationale for targeting the VEGF-A/NRP-1 pro-pain signaling system in future clinical trials.Analysis of the structure of the neuropilin-1 receptor protein may allow design of drugs targeting this critical site which also controls axon growth, cell survival – in addition to pain relief.For instance, these neuropilin-1 receptor targeted drugs could potentially block viral .

The testing of several candidate compounds, some of them on the FDA’s generally regarded as safe list, is currently underway by my group.Sneaky kamagra, fooling people into believing that they do not have erectile dysfunction treatment. But, ironically, it may be gifting us with the knowledge of a new protein, critical for pain. Two roads emerge in the forest ahead.

(1) block neuropilin-1 to limit erectile dysfunction entry, and (2) block neuropilin-1 to block pain.Rajesh Khanna is a Professor of Pharmacology, University of Arizona. This article originally appeared on The Conversation under a Creative Commons license. Read the original here..

Imagine being infected with a Buy generic viagra online deadly kamagra that buy kamagra uk review makes you impervious to pain. By the time you realize you are infected, it’s already too buy kamagra uk review late. You have spread it far and wide.

Recent findings in my lab suggest that this scenario may be one reason that people infected with erectile dysfunction, the kamagra causing erectile dysfunction treatment, may be spreading the disease without knowing it.Most accounts to date have focused on how the kamagra invades cells via the ACE2 protein buy kamagra uk review on the surface of many cells. But recent studies, which have not yet been peer-reviewed, suggest there is another route to infecting the cell that enables it to infect the nervous system. This led my research group to uncover a link between a particular cellular protein and pain – an interaction that buy kamagra uk review is disrupted by the erectile dysfunction.

Our research has now been peer-reviewed and will be published in the journal PAIN.I am a scientist who studies how proteins on cells trigger pain signals that are transmitted through the body to the brain. When these proteins are buy kamagra uk review active, the nerve cells are talking to each other. This conversation occurs at deafening levels in chronic pain.

So by studying what causes the excitability of nerve cells to change, we can begin to unravel how chronic pain becomes buy kamagra uk review established. This also allows us to design ways to mute this conversation to blunt or stop chronic pain.My laboratory has a longstanding interest in designing nonopioid-based alternatives for pain management.Linking erectile dysfunction and painYou might be wondering how my lab began to probe the connection between erectile dysfunction and pain. We were inspired by two preliminary reports that appeared on the preprint server BioRxiv buy kamagra uk review that showed that the infamous spike proteins on the surface of the erectile dysfunction kamagra bound to a protein called neuropilin-1.

This means that the kamagra can also use this protein to invade nerve cells as well as through the ACE2 protein.For the past year, some six months before the kamagra took hold, my colleagues and I had been studying the role of neuropilin-1 in the context of pain perception. Because neuropilin-1, like the buy kamagra uk review ACE2 receptor, allowed spike to enter the cells, we wondered if this alternate gateway could also be related to pain.Under normal circumstances, the neuropilin-1 protein controls the growth of blood vessels, and as well as the growth and survival of neurons.However, when neuropilin-1 binds to a naturally occurring protein called called Vascular endothelial growth factor A (VEGF-A), this triggers pain signals. This signal is transmitted via the spinal cord into higher brain centers to cause the sensation we all know as pain.Staring at this jigsaw puzzle – neuropilin-1 and VEGF-A and neuropilin and spike – we wondered if there was a link between spike and pain.Previous research has shown a link between VEGF-A and pain.

For people with osteoarthritis, for instance, studies have shown that increased activity of the VEGF gene in fluids lubricating joints, like the knee, is associated with higher pain scores.Although activity of the neuropilin-1 gene is higher in biological samples from erectile dysfunction treatment patients compared to healthy controls and activity of the neuropilin-1 gene is increased in pain-sensing neurons in an animal model of chronic pain, the role of neuropilin-1 in pain has never been explored until now.In in vitro studies done in my lab using nerve cells, we showed that when spike binds to neuropilin-1 it decreases pain signaling, which suggests that in a living animal it would also have a pain-dulling effect.When the spike protein binds to the neuropilin-1 protein, it blocks the VEGF-A protein from binding and thus hijack’s buy kamagra uk review a cell’s pain circuitry. This binding suppresses the excitability of pain neurons, leading to lower sensitivity to pain.Crystal structure of neuropilin-1 b1 domain (white surface with binding site in red) showing binding of VEGF-A (left), spike protein (middle), and the neuropilin-1 inhibitor EG00229 (right). (Credit.

Dr. Samantha Perez-Miller, CC BY-SA)From the erectile dysfunction treatment fog a new pain target emergesIf our finding that the new erectile dysfunction is attacking cells through a protein associated with pain and disabling the protein can be confirmed in humans, it may provide a new pathway for drug development to treat erectile dysfunction treatment.A small molecule, called EG00229, targeting neuropilin-1 had been reported in a 2018 study. This molecule binds to the same region of the neuropilin-1 protein as the viral spike protein and VEGF-A.

So I and my colleagues asked if this molecule was able to block pain. It did, during pain simulations in rats. Our data reaffirmed the notion of neuropilin-1 as a new player in pain signaling.There is precedence for targeting the neuropilin-1 protein for cancer treatment.

For example, a Phase 1a clinical trial of an antibody called MNRP1685A (known under the product name Vesencumab) that recognizes and binds to neuropilin-1 and blocks VEGF-binding. This was mostly well tolerated in cancer patients, but it caused pain rather than blocking it.Our studies identify a different approach because we targeted blocking the pain-triggering VEGF-A protein, which then resulted in pain relief. So our preclinical work described here provides a rationale for targeting the VEGF-A/NRP-1 pro-pain signaling system in future clinical trials.Analysis of the structure of the neuropilin-1 receptor protein may allow design of drugs targeting this critical site which also controls axon growth, cell survival – in addition to pain relief.For instance, these neuropilin-1 receptor targeted drugs could potentially block viral .

The testing of several candidate compounds, some of them on the FDA’s generally regarded as safe list, is currently underway by my group.Sneaky kamagra, fooling people into believing that they do not have erectile dysfunction treatment. But, ironically, it may be gifting us with the knowledge of a new protein, critical for pain. Two roads emerge in the forest ahead.

(1) block neuropilin-1 to limit erectile dysfunction entry, and (2) block neuropilin-1 to block pain.Rajesh Khanna is a Professor of Pharmacology, University of Arizona. This article originally appeared on The Conversation under a Creative Commons license. Read the original here..

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Elon Musk on Friday unveiled a coin-sized prototype of a brain implant developed by his startup Neuralink to enable people who are paralyzed to operate smartphones and robotic limbs with their kamagra london shops thoughts — and said the company had worked to “dramatically simplify” the device since presenting an earlier version last summer.In an event live-streamed on YouTube to more than 150,000 viewers at one point, the company staged a demonstration in which it trotted out a pig named Gertrude that was http://markgrigsby.biz/generic-daily-cialis-online/ said to have had the company’s device implanted in its head two months ago. The live stream showed what Musk claimed to be Gertrude’s real-time brain activity as it sniffed around a pen. At no point, though, did he provide evidence that the signals — rendered in beeps and bright blue wave patterns on screen — were, in fact, emanating from the pig’s brain.A pig presented at a Neuralink demonstration was kamagra london shops said to have one of the company’s brain implants in its head. YouTube screenshot“This is obviously sounding increasingly like a Black Mirror episode,” Musk said at one point during the event as he responded affirmatively to a question about whether the company’s implant could eventually be used to save and replay memories. €œThe future’s going to be weird.”advertisement Musk said that in July Neuralink received a breakthrough device designation kamagra london shops from the Food and Drug Administration — a regulatory pathway that could allow the company to soon start a clinical trial in people with paraplegia and tetraplegia.

