We observed greater BMD at total hip in women who reported regular WBPA at ages 18–29 years (p = 0.02) and 30–49 years (p = 0.02) compared with those who reported no WBPA (p = 0.019), after adjustment for confounders including current activity levels. In this cohort of older adults, recalled regular WBPA around the time of peak bone mass acquisition was less common in women than men, but associated with higher hip BMD in women in late adulthood.We considered how weight-bearing physical activity (WBPA) through the lifecourse related to bone health in late adulthood in the Hertfordshire Cohort Study (HCS), a cohort of community dwelling adults born 1931–9, to identify sex-specific differences and periods critical for optimal bone health. Available questionnaire data from 258 participants (128 men and 130 women) included current reported lifestyle factors  and WBPA, coded as participation in WBPA aged < 18 years; aged 18–29 years; aged 30–49 years and aged ≥ 50 years. Responses were recorded as none/once a month/once a week/> once a week. Hip bone mineral density (BMD) was measured using a Lunar Prodigy DXA scanner. The mean age was 75.4 (SD 2.5) years in men and 75.7 (SD 2.6) years in women. Men reported significantly higher levels of past WBPA aged < 18 years ( As a population, reduced physical activity is becoming increasingly common, and is associated with numerous adverse health consequences, including falls and fracture –3. PhysiPrevious studies have highlighted the benefits of weight-bearing activity for bone health –9 but muIn this study, we used a well-characterised longitudinal cohort of older adults to perform a lifecourse analysis of recalled weight-bearing physical activity (WBPA) and bone health. We sought to consider (1) whether higher physical activity at a particular time point was of benefit and (2) whether the same relationships were seen in men and women.Participants were recruited from the HCS , a studyPersonal recall of previous participation of WBPA was used in this study. Participants answered the following question: how often did you take part in sports and leisure time exercise involving weight-bearing activity?  for each of four age groups. The age groups were as follows: < age 18 years, aged 18–29 years, ages 30–49 years and ≥ 50 years. Responses were categorised as none, once a month, once a week and more than once a week. The responses were scored as 0 for none, 1 for once a month, 2 for once a week and 3 for more than once a week to calculate a cumulative lifetime activity score.The East and North Hertfordshire Ethical Committees granted approval for the study (10/HO311/590), and written informed consent was obtained from all participants.t tests, Mann–Whitney tests, χ2 tests or Fisher’s exact tests. The BMD variables were transformed using the Fisher–Yates rank-based inverse normal transformation to create z scores. Relationships between BMD in later life and the frequency of past WBPA were examined using linear regressions. Analyses were conducted with and without adjusting for age, BMI, social class, smoker status, alcohol consumption, current physical activity and dietary calcium intake, and, additionally, for years since menopause and HRT use in women. Data analysis was carried out using Stata statistical software .Cohort characteristics were summarised using mean and standard deviations (SD), median and interquartile ranges (IQR) or frequencies and percentages (%) as appropriate. Differences between men and women were assessed using Student’s Data on past WBPA were available for 128 men and 130 women. The characteristics of these participants are summarised in Table p = 0.006) and 15.6% (p < 0.001) of women, respectively. For both men and women, the frequency of physical activity decreased as their age increased and sex differences became less marked; in those aged 30–49 years, 23.7% men and 12.5% of women reported activity more than once a week (p = 0.18). The rate decreased further in those aged 50 years or older, with 16.2% of men and only 8.5% of women performing WBPA more than once a week (p = 0.102).There was a modest difference between men and women’s current physical activity at the time of study (median (IQR) activity time 194 110–298) minutes per day for men, 206 (146–277) minutes per day for women). There were, however, statistically significant differences between men and women in the frequency of WBPA over the lifecourse (Table 98 minuteβ) exercise weekly 0.72 z score  0.13, 1.31), p = 0.02; β exercise more than once a week 0.83 z score , p = 0.01), when adjusted for age, BMI, social class, smoker status, alcohol consumption, current physical activity, dietary calcium intake, years since menopause and HRT use, compared to those reporting no WBPA , p = 0.04; β exercise more than once a week 0.78 z score , p = 0.02), when adjusted for confounders. Furthermore, in women, there was a significant dose response between BMD at the total hip and WBPA at ages 18–29, p 0.023, and ages 30–49, p 0.019 when compared to those reported no activity , more regular PA through the lifecourse was associated with higher BMD.We next considered relationships between WBPA and BMD. No relationship was observed between WBPA and BMD in men at any timepoint. Relationships are shown in Figs. In this study, we have examined the relationship between recalled WBPA over the lifecourse and bone health in late adulthood. Men in our cohort group reported higher rates of participation in WBPA from 18 to 29 years, compared to women. However, the overall frequency of WBPA decreased as age increased in both sexes, and differences in WBPA between men and women became less pronounced with age. Indeed, the median time of current physical activity in older age was slightly higher in women than men, which may reflect the inclusion of household tasks in the LAPAQ questionnaire. We observed relationships between WBPA in women at the time of peak bone mass acquisition and BMD measured at later age, with a positive dose-related relationship between higher frequency of past self-reported WBPA at the age of bone acquisition observed and BMD at total hip and femoral neck in women. These relationships were robust to adjustment for current WBPA. This relationship was not seen in men.There are of course limitations to our study; our cohort is based on a group of men and women recruited because they were born in Hertfordshire and still lived there in adult life. However, we have previously shown this group to be representative of the general UK population with regard to lifestyle characteristics such as body mass index and smoking . Our samIn our study, we see a gender difference in physical activity participation. We hypothesise during the 1940s–1960s women will have a different physical activity profile compared to men. Several studies of nationally representative samples have shown men are more likely to participate in moderate-vigorous physical activity than women when younger –22. HoweIn line with the 1946 British Birth Cohort, we note a strong positive relationship between past WBPA at ages 18–29 and ages 30–49 and hip BMD at older adulthood in women; however, in the 1946 British Birth Cohort, the association was stronger in men than women . This maIn conclusion, we have highlighted differences in WBPA across the lifecourse using a historical cohort and reported a positive dose-related association between frequency of past WBPA and BMD in later life in women. This suggests we should encourage young women to participate in regular WBPA throughout the lifecourse, but particularly at the time of peak bone mass accrual, to reap the benefits for bone health later in life.


Sarcopenia is an adverse prognostic factor for diffuse large B‐cell lymphoma. A case of diffuse large B‐cell lymphoma whose diagnosis, severity, and therapeutic effect of sarcopenia were difficult to determine owing to lymphoma cell infiltration into the psoas major and femoral bone marrow is reported. At presentation, the cross‐sectional area of left psoas major at L3 was enlarged owing to lymphoma cell infiltration; thus, sarcopenia evaluation was impossible by L3 skeletal muscle index. The patient was bedridden; thus, sarcopenia evaluation was impossible by the Asian Working Group for Sarcopenia 2019 consensus diagnostic criteria at presentation. At the terminal stage, she could not walk due to bilateral anterior thigh pain caused by lymphoma infiltration into femoral marrow; thus, sarcopenia evaluation was impossible by the Asian Working Group for Sarcopenia 2019 consensus diagnostic criteria. Although the L3 skeletal muscle index and the Asian Working Group for Sarcopenia 2019 consensus diagnostic criteria are representative sarcopenia evaluation systems, they cannot be used to evaluate sarcopenia in some diffuse large B‐cell lymphoma patients. L3 skeletal muscle index and Asian Working Group for Sarcopenia 2019 consensus diagnostic criteria are representative sarcopenia evaluation systems, and they cannot be used to evaluate sarcopenia in some patients with diffuse large B‐cell lymphoma. Lanic et al.2/m2). L3 skeletal muscle index that is below 55.8 cm2/m2 for men and 38.9 cm2/m2 for women were defined as displaying sarcopenia. The Asian Working Group for Sarcopenia 2019 consensus diagnostic criteria defined sarcopenia as “age‐related loss of muscle mass, plus low muscle strength, and/or low physical performance,” without reference to comorbidity, and specified cutoffs for each diagnostic component; criteria for low appendicular skeletal muscle mass are <7.0 kg/m2 in men and <5.7 kg/m2 in women by bioelectrical impedance analysis; criteria for low muscle strength is defined as hand grip strength <28 kg for men and < 18 kg for women; criteria for low physical performance are 6‐meter walking speed <1.0 m/sec.Cancer cachexiaIn this study, we report a case of diffuse large B‐cell lymphoma whose diagnosis, severity, and therapeutic effect of sarcopenia were difficult to determine owing to lymphoma cell infiltration into the psoas major and femoral bone marrow. This case report demonstrates that although L3 skeletal muscle index and the Asian Working Group for Sarcopenia 2019 consensus diagnostic criteria are representative sarcopenia evaluation systems, they cannot be used to evaluate sarcopenia in some diffuse large B‐cell lymphoma patients.2. Positron emission tomography‐computed tomography (PET‐CT) revealed lymphoma cell infiltration into the left psoas major and the femur  and soluble interleukin‐2 receptor (sIL‐2R) levels. At presentation, she was afebrile, and physical examination revealed no skin changes, no lymphadenopathy, and no hepatosplenomegaly. A complete blood test revealed anemia . An increase in serum LDH , sIL‐2R , and C‐reactive protein  were recognized. However, serum albumin  was decreased. A needle biopsy was performed from the right chest wall subcutaneous mass and was histopathologically diagnosed as CD20‐positive diffuse large B‐cell lymphoma r Figure ,ii,iii. e Figure ‐ii. Seco. Because it was demonstrated that decreased chemotherapy dose offers a good compromise between efficacy and safety in patients with diffuse large B‐cell lymphoma aged >80 years,2, day 1), pirarubicin , cyclophosphamide , oncovin , prednisolone ), fatigue, and serum levels of CRP, LDH, and alb were improved . The patient consumed nutrition control food and enteral nutrition  between July 24 and September 1, 2021. The therapeutic diet and enteral nutrition calories were increased from September 2 to overcome severe sarcopenia. PET‐CT performed on September 6, immediately after the fourth course of R‐THP‐COP, which revealed that all lesions had disappeared, except for a right iliac muscle lesion , rituximab ), and R‐GDC therapy2, day 8), gemcitabine , dexamethasone , carboplatin ) on November 4, 2021 , even when diffuse large B‐cell lymphoma worsened  such as the case in our patient.We administered nutrition therapy with 30–35 kcal/kg/day of energy and approximately 1 g/kg/day of protein. Energy requirements at rest are recommended as 25–30 kcal/kg/day in line with oncology‐specific European Society of Parenteral and Enteral Nutrition guidelines.Our patient trained 5 times a week with hand, lower limb, resistance training , and aerobic exercises (gait training). As a result, the patient recovered handgrip strength, recovered the ability to walk a distance of 1800 m/day, and was able to maintain appendicular skeletal muscle mass.Yoshimura et al.Because sarcopenia is considered an adverse prognostic factor for older adult patients with diffuse large B‐cell lymphoma,Grade 4 neutropenia and febrile neutropenia might be evaded by attenuated chemotherapy regimens and prophylactic administration of G‐CSF. However, complete response could not be obtained using this therapeutic strategy.Our study has limitations. We provide empirical data suggesting that a diffuse large B‐cell lymphoma patient whose diagnosis, severity, and therapeutic effect of sarcopenia were difficult to determine owing to lymphoma cell infiltration into the psoas major and femoral bone marrow. However, it is unclear what percentage of diffuse large B‐cell lymphoma patients who show the same pathology as that of our patient when using the L3 skeletal muscle index and the Asian Working Group for Sarcopenia 2019 consensus diagnostic criteria are difficult to determine sarcopenia. Furthermore, it is unknown whether sarcopenia may be difficult to determine even in diffuse large B‐cell lymphoma patients who have a different pathology from ours when using the L3 skeletal muscle index and the Asian Working Group for Sarcopenia 2019 consensus diagnostic criteria. Therefore, in the future, we would like to perform a prospective study to clarify the questions described above.In conclusion, the L3 skeletal muscle index and the Asian Working Group for Sarcopenia 2019 consensus diagnostic criteria are representative sarcopenia evaluation systems but cannot be used to evaluate sarcopenia in some diffuse large B‐cell lymphoma patients.In addition, these sarcopenia evaluation systems have unresolved points shown below. Although the frequency of sarcopenia in diffuse large B‐cell lymphoma is approximately 55% determined using L3 skeletal muscle index,T.M. and M.T. designed this study. T.D., T.Y., T.Y., K.Y., Y.K., and I.H. contributed to gathering data. K.N. performed pathological diagnosis. T.M. wrote the main manuscript text. K.N., M.M., H.S., and F.H. analyzed data and prepared figures. All authors reviewed the manuscript.There are no conflicts of interests to report, and no funding was provided for this research.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


