CfIRF8-like interacts with the TBK1/IKKε family protein and regulates host antiviral innate immunity.

The interferon regulatory factor (IRF) family, a class of transcription factors with key functions, are important in host innate immune defense and stress response. However, further research is required to determine the functions of IRFs in invertebrates. In this study, the coding sequence of an IRF gene was obtained from the Zhikong scallop (Chlamys farreri) and named CfIRF8-like. The open reading frame of CfIRF8-like was 1371 bp long and encoded 456 amino acids. Protein domain prediction revealed a typical IRF domain in the N-terminus of the CfIRF8-like protein and a typical IRF3 domain in the C-terminus. Multiple sequence alignment confirmed the conservation of the amino acid sequences of these two functional protein domains. Phylogenetic analysis showed that CfIRF8-like clustered with mollusk IRF8 proteins and then clustered with vertebrate IRF3, IRF4, and IRF5 subfamily proteins. Quantitative real-time PCR detected CfIRF8-like mRNA in all tested scallop tissues, with the highest expression in the gills. Simultaneously, the expression of CfIRF8-like transcripts in gills was significantly induced by polyinosinic-polycytidylic acid challenge. The results of protein interaction experiments showed that CfIRF8-like could directly bind the TBK1/IKKε family protein of scallop (CfIKK2) via its N-terminal IRF domain, revealing the presence of an ancient functional TBK1/IKKε-IRF signaling axis in scallops. Finally, dual-luciferase reporter assay results showed that the overexpression of CfIRF8-like in human embryonic kidney 293T cells could specifically activate the interferon ß promoter of mammals and the interferon-stimulated response element promoter in dose-dependent manners. The findings of this preliminary analysis of the signal transduction and immune functions of scallop CfIRF8-like protein lay a foundation for an in-depth understanding of the innate immune function of invertebrate IRFs and the development of comparative immunology. The experimental results also provide theoretical support for the breeding of scallop disease-resistant strains.

An open challenge to advance probabilistic forecasting for dengue epidemics.

A wide range of research has promised new tools for forecasting infectious disease dynamics, but little of that research is currently being applied in practice, because tools do not address key public health needs, do not produce probabilistic forecasts, have not been evaluated on external data, or do not provide sufficient forecast skill to be useful. We developed an open collaborative forecasting challenge to assess probabilistic forecasts for seasonal epidemics of dengue, a major global public health problem. Sixteen teams used a variety of methods and data to generate forecasts for 3 epidemiological targets (peak incidence, the week of the peak, and total incidence) over 8 dengue seasons in Iquitos, Peru and San Juan, Puerto Rico. Forecast skill was highly variable across teams and targets. While numerous forecasts showed high skill for midseason situational awareness, early season skill was low, and skill was generally lowest for high incidence seasons, those for which forecasts would be most valuable. A comparison of modeling approaches revealed that average forecast skill was lower for models including biologically meaningful data and mechanisms and that both multimodel and multiteam ensemble forecasts consistently outperformed individual model forecasts. Leveraging these insights, data, and the forecasting framework will be critical to improve forecast skill and the application of forecasts in real time for epidemic preparedness and response. Moreover, key components of this project-integration with public health needs, a common forecasting framework, shared and standardized data, and open participation-can help advance infectious disease forecasting beyond dengue.

Models of Trachoma Transmission and Their Policy Implications: From Control to Elimination.

Despite great progress in eliminating trachoma from the majority of worldwide districts, trachoma control seems to have stalled in some endemic districts. Can mathematical models help suggest the way forward? We review specific achievements of models in trachoma control in the past. Models showed that, even with incomplete coverage, mass drug administration could eliminate disease through a spillover effect, somewhat analogous to how incomplete vaccine campaigns can eliminate disease through herd protection. Models also suggest that elimination can always be achieved if enough people are treated often enough with an effective enough drug. Other models supported the idea that targeting ages at highest risk or continued improvements in hygiene and sanitation can contribute meaningfully to trachoma control. Models of intensive targeting of a core group may point the way to final eradication even in areas with substantial transmission and within-community heterogeneity.

Ratiometric optical sensor for high-resolution imaging of pH with low cross-talk.

