The utility of 1,2‐o‐dilauryl‐rac‐glycero glutaric acid‐(6′‐methylresorufin)‐ester‐(DGGR)‐lipase activity (DLA) in monitoring clinical progression of chronic pancreatitis (CP) in dogs is unknown.To examine the association of DLA with clinical signs of CP, as assessed by a CP clinical severity score (CPCSS).Animals: Twenty‐four dogs.This is a retrospective study. Chronic pancreatitis was diagnosed based on clinical signs and DLA > 250 U/L and monitored using CPCSS and DLA.P < .001 and P = .003, respectively) than in scheduled ones . DGGR‐lipase activity was associated (P = .009) with the CPCSS, with a lower activity documented in mild‐moderate CPCSS , compared to severe score . DGGR‐lipase activity was significantly, but weakly, correlated with CPSS . DGGR‐lipase activity inefficiently discriminated mild‐moderate vs severe CP , with DLA cutoff of 428 U/L corresponding to sensitivity of 65% and specificity of 63%.The study included 134 visits . Mild‐moderate  and severe  disease were documented in 94 (70%) and 40 (30%) visits, respectively. In emergency visits  CPCSS  and DLA  were higher (Increased DLA is associated with emergency revisits in dogs with CP, possibly reflecting acute flare‐ups. DGGR‐lipase activity was associated with the CPCSS over the follow‐ups but could not differentiate disease severity. A/CPacute on chronic pancreatitisAPacute pancreatitisCIBDAIcanine inflammatory bowel disease activity indexCIEchronic inflammatory enteropathyCKDchronic kidney diseaseCPchronic pancreatitisCPCSSchronic pancreatitis clinical severity scorecPLIcanine pancreatic lipase immunoreactivityDGGR‐lipase1,2‐o‐dilauryl‐rac‐glycero glutaric acid‐(6′‐methylresorufin) ester‐lipaseRIreference interval1Chronic pancreatitis (CP) is continuous pancreatic inflammation characterized by irreversible histopathological lesions and possibly leading to pancreatic exocrine and endocrine function loss.Necropsy‐based, histological studies suggest that CP is common in dogs, with a prevalence of 34%‐64% in all necropsied dogs.There is no validated system for diagnosing CP in dogs. Similar to human medicine, noninvasive diagnosis of CP relies on presence of appropriate clinical signs, diagnostic imaging and pancreatic‐specific laboratory test findings, and vigorously ruling out concurrent diseases.Pancreatic lipases, such as 1,2‐o‐dilauryl‐rac‐glycero glutaric acid‐(6′‐methylresorufin) ester‐(DGGR)‐lipase, or serum canine pancreatic lipase immunoreactivity (cPLI), are useful in the diagnosis of AP.In addition to pancreatic lipase essays, C‐reactive protein (CRP) was significantly and positively correlated with the clinical severity of AP in dogs, as well as with serum cPLI concentration.The main aim of this retrospective study was to examine the association of a clinical severity scoring index, comprised of the CIBDAI criteria, alongside abdominal pain, with DGGR‐lipase activity, and to assess their utility in monitoring dogs diagnosed with CP as the sole or major disease. An additional aim was to assess the correlations between CRP and either the clinical severity scoring index score, or DGGR‐lipase activity, to assess its utility as an additional marker of disease severity, alongside evidence of systemic inflammation, as manifested by CRP, in dogs with CP. The study hypothesis was that serum DGGR‐lipase activity will be positively associated with the CPCSS, and will thus be a useful marker in monitoring dogs with CP, similarly to its diagnostic utility in dogs with AP.22.1This was a retrospective study, including dogs diagnosed with CP in a referral veterinary teaching hospital (VTH) between 2017 and 2021. Chronic pancreatitis was diagnosed based on the combined presence of compatible chronic or intermittent (≥3 weeks duration) gastro‐intestinal clinical signs, including ≥2 of the following: hyporexia, vomiting, diarrhea, abdominal pain,The study included dogs with and without concurrent diseases, fed various diets, and treated by different treatment regimens, as these represent the complex clinical actuality, the therapeutic and monitoring challenges in canine CP. Dogs were included with concomitant diseases only if these were deemed secondary processes, with minimal or no contribution to the clinical signs. For example, dogs with chronic kidney disease (CKD) with serum creatinine concentration ≤2.0 mg/dL during all revisits were included, as CKD was deemed subclinical, with minimal or no contribution to the relevant clinical signs. Dogs with diabetes mellitus (DM) and hyperadrenocorticism were included only if deemed stable, with no diabetic ketoacidosis or iatrogenic hypocortisolemia during follow‐up. Dogs treated for lymphoma and multiple myeloma and in complete remission were also included, if CP was considered the main disease process responsible for clinical signs.Dogs were excluded if comorbidities potentially had a major contribution to the clinical signs, or if such comorbidities could not be ruled out based on physical examination, CBC, serum chemistry, and abdominal ultrasound . Efforts were made to exclude dogs with concomitant CIEs and hepatobiliary diseases. The classical presentation of CP is described as waxing and waning, mostly low‐grade, anorexia, and gastrointestinal signs.Historical AP (before inclusion) or acute flare‐up of chronic pancreatitis (A/CP), or A/CP episodes during the study period, were recorded when dogs were presented to the emergency service with acute historical clinical signs or acute clinical deterioration during the follow‐up period, with compatible clinical signs of anorexia, frequent vomiting and marked lethargy,After the diagnosis of CP and evaluation of comorbidities, data collected on each visit included the clinical signs and DGGR‐lipase activity. Serum CRP concentration 2.2P < .001) between occurrence of an emergency visit and CPCSS ≥4.A CP clinical severity score (CPCSS) system was utilized herein, based on presence and severity of the clinical signs comprising the CIBDAI ,2.3P < .05 was considered significant in all. Statistical analyses were performed using statistical software packages .Normality was assessed using the Shapiro‐Wilk's test. The Mann‐Whitney's test was used to compare continuous variables  between groups. Associations between categorical parameters  were evaluated using the Chi‐square or Fisher's exact tests, as appropriate. The CPCSS was then divided into a severe and a mild‐moderate clinical disease severity categories, based on significant differences in frequency of emergency visits in each CPCSS level category. Associations between DGGR‐lipase activity and severity of CP  during the follow‐up period were examined using generalized linear equations. Receiver operator characteristics analysis of clustered data, with its area under the curve (ROC AUC) and its 95% confidence interval (95% CI), was performed to assess the diagnostic accuracy of serum DGGR‐lipase activity in classifying the clinical severity, as reflected by the CPCSS. The clinical score was categorized to mild‐moderate  vs severe (CPCSS ≥4) CP. The optimal serum DGGR‐lipase activity cutoff values, with their corresponding sensitivity and specificity, were those associated with the least number of misclassifications, chosen using the Youden index. Associations between continuous variables were examined using the Spearman's correlation test. All tests were 2‐tailed, and 33.1The study included 24 dogs with CP , of the following breeds: mixed breed , toy poodle , and Belgian Malinois, Maltese, Yorkshire terrier, Shih tzu, miniature schnauzer, and Weimaraner . The median age was 12.5 years , and the median body weight was 9.4 kg .In 20 dogs (83%), at least 1 episode of AP or A/CP was documented before inclusion in this study . The median duration of historical CP‐associated clinical signs, before the first recorded visit, was 55 days . Sonographic pancreatic abnormalities suggestive of CP were noted in 9 dogs (37%) upon their enrollment. The results of the CBC and serum chemistry upon diagnosis of CP are presented in Tables One concurrent chronic disease was diagnosed in 16 dogs (67%), including 6 dogs (25%) with stable  CKD, of which 1 dog was classified as International Renal Interest Society (IRIS) Stage‐1, and 5 dogs as IRIS Stage‐2,The study included 134 follow‐up visits overall , of which 90 (67%) were scheduled elective visits, and 44 (33%) were emergency visits . The median overall follow‐up period (from first to last visit) was 163 days . The median frequency of visits was every 17 days , while the median between‐visit interval was 31 days , and the median interval between visits when DGGR‐lipase activity was >250 U/L was 30.5 days . All dogs survived during the follow‐up period.Low‐fat commercial prescription dry diets were exclusively administered in 116 visits (87%), including Hill's Prescription Diet i/d low fat , Purina Pro Plan Veterinary Diets Overweight Management Canine Formula , and Royal Canin Gastrointestinal low‐fat , whereas in 18 (13%), such diets were combined with low‐fat homemade diet (fat <25% metabolizable energy). Supportive symptomatic therapy was recorded in 115 visits (86%), including antiemetics , omeprazole , appetite stimulant , and analgesia . Five dogs  were administered immunosuppressives .3.2P < .001) in unscheduled emergency visits  compared to elective visits  on emergency visits  compared to elective visits  CP. Serum DGGR‐lipase activity differed (P = .009) between the CPCSS categories, with lower activity measured in mild‐moderate CP , compared with severe CP  and severe . The CPCSS (P = .96), or DGGR‐lipase activity (P = .55) over time were both not associated with administration of immunosuppressive therapy. For every 1000 U/L increase in DGGR‐lipase activity, the CPSS increases by 0.6 . 1,2‐o‐dilauryl‐rac‐glycero glutaric acid‐(6′‐methylresorufin) ester‐lipase activity was significantly, albeit weakly correlated with the CPSS . Serum DGGR‐lipase activity poorly discriminated mild‐moderate from severe clinical disease . The optimal cutoff point, 428 U/L, corresponded to sensitivity of 65% and specificity of 63%.Neither the CPCSS nor DGGR‐lipase activity changed significantly over the follow‐up period Figures  and 3. OP = .85) nor with the CPCSS (P = .32).Serum CRP concentration  was measured in 35 visits (26%) and was above RI in 8 visits (23%). Serum CRP was neither correlated with serum DGGR‐lipase activity (4The CPCSS and serum DGGR‐lipase activity were both significantly associated with the type of visit (emergency or elective) to the hospital, which is suggestive of the severity of the disease, thus adding potentially useful information for monitoring CP in dogs. Although serum DGGR‐lipase activity and the CPCSS were significantly associated, the former was poorly predictive of the clinical severity of CP, suggesting that DGGR‐lipase activity has limited utility in monitoring the clinical progression of CP in dogs. Importantly, increases in DGGR‐lipase activity overtime were associated with higher CPCSS, but the impact on the CPCSS was minor, suggesting that only major increases in DGGR‐lipase activity overtime, might be of clinical importance.The partial clinical utility of DGGR‐lipase activity in monitoring dogs with CP was possibly negatively affected by presence of limited ongoing pancreatic active damage and pancreatic lipase activation and leakage in CP.Similarly to the present cohort, dogs diagnosed with CP are typically middle‐aged to older at diagnosis.The chronic, low‐grade gastrointestinal‐related clinical signs characteristically reported in CPComorbidities, mainly CKD and endocrinopathies, were frequent in our cohort, and such common disorders are probably inevitable in studies of naturally occurring CP.Immune‐mediated CP is reported in cocker spaniel and Cavalier King Charles spaniel breeds in the United KingdomC‐reactive protein is a useful marker for assessing severity and prognosis of AP in dogs, although not an early disease marker, since its maximal concentrations are documented days from disease onset.This study has several limitations, mainly attributed to its retrospective nature, including variable monitoring and treatment protocols, implemented by different clinicians, and the variable number of revisits per dog. While collection of clinical score indices was performed by a single investigator, some potential inaccuracies might have occurred when retrospectively and subjectively assessing the attitude and appetite of dogs upon visits. Furthermore, while some acute changes are reflected by the CPCSS, some of the clinical indices reflect changes that have occurred over a longer time period. The latter might have contributed to the weak correlation with serum DGGR‐lipase activity, which is a single‐point measure of a leakage enzyme, reflecting active pancreatic tissue damage. A shorter duration of clinical signs before presentation is associated with higher DGGR‐lipase activities in AP, affecting its diagnostic performance.In conclusion, serum DGGR‐lipase activity is only weakly correlated with the CPCS in dogs with CP.Authors declare no conflict of interest.Authors declare no off‐label use of antimicrobials.This is a retrospective study, based on data collected from medical files. An ethical approval was not required.Authors declare human ethics approval was not needed for this study.Data S1. Supporting Information.Click here for additional data file.Table S1. Complete blood count results upon diagnosis of chronic pancreatitis in 24 dogs presented to the hospital.Table S2. Serum chemistry results upon diagnosis of chronic pancreatitis in 24 dogs presented to the hospital.Click here for additional data file.Table S3. Associations between DGGR‐lipase activity and presence of clinical signs that constitute the Canine Chronic Pancreatitis Clinical Severity scoring system in 134 visits to the hospital of 24 dogs with chronic pancreatitis.Click here for additional data file.