The objective of this study is to report “real‐world” outcomes of prostatic urethral lift (PUL) in a medically complex US military veteran population while employing liberalized procedural indications.t tests.A retrospective review was conducted of patients who underwent PUL at our institution. There were no prostatic size requirements, patients were accepted on anti‐platelet/anticoagulant therapy, no benign prostatic hyperplasia (BPH) medication washout was required, and there was no maximum post‐void residual PVR. Pre‐ and post‐operative International Prostate Symptom Score (IPSS), uroflowmetry, and PVR were recorded. Statistical comparisons were performed using simple p < 0.001). There was a mean 41% decrease in PVR , which was durable for a follow‐up of up to 54 months. Maximum urinary flow rate improved by an average of 32% , which was also durable throughout follow‐ up. Forty‐four patients required catheterization pre‐operatively and 16 required catheterization post‐operatively. Therefore, 27 patients (61.4%) were rendered catheter‐free by PUL. Thirty‐nine patients were taking antiplatelet medications peri‐operatively, and 13 took anticoagulants. Only one patient (on warfarin) experienced hematuria requiring re‐admission with catheter placement.From 2013 to 2019, 91 patients underwent PUL. Mean age was 70 (range 55–92) years. The majority of our patients were classified as American Society of Anesthesiologists (ASA) class 3 versus the general population at ASA class 2. Post‐operatively, IPSS decreased by an average of 43% (23 to 13, PUL produced effective and durable results in our veteran population, including in patients with significant pre‐operative bladder decompensation and those on antiplatelets/anticoagulants. PUL has been shown across multiple studies to provide effective relief for LUTS from BPH.While TURP carries a small risk of post‐operative erectile dysfunction (ED), studies have demonstrated that PUL may actually even improve the Sexual Health Inventory in Men (SHIM) score in men with severe erectile dysfunction (ED).α‐blocker washout, 3‐month 5α‐reductase inhibitor washout, maximum urinary flow rate (Qmax) of 12 ml per second or less, 30 to 80 cc prostate, no median lobe obstruction, and pre‐operative post‐void residual (PVR) urine volume less than 250 ml.The efficacy of PUL was initially demonstrated in a clinical trial with 5‐year follow‐up, in the Luminal Improvement Following Prostatic Tissue Approximation (LIFT) study by Roehrborn et al.Despite multiple studies that have proven the broad possible applications of PUL, we aim to enhance the current literature by showing that PUL is likewise effective in patients with significant medical comorbidities (including many on long term anti‐platelet or anti‐coagulant therapy) and in patients with considerable pre‐operative bladder deconditioning and urinary retention.3t tests. Post‐operative complications and need for additional prostate procedures were also recorded and reported descriptively.This study was approved by the Institutional Review Boards at Baylor College of Medicine and the Michael E. DeBakey VA Medical Center (VAMC) in Houston. The charts of patients who underwent PUL at this large, tertiary care VAMC from 2013 to 2019 were reviewed retrospectively. Clinical characteristics of patients, including demographics, presence of urinary retention, use of anticoagulant/antiplatelet agents, and medical comorbidities, including ASA score, were recorded. Pre‐ and post‐operative subjective and objective parameters, such as International Prostate, or American Urological Association, Symptom Scores (IPSS or AUASS), Sexual Health Inventory in Men (SHIM) score, flow rate, and post‐void residual (PVR) bladder scan, were collected. In addition, details of operative procedures were noted. Pre‐ and post‐operative parameters were compared using paired The inclusion criteria were men with symptomatic BPH who had failed medical therapy or who desired surgical intervention for their BPH symptoms who were surgical candidates. Our local VA urology practice removed urinary retention requiring catheter drainage as an exclusion criterion for PUL, as a significant number of veterans were referred to urology in retention yet were observed to have robust bladder contractility on pressure‐flow studies. These patients often had a high comorbidity index, so we aimed to study if this surgical modality could be used to relieve their outlet obstruction effectively.4From 2013 to 2019, 91 veteran patients underwent PUL at our institution (Table p < 0.001) by a mean of 10 points, consistent with prior studies. The average SHIM score changed from 8.1 pre‐operatively to 9.1 post‐operatively, a trend towards improved erectile function that was not statistically significant (p = 0.57). Objectively, there was a significant decrease in post‐void residual urine volumes after PUL , which was found to be durable for a follow‐up of up to 54 months (Table p = 0.003), which was also found to be durable for a follow‐up of up to 54 months.Subjectively, IPSS decreased significantly  in the median age, pre‐operative PVR, IPSS, Qmax, or prostate volume between individuals who did and did not require a second prostate procedure. All men on medical therapy were continued on medical therapy post‐operatively to provide some benefit in post‐operative edema, bleeding, and irritative symptoms. Via shared‐decision making with the patient and their primary care provider, medications were tapered as the flow rate, PVR, and LUTS allowed.The surgical failure rate of PUL in our patient population was 11.0%. Two individuals in our study (2.1%) underwent a second PUL procedure, and eight individuals (8.8%) underwent subsequent TURP for persistent bothersome symptoms after initial PUL. There was no significant difference  and on a large median lobe in 11 individuals (12.1%), prior to demonstration and approval of use of the PUL on the median lobe. This operative plan was typically developed via shared‐decision making between the patient and a surgeon, while a pre‐operative conference of staff urologists reviewed and approved all operative plans. The operative strategies were devised to minimize operative times and bleeding risks  in this medically complex population, while still hopefully maximizing improvement in LUTS. Overall operative time ranged from 9 to 221 min, with longer procedure times generally accounted for by coupling with additional procedures, such button TURP, bladder stone removal, or urethrotomy.Of our 91 patients, 44 had complete urinary retention pre‐operatively: 18 20%) were performing clean intermittent catheterization (CIC), and 26 (28.9%) had indwelling Foley catheters , 14 reported hematuria (15.4%), and 5 reported pelvic pain (5.5%). Eight individuals (8.9%) experienced urinary tract infections (UTI). Post‐operative erectile dysfunction was reported by only one individual (1.1%). Nine individuals returned to the emergency room within 90 days of their procedure: four for UTI, two for hematuria, and three for acute retention  had undergone a prior TURP and requested minimally invasive reoperation, which similarly did not cause any operative difficulties or complications. Three individuals (3.3%) went on to develop prostate cancer, but none underwent prostatectomy so we are unable to report how prior PUL may have affected surgical extirpation in those cases.5In this study, we report our experience with PUL using more liberalized inclusion criteria, in a medically complex US military veteran population. Prior studies examined PUL within a more selected patient population with tight inclusion/exclusion criteria. However, there remains a need to determine if PUL can achieve satisfactory results when implemented with wider latitude in a real‐world clinical setting among more medically complex patients.α‐blocker within 2 weeks of procedure, or 5α‐reductase inhibitor within 3 months of procedure. In our study population, 22.4% of patients had PVR > 250 ml, 20% had Qmax > 13 ml/s, 3.7% had prostate volume > 80 cc, 15.4% had an enlarged median lobe, 6.6% had a history of prostate or bladder cancer, and 3.7% had prior TURP. In addition, 97.8% of individuals were on pharmacotherapy for BPH, which was continued until the date of surgery. In many ways, our patient population was not selected or restricted to maximize the apparent outcomes for PUL, yet the results achieved are comparable to that seen in the LIFT trial. At 1 year, the LIFT trial showed a 10.61‐point reduction in IPSS and a 4.03 ml/s increase in Qmax. PVR and SHIM did not change significantly.Specifically, the LIFT trial excluded patients with the following factors that we included in our surgical population: PVR > 250 ml, IPSS < 13, Qmax > 13 ml/s, prostate volume > 80 cc, obstructive or protruding median lobe of the prostate, previous BPH procedure, previous pelvic surgery or irradiation, history of prostate or bladder cancer, Sievert et al.Eure et al.We describe the successful implementation of PUL in a highly comorbid population. The average ASA classification among our patient cohort was 3.14. An ASA score of 3 is defined as “patients with severe systemic disease,” while 4 is defined as “patients with severe systemic disease that is a constant threat to life.” The US population has an average ASA class of 2, and an age‐matched general genitourinary patient population was shown to have an ASA of 2.5, showing that veterans have an age‐for‐age higher comorbidity rate than the civilian population.The rate of reported surgical complications from PUL varies widely across studies. The most commonly reported complication is hematuria, which has been shown to range from 4% to 78% of patients undergoing PUL. Dysuria is reported in 9% to 73% of patients, pelvic pain in 6% to 52% of patients, and urinary tract infection (UTI) in 0.1% to 7%.The durability of our results is also comparable to that seen in the LIFT trial and the BPH6 trial. The BPH6 trial had a 13.6% 2‐year retreatment rate, and the LIFT study likewise had a 13.6% 5‐year retreatment rate .The limitations of our paper include its retrospective nature and the lack of a sham control group to assess comparative outcomes. In addition, our patients did not routinely undergo urodynamic study (UDS) to assess for other etiologies of voiding dysfunction, which may in part explain why 19% still required CIC or indwelling Foley following PUL. Our experience suggests that in patients where bladder decompensation is suspected, clinicians may be advised to routinely perform UDS prior to consideration of procedures to address BPH. Finally, our paper was limited by the fact that PUL was performed by several different clinicians at the attending and resident level, meaning we were unable to control for specific surgeon technique or level of experience.6Our real‐world clinical application of the PUL demonstrated that it has effective, safe, and durable results in a medically complex veteran population, including in patients requiring catheterization, patients with significant urinary retention, and those on antiplatelets/anticoagulants. Based on our findings, we conclude that PUL is an appropriate treatment option for symptomatic BPH, even in individuals with severe LUTS and significant medical comorbidities.The authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest or non‐financial interest in the subject matter or materials discussed in this manuscript.