We synthesize lipophilic, highly efficient, and pH-insensitive oleic acid-modified quantum dots (QDs) with maximum emission at a wavelength of 628 nm. The pH sensing film is fabricated by encapsulating 5-hexadecanoylamino-fluorescein and QDs as the reference in D4-hydromed and plasticized polystyrene. Using a light-emitting diode with a central wavelength of 410 nm as an excitation source, it is shown that the emission wavelengths of the pH sensitive indicator and reference dye have no spectral overlap and match respectively the channels of a 3CCD (RGB) camera with low cross-talk. A series of validation experiments shows that this ratiometric pH optode has good properties of high sensitivity, long-term stability, and photostability. It had a fast response time of <20 s when going from pH 6.3 to pH 8.0. The pH images suggest that the proposed ratiometric pH-sensing approach has great advantage and promise for field applications.

The role of vaccination coverage, individual behaviors, and the public health response in the control of measles epidemics: an agent-based simulation for California.

BACKGROUND: Measles cases continue to occur among susceptible individuals despite the elimination of endemic measles transmission in the United States. Clustering of disease susceptibility can threaten herd immunity and impact the likelihood of disease outbreaks in a highly vaccinated population. Previous studies have examined the role of contact tracing to control infectious diseases among clustered populations, but have not explicitly modeled the public health response using an agent-based model. METHODS: We developed an agent-based simulation model of measles transmission using the Framework for Reconstructing Epidemiological Dynamics (FRED) and the Synthetic Population Database maintained by RTI International. The simulation of measles transmission was based on interactions among individuals in different places: households, schools, daycares, workplaces, and neighborhoods. The model simulated different levels of immunity clustering, vaccination coverage, and contact investigations with delays caused by individuals' behaviors and/or the delay in a health department's response. We examined the effects of these characteristics on the probability of uncontrolled measles outbreaks and the outbreak size in 365 days after the introduction of one index case into a synthetic population. RESULTS: We found that large measles outbreaks can be prevented with contact investigations and moderate contact rates by having (1) a very high vaccination coverage (≥ 95%) with a moderate to low level of immunity clustering (≤ 0.5) for individuals aged less than or equal to 18 years, or (2) a moderate vaccination coverage (85% or 90%) with no immunity clustering for individuals (≤ 18 years of age), a short intervention delay, and a high probability that a contact can be traced. Without contact investigations, measles outbreaks may be prevented by the highest vaccination coverage with no immunity clustering for individuals (≤ 18 years of age) with moderate contact rates; but for the highest contact rates, even the highest coverage with no immunity clustering for individuals (≤ 18 years of age) cannot completely prevent measles outbreaks. CONCLUSIONS: The simulation results demonstrated the importance of vaccination coverage, clustering of immunity, and contact investigations in preventing uncontrolled measles outbreaks.

Stiffness Optimal Modulation of a Variable Stiffness Energy Storage Hip Exoskeleton and Experiments on its Assistance Effect.

Lower limb energy storage assisted exoskeletons realize walking assistance by using the energy stored by elastic elements during walking. Such exoskeletons are characterized by a small volume, light weight and low price. However, energy storage assisted exoskeletons adopt fixed stiffness joints typically, which cannot adapt to changes of the wearer's height, weight, or walking speed. In this study, based on the analysis of the energy flow characteristics and stiffness change characteristics of lower limb joints during a human walking on flat ground, a novel variable stiffness energy storage assisted hip exoskeleton is designed, and a stiffness optimization modulation method is proposed to store most of the negative work done by the human hip joint when walking. Through the analysis of the surface electromyography signals of the rectus femoris and long head of the biceps femoris, it is found that the muscle fatigue of the rectus femoris is reduced by 8.5% under the optimal stiffness assistance condition, and the exoskeleton provides better assistance under the optimal stiffness assistance condition.

Research on adaptive impedance control technology of upper limb rehabilitation robot based on impedance parameter prediction.