Achieving an acceptable neurological outcome in cardiac arrest survivors remains challenging. Ischemia‐reperfusion injury induces inflammation, which may cause secondary neurological damage. We studied the association of ICU admission levels of inflammatory biomarkers with disturbed 48‐hour continuous electroencephalogram (cEEG), and the association of the daily levels of these markers up to 72 h with poor 6‐month neurological outcome.This is an observational, post hoc sub‐study of the COMACARE trial. We measured serum concentrations of procalcitonin (PCT), high‐sensitivity C‐reactive protein (hsCRP), osteopontin (OPN), myeloperoxidase (MPO), resistin, and proprotein convertase subtilisin/kexin type 9 (PCSK9) in 112 unconscious, mechanically ventilated ICU‐treated adult OHCA survivors with initial shockable rhythm. We used grading of 48‐hour cEEG monitoring as a measure for the severity of the early neurological disturbance. We defined 6‐month cerebral performance category (CPC) 1–2 as good and CPC 3–5 as poor long‐term neurological outcome. We compared the prognostic value of biomarkers for 6‐month neurological outcome to neurofilament light (NFL) measured at 48 h.p = .03), MPO (p < .01), and resistin (p = .01) concentrations at ICU admission were associated with poor grade 48‐hour cEEG. Higher levels of ICU admission OPN  and MPO  were independently associated with poor 48‐hour cEEG in a multivariable logistic regression model. Poor 6‐month neurological outcome was more common in the poor cEEG group . We found a significant fixed effect of poor 6‐month neurological outcome on concentrations of PCT , hsCRP , and OPN  measured daily from ICU admission to 72 h. However, the biomarkers did not have independent predictive value for poor 6‐month outcome in a multivariable logistic regression model with 48‐hour NFL.Higher OPN (Elevated ICU admission levels of OPN and MPO predicted disturbances in cEEG during the subsequent 48 h after cardiac arrest. Thus, they may provide early information about the risk of secondary neurological damage. However, the studied inflammatory markers had little value for long‐term prognostication compared to 48‐hour NFL. These findings show that new biomarkers and continuous EEG are disturbed following successful resuscitation after cardiac arrest at the ICU. However, these parameters alone do not add to the prediction of long‐term outcomes. Thus, established markers and especially time and neurological assessments remain hallmarks in the prediction of outcome in postcardiac arrest patients.1International Scientific Societies have recently highlighted the epidemiological relevance of sudden cardiac arrest (SCA). Although many variations due to different healthcare structures, processes of care and quality of medical treatment, SCA is the third leading cause of death in Europe, with an incidence ranging from 67 to 170 per 100,000 inhabitants.Here, we focused on molecules that have been recently associated with neutrophil infiltration to tissues 22.13 factorial design to lower or higher treatment targets of arterial blood partial pressure of oxygen , arterial blood partial pressure of carbon dioxide  and mean arterial blood pressure . These treatment targets were maintained for the first 36 h of ICU stay. The primary outcome of the COMACARE study was serum neuron‐specific enolase (NSE) concentration 48 h after cardiac arrest and cEEG grading according to Crepeau et al.The current study was a post hoc sub‐study of the COMACARE study (NCT02698917).2.2We used samples collected from 112 patients enrolled in the COMACARE‐trial in the six participating Finnish ICUs. The samples were drawn on ICU admission (median [IQR] delay from collapse to admission sample was 200 [160–230] minutes) and 24, 48, and 72 h after OHCA. We measured serum levels of PCT, hsCRP, OPN, MPO, resistin and PCSK9 by colorimetric enzyme‐linked immunosorbent assay (ELISA) following the manufacturer's instructions . The lowest detection thresholds were: 30 pg/ml for PCT, 15.625 pg/ml for CRP, 62.5 pg/ml for MPO and OPN, 31.25 pg/ml for resistin and 125 pg/ml for PCSK9. No samples fell below the detection thresholds. Intra‐ and inter‐assay coefficients of variation were below 8% for all markers. Previously published data on NSE2.3We used grading of cEEG monitoring for the first 48 h after ICU admission to the ICU interpreted by an experienced senior neurophysiologist2.4t test (continuous variables) or Pearson Chi‐Square test . Due to right‐skewed distributions, we used log‐transformed values (ln[concentration]) of all the studied inflammatory biomarkers, NSE and NFL for the statistical analyses. We studied the association of biomarker concentrations with outcome using receiver operated characteristic curves (ROC) with area under the curve (AUC) analysis.To assess group differences, we applied the Student's p < .2 in univariate analysis were added to the multivariable model. ICU admission concentration of lactate, NSE, and NFL were then added to the model together with each studied biomarker.We built multivariable logistic regression models to evaluate the independent predictive value of biomarker concentrations for poor grade cEEG recoding of the first 48 h after OHCA. The following baseline confounding variables were considered for inclusion to the models: age, sex, bystander‐initiated resuscitation, delay to arrival of first unit, delay to ROSC and norepinephrine dose at ICU admission. The variables that were associated with the outcome variable at a 2, PaO2 and MAP intervention groups and temporal change in biomarker concentrations, we employed linear models with alternative covariance structures and restricted maximum likelihood (REML) estimation. We used the MIXED procedure of the SPSS program. The method allows analysis of repeated measures and tolerates occasional missing values.To analyze the association between poor 6‐month neurological outcome and temporal change in biomarker concentrations, and between PaCOWe built multivariable regression models to assess the independent predictive value of biomarker concentrations for predicting poor 6‐month neurological outcome. Based on our previous results indicating NFL at 48 h having high discriminatory potential for poor 6‐month neurological outcome,https://www.graphpad.com to draw the figures.We performed statistical analyses with the SPSS software . We used GraphPad Prism software, version 9, 3In total, 112 patients were enrolled during the recruitation period March 22, 2016 to November 3, 2017. Of these, 111, 111, 109, and 106 patients had sera available for measurement of biomarkers at ICU admission, 24, 48, and 72 h, respectively. One patient had a missing ICU admission sample and another one a missing 72‐hour sample due to sampling error. Other missing samples were caused by early deaths or treatment withdrawals. At 30 days after OHCA, 36 patients were dead, and 76 patients were alive. Of the 30‐day survivors, one patient died before 6‐month follow‐up and two patients had severe cerebral disability (CPC 3) 6 months after OHCA. The remaining 73 patients had good 6‐month neurological outcome . No patient was lost to follow‐up. The median (IQR) ICU admission concentrations of biomarkers were: PCT 0.12 (0.10–0.20) ng/ml, hsCRP 0.83 (0.38–2.1) μg/ml, OPN 53 (41–79) ng/ml, MPO 97 (50–190) ng/ml, Resistin 40 (28–59) ng/ml and PCSK9 160 (100–210) ng/ml. Characteristics of the study population are presented in Table 3.1p < .001, respectively). In the poor cEEG group, 18% of patients had good 6‐month neurological outcome with CPC 1 and 18% with CPC 2, whereas in the good cEEG group the distribution was 63% CPC 1 and 18% CPC 2. We tested if the ICU admission concentrations of the biomarkers were different between patients with poor or good cEEG. Higher OPN (p = .03), MPO (p < .01) and resistin (p = .01) concentrations at ICU admission were associated with poor grade cEEG. , and 71 patients had good grade (1) cEEG recording of the first 48 h after OHCA. Two patients had missing cEGG data. Poor 6‐month neurological outcome was more common in the poor cEEG group compared to the good cEEG group  and ICU admission concentration of NSE, NFL, and lactate. Higher levels of ICU admission OPN, MPO and resistin were independently associated with poor cEEG in these models. , delay to ROSC , OPN (p = .02) and MPO (p < .01) with poor 48 h cEEG recording, whereas the association of resistin with the outcome variable was not significant after bootstrapping (p = .06).Finally, we assessed the independent predictive value of ICU admission concentrations of biomarkers in multivariable logistic regression models. The models were built adjusting for relevant clinical confounding factors that were associated with the outcome variable at a s. Table . Interna3.2p < .001 for all). We found a significant fixed effect of poor 6‐month neurological outcome on concentrations of PCT , hsCRP , and OPN .  on the concentrations of the biomarkers  changed as a function of time between the four measured timepoints from ICU admission to 72 h  is particularly vulnerable to hypoxia during cardiac arrest due to its high metabolic rate and limited energy reserves.Multiple studies have shown that elevated levels of inflammatory biomarkers in circulation are associated with poor outcome after cardiac arrest.Among the biomarkers here investigated, indirect–and partially controversial–data are available in both clinical and experimental models of brain ischemia–reperfusion injury (IRI).In the current study, ICU admission values of neutrophil activation markers were associated with short‐term neurological disturbance reflected as seizure activity in the cEEG. This suggests that the detrimental neutrophil activation occurs within hours after ROSC. Once the brain tissue damage has occurred, structural proteins of neurons such as NFL are increasingly seen in the circulation at 24 and 48 h after ROSC,The growing awareness about the complex network of interaction of different biological pathways is changing the attitude about the use of biomarkers, which are increasing pooled. The benefits of this approach clearly emerged from the COMMUNICATE study4.1The study is a multicenter study performed in a government‐funded healthcare system with minimal variations of treatment between centers. No patient was lost to follow‐up and missing samples were rare. Outcome assessors were blinded to biomarker results and analysis of biomarkers was performed blinded to clinical data and outcome. The two major limitations of the study are the relatively small sample size and the enrollment of highly selected good prognosis patients . Reperfusion injury is presumably greater in patients with initial non‐shockable rhythm and ROSC >45 min. These limitations prevented us from analyzing the impact of the cause of cardiac arrest  on biomarker levels. Therefore, our results need to be validated in future unselected cohorts–including patients with poorer prognosis due to other clinical causes of OHCA–in which inflammation likely plays a more important role.5In OHCA patients with successful resuscitation from VF/VT, high concentrations of OPN and MPO at ICU admission were independent predictors for disturbances in cEEG during the subsequent 48 h. Thus, these inflammatory markers may provide early information about the risk of secondary neurological damage. Higher levels of PCT, hsCRP and OPN measured daily from ICU admission to 72 h were associated with poor 6‐month neurological outcome but