MLL‐rearranged acute lymphoblastic leukemia (ALL) represents a highly aggressive ALL subtype, characterized by aberrant DNA methylation patterns. DNA methyltransferase inhibitors, such as decitabine have previously been demonstrated to be effective in eradicating MLL‐rearranged ALL cells in vitro.MLL‐rearranged ALL. Furthermore, we explored whether prolonged exposure to low‐dose decitabine could chemo‐sensitize MLL‐rearranged ALL cells toward conventional chemotherapy as well as other known epigenetic‐based and anti‐neoplastic compounds.Here, we assessed the in vivo anti‐leukemic potential of low‐dose DNA methyltransferase inhibitor decitabine using a xenograft mouse model of human MLL‐rearranged ALL by 8.5 days (P = .0181), but eventually was insufficient to prevent leukemia out‐growth, based on the examination of the MLLAF4 cell line SEM. Furthermore, we observe that prolonged pretreatment of low‐dose decitabine mildly sensitized toward the conventional drugs prednisolone, vincristine, daunorubicin, asparaginase, and cytarabine in a panel of MLL‐rearranged cell lines. Additionally, we assessed synergistic effects of decitabine with other epigenetic‐based or anticancer drugs using high‐throughput drug library screens. Validation of the top hits, including histone deacetylase inhibitor panobinostat, BCL2 inhibitor Venetoclax, MEK inhibitor pimasertib, and receptor tyrosine kinase foretinib, revealed additive and moderate synergistic effects for the combination of each drug together with decitabine in a cell line‐dependent manner.Our data reveal that decitabine prolonged survival in xenograft mice of  MLL rearrangements mark a very aggressive ALL subtype. Despite highly intensified treatment protocols, event‐free survival (EFS) chances for MLL‐rearranged infant ALL only reach 35‐40%, falling well short of survival rates of infants and older children with ALL carrying other cytogenetic aberrations (70‐90%) [Rearrangement of the MLL‐rearranged ALL is the in‐frame fusion of the MLL gene with one of multiple fusion partner genes, generating MLL fusion genes that encode chimeric proteins that drive leukemogenicity and disease maintenance [AF4 (AFF1), ENL (MLLT1), and AF9 (MLLT3), all encode proteins that are part of complexes regulating epigenetic mechanisms. As truncated parts of the MLL fusions these proteins interfere with and mistarget the regulating complexes, hijacking their activities [MLL‐rearranged acute leukemia typically presents with a highly abnormal epigenome, reflected by aberrant DNA methylation patterns [MLL‐rearranged ALL animal models [The main oncogenic hit of ntenance , 5, 6. Mtivities . As a repatterns , 9, 10 apatterns , which al models , 15, 16,l models .MLL‐rearranged ALL cells in vitro [MLL‐rearranged ALL xenograft mouse model. Furthermore, using high‐throughput combinatorial drug library screens, we explored whether prolonged low‐dose decitabine would epigenetically prime and chemo‐sensitize MLL‐rearranged ALL cells toward standard chemotherapy, as well as toward an array of other, mostly FDA‐approved compounds.However, despite their known cytotoxicity against in vitro , 17, 18,22.1scidIl2rgtm1WjlPrkdc/SzJ (NSG) mice (n = 26) were transplanted intrafemurally (i.f.) with the luciferase‐expressing MLL‐rearranged ALL reporter cell line SEM‐SLIEW (105 cells per mouse). Mice were kept in individually ventilated cages with food and water ad libitum. Bioluminescence measurements were performed under isoflurane narcotization to confirm engraftment 3 days post‐injection and to monitor disease progression every other week; RediJect d‐Luciferin (PerkinElmer) substrate was administered intraperitoneally and bioluminescence signals were visualized and whole‐body photon flux (photons/sec) quantified on an IVIS Spectrum system using Living Image software (PerkinElmer). To overcome the therapeutic limitations of the short physiological half‐life of decitabine in vivo, the cytidine deaminase inhibitor tetrahydourine  was administered i.p. in parallel, on the opposite abdominal quadrant. The control group was treated with the corresponding vehicle .Animal experiments were performed under compliance of Dutch legislation after approval of the institutional Animal Ethics Committee at the Erasmus MC, Rotterdam, the Netherlands. Immunodeficient NOD.Cg‐Mice showing overt clinical signs of leukemia and reaching humane end points as indicated by Animal Ethical Committee statutes and in compliance with ARRIVE guidelines  were humanely culled, and systemic leukemic burden was determined using multicolor flow cytometry, as described before [2.2MLL‐rearranged B‐cell precursor acute lymphoblastic leukemia (pre‐B ALL) cell lines SEM (MLL‐AF4+) and KOPN‐8 (MLL‐ENL+) were purchased from DSMZ , while the MLL‐rearranged ALL cell line ALLPO (MLL‐AF4+) was a kind gift from the lab of Dr. Cazzaniga, University of Milano‐Bicocca, Italy. SEM‐SLIEW is derived from MLL‐AF4+ cell line SEM and was modified to express the luciferase reporter gene [The ter gene .2 atmosphere. Cell line integrity was regularly checked by DNA fingerprinting as well as mycoplasma free status by mycoplasma testing.All cell lines were cultured in Gibco™ RPMI‐1640 with GlutaMAX™, supplemented with 10% fetal calf serum, 100 IU/mL penicillin, 100 IU/mL streptomycin, and 0.125 μg/mL amphotericin B  at 37°C under 5% CO2.3MLL‐rearranged ALL cell lines SEM was pretreated for 14 days with 10 nM decitabine  or equal amount of DMSO (vehicle), compound‐containing medium was refreshed every 2 days and cells passaged every 4 days. Subsequently the pretreated cells were tested on a drug library containing all 43 compounds of the Enzo SCREEN‐WELL® epigenetics library , all 59 compounds of the Cayman epigenetic library , all 157 compounds of the Sequoia anti‐neoplastic drug library , 84 FDA approved compounds of interest , as well as 26 additional compounds of interest . Control samples were treated with DMSO (maximum concentration 0.5% v/v). The cell viability was assessed by a 4‐day thiazolyl blue tetrazolium bromide  assay as previously described . The cel2.4For the validation of the top hits from the high‐throughput drug screen and synergy studies, expanded dose response curves were made using the Tecan D300 Digital Dispenser  to dispense the drug. Again the drug response on the cell viability was assessed by a MTT assay. MTT data were normalized to DMSO control, tolerating a maximum concentration of ≤0.5% (v/v). Experiments performed in triplicate for ALLPO and SEM, in duplo for KOPN8, with three technical replicates each.Ecombi=EA+EB−EA∗EB, where EA represents the fraction of inhibition by drug A alone at a specific concentration, and EB represents the fraction of inhibition by drug B alone. The excess over Bliss (EOB) is the difference between the Bliss expectation and the observed growth inhibition of the combination of A and B (Ecombi) at a given dosage. The percentage excess over Bliss (%EOB) was calculated by multiplying the EOB by 100%. A positive %EOB indicates an additive or synergistic effect, while a negative score indicates an antagonistic effect. Synergy was defined if the inhibition of the combination (Ecombi) showed an excess over BLISS of >10%, while antagonism was defined if the Ecombi showed an excess over BLISS of <−10%.Drug synergy between decitabine and the combined compounds was determined using BLISS independence model calculations , with th2.5® TGX™ Precast Gels , and subsequently transferred to nitrocellulose membranes using the Transblot Turbo Transfer System . Membranes were blocked with 5% skim milk in TBS and probed with primary antibodies against rabbit polyclonal anti‐DNMT1 . Anti‐GAPDH rabbit monoclonal antibodies  were used to detect GAPDH and confirm equal loading in all lanes. The membranes were then probed with infrared‐labeled secondary antibodies IRDye 800CW goat‐anti‐rabbit antibody  and IRDye 680 goat‐anti‐mouse antibody . Images were acquired using an Odyssey Infrared Imaging System  and protein expression was quantified using the Odyssey software Image Studio Lite version 4.0.Cell pellets of the cell lines pretreated with decitabine or vehicle were collected at several time points and lysed with RIPA buffer supplemented with protease inhibitors . Western blot analysis was performed for two independent drug exposure experiments. Twenty‐five microgram of whole cell protein lysates were resolved on 10% polyacrylamide Mini‐PROTEAN33.1MLL‐rearranged ALL, as to date bona fide genetic mouse models have not yet been reliably established for this type of leukemia. In order to generate xenografts, we used a previously described reporter cell line, SEM‐SLIEW, which is derived from the MLL‐AF4‐positive B‐cell precursor ALL cell line SEM. SEM‐SLIEW was modified to express the luciferase reporter gene, allowing for longitudinal in vivo disease monitoring by bioluminescence [5 SEM‐SLIEW cells intrafemurally into the bone marrow of immunodeficient NSG mice, creating an orthotopic model. Successful engraftment was confirmed by bioluminescence post‐transplantation, and mice were divided into a control (n = 13) and treatment group (n = 13). The treatment group was intraperitoneally injected with a low dose of decitabine (0.1 mg/kg), three times a week. The control group