The big reveal came after four former Neuralink employees told STAT that the company’s leaders have long fostered an internal culture characterized by rushed timelines and the “move fast and break things” ethos of a tech company — a pace sometimes at odds with the slow and incremental pace that’s typical of medical device development. Advertisement Friday’s event began, 40 minutes late, with a glossy video about the company’s work — and then panned to Musk, standing in front kamagra london shops of a blue curtain beside a gleaming new version of the company’s surgical “sewing machine” robot that could easily have been mistaken for a giant Apple device. Musk described the event as a “product demo” and said its primary purpose was to recruit potential new employees. It was unclear whether the kamagra london shops demonstration was taking place at the company’s Fremont, Calif., headquarters or elsewhere. Musk proceeded to reveal the new version of Neuralink’s brain implant, which he said was designed to fit snugly into the top of the skull.

Neuralink’s technological design has changed significantly since its last big update in July kamagra london shops 2019. At that time, the company’s brain implant system involved a credit-card sized device designed to be positioned behind the back of a person’s ear, with several wires stretching to the top of the skull. After demonstrating the pig’s brain activity at Friday’s event, Musk showed video footage of a pig walking on a treadmill and said Neuralink’s device could be used to “predict the position of limbs with high accuracy.” That capability would be critical to allowing someone using the device to do something like controlling a prosthetic limb, for example.Neuralink for kamagra london shops months has signaled that it initially plans to develop its device for people who are paralyzed. It said at its July 2019 event that it wanted to start human testing by the end of 2020. Receiving the breakthrough device designation from the FDA — designed to speed up the lengthy regulatory process — is kamagra london shops a step forward, but it by no means guarantees that a device will receive a green light, either in a short or longer-term time frame.

After Musk’s presentation, a handful of the company’s employees — all wearing masks, but seated only inches apart — joined him to take questions submitted on Twitter or from the small audience in the room.In typical fashion for a man who in 2018 sent a Tesla Roadster into space, Musk didn’t hesitate to use the event to cross-promote his electric car company. Asked whether the Neuralink kamagra london shops chip would allow people to summon their Tesla telepathically, Musk responded. €œDefinitely — of course.”Matthew MacDougall, the company’s head neurosurgeon, appearing in scrubs, said the company had so far only implanted its technology into the brain’s cortical surface, the coaster-width layer enveloping the brain, but added that it hoped to go deeper in the future. Still, Musk kamagra london shops said. €œYou could solve blindness, you could solve paralysis, you could solve hearing — you can solve a lot just by interfacing with the cortex.”Musk and MacDougall said they hoped to eventually implant Neuralink’s devices — which they referred to on stage simply as “links” — in the deeper structures of the brain, such as in the hypothalamus, which is believed to play a critical role in mental illnesses including depression, anxiety, and PTSD.There were no updates at the event of Neuralink’s research in monkeys, which the company has been conducting in partnership with the University of California, Davis since 2017.

At last July’s event, Musk said — without providing evidence — that a monkey had controlled a computer with its brain.At that same July 2019 event, kamagra london shops Neuralink released a preprint paper — published a few months later — that claimed to show that a series of Neuralink electrodes implanted in the brains of rats could record neural signals. Critically, the work did not show where in the brain the implanted electrodes were recording from, for how long they were recording, or whether the recordings could be linked to any of the rats’ bodily movements.In touting Friday’s event — and Neuralink’s technological capabilities — on Twitter in recent weeks, Musk spoke of “AI symbiosis while u wait” and referenced the “matrix in the matrix” — a science-fiction reference about revealing the true nature of reality. The progress the company reported on Friday fell far short kamagra london shops of that. Neuralink’s prototype is ambitious, but it has yet to show evidence that it can match up to the brain-machine interfaces developed by academic labs and other companies. Other groups have shown that they can listen in on neural activity and allow primates and people to control a computer cursor with their brain — so-called “read-out” technology — and have also shown that they can use electrical stimulation to kamagra london shops input information, such as a command or the heat of a hot cup of coffee, using “write-in” technology.

Neuralink said on Friday that its technology would have both read-out and write-in capabilities.Musk acknowledged that Neuralink still has a long way to go. In closing kamagra london shops the event after more than 70 minutes, Musk said. €œThere’s a tremendous amount of work to be done to go from here to a device that is widely available and affordable and reliable.”Following the news this week of what appears to have been the first confirmed case of a erectile dysfunction treatment re, other researchers have been coming forward with their own reports. One in Belgium, another in the Netherlands. And now, one in Nevada.What caught experts’ attention about the case of kamagra london shops the 25-year-old Reno man was not that he appears to have contracted erectile dysfunction (the name of the kamagra that causes erectile dysfunction treatment) a second time.

Rather, it’s that his second bout was more serious than his first.Immunologists had expected that if the immune response generated after an initial could not prevent a second case, then it should at least stave off more severe illness. That’s what occurred with the first known re case, in a 33-year-old Hong Kong man.advertisement Still, despite what happened to the man in Nevada, researchers are stressing this is not kamagra london shops a sky-is-falling situation or one that should result in firm conclusions. They always presumed people would become vulnerable to erectile dysfunction treatment again some time after recovering from an initial case, based on how our immune systems respond to other respiratory kamagraes, including other erectile dysfunctiones. It’s possible that these early cases of re are outliers and have features that won’t apply to the tens of millions of other people kamagra london shops who have already shaken off erectile dysfunction treatment.“There are millions and millions of cases,” said Michael Mina, an epidemiologist at Harvard’s T.H. Chan School of Public Health.

The real question that should get the most focus, Mina said, is, “What happens kamagra london shops to most people?. €advertisement But with more re reports likely to make it into the scientific literature soon, and from there into the mainstream press, here are some things to look for in assessing them.What’s the deal with the Nevada case?. The Reno resident in question first tested positive for erectile dysfunction in April after coming down with a sore throat, cough, and kamagra london shops headache, as well as nausea and diarrhea. He got better over time and later tested negative twice. But then, some kamagra london shops 48 days later, the man started experiencing headaches, cough, and other symptoms again.

Eventually, he became so sick that he had to be hospitalized and was found to have pneumonia.Researchers sequenced kamagra samples from both of his s and found they were different, providing evidence that this was a new distinct from the first. What happens when we get erectile dysfunction treatment in the first case? kamagra london shops. Researchers are finding that, generally, people who get erectile dysfunction treatment develop a healthy immune response replete with both antibodies (molecules that can block pathogens from infecting cells) and T cells (which help wipe out the kamagra). This is what happens after other viral s.In addition to fending off kamagra london shops the kamagra the first time, that immune response also creates memories of the kamagra, should it try to invade a second time. It’s thought, then, that people who recover from erectile dysfunction treatment will typically be protected from another case for some amount of time.

With other erectile dysfunctiones, protection is thought to kamagra london shops last for perhaps a little less than a year to about three years.But researchers can’t tell how long immunity will last with a new pathogen (like erectile dysfunction) until people start getting reinfected. They also don’t know exactly what mechanisms provide protection against erectile dysfunction treatment, nor do they know what levels of antibodies or T cells are required to signal that someone is protected through a blood test. (These are called the “correlates of protection.”) Why do experts expect second cases to be milder? kamagra london shops. With other kamagraes, protective immunity doesn’t just vanish one day. Instead, it kamagra london shops wanes over time.

Researchers have then hypothesized that with erectile dysfunction, perhaps our immune systems might not always be able to prevent it from getting a toehold in our cells — to halt entirely — but that it could still put up enough of a fight to guard us from getting really sick. Again, this is what happens with other respiratory pathogens.And it’s kamagra london shops why some researchers actually looked at the Hong Kong case with relief. The man had mild to moderate erectile dysfunction treatment symptoms during the first case, but was asymptomatic the second time. It was a demonstration, kamagra london shops experts said, of what you would want your immune system to do. (The case was only detected because the man’s sample was taken at the airport when he arrived back in Hong Kong after traveling in Europe.)“The fact that somebody may get reinfected is not surprising,” Malik Peiris, a virologist at the University of Hong Kong, told STAT earlier this week about the first re.