did not contribute independent prognostic value when modeled with NFL measured at 48 h.All listed authors meet the requirements of authorship and have approved the final version of the manuscript. Pirkka T. Pekkarinen, Federico Carbone, Fabrizio Montecucco, and Markus B. Skrifvars designed the study and wrote the manuscript. Pirkka T. Pekkarinen carried out data analysis and interpretation and drew the figures with major contributions from Markus B. Skrifvars All other authors  made moderate contributions to the study design and manuscript revision.This study was funded by Helsinki University Hospital funding (project M7100YLIT2) and grants from Finska Läkaresällskapet and Einar och Karin Stroems stiftelse to Pirkka T. Pekkarinen; The funders had no role in study design, data collection, statistical analysis planning, manuscript writing or selection of the publication forum.Giuseppe Ristagno has served at data monitoring committee for DSMB trial: TRansfusion Strategies in Acute Brain INjured Patients (TRAIN).Kaj Blennow has received consulting fees from Abcam, Axon, BioArctic, Biogen, JOMDD/Shimadzu, Lilly, MagQu, Prothena, Roche Diagnostics and Siemens Healthineers; honoraria for lectures from: GEECD/Roche Diagnostics and IFCC/SNIBE; has served at data monitoring committees for: Julius Clinical and Novartis and he is a co‐founder of Brain Biomarker Solutions in Gothenburg AB (BBS), which is a part of the GU Ventures Incubator Program.Henrik Zetterberg has served at scientific advisory boards and/or as a consultant for Abbvie, Alector, Annexon, Artery Therapeutics, AZTherapies, CogRx, Denali, Eisai, Nervgen, Novo Nordisk, Pinteon Therapeutics, Red Abbey Labs, Passage Bio, Roche, Samumed, Siemens Healthineers, Triplet Therapeutics, and Wave, has given lectures in symposia sponsored by Cellectricon, Fujirebio, Alzecure, Biogen, and Roche, and is a co‐founder of Brain Biomarker Solutions in Gothenburg AB (BBS), which is a part of the GU Ventures Incubator Program.Jussi Toppila has received consulting/lecture fees from: UCB Pharma Finland and SGS Fimko Ltd.Figure S1 A, Biomarker concentrations in PaCO2 target groups.Click here for additional data file.Figure S2 B, Biomarker concentrations in PaCO2 target groups.Click here for additional data file.Figure S3 C, Biomarker concentrations in MAP target groups.Click here for additional data file.Table S1 Fixed effect of poor neurological outcome on ln(concentration) of biomarkers (n = 112).Click here for additional data file.Table S2 Logistic regression analysis for the association of biomarker levels with poor 6‐month neurological outcome.Click here for additional data file.


We conducted a retrospective multi‐centre study to assess the real‐world outcome of regorafenib (REGO) and cabozantinib (CABO) in recurrent/refractory bone tumours (BTs) including osteosarcoma (OST), Ewing sarcoma (EWS) and chondrosarcoma (CS)/extra‐skeletal mesenchymal CS (ESMC).After regulatory approval, data from patients with recurrent BT (11 institutions) were extracted from CanSaRCC  database. Patient characteristics, treatment and outcomes were collected. Progression‐free survival (PFS) and overall survival (OS) were estimated using the Kaplan–Meier method.n = 37, range 40–60) and 120 mg for REGO . Twenty‐eight (42.4%) patients required dose reduction: hand‐foot syndrome 7 (10.6%), nausea/vomiting 1 (1.5%), diarrhoea 1 (1.5%), 2 elevated LFTs (3%), elevated bilirubin 1 (1.5%) and mucositis 1 (1.5%). The median OS for patients with OST, EWS, CS and ESMC was 8.5 months ; 13.4 months , 8.1  and 18.2 , respectively. Median PFS for OST, EWS, CS and ECMS was 3.5 , 3.9 , 5.53 (n = 4. 95% CI 2.13–NA) and 11.4 , respectively. Age, line of therapy, REGO versus CABO, or time from diagnosis to initiation of TKI were not associated with PFS on univariable analysis.From July 2018 to May 2022, 66 patients received REGO or CABO; 39 OST, 18 EWS, 4 CS and 5 ESMC. Median age was 27.8 years (range 12–76); median starting dose was 60 mg for CABO (Our real‐world data show that TKIs have meaningful activity in recurrent BT with acceptable toxicities when started at modified dosing. Inclusion of TKIs in earlier lines of treatment and/or maintenance therapy could be questions for future research. Real‐world national CanSaRCC data support the use of regorafenib and cabozantinib in children and adults with relapsed bone sarcoma. The most common primary bone tumours include osteosarcoma (OST), Ewing sarcoma (EWS) and chondrosarcoma (CS). The management of EWS and OS includes aggressive surgery and/or radiation in combination with chemotherapy. Surgery remains the only curative option for CS. Despite multimodality therapy, at least 30%–40% of patients will experience relapse of their disease. Patients with large or axial tumours and those with high burden of distant metastases at diagnosis have the highest risk of recurrence. There is a lack of effective treatment options for recurrent bone tumours and there remains an urgent unmet medical need.Depending on location and timing of relapse, traditional approaches to second line therapy have been dominated by cytotoxic chemotherapies.2 in children, orally once daily in 28‐day cycles. Regorafenib (REGO) is another multi‐targeted TKI which was evaluated in a phase II study of 42 adults with relapsed OST. The initial dose of REGOwas 160 mg orally for Days 1–21 of a 28‐day cycle. Here, median progression‐free survival (PFS) was significantly improved among those who received REGO compared with placebo with a PFS of 3.6 months  versus 1.7 months , respectively .Cabozantinib (CABO) is a multi‐TKI targeting MET, VEGFR2, RET, KIT, FLT3, TIE2 and AXL, with important activity in several cancers such as renal cell carcinoma and prostate cancer.Herein, we use a newly formed national database platform called CanSaRCC  to report experience using CABO and REGO in children and adults with relapsed or refractory bone tumours to add real‐world evidence to these initial trials.2t‐test/ANOVA and/or Wilcoxon rank/Kruskal–Wallis tests to compare means and medians between groups. Chi‐square test was used to compare categorical variables. For all analyses, p value <0.05 was considered statistically significant. Statistics were performed using SAS version 9.4.After research ethics board approval at the following 11 institutions: The Hospital for Sick Children (Toronto), Princess Margaret Cancer Centre (Toronto), Mount Sinai Hospital (Toronto), BC Children's Hospital (Vancouver), BC Cancer (British Columbia), Hôpital Maisonneuve Rosemont , Centre Hospitalier Universitaire de Québec (Québec City), the McGill University Health Centre , Alberta Health Services (Edmonton), CancerCare Manitoba (Winnipeg), the Saskatchewan Health Authority (Saskatchewan), patient data were collated into the CanSaRCC database. Patients of all ages with documented relapsed or refractory OST, EWS or CS who received either CABO or REGO for at least 4 weeks were between July 2018 and May 2022 were included. All patients had measurable disease at the time of initiation of TKI therapy. Patients' demographics, disease and treatment details were then collected using a case report form and summarized using descriptive statistics. Treatment‐related toxicities were graded according to CTCAEv5. Response assessment was performed by local investigators. PFS and overall survival (OS) were estimated using the Kaplan–Meier method and compared using log‐rank test. PFS was calculated from the date of initiation of the TKI to the date of disease progression or death as determined by the local investigator. Disease progression or death from the disease was considered an event for PFS. OS was calculated from the date the patient started the TKI to the date of last follow‐up (including death). Clinical benefit rate (CBR) was defined as complete response (CR) plus partial response (PR) plus stable disease (SD) > 3 months. Univariable (UVA) analyses were conducted to examine the association of patient‐, disease‐ and treatment‐related variables with outcomes of PFS, OS and length of TKI therapy . We used student's 33.1Sixty‐six patients were included with a median age of 27.8 years range 12–76) at the start of TKI, of whom, 20 (30%) were ≤ 18 years and 34 (51.5%) were male , 13.4 months , 8.1 months  and 18.2 months , respectively , 3.9 months , 5.53 (n = 4. 95% CI 2.13–NA) and 11.4 , respectively.  or 60 mg  once daily on a continuous basis. Dose reductions were required in 15 (40.5%) patients due to toxicity  patients received CABO with a starting fixed dose of 40 mg (3.2.2n = 1) and 16.33 (n = 1) months, respectively. Eight patients received REGO for more than 6 months and four patients for longer than 12 months  patients received REGO. Patients were treated with standard fixed dosing with a median starting dose of 120 mg (range 40–160 mg) administered for 21 days of a 28‐day cycle. For five patients with age ≤ 18, the starting dose was 40 mg to ensure tolerability and increased thereafter  and 3.5 months , respectively  for patients treated with CABO and 36%  with REGO. Objective responses  were observed in 4 (28.6%) to CABO and in 1 (PR) (4%) to REGO. The longest TKI treatment duration with CABO and REGO was 16.5 and 19.5 months, respectively. Nine patients (23%) had notable SD: n = 3, 6 months; n = 4, 6–12 months; n = 2, >12 months) with either REGO or CABO  and 13.2 months , respectively  with CABO and 100%  with REGO. Objective responses were seen in 4 patients  (25%) with CABO and in two patients (PR only) (100%) with REGO. The longest duration of therapy with CABO and REGO was 16.8 and 24 months, respectively. One patient had notable SD lasting >12 months)  and 14.7 (n = 1), respectively. Of four patients with CS, the median PFS with CABO and REGO is 7.09  and 3.97 (n = 1), respectively , prolonged SD . Responses in ECMS were as follows: PR , prolonged SD . The longest duration of therapy with CABO and REGO was 19.3 and 16.5 months, respectively (both ECMS). Three patients had notable SD: n = 1, <6 months; n = 1, 6–12 months; n = 1, >12 months)  with an intracardiac mass causing severe right ventricular outflow tract obstruction and bilateral lung metastases. After urgent cardiac debulking, she received 5 cycles of ifosfamide/etoposide with good response. She was started on REGO due to persistent small lung lesions  and remains on drug without progression for 16.1 months at the data cut off for study. The second case is that of an 18‐year‐old male with OST who developed bilateral small volume pulmonary metastases (largest 1.1 × 0.6 cm) less than 2 years from primary diagnosis, who started CABO at first relapse and remains on drug without progression for 16.6 months.4Using the recently established infrastructure of a national sarcoma database, herein we present meaningful real‐world activity data of REGO and CABO in children, adolescents and adults with relapsed or refractory bone tumours. Oral TKIs offer patients a viable alternative to cytotoxic chemotherapy offering reprieve from alopecia, nausea and cytopenia, and in select cases, is associated with long term disease stability. Patients either started TKI at doses lower than previously published or required dose reductions highlighting the lack of clarity around the ideal therapeutic window of TKI in bone tumours.clinicaltrials.gov identifier NCT05135975The outcome for patients with advanced bone tumours has remained stagnant over the last 40 years,2. Moreover, the starting dose of CABO was only 40 mg in half of the