was injected with the corresponding vehicle   Figure . One of P = .0181, Figure MLL rearranged ALL, decitabine was insufficient to prevent leukemia out‐growth.Leukemia progression was assessed by bioluminescence imaging every other week, and mice displaying overt signs of leukemia were sacrificed. The median survival times were 50.5 days in the decitabine‐treated mice and 42 days in the control mice revealing a prolonged survival in the treated mice of 8.5 days . Since high concentrations of decitabine cause DNA damage by the formation of DNA double strand breaks [2 decitabine is safely achievable [The chemo‐sensitizing capability of decitabine was assessed by performing a combinatorial screen of decitabine with prednisone, asparaginase, cytarabine, daunorubicin, or vincristine, which represent cornerstone drugs in current reatment , 3. Priod breaks , 32, we d breaks  to solelhievable , 35, leahievable . Due to MLL‐rearranged ALL cell lines displayed different responses in viability to the 14‐day low‐dose decitabine pretreatment. The low concentration of 5 nM of decitabine corresponded to the IC80, IC50, and IC30 values in ALL‐PO, SEM, and KOPN8, respectively , thereby depleting subsequent daughter cells from functional DNMTs in consecutive cell cycles . Depletiy Figure .MLL‐rearranged infant ALL. The in vitro efficacy of each drug combination was assessed by 4‐day dose‐response curves (MTT assays), normalized to the effects of decitabine as a single agent and analyzed for synergistic, additive, or antagonistic effects by means of the Bliss Independence model [MLL rearranged ALL in a limited range of concentrations. Additionally, the observed synergy was not consistent in all of the cell lines tested. These results indicate prolonged exposure to low‐dose decitabine is sufficient to completely deplete MLL‐rearranged ALL cells from DNTM1, however only mildly sensitizes MLL‐rearranged ALL cells toward conventional chemotherapeutics.After the 14‐day period of decitabine pretreatment, the leukemic cells were subjected to synergy testing, using 5 nM decitabine in combination with prednisone, asparaginase, cytarabine, daunorubicin, or vincristine, which are currently used in the treatment of ce model . For all3.3MLL‐rearranged ALL cells to other epigenetic‐based or anticancer drugs. For this, SEM cells were exposed to a slightly higher concentration of 10 nM decitabine (or vehicle) compared to earlier experiments, for a period of 14 days. Subsequently, the sensitivity of these cells toward 369 different compounds, derived from an epigenetic‐based drug library and an anti‐neoplasm drug library, was tested using 4‐day MTT assays with drug concentrations of 10, 100, or 1000 nM. Results of all inhibitors tested are listed in Table S2. Drug synergy was based on area under the curve (AUC) calculations. A cut‐off of ≥30% difference in AUC of drugs in the decitabine pretreated SEM cells compared to vehicle‐treated cells was applied to determine the top hits, which could be mainly categorized as either histone deacetylase (HDAC) inhibitors, receptor tyrosine kinase (RTK) inhibitors, MEK inhibitors, and BCL2 protein family inhibitors  in both children and adults [We previously demonstrated the efficacy of DNA demethylating agents, such as decitabine and zebularine, in eradicating in vitro , 10. Howd adults , 41.in vivo in mouse xenografts of the MLL‐rearranged ALL cell lines SEM and RS4;11, but could not eradicate the leukemia [MLL‐rearranged ALL cell line SEM, albeit modestly. There are, however, clear differences in the experimental design of both studies. Roolf and co‐workers treated their mice with 0.4 mg/kg decitabine daily for only four consecutive days, seven days after leukemia injection. In contrast, we treated our mice with only 0.1 mg/kg decitabine three times a week over a period of three weeks, starting treatment three days after tumor injection. Moreover, THU was co‐administered in the mice, which is known to elevate decitabine plasma levels up to 10‐fold [MLL‐rearranged ALL cells from DNMT1 (and thus to induce DNA demethylation), and prevents aspecific drug effects such as diminished DNA polymerase functioning [MLL‐rearranged ALL cells in vitro, were not indicative for similarly promising results in in vivo mouse models. Possibly, the typical experimental setup of in vitro drug response assays, in which tumor cells are cultured for a fixed period of time in the presence of increasing drug concentrations, provides a plausible explanation. If, as we show here, low concentrations of decitabine are sufficient to completely deplete MLL‐rearranged ALL cells from functional DNMT1, higher concentrations of decitabine should not provide any additional effects, other than aspecific drug effects that are not related to DNA demethylation. Thus, increasing concentrations of decitabine may eradicate most MLL‐rearranged ALL cells in in vitro drug response curves, this might not be solely due to DNA demethylation. If so, this may suggest that MLL‐rearranged ALL cells are not necessarily depending very heavily on their aberrant promotor DNA methylation patterns to maintain leukemogenic potential as observed previously [Recently, Roolf et al, reported that decitabine induced a significant delay of leukemic progression leukemia . In line 10‐fold , 25, 27.ctioning . Yet, iteviously , 9.MLL‐rearranged ALL cells toward chemotherapeutics currently used in the treatment of this type of leukemia, as well as toward various other epigenetic or anti‐neoplastic compounds. Earlier findings revealed that short‐term exposure to high‐dose decitabine could synergize with cytarabine to eradicate MLL‐rearranged ALL cells in vitro [l‐asparaginase to enhance cytotoxicity in the pediatric T‐ALL [MLL‐rearranged ALL cells to some of the current chemotherapeutics at certain concentrations in some of the cell lines tested. These observations were most notable for l‐asparaginase and cytarabine, thereby confirming the results reported by others [Additionally, we investigated whether prolonged low‐dose decitabine pretreatment could chemo‐sensitize in vitro , as wellic T‐ALL . Here, wy others , 42.RAS‐mutant KOPN8 cells than either drug alone. Previously, we showed that MEK inhibitors are effective for the treatment of RAS‐mutant MLL‐rearranged infant ALL cells [RAS mutations are found in 14‐24% of infant ALL patients and these RAS mutations decrease the survival chances even further [RAS‐wildtype cell line SEM, while showing a more pronounced chemo‐sensitizing effect in decitabine treated RAS‐mutant KOPN8 cells. Therefore, there might be a benefit for the treatment of MLL‐rearranged infant ALL harboring RAS mutations by combining decitabine and MEK inhibitors.Interestingly, the combination of decitabine and the MEK inhibitor pimasertib strongly decreased cell viability in LL cells , 39. RAS further . Here, tHowever, the in vitro chemo‐sensitizing effects of decitabine are modest and therefore clinical relevance may be rather limited. Additionally, since synergy was observed for limited concentration ranges, reaching and maintaining these exact concentration ranges in patients would be challenging due the many factors influencing the pharmacokinetics of the drugs , 45, 46.MLL‐rearranged infant ALL will be further evaluated in currrent clinical trials.Furthermore, a recent study in relapsed pediatric ALL, all above 1 year of age, revealed that the combination of decitabine and HDAC inhibitor vorinostat in the current intensive chemotherapy protocol was determined not feasible due to the high incidence of infectious toxicities, despite encouraging response rates and pharmacodynamics . The feaMLL‐rearranged ALL xenograft mouse models. Moreover, long‐term pretreatment with low‐dose decitabine moderately sensitizes MLL‐rearranged ALL cells toward conventional chemotherapeutics as well as toward known epigenetic‐based compounds and anti‐neoplastic agents, in vitro.In conclusion, our present study demonstrates that prolonged exposure to a clinically relevant low‐dose of the DNA methyltransferase inhibitor decitabine significantly, but mildly delays leukemia progression in MLL‐rearranged ALL, agents with increased stability and bioavailability could be further evaluated. Ongoing clinical trials should shed more light on theefficacy of demethylating agents for the treatment of MLL‐rearranged infant ALL.For a better understanding of the potential of demethylating agents in the treatment of P.S., P.G.C., and R.W.S. designed the study; R.W.S. contributed materials; P.S., P.G.C, S.M.P., M.K., E.H.R. A.H.W.E., and M.E.M.D. performed the experiments; P.S., P.G.C., S.M.P., and M.K analyzed data; P.S. and P.G.C. performed statistical analysis; P.S., P.G.C., and R.W.S. wrote the paper; P.S., P.G.C., J.J.M., R.P., and R.W.S. supervised the study; and all co‐authors performed critical review of the manuscript and gave their final approval.Animal experiments were approved by the institutional Animal Ethical Committee of the Erasmus MC and performed in accordance to Dutch legislation.The authors declare that no conflict of interest exists.Supporting InformationClick here for additional data file.Supporting InformationClick here for additional data file.Supporting InformationClick here for additional data file.