€œBut the re didn’t cause disease, so that’s the first point.”The Nevada case, then, provides a counterexample to that. What kind of immune response kamagra london shops did the person who was reinfected generate initially?. Earlier, we described the robust immune response that most people who have erectile dysfunction treatment seem to mount. But that kamagra london shops was a generalization. s and the immune responses they induce in different people are “heterogeneous,” said Sarah Cobey, an epidemiologist and evolutionary biologist at the University of Chicago.Older people often generate weaker immune responses than younger people.

Some studies have also indicated that milder cases of erectile dysfunction treatment induce tamer immune responses that might not provide as lasting or as thorough of a defense as stronger immune responses kamagra london shops. The man in Hong Kong, for example, did not generate antibodies to the kamagra after his first , at least to the level that could be detected by blood tests. Perhaps that explains why he contracted the kamagra again just about 4 1/2 months after recovering from his initial .In the Nevada case, researchers did not kamagra london shops test what kind of immune response the man generated after the first case.“ is not some binary event,” Cobey said. And with re, “there’s going to be some viral replication, but the question is how much is the immune system getting engaged?. €What might be broadly meaningful is when people who mounted robust immune responses start getting reinfected, and how kamagra london shops severe their second cases are.

Are people who have erectile dysfunction treatment a second time infectious?. As discussed, immune memory can kamagra london shops prevent re. If it can’t, it might stave off serious illness. But there’s a third aspect kamagra london shops of this, too.“The most important question for re, with the most serious implications for controlling the kamagra, is whether reinfected people can transmit the kamagra to others,” Columbia University virologist Angela Rasmussen wrote in Slate this week.Unfortunately, neither the Hong Kong nor the Reno studies looked at this question. But if most people who get reinfected don’t spread the kamagra, that’s obviously good news.

What happens when kamagra london shops people broadly become susceptible again?. Whether it’s six months after the first or nine months or a year or longer, at some point, protection for most people who recover from erectile dysfunction treatment is expected to wane. And without the arrival of a treatment and broad uptake of it, that could change the dynamics of local outbreaks.In some communities, it’s thought that more than 20% of residents have experienced an initial erectile dysfunction treatment case, and are thus theoretically protected from kamagra london shops another case for some time. That is still below the point of herd immunity — when enough people are immune that transmission doesn’t occur — but still, the fewer vulnerable people there are, the less likely spread is to occur.On the flip side though, if more people become susceptible to the kamagra again, that could increase the risk of transmission. Modelers are starting to factor that possibility into their forecasts.A crucial question for which there is not an answer yet is whether what happened to the man in Reno, where the second case was more severe than the first, remains a rare occurrence, kamagra london shops as researchers expect and hope.

As the Nevada researchers wrote, “the generalizability of this finding is unknown.”An advocacy group has asked the Department of Defense to investigate what it called “an apparent failure” by Moderna (MRNA) to disclose millions of dollars in awards received from the Defense Advanced Research Projects Agency in patent applications the company filed for treatments.In a letter to the agency, Knowledge Ecology International explained that a review of dozens of patent applications found the company received approximately $20 million from the federal government in grants several years ago and the funds “likely” led to the creation of its treatment technology. This was used to develop treatments to combat different kamagraes, such as Zika and, later, the kamagra that causes erectile dysfunction treatment.In arguing for an investigation, the advocacy group maintained Moderna is obligated under kamagra london shops federal law to disclose the grants that led to nearly a dozen specific patent applications and explained the financial support means the U.S. Government would have certain rights over the patents. In other kamagra london shops words, U.S. Taxpayers would have an ownership stake in treatments developed by the company.advertisement “This clarifies the public’s right in the inventions,” said Jamie Love, who heads Knowledge Ecology International, a nonprofit that tracks patents and access to medicines issues.

€œThe disclosure (also) changes the narrative about who has financed the inventive activity, often the most risky part of development.” One particular patent kamagra london shops assigned to Moderna concerns methods and compositions that can be used specifically against erectile dysfunctiones, including erectile dysfunction treatment. The patent names a Moderna scientist and a former Moderna scientist as inventors, both of which acknowledged performing work under the DARPA awards in two academic papers, according to the report by the advocacy group.advertisement The group examined the 126 patents assigned to Moderna or ModernaTx as well as 154 patent applications. €œDespite the evidence that multiple inventions were conceived in the course of research supported by the DARPA awards, not a single one of the patents or applications assigned to Moderna disclose U.S. Federal government funding,” the report kamagra london shops stated.[UPDATE. A DARPA spokesman sent us this over the weekend.

€œIt appears kamagra london shops that all past and present DARPA awards to Moderna include the requirement to report the role of government funding for related inventions. Further, DARPA is actively researching agency awards to Moderna to identify which patents and pending patents, if any at all, may be associated with DARPA support. This effort is ongoing.”]We kamagra london shops asked Moderna for comment and will update you accordingly.The missive to the Department of Defense follows a recent analysis by Public Citizen, another advocacy group, indicating the National Institutes of Health may own mRNA-1273, the Moderna treatment candidate for erectile dysfunction treatment. The advocacy group noted the federal government filed multiple patents covering the treatment and two patent applications, in particular, list federal scientists as co-inventors.The analyses are part of a larger campaign among advocacy groups and others in the U.S. And elsewhere to ensure that erectile dysfunction treatment medical products are available to poor kamagra london shops populations around the world.

The concern reflects the unprecedented global demand for therapies and treatments, and a race among wealthy nations to snap up supplies from treatment makers. In the kamagra london shops U.S., the effort has focused on the extent to which the federal government has provided taxpayer dollars to different companies to help fund their discoveries. In some cases, advocates argue that federal funding matters because it clarifies the rights that the U.S. Government has kamagra london shops to ensure a therapy or treatment is available to Americans on reasonable terms.One example has been remdesivir, the Gilead Sciences (GILD) treatment being given to hospitalized erectile dysfunction treatment patients. The role played by the U.S.

Government in kamagra london shops developing remdesivir to combat erectile dysfunctiones involved contributions from government personnel at such agencies as the U.S. Army Medical Research Institute of Infectious Diseases.As for the Moderna treatment, earlier this month, the company was awarded a $1.525 billion contract by the Department of Defense and the Department of Health and Human Services to manufacture and deliver 100 million doses of its erectile dysfunction treatment. The agreement also includes an kamagra london shops option to purchase another 400 million doses, although the terms were not disclosed. In announcing the agreement, the government said it would ensure Americans receive the erectile dysfunction treatment at no cost, although they may be charged by health care providers for administering a shot.In this instance, however, Love said the “letter is not about price or profits. It’s about kamagra london shops (Moderna) not owning up to DARPA funding inventions.

If the U.S. Wants to pay for all of the development of Moderna’s treatment, as Moderna now acknowledges, and throw in a few more billion now, and an option to spend billions more, it’s not unreasonable to have some transparency over who paid for their inventions.”This is not the first time Moderna has been accused of insufficient kamagra london shops disclosure. Earlier this month, Knowledge Ecology International and Public Citizen maintained the company failed to disclose development costs in a $955 million contract awarded by BARDA for its erectile dysfunction treatment. In all, the federal government has awarded the company approximately $2.5 billion to develop the treatment.The coming few weeks represent kamagra london shops a crucial moment for an ambitious plan to try to secure erectile dysfunction treatments for roughly 170 countries around the world without the deep pockets to compete for what will be scarce initial supplies.Under the plan, countries that want to pool resources to buy treatments must notify the World Health Organization and other organizers — Gavi, the treatment Alliance, as well as the Coalition for Epidemic Preparedness Innovations — of their intentions by Monday. That means it’s fish-or-cut-bait time for the so-called COVAX facility.Already, wealthy countries — the United States, the United Kingdom, Japan, Canada, and Australia, among others, as well as the European Union — have opted to buy their own treatment, signing bilateral contracts with manufacturers that have secured billions of doses of treatment already.