adult patients (13/30) and median dose of REGO was 120 mg for all patients. In four paediatric patients, REGO was started at 40 mg and dose slowly increased to tolerance. We suggest exploring a ‘go slow’ approach to maximize tolerance to drug, a strategy similar to that implemented in other cancers.This study included patients of all ages, and we observed variability in dosing practices across ages and institutions. Many paediatric patients were treated with flat dosing instead of dosing per mCS is a rare form of bone cancer that is mainly treated with surgery and is generally unresponsive to traditional chemotherapy options.Other TKIs have been examined in recurrent/refractory bone tumours including sorafenib in OST (PFS 4 (95% CI 2–5)),This study was conducted using a national database  that permitted the capture of data for patients with sarcoma diagnosed across a wide geographical area and facilitated meaningful analysis on a rare subset of patients. This infrastructure that includes pre‐defined data elements, quality check and longitudinal follow‐up offers many opportunities to collect real‐world data to help supplement clinical trials. This is the first study conducted through the CanSaRCC national collaboration of 11 sites across Canada permitting the unique opportunity to increase the sample size of patients with rare bone sarcomas receiving TKIs as a therapeutic intervention. In this regard, institutions were permitted to offer imaging evaluations at their own discretion and provided their own assessment of response and toxicity to drug. Therefore, our description of PFS is made within these limitations. We also did not collect details on disease burden prior to starting therapy and thus could not comment on whether TKI slowed the pace of disease progression. Furthermore, despite this national effort, the rarity of relapsed and refractory bone tumours precluded our ability to identify any patient factors that may predict response to TKI. Other limitations to this study include: (1) lack of information on the timing of when dose reductions occurred (first course or later), (2) no information on need for additional medications to treat side effects of TKIs and (3) the absence of information on whether the use of the TKI contributed to the ability to perform local control. Despite these limitations, further exploration of tumour biomarkers predicting response to anti‐angiogenic therapy in bone tumours is of utmost interest for future projects.In summary, we demonstrate meaningful real‐world outcomes using TKI in children, adolescents and adults with relapsed/refractory bone tumours. Future trials should consider including TKIs as maintenance treatment. More national and international joint collaborations through sarcoma‐oriented databases such as CanSaRCC will help to share precise data and facilitate interdisciplinary clinical and translational research in sarcoma.Hagit Peretz‐Soroka: Conceptualization ; data curation (lead); formal analysis (lead); methodology (lead); project administration (lead); resources (lead); validation (lead); writing – review and editing . Tushar Vora: Data curation . Jonathan Noujaim: Conceptualization ; data curation ; writing – review and editing . Nicolas Marcoux: Data curation ; writing – review and editing . Sarah Cohen‐Gogo: Data curation ; writing – review and editing . Thierry Alcindor: Data curation ; writing – review and editing . Caroline Holloway: Data curation ; writing – review and editing . Caroline Rodrigues: Data curation ; formal analysis ; validation ; writing – review and editing . Hatim Karachiwala: Data curation ; writing – review and editing . Saima Alvi: Data curation ; writing – review and editing . Ursula Lee: Data curation ; writing – review and editing . Sylvia Cheng: Data curation ; writing – review and editing . Shantanu Banerji: Data curation ; writing – review and editing . Sapna Oberoi: Data curation ; writing – review and editing . Xiaolan Feng: Data curation ; writing – review and editing . Alannah Smrke: Data curation ; writing – review and editing . Christine Simmons: Data curation ; writing – review and editing . Albiruni R.A. Razak: Data curation ; methodology ; writing – review and editing . Abha Gupta: Conceptualization (lead); formal analysis ; methodology (lead); project administration ; resources (lead); supervision (lead); writing – original draft (lead); writing – review and editing (lead).This work was supported by CanSaRCC.None of the authors have any conflicts of interest to disclose.Ethics approval was obtained through University Health Network which supports the consortium agreement with CanSaRCC permitting multi‐institutional data and the lead site of this project.


Immunotherapy has become a mainstay of treatment for many cancers. Multiple immune checkpoint inhibitors have been used to treat malignancies, including anti‐programed death‐1 (PD1) and anti‐cytotoxic T‐lymphocyte‐associated protein (anti‐CTLA4). However, a significant percentage of patients develop resistance to these immunotherapy drugs. Therefore, novel strategies were developed to target other aspects of the immune response. Lymphocyte activation gene‐3 (LAG‐3) is a cell‐surface molecule found on natural killer cells and activated T‐cells which negatively regulates T‐cell proliferation and function. LAG‐3 inhibitors interact with LAG‐3 ligands on the surface of T‐cells to block T‐regulatory (Treg) cell activity, suppress cytokine secretion and restore dysfunctional effector T‐cells which subsequently attack and destroy cancer cells. This review reports the dermatologic side effects associated with LAG‐3 inhibitors used in the treatment of melanomas. Using PRISMA 2022 guidelines, a comprehensive literature review of PubMed, Google Scholar, Embase, Cochrane, and Web of Science databases was conducted. Three studies were identified that demonstrated that the use of LAG‐3 inhibitors, whether as a single agent or in combination with other immune checkpoint inhibitors, resulted in stomatitis, pruritus, rash, dry skin, erythema, and vitiligo. Further research is warranted to assess the cutaneous adverse events observed with LAG‐3 inhibitors in treating melanoma and to identify populations most vulnerable to such side effects. This review reports the dermatologic side effects associated with LAG‐3 inhibitors used in the treatment of melanomas. Using PRISMA 2022 guidelines, a comprehensive literature review of PubMed, Google Scholar, Embase, Cochrane, and Web of Science databases was conducted. Three studies were identified that demonstrated that the use of LAG‐3 inhibitors, whether as a single agent or in combination with other immune checkpoint inhibitors, resulted in stomatitis, pruritus, rash, dry skin, erythema and vitiligo. Further research is warranted to assess the cutaneous adverse events observed with LAG‐3 inhibitors in treating melanoma and to identify populations most vulnerable to such side effects. What is already known about this topicLAG‐3 inhibitors have been studied, as single agents or in combination with other checkpoint inhibitors, in the treatment of different skin cancers.What does this study add?This study demonstrates that LAG‐3 inhibitors, whether as a single agent or in combination with other checkpoint inhibitors, may result in a variety of transient cutaneous conditions, including stomatitis, pruritus, dermatitis, dry skin, erythema, and vitiligo in the treatment of different cancers.1Most patients with early‐stage melanoma are fully treated with resection of the primary lesion. Complications, such as metastasis and difficult‐to‐resect lesions, can make treatment plans more challenging.Lymphocyte activation gene‐3 (LAG‐3), mainly found on natural killer cells and activated T‐cells, has recently been studied as a potential target for immunotherapy. LAG‐3 aims to inhibit T‐cell proliferation and function while promoting T‐regulatory cell (Treg) activity.As LAG‐3 inhibitors gain popularity in the clinical world to treat melanoma, more adverse effects have been reported. A common category of side effects comprises dermatologic reactions with a variety of presentations. In this systematic review, we analyse and summarise the most up‐to‐date literature to outline the cutaneous adverse events associated with LAG‐3 inhibitors.2A comprehensive literature search was conducted using PubMed, Google Scholar, Embase, Cochrane, and Web of Science databases to select relevant articles using PRISMA  guidelines (2022). The initial search was conducted in May 2023, after which the titles and abstracts were screened for inclusion criteria by two independent reviewers . Three reviewers  reviewed full texts of shortlisted articles to ensure they met the inclusion criteria. Any disagreements were resolved by a fourth reviewer (H.G.). Following that, pertinent variables such as type of study, signs/type of cutaneous toxicity, patient demographics, a short description of the study, and effectiveness of treatment were extracted from each study.2.1Combinations of search terms were run in both databases. We used the following search string to identify relevant articles:“lag3” AND “toxicity”: 58 resultsAND“lag3 inhibitor” AND “melanoma” AND “toxicity”: 9 resultsAND“relatlimab” AND “toxicity”: 1 resultOur search was limited to peer‐reviewed journal articles published in the last decade (2015–2023). We assessed article quality, study context and design, and outcomes. Inclusion criteria included original human studies that were on PubMed and Google Scholar, written in English language and those that specifically mentioned the dermatological toxicities seen with LAG‐3 inhibitors.Exclusion criteria involved studies that were not accessible for full‐text review, those without a discussion of cutaneous toxicities, and those which were not original clinical trials involving humans.A total of 68 records were generated using the above search terms, out of which 34 studies were extracted. After screening the titles/abstracts and full texts for inclusion criteria, a final number of 6 studies were shortlisted for our systematic review.3Study selections are detailed in Figure Study selections are detailed in Figure n = 6, 2.4%), dry skin , and erythema , but these were seen in a minority of trial subjects.Of the 6 studies identified in the systematic review, all were clinical trial data from phase I, Phase I/II or Phase II/III trials. The median ages of subjects in the three included studies were 63 years, 63.5 years, and 58 years, respectively. The age range of patients included in the study was 19–94 years. A total of 621 patients taking LAG‐3 were identified. Among the 621 subjects, the most common adverse effects noted were pruritus and rash. A total of 102 (16.4%) subjects experienced pruritus and approximately 114 (18.3%) experienced rash, “immune mediated rash” or maculopapular rash. In Tawbi et al trial, 37 (10.4%) participants experienced vitiligo.4n = 11), it is difficult to draw any conclusions.LAG‐3 inhibitors used in combination with other immunotherapy drugs as in Tawbi et al and Schoffski et al trials, increased the incidence of cutaneous adverse events, regardless of whether it concurrent with a checkpoint inhibitor or solo‐therapy.Of the six studies analysed, none focused on cutaneous adverse events as a primary endpoint. Therefore, it is possible other cutaneous side effects of LAG‐3 inhibitors remain unreported. Dermatological side effects are among the most prevalent adverse effects of anti‐cancer immunotherapy drugs. These effects have been extensively reported, including acneiform rash, alopecia, vitiligo, xerosis, pruritus, eczema‐like or psoriatic lesions, lichenoid dermatitis, nonspecific maculopapular rash, oral mucositis, paronychia, onycholysis, and even induction of secondary skin tumours such as squamous cell carcinoma and keratoacanthomas.5Findings regarding cutaneous adverse effects of LAG‐3 inhibitors are limited. Per our systematic review, we identified six studies that demonstrated that the use of LAG‐3 inhibitors, whether as a single agent or in combination with other immune checkpoint inhibitors, resulted in a variety of dermatological conditions, including stomatitis, pruritus, rash, dry skin, erythema, and vitiligo. Further research is warranted to assess the cutaneous adverse events observed with the use of LAG‐3 inhibitors in treating melanoma and to identify populations most vulnerable to such side effects.None to declare.Hira Ghani: Writing – original draft ; Writing – review & editing . Samavia Khan: Writing – original draft ; Writing – review & editing . Marielle Jamgochian: Writing – original draft ; Writing – review & editing . Beth Richards: Supervision . Erica DeCecco: Writing – original draft ; Writing – review & editing . Rebecca Fliorent: Writing – original draft ; Writing – review & editing . Nithisha Cheedalla: Writing – original draft ; Writing – review & editing . Khalil A Khatri: Writing – original draft ; Writing – review & editing . Barbar Rao: Writing – original draft ; Writing – review & editing .Not applicable.