Refractory aggressive prolactinomas are detected after the unresponsiveness to conventional therapies. We report two cases that underwent temozolomide treatment and have been in near‐complete remission ever since. We suggest the pathology techniques for earlier detection and, subsequently, treatment with temozolomide to reduce morbidities and better respond to therapy. Patients with refractory aggressive prolactinomas are diagnosed after failure of usual treatments. Since they can have near‐complete remission after treatment with Temozolomide, earlier diagnosis with pathology and treatment can avoid morbidities. Most macroprolactinomas are resolved with conventional therapies with dopamine agonists (such as cabergoline), surgery, and radiation.European Society of Endocrinology guidelines suggest temozolomide (TMZ) monotherapy to be applied after the failure of conventional therapies. TMZ has been shown to shrink pituitary tumors and normalize hormone hypersecretion; thus, TMZ can play an important role in aggressive pituitary adenomas treatment.22.1A 22‐year‐old man attended a neurosurgery outpatient clinic with headaches, blurred vision, decreased libido, and ptosis in the right eye. Initial laboratory results were as follows: Luteinizing hormone and follicle‐stimulating hormone serum level of 4 mIU/ml , thyroid‐stimulating hormone of 0.9 mU/L (reference range: 0.5–4.5 mU/L), FT4 of 0.8 ng/dl, (reference range: 0.8–1.8 ng/dl), prolactin (PRL) of >200 ng/ml (reference range < 20 ng/ml), insulin‐like growth factor‐1 of 175 ng/ml (reference range:182–780 mcg/ml), testosterone of 48 ng/dl (reference range:300–1100 ng/dl), adrenocorticotrophic hormone (ACTH) of 17 pg/ml (reference range:10–60 pg/ml), and serum basal cortisol level of 11 μg/dl (reference: 5–25 μg/dl). Prolactin laboratory results are shown in Table He underwent endoscopic transsphenoidal surgery (ETSS) based on the patient's desire (opting for surgery instead of cabergoline therapy as the first line of treatment) and cranial nerve involvement (ptosis), and 24 h post‐operation PRL was 250 ng/ml. The histopathologic examination revealed a densely granulated prolactinoma with increased mitotic activity, Ki‐67 proliferative labeling index of 4% and focal immunoreactivity for P53 (in about 8% of tumor cells)  in 3 months, and PRL level decreased; then, treatment was continued for 6 months. Now, the tumor has remarkably shrunk in size  and according to residual tumor in cavernous sinus; the patient underwent a second surgery, and subsequently, the patient attended 29 sessions of conventional radiotherapy with post‐operation and radition PRL of 114 ng/ml (Table 2 for 5 days every 28 days in 3 months) led to a decrease in PRL level; then, treatment continued for 6 months. As shown in Figure Furthermore, MGMT quantitative methylation analysis was requested that showed negative results (<5%). In the IHC study for ER, diffuse weak immunoreactivity was observed in tumor cells Figure . Therefo3Most prolactinomas are benign and responsive to medical therapy. However, in the case of aggressive prolactinomas, due to recurrence and local invasion of these tumors, multiple approaches such as medical therapy, surgery, radiotherapy, and chemotherapeutic agents will be required.The shortest duration of treatment with TMZ belongs to Strowd et al.This study used IHC staining to investigate the tumor characteristics. Although we did not have access to a DR2, pathology studies indicated high mitotic index, Ki67 > 3%, positive PS3, densely granulated cells, and low expression of MGMT. The invasion of the tumor to the cavernous sinus and resistance to medical therapy, in addition to the pathologic studies mentioned above indicated that the tumor was invasive and aggressive.In our cases, the pathology of the tumors was associated with poor estrogen expression. The significant lactotroph regulators are estradiol and dopamine, which play an important role in the regulation and control of cell proliferation and PRL secretion.Mahboobifard et al.Since, unlike multiple previous therapies, these patients responded significantly to treatment with TMZ, the need for a well‐established protocol for aggressive pituitary adenoma or earlier use of this agent in this respect can be helpful. The present study results obtained in these two cases require further research in this field.Zahra Davoudi has made major contributions to the manuscript's conception, writing, and revision. Mohammad Hallajnejad was a significant contributor in conception, writing and revising the manuscript. Elena Jamali performed histological examination and contributed to writing the manuscript. Mohammadjavad Honarvar has contributed to acquiring the data and drafting and revising the manuscript. All authors have read and approved the manuscript.The authors declare that they have no competing interests.This study is according to the ethical principles of the Helsinki Declaration.Written consent for publication of the patients' data was obtained from the patients.


Sarcopenia is an important clinical syndrome in older people living with HIV (PLWH). With a change to the Asia sarcopenia definition in 2019, we aimed to determine whether health outcomes were associated with different definitions of sarcopenia among Asian PLWH.We performed a prospective cross‐sectional study enrolling PLWH aged ≥35 years from January 2018 to November 2021. We defined sarcopenia by the Asia Working Group of Sarcopenia (AWGS) criteria in 2014 and 2019. AWGS‐2014 included low muscle mass plus weak handgrip strength and/or slow gait speed. AWGS‐2019 included low muscle mass plus low muscle strength or physical performance, while the presence of all defines severe sarcopenia. We measured appendicular skeletal muscle mass using dual‐energy X‐ray absorptiometry, handgrip strength, usual gait speed, five‐time chair stand test and Short Physical Performance Battery. Correlations between each sarcopenia definition and health‐related quality of life (using EQ‐5D‐5L and SF‐36) and functional disability were determined.3, 67 (45%) had multimorbidity, 64 (43%) had polypharmacy. Prevalence of sarcopenia by AWGS‐2014, AWGS‐2019 and severe sarcopenia was 17.3%, 27.3% and 18.0%, respectively. Age, education and polypharmacy were associated with sarcopenia. Sarcopenia (AWGS‐2014) and severe sarcopenia were associated with mobility, physical functioning and physical component score (SF‐36). All three criteria were associated with impaired instrumental activities of daily living (IADL). After age and sex adjustment, sarcopenia (AWGS‐2014)  and severe sarcopenia  were associated with mobility and physical component score (SF‐36) . Sarcopenia (AWGS 2014) , sarcopenia (AWGS‐2019)  and severe sarcopenia  were associated with impaired IADL in fully adjusted models.One hundred and fifty Asian PLWH were enrolled, 132 (88%) were male, mean age was 60±10 years, duration of HIV diagnosis was 13 (IQR 8–18) years and current CD4 count was 574 (IQR 362–762) cells/mmIn a sample of Asian PLWH, 17.3%, 27.3% and 18.0% had sarcopenia as defined by AWGS‐2014, AWGS‐2019 and severe sarcopenia, respectively. Sarcopenia by AWGS‐2014 and severe sarcopenia correlated with parameters of poor health outcomes, while sarcopenia by AWGS‐2019 correlated with functional disability. Tfunction .Sarcopenia is appreciated to be an important phenomenon among older people living with HIV (PLWH) . The pooSince the development of the first consensus definition of sarcopenia in 2009 . A revisCurrently, there are no data comparing the AWGS‐2014 and AWGS‐2019 definitions of sarcopenia among PLWH in Asia. It is uncertain which definition of sarcopenia would be more applicable in PLWH. Therefore, we performed this study to determine the prevalence and risk factors of sarcopenia among PLWH living in Hong Kong SAR, China, and the correlation between different definitions of sarcopenia and health outcomes.22.1We performed an observational cross‐sectional study involving PLWH recruited from January 2018 to November 2021 at the Prince of Wales Hospital Infectious Diseases clinic in Hong Kong. This clinic received referrals from other HIV clinics for screening or management of chronic comorbidities in PLWH. Inclusion criteria were positive HIV antibody and age of 35 years old or above. The only exclusion criterion was the refusal to consent. The study protocol was approved by the Joint Chinese University of Hong Kong—New Territories East Cluster Clinical Research Ethics Committee.2.2We recorded demographic and clinical information for all participants at each study visit. This included date of birth, sex, smoking, alcohol intake, comorbidities included in Charlson's Comorbidity Index, hepatitis B and C co‐infection, year of diagnosis of HIV, history of AIDS‐defining illness, current and previous anti‐retroviral drug regimens, medications other than anti‐retroviral drugs, current CD4 count, CD4:CD8 ratio and HIV RNA level. We defined multimorbidity as the presence of two or more chronic comorbidities, and polypharmacy as taking five or more non‐anti‐retroviral drugs.During the study visit, we measured handgrip strength, gait speed, chair stand test and SPPB. We measured handgrip strength three times for both hands, using Jamar Hydraulic Hand dynamometer , with the participant sitting with 90° elbow flexion. The best performance of all trials was used for analyses. We calculated gait speed by measuring the average time of two trials taken to walk 6 metres at a normal pace, using a stop‐watch. We performed the chair stand test by measuring the time taken to perform five chair stands. We performed SPPB, which included the ability to stand for up to 10 seconds with feet positioned in side‐by‐side, semi‐tandem and tandem positions, usual gait speed and five‐time chair stand test . All par2.32 in men and <5.4 kg/m2 in women) plus weak handgrip strength (<25 kg in men and <18 kg in women) and/or slow gait speed (≤0.8 m/second) [We defined sarcopenia using AWGS‐2014 and AWGS‐2019 criteria. AWGS‐2014 defines sarcopenia as the presence of low muscle mass (height‐adjusted muscle mass <7 kg/m/second) . AWGS‐20/second) .2.4We measured the following health outcomes: health‐related quality of life (QOL) and functional disability. We measured health‐related QOL by the EuroQOL 5‐dimensional 5‐Level questionnaire (EQ‐5D‐5L) and 36‐item Short Form Health Survey (SF‐36). The EQ‐5D‐5L questionnaire contains five dimensions of QOL: mobility, self‐care, usual activities, pain/discomfort and anxiety/depression. Each of these dimensions is graded as “no problem,” “slight problem,” “moderate problem,” “severe problem” and “extreme problem.” Participants with any severity of the problem in a particular dimension were considered as having a problem with that dimension. The EQ‐5D‐5L index was converted from the EQ‐5D‐5L health states using an established Hong Kong value set by weighting each participant's self‐report health status to a single preference‐based health