That raises the possibility that less wealthy countries will kamagra london shops be boxed out of supplies.advertisement And yet Richard Hatchett, the CEO of CEPI, insists there is a path to billions of doses of treatment for the rest of the world in 2021. STAT spoke with Hatchett this week. A transcript of the conversation, kamagra london shops lightly edited for clarity and length, follows. You said this is a critical time for CEPI. Can you explain what needs to happen between now and mid-September for this joint purchasing approach to be a success?.

Advertisement The critical moment is now for countries to commit to the COVAX facility, because that will enable us to secure ample quantities of treatment and then to be able to convey kamagra london shops when that treatment is likely to become available based on current information.What we’re now here asking countries to do is to indicate their intent to participate by Aug. 31, and to make a binding commitment by Sept. 18. And to provide funds in support of that binding commitment by early October. Our negotiations with companies are already taking place and it will be important for us from a planning purpose that countries indicate their intent to participate.Those binding commitments we think will be sufficient to allow us to then secure the advance purchase agreements, particularly with those companies that don’t have a prior contractual obligation to COVAX.

And then obviously, we need the funds to live up to those advance purchase agreements.Is it possible this thing could still fall apart?. There appears to be some concern COVAX has been boxed out by rich countries. There was always a possibility that there wouldn’t be sufficient uptake. But I think we’re very encouraged at this point by the level of commitment, both from countries that would be beneficiaries of the advance market commitment — that’s the lower-income, lower-middle-income countries — as well as the self-financing countries. To have over 170 countries expressing interest in participating — they see the value.We’re much more encouraged now that it’s not going to fall apart.

We still need to bring it off to maximize its value. And we’re right at the crunch moment where countries are going to have to make these commitments. So, the next month is really absolutely critical to the facility. I am confident at this point that the world recognizes the value and wants it to work.I’ve been keeping tabs on advance purchase agreements that have been announced. And at this point, a small number of rich countries have nailed down a lot of treatment — more than 3 billion doses.

How hard does that make your job?. The fact that they’re doing it creates anxiety among other countries. And that in itself can accelerate the pace. So, I’m not going to say that we’re not watching that with concern.I will say that for COVAX and the facility, this is absolutely critical moment. I think we still have a window of opportunity between now and mid-September — when we’re asking that the self-financing countries to make their commitments — to make the facility real and to make it work.

Between doses that are committed to COVAX through the access agreements and other agreements — these are discussions with partners that CEPI has funded as well as partners that CEPI has not funded — we still see a pathway for COVAX to well over 3 billion doses in 2021.I think it’s really important to bear in mind is that there are at least a few countries — and I think the U.S. And the U.K. Most publicly — that may be in a situation of significant oversupply. I believe the U.S. And U.K.

Numbers, if you add them together, would result in enough treatment for 600 million people to receive two doses of treatment each. And, you know, there is no possible way that the U.S. Or the U.K. Can use that much treatment.So, there may be a lot of extra supply that looks like it’s been tied up sloshing around later. I don’t think that the bilateral deals that have been struck are going to prevent COVAX from achieving its goals.But if so much treatment has been pre-ordered by rich countries, can countries in the COVAX pool get enough for their needs?.

One of the things that we’ve argued through COVAX is that to control the kamagra or to end the acute phase of the kamagra to allow normalcy to start to reassert itself, you don’t have to vaccinate 100% of your population.You need to vaccinate those at greatest risk for bad outcomes and you need to vaccinate certain critical workers, particularly your health care workforce. And if you can achieve that goal, which for most countries means vaccinating between 20% and maybe 30% of the population, then you can transform the kamagra into something that is much more manageable. Then you can buy yourself time to vaccinate everybody who wants to be vaccinated.We’ve argued the COVAX facility really offers the world the best shot at doing that globally in the fastest possible way, as well as providing for equitable access. This is a case where doing the equitable thing is also doing the efficient thing.CEPI has provided funding to nine treatments. Is it true that all those manufacturers aren’t required to provide the COVAX facility with treatment?.

That is correct. One of the things that we did, and I think it was an important role that CEPI played early on, was that we moved money very, very quickly, in small increments. You know, some of the early contracts were only $5 million or $10 million, to get programs up and running while we potentially put in place much larger-scale, longer-term contracts.If you were doing it over again, would you have given money without strings attached?. Yes, I think I would have. I think that was critically important to initiating programs.Our contract with Moderna was established in about 48 hours.

And that provided critical funding to them to manufacture doses that got them into clinical trials within nine weeks of the genetic sequences [of the erectile dysfunction kamagra] being released.And if you look at the nine programs that we’ve invested in, seven are in clinical trials. Two — the AstraZeneca program now and the Moderna program — are among the handful in Phase 3 clinical trials. And, I think the number of projects that that we funded initially, which started in kind of a biotech or academic phase that have now been picked up by large multinational corporations, there’s at least four. The Themis program being picked up by Merck, Oxford University by AstraZeneca, the University of Queensland by CSL, and Clover being in partnership with GSK, I think that speaks to the quality of the programs that we selected.So, I think that combination of rapid review, speed of funding, getting those programs started, getting them oriented in the right direction, I think all of that is critical to where we are now.Companies that got money from CEPI to build out production capacity — that money came with strings attached, right?. Yes, exactly.

So, where CEPI has made investments that create manufacturing, or secure manufacturing capacity, the commitment has been that the capacity that is attributable to the CEPI investment is committed — at least right of first refusal — to the global procurement facility.WASHINGTON — The Trump administration removed a top Food and Drug Administration communications official from her post on Friday in the wake of several controversial agency misstatements, a senior administration official confirmed to STAT.The spokeswoman, Emily Miller, had played a lead role in defending the FDA commissioner, Stephen Hahn, after he misrepresented data regarding the use of blood plasma from recovered erectile dysfunction treatment patients. The New York Times first reported Miller’s ouster. Miller’s tenure at as the top FDA spokeswoman lasted only 11 days. Her appointment was viewed with alarm by agency officials who felt her presence at the agency was emblematic of broader political pressure from the Trump administration, STAT first reported earlier this week.advertisement Before joining the FDA, Miller had no experience in health or medicine. Her former role as assistant commissioner for media affairs is typically not an appointment filled by political appointees.

The FDA’s communications arm typically maintains a neutral, nonpolitical tone.Miller’s appointment particularly alarmed FDA staff and outside scientists given her history in right-wing political advocacy and conservatism journalism. Her résumé included a stint as a Washington Times columnist, where she penned columns with titles that include “New Obamacare ads make young women look like sluts,” and a 2013 book on gun rights titled “Emily Gets Her Gun. But Obama Wants to Take Yours.”advertisement She also worked as a reporter for One America News Network, a right-wing cable channel that frequently espouses conspiracy theories and has declared an open alliance with President Trump.Miller quickly made her presence known at the FDA. In the wake of Hahn’s misstatements on blood plasma, she aggressively defended the commissioner, falsely claiming in a tweet that the therapy “has shown to be beneficial for 35% of patients.” An FDA press release on blood plasma, issued less than a week after her appointment, similarly alarmed agency insiders by trumpeting the emergency authorization as “Another Achievement in Administration’s Fight Against [the] kamagra.”.

Elon Musk on Friday unveiled a coin-sized prototype of a brain implant developed by his startup Neuralink to enable people who are paralyzed to operate smartphones and robotic limbs with their thoughts — and said the company had worked to “dramatically simplify” the device since presenting an earlier version last summer.In an event live-streamed on YouTube to more than 150,000 viewers at one point, the company staged a demonstration in which it trotted out a pig named Gertrude that was buy kamagra uk review said to have had the company’s device implanted in its head two months ago. The live stream showed what Musk claimed to be Gertrude’s real-time brain activity as it sniffed around a pen. At no point, though, did he provide evidence that the signals — rendered in beeps and bright blue wave patterns on screen — were, in fact, emanating from the pig’s brain.A pig presented at a Neuralink demonstration was said to have one of the buy kamagra uk review company’s brain implants in its head. YouTube screenshot“This is obviously sounding increasingly like a Black Mirror episode,” Musk said at one point during the event as he responded affirmatively to a question about whether the company’s implant could eventually be used to save and replay memories. €œThe future’s going to be weird.”advertisement Musk said that in July Neuralink received a breakthrough device designation from the Food and Drug Administration — a regulatory pathway that could allow the company to soon buy kamagra uk review start a clinical trial in people with paraplegia and tetraplegia.