To develop and evaluate German versions of the Parent Adherence Report Questionnaire (PARQ) and Child Adherence Report Questionnaire (CARQ) and to evaluate adherence in patients with juvenile idiopathic arthritis (JIA).The PARQ and CARQ were translated into German, cross-culturally adapted and administered to patients (age ≥ 8 years) and their parents enrolled in the Inception Cohort Study of newly diagnosed JIA patients (ICON).The psychometric issues were explored by analyzing their test–retest reliability and construct validity.n = 465) completed the PARQ and CARQ at the 4-year follow-up. Mean age and disease duration of patients were 10.1 ± 3.7 and 4.7 ± 0.8 years, respectively. The rate of missing values for PARQ/CARQ was generally satisfactory, test-retesting showed sufficient reliability. PARQ/CARQ mean child ability total scores  for medication were 73.1 ± 23.3/76.5 ± 24.2, for exercise: 85.6 ± 16.5/90.3 ± 15.0, for splints: 72.9 ± 24.2/82.9 ± 16.5. Construct validity was supported by PARQ and CARQ scores for medications, exercise and splints showing a fair to good correlation with the Global Adherence Assessment (GAA) and selected PedsQL scales. Adolescents showed poorer adherence than children. About one third of the parents and children reported medication errors. Perceived helpfulness was highest for medication, and adverse effects were reported the greatest barrier to treatment adherence.Four hundred eighty-one parents and their children with JIA (The German versions of the PARQ and CARQ appear to have a good reliability and sufficient construct validity. These questionnaires are valuable tools for measuring treatment adherence, identifying potential barriers and evaluating helpfulness of treatments in patients with JIA.The online version contains supplementary material available at 10.1186/s12969-023-00811-0. The response rate was 82%. Thus, test–retest reliability of the PARQ and CARQ was assessed in 58 parents and 39 JIA patients, respectively.Intra-class correlation coefficients (ICC) for the medication scores showed moderate to excellent reproducibility . ICC values for the exercise score ranged from poor to excellent concordance (PARQ/CARQ ICC = 0.28- 0.45/ ICC = 0–0.93). Splint scores’ reproducibility was also poor to excellent (PARQ/CARQ ICC = 0.01–0.90/ ICC = 0.00–0.93).r = -0.37, CATS: r = -0.47; exercises: frequency: r = -0.25, CATS = -0.36; splints: frequency: r = -0.59, CATS: r = -0.68). Hence, the strongest correlation was found for splint therapy, indicating substantial agreement. Correlations between the PedsQL Treatment subscale and PARC CATS as well as CARQ CATS were slight to moderate.Correlations between the GAA with the VAS “frequency of following treatment” and the PARQ CATS for all three treatment domains were substantial to fair according to Landis & Koch  (medicatr = -0.36).When the answer to the yes/no format question on errors in medication behavior: “when feeling worse when taking medicine, sometimes stopped taking it” was correlated with the PedsQL 3.0 treatment subscale single item “medicine makes child feel sick”, a fair correlation was observed (r = -0.29). For further results see Additional file, Table Looking at exercises, correlations between the VAS “negative reactions in response to treatment” and the PedsQL 3.0 treatment subscale single item “physical therapy or daily exercises hurt” resulted in fair correlation r = -0.9. For fuPresumed differences in CATS-PARQ and CATS-CARQ for different patient groups could be detected but were not significant overall  was 33.5 months (SD 18.2), while patients who experienced AE (n = 87) were prescribed MTX for a mean of 39.6 months (SD 14.4) (p = 0.001). However, we did not see an association of adherence to MTX in PARQ-CATS or CARQ-CATS with duration of MTX therapy , 75 (86.2%) were treated with methotrexate (MTX). The average cumulative duration of MTX therapy in patients without AE  and also in patients ≥ 13 years (Δ PARQ – CARQ for the CATS was in mean -11.6 (SD 16.2), p50: -5.0, p = 0.043). Results are presented in Fig. In an additional analysis, the CATS of the PARQ was contrasted with the CATS of the CARQ with respect to the 3 treatment categories. The comparison of both measures showed good agreement regarding drug therapy but revealed significant differences for exercise therapy, which could be shown in patients 8–12 years (ΔPARQ—CARQ for the CATS was in mean -7.5 (SD 17.8), p50: -4.3, This study determined the psychometric properties of the German versions of PARQ and CARQ in a large cohort of JIA patients. Both questionnaires were found to have satisfactory psychometric properties, making them reliable and valid tools for assessing treatment adherence, helpfulness of treatments, and detecting possible treatment barriers in patients with JIA.Overall, PARQ and CARQ scores were high in our study with scores ranging mostly from 70 to 90, suggesting good overall adherence in this patient group. Our results are comparable to data presented by Lohse et al.  who founBoth the PARQ and the CARQ showed an acceptable rate of missing values apart from the questions regarding splint therapy, which counted most missing responses.Whereas the intra-class correlation coefficients (ICC) for the medication scores showed moderate to excellent reproducibility, the ICC values for the exercise score and the splint score ranged from poor to excellent concordance. One interpretation of the results would be that the medication of patients with JIA remained mostly unchanged in the time between the two tests (test–retest), whereas the prescription of doing exercises or wearing splints was subject to greater fluctuation. In addition, the number of patients with the respective medical measures in the test–retest group is quite small, which leads to a large range when questions are answered differently in the two tests. Comparing the CATS of the PARQ with the CATS of the CARQ showed good agreement regarding drug therapy but significant differences for exercise therapy. One possible reason for this difference could be that the respective therapies are rated differently by children and their parents regarding helpfulness.From the children's perspective, the usefulness of the therapies was rated highest for exercise, while parents found drug therapy most helpful, which is in line with data from April et al. . CorrespAnother treatment we studied was splint therapy, which is not widely used today, as reflected in the proportion of patients in our cohort who received this treatment (21%). Both parents and patients agreed that splint therapy was the least helpful treatment—an assessment that may also have influenced the incomplete responses to the relevant questions in the PARQ (many missings)—and the CATS score for splint therapy was the lowest from the parents' perspective.For discriminant validity, several parameters were examined for their association with treatment adherence: The socioeconomic status (SES) as a major influence factor on adherence has been widely discussed in literature. Various studies suggest that a lower SES is associated with non-adherence –13. A stThere was no statistically significant difference in CARQ-CATS for any of the parameters examined , whereas in the PARQ lower general well-being and more pain led to higher adherence to exercise therapy as reported by parents.Generally, JIA patients are fairly young at disease onset (5.4 years ± 3.6 in our study sample) which is why caregivers are highly and continuously involved into disease management from disease onset onwards. As such, younger patients were found to be more adherent . AlthougThere are a few limitations in this study: Using self-questionnaires remains a subjective method of measuring patient adherence, and we do not have objective measurement criteria for comparison available. As disease duration was similar among patients in ICON, we were unable to investigate the influence of this factor on treatment adherence. Our data show patient characteristics after 4 years of follow-up. Patients are expected to be well adjusted to their therapy by then and to have low disease activity or pain which is the case in our study sample. In addition, adherence appears to change, as may perceived barriers, so comparisons at different time points of prospective follow-ups would be desirable. As the questionnaire is quite long, it is more suitable for studies than for everyday clinical use.Both the German version of the PARQ and the CARQ appear to be valid and useful measures of adherence in JIA, providing important additional information on treatment adherence compared to general adherence measures, such as the GAA. The validation of the questionnaire in German language expands the circle of users, which may allow a more frequent evaluation of adherence and its relevance on the therapeutic success. Self-reported treatment adherence in JIA patients was good after 4 years of specialized care. The perceived usefulness of medications was rated highest, while adverse effects were reported as the greatest barrier to treatment adherence. These are important implications for good patient care, as possible side effects should be actively addressed and, if they occur, ways of alleviating them should be provided. Subsequent studies should focus on assessing, to what extent adherence influences the long-term outcome of JIA.We will further investigate if and how adherence changes over time. With this comes the search for strategies to prevent non-adherence and further improve adherence in JIA patients so that the best possible outcome can be achieved.Additional file 1: Table 1. Distribution of missing values for PARQ and CARQ. Table 2. Convergent validity: correlations between CATS  and the GAA and PedsQL subscale items. Figure 1. Discriminant validity of PARQ (A) and CARQ (B) Child ability total score, displaying different groups with possible differences in adherence.