index . The EurParticipants also completed the Chinese (Hong Kong) version of SF‐36 , which cFunctional disability was defined as an impairment in any domains of activities of daily living (ADL) or instrumental ADL (IADL) . We meas2.5t and Mann–Whitney U test, as appropriate. Age, sex and variables identified to be associated with each definition of sarcopenia in the above univariate analyses were included in multivariable binary logistic stepwise regression models, to determine the variables that were independently associated with each definition of sarcopenia and severe sarcopenia. For each regression analysis, collinearity was assessed using the variance inflation factor.We presented descriptive statistics as number (percentage), mean ± standard deviation or median (interquartile range/IQR), as appropriate. We determined agreement between the different definitions of sarcopenia and severe sarcopenia using Cohen's kappa test. Kappa was interpreted as poor if value was < 0.20, fair if 0.21–0.4, moderate if 0.41–0.60, good if 0.61–0.80 and very good if 0.81–1.00 [t‐test, as appropriate. The logistic regression model for binary outcome measure and linear regression model for continuous outcome measure were used to determine the association between sarcopenia and these outcomes in multivariable models. The associations between each definition of sarcopenia and the outcome measures were determined in two multivariable models: model 1 adjusted for age and sex, and model 2 adjusted for age, sex and variables with significant independent association with each definition of sarcopenia. Correlation between different components included in the definitions of sarcopenia and disability and health‐related QOL measures were determined using logistic regression for binary outcome measures and linear regression analyses for continuous outcome measures. Statistical significance was defined as a p‐value less than 0.05. Statistical analyses were conducted using SPSS (IBM version 26).Associations between different definitions of sarcopenia or severe sarcopenia and disability and health‐related QOL measures were determined using the chi‐square test and Student's 33, and 94% having undetectable HIV RNA (<20 copies/ml). Multimorbidity and polypharmacy were present in 45% and 43% of participants, respectively. The baseline demographic and clinical characteristics are shown in Table One hundred and fifty‐six PLWH who were followed up in the clinic were invited to participate in this study, six refused to consent, and 150 participants were recruited. The mean age was 60±10 years, 88.0% were male, 98.7% were Chinese and the median (IQR) duration of HIV diagnosis was 13 , 17, 18 Among all participants, 26 17.3%) and 41 (27.3%) had sarcopenia as defined by AWGS‐2014 and AWGS‐2019 criteria, respectively, while 27 (18.0%) had severe sarcopenia according to AWGS‐2019 criteria , this l5Among this sample of Chinese PLWH, the AWGS‐2019 definition identified a higher prevalence of sarcopenia compared with the AWGS‐2014 definition. While the AWGS‐2014 definition and severe sarcopenia defined by the AWGS‐2019 criteria correlated with the most parameters of poorer health‐related QOL, the AWGS‐2019 definition could potentially identify early‐risk individuals who may benefit from early interventions to prevent future disability.GL has received research grants and consultancy fees from Gilead Sciences, MSD and ViiV.FWLL: data collection, data analysis, writing original draft, review and edit writing. TL, HYH and YYC: data collection and review writing. SKC and VW: data collection, data analysis and review writing. TCYK: conceptualization, methodology and review writing. GL: conceptualization, methodology, data collection, data analysis, writing original draft, review and edit writing, supervision. All authors have read and approved the final manuscript.This study was supported by the Hong Kong AIDS Trust Fund (MSS 319R).Table S1. Multivariate regression analyses of variables associated with AWGS 2014 definition of sarcopenia.Table S2. Multivariate regression analyses of variables associated with AWGS 2019 definition of sarcopenia.Table S3. Multivariate regression analyses of variables associated with severe sarcopenia (AWGS 2019).Table S4. Correlations between muscle mass, muscle strength and physical performance parameters and health‐related quality of life and disability.Table S5a. Correlations between different cutoffs of muscle strength (handgrip strength) and gait speed and health‐related quality of life and disability.Table S5b. Correlations between different cutoffs of five chair stand test, short physical performance battery (SPPB) and physical performance parameters and health‐related quality of life and disability.Click here for additional data file.


Lonicera japonica polysaccharide (LJP) by comparing the polysaccharide retention rate and the protein clearance rate of five different methods. The response surface methodology (RSM) based on the Box–Behnken design (BBD) was used to optimize the deproteinization conditions as follows: TCA: n‐butanol = 1: 5.1, polysaccharide solution: (TCA–n‐butanol) = 1: 2.8, and shook for 33 min. LJP could promote the thymus and spleen indexes of cyclophosphamide (CTX)‐induced immune‐deficient mice. Besides, the contents of cytokine interleukin‐2 (IL‐2) and hemolysin in mice serum were augmented after treatment with LJP. Based on serum metabolomics analysis, a total of 14 metabolites  were selected as the potential biological biomarkers related to the LJP for treating CTX‐induced mice. After the pathway enrichment analysis, these metabolites were mainly involved in the relevant pathways of arginine biosynthesis, Citrate cycle, and other metabolic pathways. Network pharmacology further showed that there were 57 key targeting proteins in the intersection of the potential biological biomarkers and immunodeficiency‐related targeting proteins according to protein–protein interactions analysis (PPI). The biological function analysis indicated that the potential biological processes were mainly associated with tricarboxylic acid (TCA) cycle, phospholipid metabolic process, metabolic process, and so on. In conclusion, serum metabolomics combined with network pharmacology could be helpful to clarify the immunomodulatory mechanism of LJP and provide a literature basis for further clinical research on the therapeutic mechanism of LJP.In this study, TCA–n‐butanol was chosen as the best deproteinization method for  Lonicera japonica polysaccharide was determined and its process was optimized by response surface method. Pharmacological experiments showed that polysaccharides had therapeutic effect on immunodeficiency mice induced by cyclophosphamide (CTX). The immunomodulatory mechanism of polysaccharide was elucidated by the combination of serum metabolomics and network pharmacology.In this paper, the best protein removal method of  The supernatant was collected, concentrated, and added 4 volumes of absolute ethanol, then allowed to stand at 4°C overnight. The precipitate was collected and washed with absolute ethanol and diethyl ether, then dried under vacuum at 60°C. After that, the Lonicera japonica crude polysaccharide was obtained , vigorously shook for 20 min, then centrifuged , and collected the upper layer. The other parts repeated this procedure 2 ~ 8 times. Then, the 2.3.3The polysaccharide after removing protein by trypsin enzymolysis was taken, divided into eight parts, dissolved in distilled water, and named 1 ~ 8. The latter processes were similar to Sevage method and deproteinized eight parts for 1 ~ 8 times, respectively. Then the polysaccharide retention rate and protein clearance rate were calculated.2.3.4Lonicera japonica crude polysaccharides were dissolved in distilled water, added the equal volume of 20% tricarboxylic acid (TCA) reagent, and intensely shook for 30 min. After waiting for 1 h at 4°C, the polysaccharide solution was centrifuged , and adjusted to pH 7 with 6 mol/L NaOH, then precipitated and collected. The polysaccharide retention rate and protein clearance rate were calculated  reagent, shook for 15 min, and waited for 1 h at 4°C, collected the bottom layer and the two groups repeated this procedure 2 times. The polysaccharide was concentrated, precipitated, and dried and then calculated the polysaccharide retention rate and protein clearance rate.Taken two equal 2.4A three‐factor, three‐level Box–Behnken design (BBD) designed with Design Expert Software was applied to optimize the best condition of deproteinization. Three independent variables, TCA: n‐butanol (v/v) (A), polysaccharide solution: (TCA–n‐butanol) (v/v) (B), and shaking time (min) (C), were used in the experimental design. The comprehensive score (Y) was regarded as the response. And the BBD is described in Table 2.5the Guide for the Care and Use of Laboratory Animals and approved by the Animal Ethics Committee of the Shandong University of Traditional Chinese Medicine. Sheep red blood cells (SRBC) were obtained from Nanjing constipation Biotechnology Co., Ltd, China. Mouse IL‐2 Enzyme‐Linked Immunosorbent Assay (ELISA) kit was provided by Assay Biotechnology (USA).Twenty‐four male Kunming mice, weighing 22–28 g, were provided by Shandong Lukang Pharmaceutical Co., Ltd. Laboratory Animal Center . All animal experiments were performed according to 2.6n = 6), including normal group, model group, LNT group , and LJP group (treated with 800 mg/kg polysaccharide which deproteinized protein with the best method and the best condition). All groups received intragastric administration of 10 ml/kg each time for three days, while the normal group and model group were given the same volume of physiological saline. Then all groups were intraperitoneally injected with 50 mg/kg cyclophosphamide (CTX) once a day for three consecutive days, except the control group treated with the same volume of physiological saline, to build the CTX immunocompromised mice. All mice were allowed free access to food and water during the experiment. After successful modeling, all groups were continued to be administered for 10 days.After two days of adaptive feeding, 24 mice were randomly divided into four groups  to isolate the serum and the plasma. The serum was collected, accurately transferred 150 μl, 450 μl methanol added, vortex‐mixed for 60 s, and centrifuged . Finally, the supernatant was injected into HPLC‐TOF‐MS (high‐performance liquid chromatography time‐of‐flight mass spectrometry) for analysis.2.1018 column . The column temperature was 35°C while the flow rate was 0.25 ml/min. The injection volume was 5 μl. The mobile phase used 0.1% aqueous formic acid (A) and acetonitrile (B). The gradient elution was as follows: 20%–85% B over 0–10 min, 85%–100% B over 11–20 min, and 100% B over 21–30 min. Mass spectrometry conditions were set as follows: the capillary voltage was 4000 V, the drying gas temperature was 350°C, and the gas flow rate was 8 L/min. The mass collection