The big reveal came after four former Neuralink employees told STAT that the company’s leaders have long fostered an internal culture characterized by rushed timelines and the “move fast and break things” ethos of a tech company — a pace sometimes at odds with the slow and incremental pace that’s typical of medical device development. Advertisement Friday’s event began, 40 minutes late, with a glossy video about the buy kamagra uk review company’s work — and then panned to Musk, standing in front of a blue curtain beside a gleaming new version of the company’s surgical “sewing machine” robot that could easily have been mistaken for a giant Apple device. Musk described the event as a “product demo” and said its primary purpose was to recruit potential new employees. It was unclear whether the demonstration was taking place buy kamagra uk review at the company’s Fremont, Calif., headquarters or elsewhere. Musk proceeded to reveal the new version of Neuralink’s brain implant, which he said was designed to fit snugly into the top of the skull.

Neuralink’s technological design has changed significantly since its buy kamagra uk review last big update in July 2019. At that time, the company’s brain implant system involved a credit-card sized device designed to be positioned behind the back of a person’s ear, with several wires stretching to the top of the skull. After demonstrating the pig’s brain activity at Friday’s event, Musk showed video footage of a pig buy kamagra uk review walking on a treadmill and said Neuralink’s device could be used to “predict the position of limbs with high accuracy.” That capability would be critical to allowing someone using the device to do something like controlling a prosthetic limb, for example.Neuralink for months has signaled that it initially plans to develop its device for people who are paralyzed. It said at its July 2019 event that it wanted to start human testing by the end of 2020. Receiving the breakthrough device designation from the FDA — designed to speed up the lengthy regulatory process — buy kamagra uk review is a step forward, but it by no means guarantees that a device will receive a green light, either in a short or longer-term time frame.

After Musk’s presentation, a handful of the company’s employees — all wearing masks, but seated only inches apart — joined him to take questions submitted on Twitter or from the small audience in the room.In typical fashion for a man who in 2018 sent a Tesla Roadster into space, Musk didn’t hesitate to use the event to cross-promote his electric car company. Asked whether the Neuralink chip would allow people to summon their Tesla telepathically, Musk buy kamagra uk review responded. €œDefinitely — of course.”Matthew MacDougall, the company’s head neurosurgeon, appearing in scrubs, said the company had so far only implanted its technology into the brain’s cortical surface, the coaster-width layer enveloping the brain, but added that it hoped to go deeper in the future. Still, Musk buy kamagra uk review said. €œYou could solve blindness, you could solve paralysis, you could solve hearing — you can solve a lot just by interfacing with the cortex.”Musk and MacDougall said they hoped to eventually implant Neuralink’s devices — which they referred to on stage simply as “links” — in the deeper structures of the brain, such as in the hypothalamus, which is believed to play a critical role in mental illnesses including depression, anxiety, and PTSD.There were no updates at the event of Neuralink’s research in monkeys, which the company has been conducting in partnership with the University of California, Davis since 2017.

At last July’s event, Musk said — without providing evidence — that a monkey had controlled a computer with its brain.At that same July 2019 event, Neuralink released a preprint paper — buy kamagra uk review published a few months later — that claimed to show that a series of Neuralink electrodes implanted in the brains of rats could record neural signals. Critically, the work did not show where in the brain the implanted electrodes were recording from, for how long they were recording, or whether the recordings could be linked to any of the rats’ bodily movements.In touting Friday’s event — and Neuralink’s technological capabilities — on Twitter in recent weeks, Musk spoke of “AI symbiosis while u wait” and referenced the “matrix in the matrix” — a science-fiction reference about revealing the true nature of reality. The progress the company reported on Friday fell far short buy kamagra uk review of that. Neuralink’s prototype is ambitious, but it has yet to show evidence that it can match up to the brain-machine interfaces developed by academic labs and other companies. Other groups have shown that they can listen in on neural activity and allow primates and people buy kamagra uk review to control a computer cursor with their brain — so-called “read-out” technology — and have also shown that they can use electrical stimulation to input information, such as a command or the heat of a hot cup of coffee, using “write-in” technology.

Neuralink said on Friday that its technology would have both read-out and write-in capabilities.Musk acknowledged that Neuralink still has a long way to go. In closing buy kamagra uk review the event after more than 70 minutes, Musk said. €œThere’s a tremendous amount of work to be done to go from here to a device that is widely available and affordable and reliable.”Following the news this week of what appears to have been the first confirmed case of a erectile dysfunction treatment re, other researchers have been coming forward with their own reports. One in Belgium, another in the Netherlands. And now, one in Nevada.What caught experts’ buy kamagra uk review attention about the case of the 25-year-old Reno man was not that he appears to have contracted erectile dysfunction (the name of the kamagra that causes erectile dysfunction treatment) a second time.

Rather, it’s that his second bout was more serious than his first.Immunologists had expected that if the immune response generated after an initial could not prevent a second case, then it should at least stave off more severe illness. That’s what occurred with the first known re case, in a 33-year-old Hong Kong man.advertisement Still, despite what happened to the man in Nevada, researchers are stressing buy kamagra uk review this is not a sky-is-falling situation or one that should result in firm conclusions. They always presumed people would become vulnerable to erectile dysfunction treatment again some time after recovering from an initial case, based on how our immune systems respond to other respiratory kamagraes, including other erectile dysfunctiones. It’s possible that these early cases of re are outliers and have features that won’t apply to the tens of millions of other people who have already shaken off erectile dysfunction treatment.“There are millions and millions of cases,” said Michael Mina, an epidemiologist buy kamagra uk review at Harvard’s T.H. Chan School of Public Health.

The real question that should get the most focus, Mina said, is, “What happens buy kamagra uk review to most people?. €advertisement But with more re reports likely to make it into the scientific literature soon, and from there into the mainstream press, here are some things to look for in assessing them.What’s the deal with the Nevada case?. The Reno resident in question first tested positive for erectile dysfunction in April after coming down with a sore throat, cough, and buy kamagra uk review headache, as well as nausea and diarrhea. He got better over time and later tested negative twice. But then, some 48 days later, the man buy kamagra uk review started experiencing headaches, cough, and other symptoms again.

Eventually, he became so sick that he had to be hospitalized and was found to have pneumonia.Researchers sequenced kamagra samples from both of his s and found they were different, providing evidence that this was a new distinct from the first. What happens when we get erectile dysfunction treatment in the first case? buy kamagra uk review. Researchers are finding that, generally, people who get erectile dysfunction treatment develop a healthy immune response replete with both antibodies (molecules that can block pathogens from infecting cells) and T cells (which help wipe out the kamagra). This is what happens after other viral s.In addition to fending off the kamagra the first time, that immune response also creates memories buy kamagra uk review of the kamagra, should it try to invade a second time. It’s thought, then, that people who recover from erectile dysfunction treatment will typically be protected from another case for some amount of time.

With other erectile dysfunctiones, protection is thought buy kamagra uk review to last for perhaps a little less than a year to about three years.But researchers can’t tell how long immunity will last with a new pathogen (like erectile dysfunction) until people start getting reinfected. They also don’t know exactly what mechanisms provide protection against erectile dysfunction treatment, nor do they know what levels of antibodies or T cells are required to signal that someone is protected through a blood test. (These are called the “correlates of protection.”) Why do experts expect second cases buy kamagra uk review to be milder?. With other kamagraes, protective immunity doesn’t just vanish one day. Instead, it wanes over time buy kamagra uk review.