Consumers have recently preferred food that is easy to make and of excellent quality, as well as food that is safe, natural, and minimally processed, but has a longer shelf life. Food deteriorates over time as a result of microbiological, chemical, or physical changes. Phytochemicals derived from medicinal and food plants have long been recognized for their biological activity to protect plants. These bioactivities are designed to increase the shelf life of food while inhibiting the growth of microorganisms. The use of natural plant food preservatives containing bioactive compounds as health‐promoting agents is particularly intriguing. Furthermore, due to their effectiveness against food spoilage and foodborne pathogens, natural plant‐origin antimicrobial compounds have been investigated as alternatives to synthetic antimicrobial compounds for preserving food quality. This review focused on the plant composition and properties that can be utilized as a natural food preservative, as well as the possibilities of using Mongolian medicinal plants. The use of natural plant food preservatives containing bioactive compounds as health‐promoting agents is particularly intriguing. This review focused on the plant composition used as a natural food preservative, as well as the possibility of using Mongolian medicinal plants. As pathThe food industry is under significant strain as a result of the use of synthetic food additives such as artificial preservatives and antibacterial physical treatments that extend the shelf life of food by preventing bacterial growth. Today, consumers demand ready‐to‐eat, natural, microbiologically safe, and organic foods. Even short shelf life foods require special protection against bacterial contamination during their processing, storage, and transportation  DC are all used in Traditional Mongolian Medicine to treat liver diseases. To date, medicinal and food plant research refers to the development of new products or alternative applications in the pharmaceutical and food industries , which is used to treat typhoid fever, poisoning, and blood fever, as well as to relieve pain, reduce temperature, and expel bile. Dianthus superbus L. , Gentiana barbata Froel , Hippophae rhamnoides (Wild.) L., Inula Britannica L., Odontites ruber Gilib , Oxytropis strobilacea Bunge , Polygonum hydropiper Lour, Vaccinium vitis‐idaea L. , and Zygophyllum potanini Maxim  , a local medicinal plant, demonstrated strong antioxidant (31.93 ± 0.65 μg/mL at IC50) and antibacterial activities in ethanol extract against gram‐positive strains M. luteus and S. aureus. Herbs for food preservation can be utilized as whole plants, in parts, and in various forms such as extracts, solutions, and dried forms. As a result, it is appropriate to utilize the plant parts containing the most biologically active chemicals. Eighteen known compounds were extracted and identified using serial column chromatography of the ethyl acetate fraction of the plant extract using several packing materials and the researchers also investigated the antibacterial properties of isolated compounds found in medicinal plants against bacterial strains P. aeruginosa, E. coli, E. faecalis, M. luteus, and S. aureus by the disk diffusion method. The ethyl gallate inhibited the growth of M. luteus. (10.3–15.8 mm), E. faecalis (9.2–13.2 mm), E. coli, (9.2–13.5 mm), and S. aureus (9.8 mm) at 200–1000 μg/disk using the disk diffusion method , S. aureus (24.2 mm), and E. faecalis (17.1 mm), respectively. Furthermore, the root extract of Paeonia anomala exposed the highest antibacterial properties against E. coli (10 mm) and M. luteus (25.7 mm). Besides, the antibacterial activities of the plant extracts were evaluated in the different solvent fractions  and concentrations (0.5–4 mg/disc). The strong antibacterial activities were observed for ethyl acetate and n‐butanol fractions obtained from the whole herb of Sedum hybridum and Sedum aizoon as well as the ethyl acetate fraction of the leaf extract of Dasiphora fruticosa and root extract of Paeonia anomala against S. aureus and M. luteus, respectively. Moreover, the ethyl acetate and n‐butanol fractions of flower extracts of the Dasiphora fruticosa and Sedum aizoon were found to have a clear antibacterial effect against E. faecalis, while the whole herb extract of Sedum aizoon at 2 and 4 mg/disc demonstrated effective antibacterial activity against S. aureus  producers in foods  and their active components  MIC50 values against Candida spp were 84, 22, 181, and 169 mg/mL, respectively. The GM MIC50 values for dermatophytes of Scutellaria scordifolia L., Aquilegia sibirica Fisch. Et Schrenk were 32 and 256 mg/mL, correspondingly. For Malassezia furfur, Scutellaria scordifolia L. showed the best activity with MIC50 value of 64 mg/mL. In particular, S. scordifolia L. methanol extract exhibited the best activity against Candida spp., dermatophytes, and Malassezia furfur with GM MIC50 values of 22, 32, and 64 mg/mL, respectively , cycloartane −13 (22.8%), flavonoids −22 (38.5%), alkaloids and nitrogen‐containing compounds −10 (17.5%) and phenolic acids, and fatty acids. From these 19 new natural compounds belonging to cycloartane glycosides, labdane diterpene, flavoalkaloids, and nitrile nitrogen compound have been identified. The presence of flavoalkaloid can consider a specific characterization of Aquilegia species , followed by yeast cultures such as C. tropicalis, C. krusei, and C. parapsilosis have susceptible to the extract at a MIC of 12.5 μg/mL. The highest MICs of the extract were 250 μg/mL against C. glabrata ; investigation ; resources ; software ; writing – original draft . Saruul Idesh: Formal analysis ; methodology ; project administration ; supervision ; writing – original draft ; writing – review and editing . Tuya Narangerel: Data curation ; investigation ; methodology ; validation ; writing – original draft . Tuyagerel Batmunkh: Funding acquisition ; validation ; visualization . Alideertu Dong: Methodology .The authors declare that they do not have any conflict of interest.


A novel form of cell death termed cuproptosis was proposed recently. miRNAs play important roles in colorectal cancer (CRC). However, their relationships have not been reported.miRNAs that negatively regulate 16 cuproptosis regulators were predicted using Targetscan database. The univariate Cox, LASSO, and multivariate Cox regression analyses were performed to select cuproptosis‐related miRNAs. GSEA and ssGSEA analysis was carried out for functional enrichment analysis. The immune cell proportion score (IPS) and the efficiencies of multiple chemotherapy drugs were compared between different risk groups. The CCK8, cell colony, edu, and flow cytometry assays were performed to validate the roles of miRNA. Luciferase reporter assay confirmed the regulatory mechanism of miRNA on cuproptosis.p < 0.001, 95% HR = 1.243 (1.129–1.369)). The nomogram could efficiently predict the overall survival rate (AUC = 0.836). Then, the level of immunosuppressive pathways, immunosuppressive cells, stromal‐activated genes, and stromal score was higher in the high‐risk group. The IPS analysis showed a better response to immunotherapy in the low‐risk group. Also, the risk score was closely correlated with efficiencies of multiple chemotherapy drugs. Furthermore, miR‐653 was highly expressed in CRC tissues (p < 0.001), closely correlated with T stage (p < 0.001), metastasis (p < 0.001), and tumor stage (p < 0.001). High expression of miR‐653 predicted a shorter overall survival (p = 0.0282) and disease‐free survival (p = 0.0056). In addition, miR‐653 promoted cell proliferation, inhibited apoptosis, and negatively regulated the expression of DLD through directly binding to the 3’‐UTR of DLD mRNA.Six cuproptosis‐related miRNAs  were screened out for model construction. The risk score could act as an independent prognostic indicator in CRC (We constructed a cuproptosis‐related miRNA signature for the prediction of CRC patient survival and immunotherapy sensitivity. miR‐653 was highly expressed in CRC tissues, promoted cell proliferation, and inhibited apoptosis by negatively regulating the expression of DLD. In the manuscript, we systemically discussed a new format of cell death mechanism—cuproptosis, distinct from other known mechanisms including necrosis, apoptosis, autophagy, necroptosis, pyrotosis, and ferroptosis. We constructed a cuproptosis‐related prognosis model with 6 cuproptosis‐related miRNAs. The nomogram was constructed and could efficiently predict the overall survival rate of 1, 3, and 5 years. The cuproptosis‐related prognosis model was closely correlated with clinical‐pathological features and immune cell infiltration. In addition, the risk score contributes to predicting the efficiencies of multiple chemotherapy and immunotherapy drugs. Cell death can be executed through several patterns, including apoptosis, necroptosis, pyroptosis, ferroptosis, alkaliptosis, oxeiptosis, and so on.miRNAs are short noncoding RNAs with 18–25 nucleotides.Herein, we identified 6 cuproptosis‐related miRNAs, which are closely associated with the prognosis of CRC patients, and constructed a risk prediction model. Further analysis revealed that the cuproptosis‐related miRNAs signature could be used for prognosis evaluation and immunotherapy selection. What's more, we demonstrated that miR‐653 was highly expressed in colorectal cancer, closely correlated with clinicopathological features, and promoted cell proliferation by negatively regulating the expression of DLD.22.1The miRNA and mRNA expression data and relevant clinicopathological information on CRC were downloaded from The Cancer Genome Atlas (TCGA) database. The miRNA data includes 9 normal and 533 cancer tissues, and the mRNA data includes 51 normal and 638 cancer tissues. The intersect tissues include 9 normal and 526 cancer tissues. The work was conducted based on the 535 CRC tissues. In addition, 92 paired fresh frozen colorectal cancer tissues and adjacent normal tissues were collected from our hospital and stored in liquid nitrogen. All clinicopathological features were diagnosed by two pathologists. The present study was approved by the Ethics Committee of Fudan University Shanghai Cancer Center.2.2A total of 16 cuproptosis regulators: FDX1, MTF1, DBT, CDKN2A, DLST, DLAT, LIPT1, LIAS, GLS, DLD, PDHA1, PDHB, GCSH, SLC31A1, ATP7A, and ATP7B, were collected from lipoylated TCA cycle pathway of copper‐induced cell death2.3i) and exp (miRNAi), respectively, represent the risk coefficient and expression of each miRNA. Based on the median risk score, the samples were classified into high‐risk and low‐risk groups. The Kaplan–Meier curve was performed by R package “survminer.” To evaluate the accuracy of signature, the receiver operating characteristic (ROC) curve was conducted by R package “timeROC.” Via R package “survival,” “regplot,” and “rms,” a nomogram was established to predict overall survival rates of 1, 3, and 5 years.The CRC patients of TCGA database were divided into train group and test group by geometric proportion delamination sample method with the function of createDataPartition (package “caret”). Then, prognostic cuproptosis‐related miRNAs were identified through univariate regression analysis, and these miRNAs were further analyzed to establish risk score by LASSO and multiple Cox regression model. The risk score of each sample was calculated as below:2.4p < 0.05 were considered significantly different.Gene set enrichment analysis (GSEA) was conducted to assess related biological roles and potential functional pathways between the two groups using the hallmark gene sets (v7.5.1) and KEGG gene sets (v7.5.1).2.5Several computational methods including CIBERSORT, EPIC, MCPCOUNTER, QUANTISEQ, TIMER, and XCELL were employed to evaluate the immune infiltration. Single‐sample gene set enrichment analysis (ssGSEA) was used to analyze the difference in tumor‐infiltrating immune cells between the two risk groups. ESTIMATE algorithm was used to assess the immune score, stromal score, and estimate score of all the samples. The consensus molecular subtype (CMS) of CRC was evaluated with “CMScaller” package.2.6The somatic mutation data were downloaded from the TCGA database. The significantly mutated genes and TMB were verified with R package “maftool.”2.7https://tcia.at/home). The IPS was compared between the high‐ and low‐risk groups. The “pRRophetic” package was used to assess the efficiencies of different anti‐tumor medicines. The half‐maximal inhibitory concentration (IC50) of 251 common chemotherapy medicines was compared between different risk groups.The immune cell proportion score (IPS) data of TCGA samples was assessed from The Cancer Immunome Altas . 500 ng total RNA was reversely transcribed for cDNA with primeScript™ RT reagent kit (TaKaRa). Relative RNA expression was detected by qPCR with SYBR Premix Ex Taq™ (TaKaRa). U6 was used as miRNA control. The specific primers were presented as follows: miR‐653, loop: GTCGTATCCAGTGCAGGGTCCGAGGTATTCGCACTGGATACGACGGTTCA, Forward: CGCGCGTTGAAACAATCTCTAC, Reverse: AGTGCAGGGTCCGAGGTATT; U6, loop: GTCGTATCCAGTGCAGGGTCCGAGGTATTCGCACTGGATACGACAAAATATGG, Forward: GCTCGCTTCGGCAGCACATATAC, Reverse: AGTGCAGGGTCCGAGGTATT; DLD, Forward: GAAAAATGAAACACTTGGTGGAACA, Reverse: CGCCATCAGCTTTCGTAGC; MTF1, Forward: GCCGCGGAGACAAGTCATTA, Reverse: GCCCTCTTCACCCCCTACTA; ACTB, Forward: CTTCGCGGGCGACGAT, Reverse: CCACATAGGAATCCTTCTGACC.2.91000 cells/well were seeded in the 96‐well plate. After culturing for 24 h, 10 μl/well CCK8 (NCM Biotech) was added. Followed by continued incubation for 2 hours, the absorbance was measured at 450 nm. The absorbance was measured for 4 consecutive days. All experiments were executed in triplicate.2.102. After culturing for 2 weeks, the culture medium was discarded and the plates were washed by Phosphate Buffered Saline (PBS). Then, the plates were fixed with 4% polymethanol for 20 min and stained with 0.1% crystal violet for 20 min. Finally, the plates were photographed and calculated. All experiments were executed in triplicate.600 cells/well were seeded in the 6‐well plate at 37°C with 5% CO2.11The EdU assay was performed by EdU Cell Proliferation Kit with Alexa Fluor 488 (Beyotime Biotechnology). 150,000 cells were seeded in 24‐well plates and cultured for 24 h. The next day, cells were incubated with 50 μM EdU for 2 h. Then, the cells were fixed, permeabilized, and stained by EdU staining. Finally, cell nuclei were stained by Hoechst 33342 for 30 min. Three random fields were selected to calculate cells and photographs. The percentage of EdU‐positive cells was computed by the formula: (EdU cells/Hoechst cells) × 100%. All experiments were performed in triplicate.2.12Cell apoptosis was detected by Annexin V‐PE/7‐AAD Apoptosis Detection Kit (Vazyme). Cells were dissociated by trypsin without EDTA. After washing twice with precooled PBS, the cells were diluted in 100 μL binding buffer. Then, 5 μL Annexin V‐PE and 5 μl 7‐AAD were added into the above binding buffer. After incubation for 10 min at room temperature, 400 μL binding buffer was added. Finally, the cell apoptosis state was analyzed by flow cytometry. All experiments were performed in triplicate.2.13Cells were lysed with RIPA lysis buffer supplemented with 1% phenylmethanesulfonyl fluoride. Then, the protein concentration was measured with BCA Protein Assay Kit (Beyotime). After adding SDS‐PAGE Sample Loading Buffer, the cell lysis was boiled at 100°C for 30 min. Protein lysates were separated by SDS‐PAGE and transferred onto PVDF membranes. The membranes were blocked with 5% fat‐free milk for 1.5 h at room temperature and incubated with primary antibodies  at 4°C overnight. Next day, the membranes were incubated with HRP‐conjugated secondary antibody for 2 h at room temperature. The specific protein was imaged with ECL reagent (Millipore).2.14The luciferase reporter plasmids  were generated by HarO Life Co. The overexpression and knockdown vector of miR‐653 were constructed in RiBoBio. The luciferase reporter plasmids were co‐transfected into cells with mimics, inhibitor, or negative control using Lipofectamine™ 2000 reagent. After 48 h, the firefly luciferase and renilla luciferase activity were detected with luciferase reporter assay kit (Promega). Then, the ratio of firefly luciferase/Renilla luciferase activity was calculated.2.15p value < 0.05 was deemed as being statistically significant.The data were analyzed with R software (version 4.1.2) and Strawberry Perl (version 5.1.0). 33.1The process of our study was described in Figure 3.2n = 241) for model building and test set (n = 239) for validation. From the above 72 miRNAs, the univariate Cox regression analysis showed that 10 miRNAs were finally confirmed to be related to the prognosis of CRC patients in the train group . The weighted coefficients of 6 miRNAs were shown in Table Before the prognosis model was established, the CRC samples with complete pathological information were randomly divided into train set  and clinicopathological factors , we constructed a nomogram to predict CRC patients' 1‐, 3‐, and 5‐year overall survival rate in the TCGA database Figure . The nom3.5Although immune checkpoint therapy has achieved significant improvement in clinical treatment, amounts of patients still did not respond to therapy.3.6Studies have shown that high TMB improved the survival of patients receiving immunotherapy across diverse cancers and TMB may act as a predictive biomarker.3.7To further validate the model in clinical samples, we selected the differentially expressed miRNA (has‐miR‐653) with the highest expression from the 6 model miRNAs. First, we detected the expression of miR‐653 in 92 paired fresh frozen colorectal cancer tissues and adjacent normal tissues. The results showed that miR‐653 was significantly highly expressed in colorectal cancer tissues compared with adjacent normal tissues Figure . Then, w3.8To explore the effects of miR‐653 in colorectal cancer cells, the expression of miR‐653 in multiple colorectal cancer cells was detected. We found that the expression of miR‐653 was high in 8 colorectal cancer cells compared with normal colorectal mucosa cell Figure . SW620 cAccording to above prediction from Targetscan database, MTF1 and DLD of key cuproptosis genes might be the target of miR‐653. To further explore the mechanism of miR‐653 on cuproptosis, we detected the expression of MTF1 and DLD under the alteration of miR‐653. qPCR results showed that miR‐653 inhibitor increased the expression of both MTF1 and DLD, while miR‐653 mimics decreased the expression of these two genes, of which DLD expression exhibited a bigger change Figure . Therefo4A single miRNA can regulate several genes' expression and subsequent signaling pathways involved in tumorigenesis and tumor progression.p < 0.001, 95% HR = 1.243 (1.129–1.369)) and the nomogram could efficiently predict the overall survival rate (AUC = 0.836). According to the previous studies, pyroptosis and ferroptosis signatures were significantly correlated with the type of tumor microenvironment and response to immunotherapy and chemotherapy.With the deep research of multiple programmed cell death, such as autophagy, pyroptosis, and ferroptosis, we have got a better understanding of cancer development, prediction assessment, and clinical therapy. As a novel form of cell death, cuproptosis introduced a new insight into tumor cognition. Although cuproptosis has been rarely reported in cancer development and progression up to now, the dynamic balance of intracellular copper concentration has been demonstrated to influence multiple biological processes and human diseases, such as cell proliferation, autophagy, Wilson's disease, and Menke's disease.Previously, the tumors were divided into “hot” and “cold” tumors based on the immunoscore, which was estimated by the location, type, and density of immune cells.The ICI targets PD1 (nivolumab), PDL1 (atezolizumab), and CTLA4 (ipilimumab) were approved by FDA for CRC.Many studies proved the effectiveness of miRNA‐based signatures in the prognosis and treatment of numerous tumors.5In summary, a cuproptosis‐related miRNAs model was established to properly predict the prognosis. Targeting this signature, we can distinguish the immune types of CRC, contributing to individual therapy and improving the sensitivity of immunotherapy. In addition, miR‐653 was highly expressed in colorectal cancer tissues, closely correlated with the clinicopathological features, negatively regulated the expression of DLD, promoted cell proliferation, and inhibited apoptosis of colorectal cancer.Zhonglin Zhu: Conceptualization ; data curation ; methodology ; writing – original draft . Tianan Guo: Formal analysis ; investigation ; visualization . Junyong Weng: Funding acquisition ; methodology ; software . Shanbao Li: Investigation ; methodology ; resources . Congcong Zhu: Data curation ; investigation . Qiuyan Zhao: Resources ; software . Ye Xu: Conceptualization ; project administration ; supervision ; validation ; writing – review and editing .This study was supported by the Science and Technology Commission of Shanghai Municipality (20DZ1100101), Shanghai Hospital Development Center (SKXZ2028), and National Natural Science Foundation of China (82003060).The authors have declared that no competing interests exist.Not applicable.Figure S1‐S5Click here for additional data file.Table S1Click here for additional data file.Table S2Click here for additional data file.Table S3Click here for additional data file.Table S4Click here for additional data file.Table S5Click here for additional data file.Table S6Click here for additional data file.Table S7Click here for additional data file.