range was 50–1000  (https://hmdb.ca/) and Kyoto Encyclopedia of Genes and Genomes (KEGG) (https://www.kegg.jp/) databases were used to further identify the biomarkers. MetaboAnalyst 5.0  was combined to construct the endogenous biomarkers' analytical metabolic pathway.Agilent Qualitative Analysis was used to extract the data, identify and integrate chromatographic peaks. The peaks aligned and matched were used by Mass Profiler. Multivariate data (MVD) analysis was performed by the supervised learning method with the partial least‐squares discriminant analysis (PLS‐DA) and orthogonal partial least‐squares discriminant analysis (OPLS‐DA) by using SIMCA‐P 13.0 . Biomarkers were discovered by screening for metabolic differences . These upstream proteins and pathological proteins were imported into STRING for protein–protein interactions analysis (PPI). The minimum required interaction score was set at 0.9 and hid disconnected nodes in the network to link their interactions. In this network, every node stood for a protein, and the edges stood for their relationship. For analyzing the synthetic biological functional annotation information, the collected proteins were connected to their official gene symbol (UniProt ID) and imported into the Database for Annotation, Visualization and Integrated Discovery (DAVID) (https://david.ncifcrf.gov/), which could find the most significant enrichment biological annotation, selected the Homo sapiens. Based on the Gene Ontology (GO) analysis, the genes molecular functions information was determined. Data visualization was carried out with a threshold (p < .05).In order to further analyze the affection of biomarkers, MetScape for Cytoscape software, which can integrate biomolecular interaction networks with high‐throughput expression data into a unified KEGG‐based conceptual framework, was used to dig the upstream proteins of biomarkers. Meanwhile, the proteins related to immunomodulatory were collected based on the GeneCards database  and statistical testing and comparisons were performed by using the one‐way analysis of variance (ANOVA) method. Statistical analyses were done using SPSS 21.0. A value of 33.1Lonicera japonica polysaccharides were deproteinized by the enzymatic method, Sevage method, enzymatic–Sevage method, TCA method, and TCA–n‐butanol method, respectively. Considering the high polysaccharide retention rate and protein clearance rate, the trypsin method could be used for deproteinization as the best enzymatic method  is a collection of statistical and mathematical techniques useful for developing, improving, and optimizing processes , indicating that the factors were not a simple linear correlation. The order of the influence of single factors on the comprehensive score was polysaccharide solution: (TCA–n‐butanol) (B) > TCA: n‐butanol (A) > shaking time (C).The analysis of variance (ANOVA) of the regression model is shown in Table 3.3.2To further explain the interaction between the independent variables and response values, three‐dimensional (3D) response surface plots and two‐dimensional (2D) contour plots are displayed in Figure 3.3.3By analyzing these data, the maximum comprehensive score of 90.75 was obtained at the following optimum conditions: TCA:n‐butanol = 1:5.05, polysaccharide solution: (TCA–n‐butanol) = 1: 2.78, and shook for 32.90 min. For the convenience of operation, the TCA:n‐butanol was 1:5.1, the polysaccharide solution: (TCA–n‐butanol) was 1:2.8, and shook for 33 min. To verify this condition, three confirmation experiments were performed, and the average comprehensive score was 91.80, which was close to the predicted value. This result proved the validity of the prediction. Under the optimal condition, LJP was prepared and its immunomodulatory activity was further investigated.3.43.4.1The thymus and spleen are the main immune organs of the body, which affect the organism's immune function and the ability to resist disease. According to Figure 3.4.2The immune response associated with levels of cytokines is a multistep process. IL‐2 is an important cytokine that directly affects cellular immunity and humoral immunity. Under certain conditions, serum hemolysin would combine with SRBC and cause SRBC hemolysis  were used to validate the predictive ability of the PLS‐DA model , and 3.5.3To further explore the metabolic pathways of potential biomarkers related to LJP in the treatment of immunocompromised mice, MetaboAnalyst 5.0 was used to perform the pathway enrichment analysis against the potential biomarkers. As shown in Figure 3.6To further illustrate the potential mechanism of LJP on immunomodulatory effect, PPI was used to analyze the correlation between metabolic pathways and corresponding targets. As displayed in Figure Figure 4As one of the oldest medicine systems in the world, TCM has the characteristics of multiple components and multiple targets and has shown great advantages in the treatment of various diseases  = 1:2.8, and shook for 33 min.In this work, we investigated five methods to remove proteins: Enzymatic method, Sevage method, Enzymatic–Sevage, TCA method, and TCA–n‐butanol method. We comprehensively explored the protein removal methods of Thymus and spleen are the main central immune organs and the largest peripheral immune organs, respectively  = 1:2.8, and shook for 33 min. After the CTX‐induced mice were treated with LJP, the thymus and spleen indexes were promoted, and the contents of IL‐2 and hemolysin in mice serum were also restored. Based on the serum metabolomics analysis, a total of 14 potential biomarkers about immune and LJP treatment have been identified in different groups. Taking these metabolites as the potential molecular targets, LJP could be inferred to partially recover the metabolism pathways of arginine biosynthesis, citrate cycle, and so on. Network pharmacology results suggested that LJP may protect immunosuppressed mice via the regulation of mainly ten biological processes including gluconeogenesis, tricarboxylic acid cycle, and so on. To sum up, our findings suggest that metabolomics method together with network pharmacology would be useful to explore the pathological mechanisms and clarify the mechanisms of the action of LJP for the treatment of immunomodulatory effects.There are no conflicts of interest to declare.


Pediatric cancer incidence in Mexico is ~160/million/year with leukemias making 49.8% of the cases. While survival rates have been reported in various Mexican studies, no data is available from the Telethon Pediatric Oncology Hospital‐HITO, a nonprofit private institution specialized exclusively in comprehensive pediatric oncology care in the country that closely follows high‐income countries' advanced standards of cancer care.To determine overall survival (OS) and relapse‐free survival (RFS) in patients treated at HITO between December 2013 and February 2018.n = 230) and 3 (n = 132) years of follow‐up after admission were computed by sex, age, and cancer location, and separately for a subsample  who fulfilled the HITO criteria . TOCNS accounted for 45.1%, but ALL was the most frequent single diagnosis with 28%. Three‐year OS for patients with ALL, TWCNS, and TOCNS who fulfilled the HITO criteria were 91.9%, 86.7%, and 79.3%, respectively; for 3‐year RFS these were 89.2%, 60%, and 72.4%. Boys showed slightly higher OS and RFS, but no major differences or trends were seen by age group.Secondary analysis of data extracted from medical records. It included 286 children aged 0–17 years diagnosed with various cancers grouped into three categories based on location: (1) Acute lymphoblastic leukemia (ALL), (2) tumors within the central nervous system (TWCNS), and (3) tumors outside the CNS (TOCNS). OS and RFS rates for patients who completed 1 (This study sets a relevant reference in terms of survival and relapse for children with cancer in Mexico treated at a private oncology center that uses a comprehensive and integrated therapeutic model. However, efforts have faced various challenges associated with insufficient funding, ranging from limited infrastructure to poorly trained staff.Child survival from cancer in Mexico has improved considerably due to better public health interventions; yet, survival is still half of the rates observed in high‐income countries (HIC).While survival from pediatric cancer has been linked to various factors, including genetic susceptibility, age at diagnosis, type of hospital, nutritional status, and stage at diagnosis and treatment,In this context, the aim of this study was to determine the overall survival (OS) and relapse‐free survival (RFS) rates for patients admitted to the Telethon Pediatric Oncology Hospital (HITO), a specialized nonprofit private institution that closely follows advanced standards of cancer care followed in HIC.Written permission to use, analyze, and publish the data was given by the HITO Ethics and Research Committee (ID: CEI‐2018‐005). Informed consent was not obtained, as this was a secondary data analysis. However, complete anonymity was maintained throughout the analysis and reporting process.22.1This was a retrospective secondary survival analysis of data extracted from medical records of pediatric patients treated for cancer at HITO. The study period lasted 50 months, starting from the hospital inauguration in December 2013 until February 2018. Standard diagnostic methods were followed as per disease condition and protocol recommendations, including imaging , pathology , and hematopathology  procedures.2.2This study was carried out at a hospital located in the city of Querétaro, 200 km north of Mexico City. From the 74 pediatric cancer units in the country, this is the only hospital in Mexico exclusively focused on the treatment of pediatric cancer.When HITO initiated activities, it had a medical and paramedical staff of 260; by the end of the study period, it had 350. Pediatric subspecialists in oncology, neurosurgery, oncologic surgery, transplant medicine, critical and emergency medicine, anesthesiology, radiotherapy, and radiooncology are the core medical staff, but nephrologists, endocrinologists, hematologists, pathologists, urologists, and orthopedic specialists are also affiliated.HITO's infrastructure and services include clinical, pathological, cytogenic/molecular biology, and hematological diagnostic labs along with diagnostic/follow‐up imaging. The hospital has 26 cubicles for ambulatory chemotherapy, an Eleckta® device for radiotherapy, a hematopoietic stem cell transplantation unit, and two fully equipped operating rooms. There is a 24/7 TRIAGE/shock area, intensive care unit (ICU), and blood bank. HITO also has an adjacent 74‐room building (Casa Teletón) that provides housing and food to caretakers during the critical stages of treatment.The hospital has an inpatient capacity of 26 beds (four for ICU) that served a yearly average of 61 new patients in active therapy between 2014 and 2017 . Mean hospital bed occupancy rate within the last 5 