Researchers have then hypothesized that with erectile dysfunction, perhaps our immune systems might not always be able to prevent it from getting a toehold in our cells — to halt entirely — but that it could still put up enough of a fight to guard us from getting really sick. Again, this is what happens with other respiratory pathogens.And it’s why some researchers actually looked at the buy kamagra uk review Hong Kong case with relief. The man had mild to moderate erectile dysfunction treatment symptoms during the first case, but was asymptomatic the second time. It was a demonstration, experts said, of what you would want your immune system to do buy kamagra uk review. (The case was only detected because the man’s sample was taken at the airport when he arrived back in Hong Kong after traveling in Europe.)“The fact that somebody may get reinfected is not surprising,” Malik Peiris, a virologist at the University of Hong Kong, told STAT earlier this week about the first re.

€œBut the re didn’t cause disease, so that’s the first point.”The Nevada case, then, provides a counterexample to that. What kind of buy kamagra uk review immune response did the person who was reinfected generate initially?. Earlier, we described the robust immune response that most people who have erectile dysfunction treatment seem to mount. But that buy kamagra uk review was a generalization. s and the immune responses they induce in different people are “heterogeneous,” said Sarah Cobey, an epidemiologist and evolutionary biologist at the University of Chicago.Older people often generate weaker immune responses than younger people.

Some studies have also indicated that milder buy kamagra uk review cases of erectile dysfunction treatment induce tamer immune responses that might not provide as lasting or as thorough of a defense as stronger immune responses. The man in Hong Kong, for example, did not generate antibodies to the kamagra after his first , at least to the level that could be detected by blood tests. Perhaps that explains why he contracted the buy kamagra uk review kamagra again just about 4 1/2 months after recovering from his initial .In the Nevada case, researchers did not test what kind of immune response the man generated after the first case.“ is not some binary event,” Cobey said. And with re, “there’s going to be some viral replication, but the question is how much is the immune system getting engaged?. €What might buy kamagra uk review be broadly meaningful is when people who mounted robust immune responses start getting reinfected, and how severe their second cases are.

Are people who have erectile dysfunction treatment a second time infectious?. As discussed, buy kamagra uk review immune memory can prevent re. If it can’t, it might stave off serious illness. But there’s a third aspect of this, too.“The most important question for re, with the most serious implications for buy kamagra uk review controlling the kamagra, is whether reinfected people can transmit the kamagra to others,” Columbia University virologist Angela Rasmussen wrote in Slate this week.Unfortunately, neither the Hong Kong nor the Reno studies looked at this question. But if most people who get reinfected don’t spread the kamagra, that’s obviously good news.

What happens when people buy kamagra uk review broadly become susceptible again?. Whether it’s six months after the first or nine months or a year or longer, at some point, protection for most people who recover from erectile dysfunction treatment is expected to wane. And without the arrival of a treatment and broad uptake of it, that could change the dynamics of local outbreaks.In some communities, it’s thought that more than 20% of residents have experienced an initial erectile dysfunction treatment case, and are thus theoretically protected from buy kamagra uk review another case for some time. That is still below the point of herd immunity — when enough people are immune that transmission doesn’t occur — but still, the fewer vulnerable people there are, the less likely spread is to occur.On the flip side though, if more people become susceptible to the kamagra again, that could increase the risk of transmission. Modelers are starting to factor that possibility into their forecasts.A crucial question for which there is not an answer yet is whether what happened to the man in Reno, where the second case was more severe than the first, remains a buy kamagra uk review rare occurrence, as researchers expect and hope.

As the Nevada researchers wrote, “the generalizability of this finding is unknown.”An advocacy group has asked the Department of Defense to investigate what it called “an apparent failure” by Moderna (MRNA) to disclose millions of dollars in awards received from the Defense Advanced Research Projects Agency in patent applications the company filed for treatments.In a letter to the agency, Knowledge Ecology International explained that a review of dozens of patent applications found the company received approximately $20 million from the federal government in grants several years ago and the funds “likely” led to the creation of its treatment technology. This was used to develop treatments to combat different kamagraes, such as Zika and, later, the kamagra that causes erectile dysfunction treatment.In arguing for an investigation, the buy kamagra uk review advocacy group maintained Moderna is obligated under federal law to disclose the grants that led to nearly a dozen specific patent applications and explained the financial support means the U.S. Government would have certain rights over the patents. In other words, buy kamagra uk review U.S. Taxpayers would have an ownership stake in treatments developed by the company.advertisement “This clarifies the public’s right in the inventions,” said Jamie Love, who heads Knowledge Ecology International, a nonprofit that tracks patents and access to medicines issues.

€œThe disclosure (also) changes the narrative about who has financed the inventive activity, often the most risky part of development.” One particular patent assigned to Moderna concerns methods and compositions that can be buy kamagra uk review used specifically against erectile dysfunctiones, including erectile dysfunction treatment. The patent names a Moderna scientist and a former Moderna scientist as inventors, both of which acknowledged performing work under the DARPA awards in two academic papers, according to the report by the advocacy group.advertisement The group examined the 126 patents assigned to Moderna or ModernaTx as well as 154 patent applications. €œDespite the evidence that multiple inventions were conceived in the course of research supported by the DARPA awards, not a single one of the patents or applications assigned to Moderna disclose U.S. Federal government funding,” the buy kamagra uk review report stated.[UPDATE. A DARPA spokesman sent us this over the weekend.

€œIt appears that all past and present DARPA awards to Moderna include the requirement to report the role of government funding for related inventions buy kamagra uk review. Further, DARPA is actively researching agency awards to Moderna to identify which patents and pending patents, if any at all, may be associated with DARPA support. This effort is ongoing.”]We asked Moderna for comment and will update you accordingly.The missive to the Department of Defense follows a recent buy kamagra uk review analysis by Public Citizen, another advocacy group, indicating the National Institutes of Health may own mRNA-1273, the Moderna treatment candidate for erectile dysfunction treatment. The advocacy group noted the federal government filed multiple patents covering the treatment and two patent applications, in particular, list federal scientists as co-inventors.The analyses are part of a larger campaign among advocacy groups and others in the U.S. And elsewhere to ensure that erectile dysfunction treatment medical products are available to poor populations buy kamagra uk review around the world.

The concern reflects the unprecedented global demand for therapies and treatments, and a race among wealthy nations to snap up supplies from treatment makers. In the U.S., the buy kamagra uk review effort has focused on the extent to which the federal government has provided taxpayer dollars to different companies to help fund their discoveries. In some cases, advocates argue that federal funding matters because it clarifies the rights that the U.S. Government has to ensure a buy kamagra uk review therapy or treatment is available to Americans on reasonable terms.One example has been remdesivir, the Gilead Sciences (GILD) treatment being given to hospitalized erectile dysfunction treatment patients. The role played by the U.S.

Government in developing remdesivir to combat erectile dysfunctiones involved contributions from government buy kamagra uk review personnel at such agencies as the U.S. Army Medical Research Institute of Infectious Diseases.As for the Moderna treatment, earlier this month, the company was awarded a $1.525 billion contract by the Department of Defense and the Department of Health and Human Services to manufacture and deliver 100 million doses of its erectile dysfunction treatment. The agreement also includes an option to purchase another 400 million doses, although the terms were not disclosed buy kamagra uk review. In announcing the agreement, the government said it would ensure Americans receive the erectile dysfunction treatment at no cost, although they may be charged by health care providers for administering a shot.In this instance, however, Love said the “letter is not about price or profits. It’s about (Moderna) not buy kamagra uk review owning up to DARPA funding inventions.

If the U.S. Wants to pay for all of the development of buy kamagra uk review Moderna’s treatment, as Moderna now acknowledges, and throw in a few more billion now, and an option to spend billions more, it’s not unreasonable to have some transparency over who paid for their inventions.”This is not the first time Moderna has been accused of insufficient disclosure. Earlier this month, Knowledge Ecology International and Public Citizen maintained the company failed to disclose development costs in a $955 million contract awarded by BARDA for its erectile dysfunction treatment. In all, the federal government has awarded the company approximately $2.5 billion to develop the treatment.The coming few weeks represent a crucial moment for an ambitious plan to try to secure erectile dysfunction treatments for roughly 170 countries around the world without the deep pockets to compete for what will be scarce initial supplies.Under the plan, countries that want to pool resources to buy treatments must notify the World Health buy kamagra uk review Organization and other organizers — Gavi, the treatment Alliance, as well as the Coalition for Epidemic Preparedness Innovations — of their intentions by Monday. That means it’s fish-or-cut-bait time for the so-called COVAX facility.Already, wealthy countries — the United States, the United Kingdom, Japan, Canada, and Australia, among others, as well as the European Union — have opted to buy their own treatment, signing bilateral contracts with manufacturers that have secured billions of doses of treatment already.