Patients with functional mitral regurgitation (FMR) and nonischemic dilated cardiomyopathy (DCM) are associated with high mortality.Our study aimed to compare the clinical outcomes between different treatment strategies and identify predictors associated with the adverse outcomes.A total of 112 patients with moderate or severe FMR and nonischaemic DCM were included in our study. The primary composite outcome was all‐cause death or unplanned hospitalization for heart failure. The secondary outcomes were individual components of the primary outcome and the cardiovascular death.p < .001). The 1‐, 3‐, and 5‐year survival rates for patients with MVr were 96.6%, 91.8%, and 77.4%, respectively, which were significantly higher than that of medical group: 81.2%, 71.9%, and 65.1%, respectively . Left ventricular ejection fraction (LVEF) < 41.5% (p < .001) and atrial fibrillation (p = .02) were independently associated with the primary outcome. LVEF < 41.5% (p = .007), renal insufficiency (p = .003), and left ventricular end‐diastolic diameter > 66.5 mm (p < .001) were independently associated with heightened risk for all‐cause death.In this study, the primary composite outcome occurred in 26 patients (44.8%) in mitral valve repair (MVr) group and 37 patients (68.5%) in medical group (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.14–0.55; Compared with medical therapy, MVr was associated with a better prognosis in patients with moderate or severe FMR and nonischemic DCM. We observed that LVEF < 41.5% was the only independent predictor of the primary outcome and all individual components of secondary outcomes. Outcomes and predictors of patients with moderate or severe functional mitral regurgitation and nonischemic dilated cardiomyopathy. CI, confidence interval; HR, hazard ratio; LVEF, left ventricular ejection fraction; MVr, mitral valve repair. DCMdilated cardiomyopathyFMRfunctional mitral regurgitationLVEFleft ventricular ejection fractionMRmitral regurgitationMVmitral valveMVrmitral valve repair1Functional mitral regurgitation (MR), which occurs in the setting of left ventricular remodeling and structurally normal mitral valve (MV), is frequently occurred in patients with ischemic cardiomyopathy and nonischemic dilated cardiomyopathy (DCM). Despite medical and surgical therapeutic advances,With controversial outcomes, it remains unclear whether mitral valve repair (MVr) could improve the prognosis in patients with FMR. Additionally, for patients with FMR and nonischemic DCM, the current European Society of Cardiology/European Association for Cardio‐Thoracic Surgery and American College of Cardiology/American Heart Association guidelines consider MVr as a class IIb recommendation.FMR is frequently observed in patients with nonischemic DCM and promotes further the process of left ventricular remodeling (MR begets MR). Therefore, it is logical to hypothesize that the correction of MR may improve the prognosis among patients with nonischemic DCM. However, current studies reporting the survival after mitral regurgitation repair for FMR are controversial.The aims of our study were as follows: (i) describe our practices in the management of patients with moderate or severe FMR and nonischemic DCM at our academic center; (ii) compare the clinical outcomes between different treatment strategies; (iii) identify risk factors associated with the adverse outcomes.22.1Our study complied with the 2013 Declaration of Helsinki. This study was approved by the local review board (No. 2021‐S239) and the written informed consent was waived. Between January 2012 and December 2020, patients with moderate or severe FMR and nonischaemic DCM were retrospectively identified after the echocardiographic and clinical evaluation from our institution database.Mitral valve morphologic description of abnormal, thickening, myxoma, or prolapse‐defined organic MR. The severity of MR was divided into none, mild, moderate, and severe.2.2It was up to the Heart Team  to decide whether to perform MVr based on the patient's characteristics, anatomical suitability, and the willingness of patients. Patients who refused or decided not to undergo surgery were classified as the medical group. Both surgical and medical patients were treated with standard guideline‐directed medications,All operations were performed with a standard cardiopulmonary bypass of mild hypothermia. The exposure of MR was achieved by either the left atrial (Waterston's groove) or biatrial approach. MVr was accomplished using restrictive mitral ring annuloplasty.2.3The follow‐up data were verified through inpatient and outpatient medical records, telephone contact with the patients, or interviews with relatives. The follow‐up ended in September 2021, or when the patient died. The primary composite outcome of our study was all‐cause death or unplanned hospitalization for heart failure . The secondary outcomes were individual components of the primary outcome and the cardiovascular death.2.4p value.The Cox proportional hazards regression model was built to demonstrate that the association between treatment strategies and survival was independent of differences in baseline demographic and clinical variables. The adjustment variables included age, sex, heart rates, systolic blood pressure, New York Heart Association Class III/IV, hypertension, dyslipidemia, diabetes mellitus, renal insufficiency, stroke, history of prior non‐MVr, left bundle branch block, atrial fibrillation, serum creatinine level, hemoglobin, left atrial diameter, left ventricular end‐diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), MR severity and tricuspid regurgitation (≥moderate). The event‐free survival curves were analyzed by the Kaplan–Meier method and the differences in survival estimates were tested by the logarithmic ranking test. Cox's hazard regression model was built to identify predictors of the primary outcome and secondary outcomes. The results of the Cox proportional hazards analysis were presented as hazard ratio (HR), 95% confidence interval (CI), and p < .05. All statistical analyses were performed using SPSS version 26.Patients in the medical group were defined as the reference group in our analyses. Differences were deemed to be statistically significant with a two‐sided 33.1In total, 112 patients  with moderate or severe FMR and nonischemic DCM were evaluated in our study. The median follow‐up was 38 months . Among those 112 patients, MVr was pursued in 58 patients, and 54 patients received medical therapy  underwent concomitant surgical tricuspid valve annuloplasty, and the atrial maze procedure was performed in 10 patients (17.2%) for atrial fibrillation. The mean cardiopulmonary bypass and cross‐clamping times were 117.1 ± 38.0 and 64.7 ± 26.2 min, respectively.3.2p < .001)  in the MVr group and 1.9% (one patient) in the medical group. The primary composite outcome of death from any cause or unplanned hospitalization for heart failure occurred in 26 patients (44.8%) in the MVr group and 37 patients (68.5%) in the medical group     deaths occurred in the MVr group, as compared with 20 (37.0%) in the medical group. The 1‐, 3‐, and 5‐year survival rates for patients with MVr were 96.6%, 91.8%, and 77.4%, respectively, which were significantly higher than the survival of the medical group: 81.2%, 71.9%, and 65.1%, respectively  Figure . Twenty‐) Figure . Event‐f) Figure .3.3p < .001) and atrial fibrillation  were independently associated with the primary outcome , renal insufficiency , and LVEDD > 66.5 mm  were independent predictors of all‐cause death. Significantly lower survival rates were observed in patients with LVEF < 41.5%, renal insufficiency, and LVEDD > 66.5 mm  was the only independent predictor of unplanned hospitalization for heart failure. Significantly lower survival rates were observed in patients with LVEF < 41.5%  and LVEDD > 66.5 mm  were independent predictors of cardiovascular death. Significantly lower survival rates were observed in patients with LVEF < 41.5% and LVEDD > 66.5 mm  and all individual components of secondary outcomes .FMR is a frequent presentation in patients with nonischemic DCM, as well as those with ischemic cardiomyopathy. It was reported that patients with FMR and nonischemic DCM are associated with multiple comorbidities and poor long‐term survival, with only 30% of the 5‐year survival.The best strategy to treat FMR in nonischemic DCM is widely debated. MVr has been reported to be a good solution for patients with FMR and nonischemic DCM.With the hospital mortality of 1.7% in patients who received MVr, our hospital mortality was comparable with the results in the previous studies.To achieve a better outcome for nonischemic FMR patients undergoing MVr, it might be useful to identify the predictors for the primary outcome and secondary outcomes. As expected, a low LVEF was a powerful predictor of adverse outcomes. LVEF is the most commonly utilized parameter of cardiac function and patients with higher LVEF were associated with a linear decrease in mortality.2) was independently associated with heightened risk for all‐cause death. As in previous studies, reduced kidney function seems to associate with worse outcomes in patients with heart failure.It has been reported that impaired renal function was an independent predictor of all‐cause death in patients with heart failure.Apart from LVEF and renal insufficiency, some researchers have reported that the poor survival for patients with FMR and nonischemic DCM was related to MR severity, New York Heart Association class, and age.4.1First, the observational data could only represent our single‐center experience and are thus influenced by inherent biases. Second, there might be potential bias in the treatment strategies, which serves as an important limitation. Therefore, we attempted to adjust for differences by using a multivariate Cox regression model to minimize treatment bias. It is important to note, however, that this method was not a complete substitute for a true randomized comparison and some unrecognized confounding factors might have affected the results. Finally, the number of patients in this study is relatively small, which may be insufficient to recognize the potential predictors for adverse outcomes. Additionally, those predictors with moderate relevant risk might have been ignored. Our findings, therefore, require further confirmation in a larger size of the data set and randomized trials.5MVr in contrast to medical therapy was associated with a better prognosis in patients with moderate or severe FMR and nonischemic DCM. We observed that LVEF < 41.5% was the only independent predictor of the primary outcome  and all individual components of secondary outcomes .The authors declare no conflict of interest.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.