Introduction: With the aggravation of aging and the growing number of stroke patients suffering from hemiplegia in China, rehabilitation robots have become an integral part of rehabilitation training. However, traditional rehabilitation robots cannot modify the training parameters adaptively to match the upper limbs' rehabilitation status automatically and apply them in rehabilitation training effectively, which will improve the efficacy of rehabilitation training. Methods: In this study, a two-degree-of-freedom flexible drive joint rehabilitation robot platform was built. The forgetting factor recursive least squares method (FFRLS) was utilized to estimate the impedance parameters of human upper limb end. A reward function was established to select the optimal stiffness parameters of the rehabilitation robot. Results: The results confirmed the effectiveness of the adaptive impedance control strategy. The findings of the adaptive impedance control studies showed that the adaptive impedance control had a significantly greater reward than the constant impedance control, which was in line with the simulation results of the variable impedance control. Moreover, it was observed that the levels of robot assistance could be suitably modified based on the subject's different participation. Discussion: The results facilitated stroke patients' upper limb rehabilitation by enabling the rehabilitation robot to adaptively change the impedance parameters according to the functional status of the affected limb. In clinic therapy, the proposed control strategy may help to adjust the reward function for different patients to improve the rehabilitation efficacy eventually.

KRT19 is a Promising Prognostic Biomarker and Associates with Immune Infiltrates in Serous Ovarian Cystadenocarcinoma.

Background: Ovarian cancer (OV) is the highest prevalent gynecologic tumor with complicated pathogenesis; high-grade serous ovarian cystadenocarcinoma (HGSOC) is the most epidemiological and malignant subtype of OV. Keratin type I cytoskeleton 19 (KRT19) is an intermediate filament protein which plays essential roles in the maintenance of epithelial cells. However, its role in OV remains largely unknown. Methods: Bioinformatic analysis with various databases was conducted in this study. In details, KRT19 expression was assessed using databases including The Cancer Genome Atlas (TCGA), Genotype-Tissue Expression (GTEx), Gene Expression Omnibus (GEO) and Human Protein Atlas (HPA). GO-KEGG and GSEA analysis were performed by R packages. The biological function of KRT19 was analyzed based on the single-cell sequencing information from CancerSEA database. The association of KRT19 expression with immunomodulator and chemokine was predicted via the TISIDB database. Results: The expression of KRT19 was significantly upregulated in ovarian samples compared with normal controls. KRT19 expression was negatively associated with prognosis in OV, and further analysis revealed that KRT19 had promising diagnostic significance in distinguishing OV cancer from normal samples. GO-KEGG and GSEA analysis indicated that KRT19 was associated with multiple biological functions and pathways including epidermis development, apical junction, inflammatory response, and epithelial mesenchymal transition. By using different GEO series, we found that KRT19 was differentially expressed in OV-associated tissues. Furthermore, the increased KRT19 expression was positively correlated with the immune infiltration levels of the most immune cells in OV. Conclusion: This study demonstrated that KRT19 is a promising prognosis and diagnosis biomarker that determines cancer progression and is correlated with tumor immune cells infiltration in OV, suggesting being a molecular target for immunotherapies.

Triple A syndrome-related achalasia treated by per-oral endoscopic myotomy: Three case reports.

BACKGROUND: Triple A syndrome is a rare autosomal recessive disease characterized by adrenocorticotropic hormone-resistant adrenal insufficiency, alacrima and achalasia. In the last 5 years, per-oral endoscopic myotomy (POEM) has proved highly successful in treating primary achalasia over the long term, but its long-term performance has not been certified by achalasia related to Triple A syndrome. CASE SUMMARY: Triple A syndrome is a rare autosomal recessive disease characterized by adrenocorticotropic hormone-resistant adrenal insufficiency, alacrima and achalasia. In the past 5 years, POEM has proved highly successful in treating primary achalasia over the long term, but its long-term performance has not been certified by achalasia related to Triple A syndrome. Eckardt scores and esophageal manometry improved significantly during the 2 years following POEM; however, grade-A reflux esophagitis recurred in 66.7% of patients in 12 mo post-procedure. CONCLUSION: Based on these case studies, POEM is efficacious and safe for a treatment of achalasia associated with Triple A syndrome.

Modeling and Position Control Simulation Research on Shape Memory Alloy Spring Actuator.

The shape memory alloy (SMA) actuator is widely used in aerospace, medical and robot fields because of its advantages of low driving voltage, large driving force, no noise and high-power-weight ratio. Therefore, it is of great significance to establish the theoretical model of the SMA actuator and analyze the driving characteristics of the SMA actuator. On the basis of summarizing the constitutive model of the shape memory alloy spring, the phase transformation dynamics model of SMA including the minor hysteresis loop is established using the Duhem model in this paper, and the theoretical models of the bias and differential SMA spring actuator are established. At the same time, a PID position controller including anti-saturation and anti-overheating functions is proposed to control the position of the SMA actuator. Finally, the position control simulation model of the SMA spring actuator is established and simulated. Simulation results show that the position of the SMA actuator can be well controlled by using the model and control method established in this paper.