That raises the possibility that less wealthy countries will be boxed out of buy kamagra uk review supplies.advertisement And yet Richard Hatchett, the CEO of CEPI, insists there is a path to billions of doses of treatment for the rest of the world in 2021. STAT spoke with Hatchett this week. A transcript buy kamagra uk review of the conversation, lightly edited for clarity and length, follows. You said this is a critical time for CEPI. Can you explain what needs to happen between now and mid-September for this joint purchasing approach to be a success?.

Advertisement The critical moment is now for countries to commit to the buy kamagra uk review COVAX facility, because that will enable us to secure ample quantities of treatment and then to be able to convey when that treatment is likely to become available based on current information.What we’re now here asking countries to do is to indicate their intent to participate by Aug. 31, and to make a binding commitment by Sept. 18. And to provide funds in support of that binding commitment by early October. Our negotiations with companies are already taking place and it will be important for us from a planning purpose that countries indicate their intent to participate.Those binding commitments we think will be sufficient to allow us to then secure the advance purchase agreements, particularly with those companies that don’t have a prior contractual obligation to COVAX.

And then obviously, we need the funds to live up to those advance purchase agreements.Is it possible this thing could still fall apart?. There appears to be some concern COVAX has been boxed out by rich countries. There was always a possibility that there wouldn’t be sufficient uptake. But I think we’re very encouraged at this point by the level of commitment, both from countries that would be beneficiaries of the advance market commitment — that’s the lower-income, lower-middle-income countries — as well as the self-financing countries. To have over 170 countries expressing interest in participating — they see the value.We’re much more encouraged now that it’s not going to fall apart.

We still need to bring it off to maximize its value. And we’re right at the crunch moment where countries are going to have to make these commitments. So, the next month is really absolutely critical to the facility. I am confident at this point that the world recognizes the value and wants it to work.I’ve been keeping tabs on advance purchase agreements that have been announced. And at this point, a small number of rich countries have nailed down a lot of treatment — more than 3 billion doses.

How hard does that make your job?. The fact that they’re doing it creates anxiety among other countries. And that in itself can accelerate the pace. So, I’m not going to say that we’re not watching that with concern.I will say that for COVAX and the facility, this is absolutely critical moment. I think we still have a window of opportunity between now and mid-September — when we’re asking that the self-financing countries to make their commitments — to make the facility real and to make it work.

Between doses that are committed to COVAX through the access agreements and other agreements — these are discussions with partners that CEPI has funded as well as partners that CEPI has not funded — we still see a pathway for COVAX to well over 3 billion doses in 2021.I think it’s really important to bear in mind is that there are at least a few countries — and I think the U.S. And the U.K. Most publicly — that may be in a situation of significant oversupply. I believe the U.S. And U.K.

Numbers, if you add them together, would result in enough treatment for 600 million people to receive two doses of treatment each. And, you know, there is no possible way that the U.S. Or the U.K. Can use that much treatment.So, there may be a lot of extra supply that looks like it’s been tied up sloshing around later. I don’t think that the bilateral deals that have been struck are going to prevent COVAX from achieving its goals.But if so much treatment has been pre-ordered by rich countries, can countries in the COVAX pool get enough for their needs?.

One of the things that we’ve argued through COVAX is that to control the kamagra or to end the acute phase of the kamagra to allow normalcy to start to reassert itself, you don’t have to vaccinate 100% of your population.You need to vaccinate those at greatest risk for bad outcomes and you need to vaccinate certain critical workers, particularly your health care workforce. And if you can achieve that goal, which for most countries means vaccinating between 20% and maybe 30% of the population, then you can transform the kamagra into something that is much more manageable. Then you can buy yourself time to vaccinate everybody who wants to be vaccinated.We’ve argued the COVAX facility really offers the world the best shot at doing that globally in the fastest possible way, as well as providing for equitable access. This is a case where doing the equitable thing is also doing the efficient thing.CEPI has provided funding to nine treatments. Is it true that all those manufacturers aren’t required to provide the COVAX facility with treatment?.

That is correct. One of the things that we did, and I think it was an important role that CEPI played early on, was that we moved money very, very quickly, in small increments. You know, some of the early contracts were only $5 million or $10 million, to get programs up and running while we potentially put in place much larger-scale, longer-term contracts.If you were doing it over again, would you have given money without strings attached?. Yes, I think I would have. I think that was critically important to initiating programs.Our contract with Moderna was established in about 48 hours.

And that provided critical funding to them to manufacture doses that got them into clinical trials within nine weeks of the genetic sequences [of the erectile dysfunction kamagra] being released.And if you look at the nine programs that we’ve invested in, seven are in clinical trials. Two — the AstraZeneca program now and the Moderna program — are among the handful in Phase 3 clinical trials. And, I think the number of projects that that we funded initially, which started in kind of a biotech or academic phase that have now been picked up by large multinational corporations, there’s at least four. The Themis program being picked up by Merck, Oxford University by AstraZeneca, the University of Queensland by CSL, and Clover being in partnership with GSK, I think that speaks to the quality of the programs that we selected.So, I think that combination of rapid review, speed of funding, getting those programs started, getting them oriented in the right direction, I think all of that is critical to where we are now.Companies that got money from CEPI to build out production capacity — that money came with strings attached, right?. Yes, exactly.

So, where CEPI has made investments that create manufacturing, or secure manufacturing capacity, the commitment has been that the capacity that is attributable to the CEPI investment is committed — at least right of first refusal — to the global procurement facility.WASHINGTON — The Trump administration removed a top Food and Drug Administration communications official from her post on Friday in the wake of several controversial agency misstatements, a senior administration official confirmed to STAT.The spokeswoman, Emily Miller, had played a lead role in defending the FDA commissioner, Stephen Hahn, after he misrepresented data regarding the use of blood plasma from recovered erectile dysfunction treatment patients. The New York Times first reported Miller’s ouster. Miller’s tenure at as the top FDA spokeswoman lasted only 11 days. Her appointment was viewed with alarm by agency officials who felt her presence at the agency was emblematic of broader political pressure from the Trump administration, STAT first reported earlier this week.advertisement Before joining the FDA, Miller had no experience in health or medicine. Her former role as assistant commissioner for media affairs is typically not an appointment filled by political appointees.

The FDA’s communications arm typically maintains a neutral, nonpolitical tone.Miller’s appointment particularly alarmed FDA staff and outside scientists given her history in right-wing political advocacy and conservatism journalism. Her résumé included a stint as a Washington Times columnist, where she penned columns with titles that include “New Obamacare ads make young women look like sluts,” and a 2013 book on gun rights titled “Emily Gets Her Gun. But Obama Wants to Take Yours.”advertisement She also worked as a reporter for One America News Network, a right-wing cable channel that frequently espouses conspiracy theories and has declared an open alliance with President Trump.Miller quickly made her presence known at the FDA. In the wake of Hahn’s misstatements on blood plasma, she aggressively defended the commissioner, falsely claiming in a tweet that the therapy “has shown to be beneficial for 35% of patients.” An FDA press release on blood plasma, issued less than a week after her appointment, similarly alarmed agency insiders by trumpeting the emergency authorization as “Another Achievement in Administration’s Fight Against [the] kamagra.”.