years was 52%. Most patients (42%) are residents of Querétaro State, but patients also come from many other Mexican states, especially from neighboring Guanajuato (15%).Care ranges from diagnostics to reintegration to daily life. Therapeutic services offered include oncological surgery, chemotherapy, radiotherapy, and bone marrow transplantation (BMT). During the period of stay at the hospital, patients and caregivers are accommodated in Casa Teletón to minimize dropouts and for early detection of complications. Caregivers receive continuous training in numerous courses and workshops regarding cancer management.2.3The study population comprised 305 children aged 0–17 years with new diagnosis of various types of cancers during the study period. However, the final sample with complete and accurate data for analysis included 286 patients (19 patients had inconsistent diagnostic and follow‐up dates). Each medical treatment given at the hospital followed advanced standardized protocols of care used in HICs that lead to the highest possible survival, such as those of the Children's Oncology Group (COG) of the United States for solid tumors,2.4n = 80); (II) tumors within the central nervous system (TWCNS) (n = 55) including astrocytomas 23, medulloblastomas 11, ependymomas 6, adamantinomatous craniopharyngiomas 4, intracranial germ cell tumors 4, atypical teratoid/rhabdoid tumors 2, neuronal and mixed neuronal‐glial tumors 2, non‐medulloblastoma embryonal tumors 1, choroid plexus carcinomas 1, and tumors of the pineal region 1; and (III) tumors outside the CNS (TOCNS) (n = 132) including osteosarcomas 25, retinoblastomas 24, non‐rhabdomyosarcoma soft‐tissue sarcomas 16, rhabdomyosarcomas 12, extracranial germ cell tumors 12, neuroblastomas 10, Langerhans cell histiocytosis 9, Ewing's sarcomas 8, Wilms tumors 8, rare tumors 4, hepatoblastomas 3, and hepatocellular carcinomas 1.Data was extracted from clinical records. Due to the relatively small samples available for individual malignancies, cancers were classified into three major groups based on its location: (I) ALL (n = 22).Information extracted included patients' sex, age, occurrence of relapse, and status at the time of the study . Children who received a hematopoietic stem cell transplantation (HSCT) were not analyzed (2.5n = 230) and three (n = 132) years of follow‐up after admission. Kaplan–Meier plots were used to depict these graphically.Frequencies and percentages were used to depict basic characteristics of the study population. RFS was defined as the time from diagnosis to disease progression. OS was defined as the time from diagnosis to death from any cause. RFS and OS as functions of time since diagnosis, were estimated using the method of Kaplan and Meier,A separate analysis was conducted with patients who fulfilled the HITO criteria . This was considered crucial to accurately portray the OS and RFS of patients treated with the HITO model of care, as some patients only received palliative care due to their advance stage . For ALL, three patients were excluded  leaving 77 available for analysis (80/77 = 96.2%). For TWCNS, 19 children had to be excluded , leaving 36 patients available (36/55 = 65.4%). For TOCNS, 20 patients were excluded  leaving 109 available (109/129 = 84.5%). Figure n = 77). Cox regression analysis was used to compute crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI) to identify predictors of OS and RFS in children with ALL.Patients with ALL constituted the largest group and were thus used for a sub‐analysis  and 3 (n = 110) after admission. OS was higher in this subsample compared with the full sample for all cancer groups in both follow‐up years analyzed . Overall, ALL reached 93.8% and 91.9% survival, TWCNS 90.3% and 86.7%, and TOCNS 95.8% and 79.3% at years 1 and 3, respectively. Both 1‐ and 3‐year survival rates tended to decrease with age group. For FRS, overall rates were slightly higher for years 1 and 3 when using the HITO criteria than with the full sample . Children with ALL reached 95.3% and 89.2% free of relapse, TWCNS 87.1% and 60%, and TOCNS 83.1% and 72.4% at years 1 and 3, respectively. Neither OS nor RFS showed clear trends in rates by age group (Table Table n = 77) are shown in Table Crude and adjusted HRs with 95% CIs for surviving and free of relapse children with ALL aged 0–17 years who fulfilled the HITO criteria , 80 were ALL and 36 were non‐ALL . From the leukemias, the proportion of ALL was 86%, very similar to the 85.1% reported in a study with children aged <15 years diagnosed in public hospitals of Mexico City during 2006–2007.From all hematological malignancies admitted at HITO during the study period ; differences seemed to relate to the small sample, especially when stratifying data. Also, crude  and adjusted  estimates for sex were not significant in regression analyzes. From the cultural perspective, we have no data suggesting a possible parental bias whereby caretakers might give more value and care to boys. Financially, this can be ruled out, as the full treatment given, including the parents' support in the adjacent facilities devised for that purpose, were completely free of charge.On the other hand, some differentials by sex with regards to ALL survival and relapse were observed, as it has been reported by other authors.We tried to identify predictors of survival and relapse in patients with ALL using Cox regression. Risk category is a well‐established predictor of survival with higher HR in the high‐risk and very high‐risk categories compared with the standard‐risk category.Based on the HITO model, 1‐year relapse rate was 4.7%, 12.9%, and 16.9% for ALL, TWCNS, and TOCNS, respectively. All patients who relapsed after the first year were given a second‐line treatment with the intention to cure.We decided to conduct a specific analysis with patients who fulfilled the HITO criteria. This was done to better assess the therapeutic performance of the HITO model. After exclusion, OS tended to increase, as one would have expected . This finding points to the value of using an integrated and comprehensive care model.Compared with the full analyzes, the sub‐analysis showed higher OS, especially for TWCNS. This indicates that excluded patients had a considerably poorer prognosis due to an advanced cancer stage without proper diagnosis/treatment, and/or because therapy used initially was not followed. These were patients that did not accept the standardized oncologic therapy , had been previously treated elsewhere, or died before an accurate histopathological diagnosis was established. Regardless of whether patients followed the HITO model or not, all children received the best available treatment at the time of initial assessment according to the consensus of the specialists' working group.While treatment duration for most conditions diagnosed at HITO is at least 1 year, 1‐year survival was included because mortality due to chemotherapy complications within the first months of treatment in LMIC can reach 23% compared with 3% in HIC. Mortality has been associated with inadequate nutrition and poor hospital accessibility. After initial treatment, children from low‐income settings are sent to their homes located far away, and with poor access to hospital facilities. These hospitals are often deprived of means to handle severe complications caused by the toxicity of the intense induction chemotherapy.r = 0.44) and TWCNS (r = 0.43).Early relapse has also been used to predict survival.n = 9), high risk neuroblastoma (n = 5), and chronic myelogenous leukemia (n = 3). The100‐day post‐transplant survival was 100%, and post‐transplant relapse was 27% during the study period.Results from HSCT patients were not presented, as these patients belonged to two different groups: those who were initially treated using the HITO model and then transplanted, and those transferred from another institution just for the transplant. Patients from the latter group, who represented more than half of all HSCT, had incomplete data regarding the previous treatment received. Therefore, the scant number of HSCT HITO patients with complete data precluded meaningful estimates. All trasplants were allogeneic of related donors (46%), autologous (27%), and haploidentical (27%). Initial diagnoses included mostly ALL in second remission  the sample size for individual cancers other than ALL were too small, especially for TWCNS, to produce stable survival estimates; the 19 patients excluded initially due to incomplete or inaccurate data were the result of missing data, typing mistakes, and incoherent information, and are therefore unlikely to have biased the results observed, (2) the grouping of cancers within and outside the CNS precluded direct comparisons with other studies that do not use such categorization; it was used, as it is the official classification of the Mexican Secretariat of Health,In spite of increasing funding to treat pediatric cancer in Mexico, survival has not increased as expected.We believe that the findings presented here highlight the value of implementing a successful therapeutic model in a country with relatively limited resources such as Mexico that could be of use in similar settings.Joel Monárrez‐Espino: Conceptualization (lead); data curation (supporting); formal analysis (lead); investigation (lead); methodology (lead); project administration ; supervision ; validation ; writing – original draft (lead); writing – review and editing (lead). Lourdes Romero‐Rodríguez: Conceptualization (supporting); data curation (lead); formal analysis (supporting); investigation ; methodology ; project administration ; validation ; writing – review and editing . Gabriela Escamilla‐Asiain: Conceptualization (lead); data curation ; investigation ; methodology ; project administration (lead); supervision (lead); writing – review and editing . Andrea Ellis‐Irigoyen: Data curation (supporting); investigation (supporting); methodology (supporting); validation (supporting); writing – review and editing (supporting). María del Pilar Cubría‐Juárez: Data curation (supporting); investigation (supporting); methodology (supporting); validation (supporting); writing – review and editing (supporting). Douglas Sematimba: Data curation (supporting); methodology (supporting); validation (supporting); writing – review and editing (supporting). Carlos Rodríguez‐Galindo: Data curation (supporting); methodology (supporting); validation (supporting); writing – review and editing (supporting). Lourdes Vega‐Vega: Conceptualization ; investigation (supporting); methodology (supporting); supervision (supporting); writing – review and editing (supporting).The following sentences were added: All procedures preformed were in accordance with national and international ethical standards.The authors declare no conflict of interest.SUPPLEMENTARY TABLE S1 Summary of the treatment protocols used by type of pediatric malignancy at HITO, Querétaro, MexicoClick here for additional data file.