Nontoxic Tb3+-induced hyaluronic nano-poached egg aggregates for colorimetric and luminescent detection of Fe3+ ions.

This study demonstrates that a luminescent Tb3+ complex with green emission can be complexed with hyaluronic (hya) to form nanoparticles. The structure of complexation is composed of a Tb(acac)2phen core with a hya surface, similar to those of the nano-poached eggs. What makes the structure unique is that Tb(acac)2phen and hya are connected by chemical bonds. To confirm their utility, we illustrate that the luminescence is rapidly and selectively quenched in the presence of Fe3+. Initial cytotoxicity experiments with human liver carcinoma cells show that the luminescent lanthanide complexes are cytotoxic, however, complexing lanthanides to hya renders them cytocompatible. The new complex integrates the advantages of superior lanthanide luminescence, the unique shape of nano-poached eggs, compatibility with aqueous systems, and cytocompatibility. Tb3+-induced hyaluronic nano-poached eggs (THNE) can, therefore, be used for Fe3+ detection in aqueous systems.

A novel TBK1/IKKϵ is involved in immune response and interacts with MyD88 and MAVS in the scallop Chlamys farreri.

Inhibitor of κB kinase (IKK) family proteins are key signaling molecules in the animal innate immune system and are considered master regulators of inflammation and innate immunity that act by controlling the activation of transcription factors such as NF-κB. However, few functional studies on IKK in invertebrates have been conducted, especially in marine mollusks. In this study, we cloned the IKK gene in the Zhikong scallop Chlamys farreri and named it CfIKK3. CfIKK3 encodes a 773-amino acid-long protein, and phylogenetic analysis showed that CfIKK3 belongs to the invertebrate TBK1/IKKϵ protein family. Quantitative real-time PCR analysis showed that CfIKK3 mRNA is ubiquitously expressed in all tested scallop tissues. The expression of CfIKK3 transcripts was significantly induced after challenge with lipopolysaccharide, peptidoglycan, or poly(I:C). Co-immunoprecipitation (co-IP) assays confirmed the direct interaction of CfIKK3 with MyD88 (the key adaptor in the TLR pathway) and MAVS (the key adaptor in the RLR pathway), suggesting that this IKK protein plays a crucial role in scallop innate immune signal transduction. In addition, the CfIKK3 protein formed homodimers and bound to CfIKK2, which may be a key step in the activation of its own and downstream transcription factors. Finally, in HEK293T cells, dual-luciferase reporter gene experiments showed that overexpression of CfIKK3 protein activated the NF-κB reporter gene in a dose-dependent manner. In conclusion, our experimental results confirmed that CfIKK3 could respond to PAMPs challenge and participate in scallop TLR and RLR pathway signaling, ultimately activating NF-κB. Therefore, as a key signaling molecule and modulator of immune activity, CfIKK3 plays an important role in the innate immune system of scallops.

Scallop interferon regulatory factor 1 interacts with myeloid differentiation primary response protein 88 and is crucial for antiviral innate immunity.

The interferon regulatory factor (IRF) family comprises transcription factors that are crucial in immune defense, stress response, reproduction, and development. However, the function of IRFs in invertebrates is unclear. Here, the full-length cDNA of an IRF-encoding gene (CfIRF1) in the Zhikong scallop (Chlamys farreri) comprising 2007 bp with an open reading frame of 1053 bp that encoded 350 amino acids was characterized, and its immune function was studied. The CfIRF1 protein contained a typical IRF domain at its N-terminus. CfIRF1 was clustered with other proteins of the IRF1 subfamily, implying that they were closely related. CfIRF1 mRNA transcripts could be detected in all tested scallop tissues, with the highest expression observed in the gills and hepatopancreas. CfIRF1 expression was significantly induced by the polyinosinic-polycytidylic acid and acute viral necrosis virus challenge. CfIRF1 could directly interact with myeloid differentiation primary response protein 88 (MyD88), the key adaptor molecule of the toll-like receptor signaling pathway. CfIRF1 did not interact with scallop IKK1 (IKKα/ß family protein), IKK2, IKK3 (IKKε/TBK1 family protein), or with other IRF family proteins (IRF2 or IRF3). However, CfIRF1 interacted with itself to form a homodimer. CfIRF1 could specifically activate the interferon ß promoter of mammals and the promoter containing the interferon-stimulated response element (ISRE) in a dose-dependent manner. The truncated form of CfIRF1 had a significantly reduced ISRE activation ability, indicating that structural integrity was crucial for CfIRF1 to function as a transcription factor. Our findings provide insights into the functions of mollusk IRFs in innate immunity. The research results also provide valuable information that enriches the theory of comparative immunology and that can help prevent diseases in scallop farming.