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They will also cheap kamagra pills help cultivate future kamagra not working growth in this rapidly progressing field. The 10 guiding principles identify areas where the International Medical Device Regulators Forum (IMDRF), international standards organizations and other collaborative bodies could work to advance GMLP. Areas of collaboration include research, creating educational tools and resources, international harmonization, and consensus standards, which may help inform regulatory policies and regulatory guidelines. We envision kamagra not working these guiding principles may be used to. Adopt good practices that have been proven in other sectors Tailor practices from other sectors so they are applicable to medical technology and the health care sector Create new practices specific for medical technology and the health care sector As the AI/ML medical device field evolves, so too must GMLP best practice and consensus standards.

Strong partnerships with our international public health partners will be crucial if we are to empower stakeholders to advance responsible innovations in this area. Thus, we expect kamagra not working this initial collaborative work can inform our broader international engagements, including with the IMDRF. We welcome your continued feedback through the public docket (FDA-2019-N-1185) at Regulations.gov, and we look forward to engaging with you on these efforts. The Digital Health Center of Excellence is spearheading this work for the FDA. Contact us directly at Digitalhealth@fda.hhs.gov, software@mhra.gov.uk, and kamagra not working mddpolicy-politiquesdim@hc-sc.gc.ca.

Guiding principles Multi-Disciplinary Expertise Is Leveraged Throughout the Total Product Life Cycle. In-depth understanding of a model's intended integration into clinical workflow, and the desired benefits and associated patient risks, can help ensure that ML-enabled medical devices are safe and effective and address clinically meaningful needs over the lifecycle of the device. Good Software Engineering and kamagra not working Security Practices Are Implemented. Model design is implemented with attention to the "fundamentals". Good software engineering practices, data quality assurance, data management, and robust cybersecurity practices.

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Users are provided ready access to clear, contextually relevant information that is appropriate for the intended audience (such as health care providers or patients) including. The product's intended use and indications for use, performance of the model for appropriate subgroups, characteristics of the data used to train and test the model, acceptable inputs, known limitations, user interface interpretation, and clinical workflow integration of the model. Users are also made kamagra not working aware of device modifications and updates from real-world performance monitoring, the basis for decision-making when available, and a means to communicate product concerns to the developer. Deployed Models Are Monitored for Performance and Re-training Risks Are Managed. Deployed models have the capability to be monitored in "real world" use with a focus on maintained or improved safety and performance.

Additionally, when models are periodically or continually trained after deployment, there are appropriate controls in place to manage risks of overfitting, unintended bias, or degradation of the model (for example, dataset drift) that may impact the safety and performance kamagra not working of the model as it is used by the Human-AI team.Date and time. October 27, 2021, 11:00am - 5:00 pm EDTLocation. Via ZoomChair. Lorraine Greaves (Chair), Louise Pilote (Vice-chair)Secretariat.

The 10 guiding principles identify areas where the International Medical Device Regulators Forum (IMDRF), international standards organizations and other collaborative bodies could work to buy kamagra uk review http://guide.thetrademarkhub.com/no-access/ advance GMLP. Areas of collaboration include research, creating educational tools and resources, international harmonization, and consensus standards, which may help inform regulatory policies and regulatory guidelines. We envision these guiding principles may be used to.

Adopt good practices that have been proven in other sectors Tailor practices from other sectors so they are buy kamagra uk review applicable to medical technology and the health care sector Create new practices specific for medical technology and the health care sector As the AI/ML medical device field evolves, so too must GMLP best practice and consensus standards. Strong partnerships with our international public health partners will be crucial if we are to empower stakeholders to advance responsible innovations in this area. Thus, we expect this initial collaborative work can inform our broader international engagements, including with the IMDRF.

We welcome your buy kamagra uk review continued feedback through the public docket (FDA-2019-N-1185) at Regulations.gov, and we look forward to engaging with you on these efforts. The Digital Health Center of Excellence is spearheading this work for the FDA. Contact us directly at Digitalhealth@fda.hhs.gov, software@mhra.gov.uk, and mddpolicy-politiquesdim@hc-sc.gc.ca.

Guiding principles buy kamagra uk review Multi-Disciplinary Expertise Is Leveraged Throughout the Total Product Life Cycle. In-depth understanding of a model's intended integration into clinical workflow, and the desired benefits and associated patient risks, can help ensure that ML-enabled medical devices are safe and effective and address clinically meaningful needs over the lifecycle of the device. Good Software Engineering and Security Practices Are Implemented.

Model design is implemented with attention buy kamagra uk review to the "fundamentals". Good software engineering practices, data quality assurance, data management, and robust cybersecurity practices. These practices include methodical risk management and design process that can appropriately capture and communicate design, implementation, and risk management decisions and rationale, as well as ensure data authenticity and integrity.

Clinical Study Participants and Data buy kamagra uk review Sets Are Representative of the Intended Patient Population. Data collection protocols should ensure that the relevant characteristics of the intended patient population (for example, in terms of age, gender, sex, race, and ethnicity), use, and measurement inputs are sufficiently represented in a sample of adequate size in the clinical study and training and test datasets, so that results can be reasonably generalized to the population of interest. This is important to manage any bias, promote appropriate and generalizable performance across the intended patient population, assess usability, and identify circumstances where the model may underperform.

Training Data Sets Are Independent of Test Sets buy kamagra uk review. Training and test datasets are selected and maintained to be appropriately independent of one another. All potential sources of dependence, including patient, data acquisition, and site factors, are considered and addressed to assure independence.

Selected Reference Datasets Are Based Upon Best Available Methods. Accepted, best available methods for developing a reference dataset (that is, a buy kamagra uk review reference standard) ensure that http://sherimackey.com/2011/01/21/potential-what-is-it/ clinically relevant and well characterized data are collected and the limitations of the reference are understood. If available, accepted reference datasets in model development and testing that promote and demonstrate model robustness and generalizability across the intended patient population are used.

Model Design Is Tailored to the Available Data and Reflects the Intended Use of the Device. Model design is suited to buy kamagra uk review the available data and supports the active mitigation of known risks, like overfitting, performance degradation, and security risks. The clinical benefits and risks related to the product are well understood, used to derive clinically meaningful performance goals for testing, and support that the product can safely and effectively achieve its intended use.

Considerations include the impact of both global and local performance and uncertainty/variability in the device inputs, outputs, intended patient populations, and clinical use conditions. Focus Is Placed on the Performance of buy kamagra uk review the Human-AI Team. Where the model has a "human in the loop," human factors considerations and the human interpretability of the model outputs are addressed with emphasis on the performance of the Human-AI team, rather than just the performance of the model in isolation.

Testing Demonstrates Device Performance During Clinically Relevant Conditions. Statistically sound test plans are developed and executed to generate clinically buy kamagra uk review relevant device performance information independently of the training data set. Considerations include the intended patient population, important subgroups, clinical environment and use by the Human-AI team, measurement inputs, and potential confounding factors.

Users Are Provided Clear, Essential Information. Users are provided ready access to clear, contextually relevant information that is appropriate for the intended audience (such as health care buy kamagra uk review providers or patients) including. The product's intended use and indications for use, performance of the model for appropriate subgroups, characteristics of the data used to train and test the model, acceptable inputs, known limitations, user interface interpretation, and clinical workflow integration of the model.

Users are also made aware of device modifications and updates from real-world performance monitoring, the basis for decision-making when available, and a means to communicate product concerns to the developer. Deployed Models Are Monitored for buy kamagra uk review Performance and Re-training Risks Are Managed. Deployed models have the capability to be monitored in "real world" use with a focus on maintained or improved safety and performance.

Additionally, when models are periodically or continually trained after deployment, there are appropriate controls in place to manage risks of overfitting, unintended bias, or degradation of the model (for example, dataset drift) that may impact the safety and performance of the model as it is used by the Human-AI team.Date and time. October 27, buy kamagra uk review 2021, 11:00am - 5:00 pm EDTLocation. Via ZoomChair.

Lorraine Greaves (Chair), Louise Pilote (Vice-chair)Secretariat. Jenna Griffiths, Laetitia Guillemette, Therapeutic Products Directorate (TPD)Participants.