Prevention of diet-induced obesity by safflower oil: insights at the levels of PPARalpha, orexin, and ghrelin gene expression of adipocytes in mice.

The aim of this study was to investigate the prevention of diet-induced obesity by a high safflower oil diet and adipocytic gene expression in mice. Forty 3-week-old C57BL/6 mice were randomly divided into three groups: control group (CON, 5% lard + 5% safflower oil), high lard group (LAR, 45% lard + 5% safflower oil), and high safflower oil group (SAF, 45% safflower oil + 5% lard). After 10 weeks, 10 mice of the LAR group were switched to high safflower oil diet (LAR-SAF). Ten weeks later, glucose tolerance tests were performed by intraperitoneal injection of glucose. Circulating levels of lipid and insulin were measured and white adipose tissues were taken for gene chip and reverse transcriptase-polymerase chain reaction analysis. The LAR group showed higher body weight, adiposity index, insulin, and lipids than the CON group (P<0.05). The body weight in the LAR-SAF group decreased after dietary reversal. The plasma biochemical profiles decreased in the LAR-SAF and SAF groups (P<0.05) compared with those of the LAR group. The blood glucose level of the LAR-SAF group was reduced during intraperitoneal glucose tolerance test compared with that of the LAR group. The LAR-SAF group had lower levels of Orexin and Ghrelin gene expression, whereas the level of PPARalpha gene expression was significantly enhanced compared with that of the LAR group. So, the SAF diet can alter adipocytic adiposity-related gene expression and result in effective amelioration of diet-induced obesity.

Facebook and Twitter vaccine sentiment in response to measles outbreaks.

Social media posts regarding measles vaccination were classified as pro-vaccination, expressing vaccine hesitancy, uncertain, or irrelevant. Spearman correlations with Centers for Disease Control and Prevention-reported measles cases and differenced smoothed cumulative case counts over this period were reported (using time series bootstrap confidence intervals). A total of 58,078 Facebook posts and 82,993 tweets were identified from 4 January 2009 to 27 August 2016. Pro-vaccination posts were correlated with the US weekly reported cases (Facebook: Spearman correlation 0.22 (95% confidence interval: 0.09 to 0.34), Twitter: 0.21 (95% confidence interval: 0.06 to 0.34)). Vaccine-hesitant posts, however, were uncorrelated with measles cases in the United States (Facebook: 0.01 (95% confidence interval: -0.13 to 0.14), Twitter: 0.0011 (95% confidence interval: -0.12 to 0.12)). These findings may result from more consistent social media engagement by individuals expressing vaccine hesitancy, contrasted with media- or event-driven episodic interest on the part of individuals favoring current policy.

The distribution of district-level leprosy incidence in India is geometric-stable, consistent with subcriticality.

Mathematical models predict that the community-level incidence of a controlled infectious disease across a region approaches a geometric distribution. This could hold over larger regions, if new cases remain proportional to existing cases. Leprosy has been disappearing for centuries, making an excellent candidate for testing this hypothesis. Here, we show the annual new case detection rate of leprosy in Indian districts to be consistent with a geometric distribution. For 2008-2013, goodness-of-fit testing was unable to exclude the geometric, and the shape parameter of the best fit negative binomial distribution was close to unity (0.95, 95% CI 0.87-1.03). Ramifications include that a district-level cross-sectional survey may reveal whether an infectious disease is headed towards elimination, that apparent outliers are expected and not necessarily representative of program failure, and that proportion 1/e of a small geographical unit may not meet a control threshold even when a larger area has.

Spatial distribution of leprosy in India: an ecological study.

BACKGROUND: As leprosy elimination becomes an increasingly realistic goal, it is essential to determine the factors that contribute to its persistence. We evaluate social and economic factors as predictors of leprosy annual new case detection rates within India, where the majority of leprosy cases occur. METHODS: We used correlation and linear mixed effect regressions to assess whether poverty, illiteracy, nighttime satellite radiance (an index of development), and other covariates can explain district-wise annual new case detection rate and Grade 2 disability diagnoses. RESULTS: We find only weak evidence of an association between poverty and annual new case detection rates at the district level, though illiteracy and satellite radiance are statistically significant predictors of leprosy at the district level. We find no evidence of rapid decline over the period 2008-2015 in either new case detection or new Grade 2 disability. CONCLUSIONS: Our findings suggest a somewhat higher rate of leprosy detection, on average, in poorer districts; the overall effect is weak. The divide between leprosy case detection and true incidence of clinical leprosy complicates these results, particularly given that the detection rate is likely disproportionately lower in impoverished settings. Additional information is needed to distinguish the determinants of leprosy case detection and transmission during the elimination epoch.

Probabilistic forecasts of trachoma transmission at the district level: A statistical model comparison.

The World Health Organization and its partners are aiming to eliminate trachoma as a public health problem by 2020. In this study, we compare forecasts of TF prevalence in 2011 for 7 different statistical and mechanistic models across 9 de-identified trachoma endemic districts, representing 4 unique trachoma endemic countries. We forecast TF prevalence between 1-6 years ahead in time and compare the 7 different models to the observed 2011 data using a log-likelihood score. An SIS model, including a district-specific random effect for the district-specific transmission coefficient, had the highest log-likelihood score across all 9 districts and was therefore the best performing model. While overall the deterministic transmission model was the least well performing model, although it did comparably well to the other models for 8 of 9 districts. We perform a statistically rigorous comparison of the forecasting ability of a range of mathematical and statistical models across multiple endemic districts between 1 and 6 years ahead of the last collected TF prevalence data point in 2011, assessing results against surveillance data. This study is a step towards making statements about likelihood and time to elimination with regard to the WHO GET2020 goals.

Short-term leprosy forecasting from an expert opinion survey.

We conducted an expert survey of leprosy (Hansen's Disease) and neglected tropical disease experts in February 2016. Experts were asked to forecast the next year of reported cases for the world, for the top three countries, and for selected states and territories of India. A total of 103 respondents answered at least one forecasting question. We elicited lower and upper confidence bounds. Comparing these results to regression and exponential smoothing, we found no evidence that any forecasting method outperformed the others. We found evidence that experts who believed it was more likely to achieve global interruption of transmission goals and disability reduction goals had higher error scores for India and Indonesia, but lower for Brazil. Even for a disease whose epidemiology changes on a slow time scale, forecasting exercises such as we conducted are simple and practical. We believe they can be used on a routine basis in public health.

Fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery for a pituitary tumor: A case report.

INTRODUCTION: The fatal type of antiphospholipid syndrome is a rare but life-threating condition. It may be triggered by surgery or infection. Endoscopic transnasal-transsphenoidal surgery is a common procedure for pituitary tumor. We report a catastrophic case of a young woman died of fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery. METHODS AND RESULT: A 31-year-old woman of a history of stroke received endoscopic transnasal-transsphenoidal surgery for a pituitary tumor. The whole procedure was smooth. However, the patient suffered from acute delirium on postoperative day 4. Then, her consciousness became comatose state rapidly with dilatation of pupils. Urgent magnetic resonance imaging of brain demonstrated multiple acute lacunar infarcts. The positive antiphosphoipid antibody and severe thrombocytopenia were also noted. Fatal antiphospholipid syndrome was diagnosed. Plasma exchange, corticosteroids, anticoagulant agent were prescribed. The hemodynamic condition was gradually stable. However, the consciousness was still in deep coma. The patient died of organ donation 2 months later. CONCLUSION: If patients have a history of cerebral stroke in their early life, such as a young stroke, the APS and higher risk of developing fatal APS after major surgery should be considered. The optimal management of APS remains controversial. The best treatment strategies are only early diagnosis and aggressive therapies combing of anticoagulant, corticosteroid, and plasma exchange. The intravenous immunoglobulin is prescribed for patients with refractory APS.