Adalimumab is administered and dosed using a standardized treatment regimen. Although therapeutic drug monitoring (TDM) may help optimize treatment efficacy, the lower cut‐off concentration of adalimumab needed to retain disease remission has not been established. This cross‐sectional study of patients with Crohn's disease on stable medication aimed to determine a lower therapeutic drug concentration threshold of adalimumab associated with biochemical disease remission.C‐reactive protein (CRP) and fecal calprotectin were used as established markers and albumin as an explorative marker of disease activity. Time since introduction, treatment interval, drug dosage, serum drug concentration and antidrug antibodies, disease duration, age, and sex were recorded.The study included 101 patients who were divided into “active disease” and “remission” groups for inflammatory markers based on cut‐off levels of 5 mg/L for CRP and 50 mg/kg for fecal calprotectin. Cut‐off levels for albumin of 36.5 and 41.5 g/L were also added as further indicatives of remission. Receiver operating characteristic analysis found optimal thresholds for adalimumab associated with remission at 6.8–7.0 mg/L for the combination of CRP and fecal calprotectin and when combining CRP, fecal calprotectin, and albumin.In patients with Crohn's disease, serum adalimumab of at least 6.8 mg/L was associated with biochemical disease remission based on CRP and fecal calprotectin, supporting the use of TDM to ensure disease control. Albumin should be further tested in this setting. In this article, we examined the lower adalimumab serum concentration levels found to be associated with biochemical remission in patients with Crohn's disease. Serum adalimumab level of at least 6.8 mg/L was associated with biochemical disease remission based on C‐reactive protein (CRP) and fecal calprotectin, supporting the use of therapeutic drug monitoring (TDM) to ensure disease control. Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract that is characterized by transmural and discontinuous inflammation of the intestinal wall. Common complications of Crohn's disease include strictures, fistulas, and abscesses, and surgery is frequently required to address these complications.Lack of response and loss of response represent major challenges in anti‐TNF‐α treatment. Primary nonresponse, defined as insufficient clinical response after induction therapy, is reported in about one‐third of the patients. Furthermore, even after an initial treatment response, as many as half of all patients experience a secondary loss of response at some point during the maintenance phase.Even though TDM is increasingly available to clinicians in everyday use, evidence regarding the therapeutic consequence of TDM remains sparse and conflicting.In this study, we used C‐reactive protein (CRP) and fecal (f‐) calprotectin (established markers) and serum albumin (explorative marker) as distinct markers of inflammatory activity in Crohn's disease patients on maintenance treatment. We aimed to identify a lower cut‐off serum level associated with biochemical remission in ADL‐treated patients.This cross‐sectional study, which was conducted at Stavanger University Hospital, Stavanger, Norway, included patients who were diagnosed with Crohn's disease and were at least 16 years old. The patients were recruited from the outpatient clinic at the hospital. Included patients were receiving maintenance treatment with ADL, with a minimum of three doses administered before inclusion. The patients had one study visit along with their regularly scheduled trimonthly medical checkup from 1 April to 30 September 2014. The exclusion criteria were inability to provide consent and inability to adhere to the study protocol. The patients described here belong to a larger IBD cohort, and some descriptive data have been reported previously.CRP and albumin concentrations in blood were measured at the study visit and analyzed using the CRP VARIO 6K2641 and Serum Albumin BCP (Bromocresol purple), Architect c16000TM ; f‐calprotectin was extracted from first morning defecation within 3 days before and 3 days after the study visit and was quantified using the automated EliA Calprotectin 2 enzyme fluoroimmunoassay .versus active disease was categorized biochemically by CRP > 5 mg/L and/or f‐calprotectin > 50 mg/kg. Patients were consequently divided into an active disease group and a remission group for each marker. These cut‐off levels were applied for analysis of ADL levels and for developing the receiver operating characteristic (ROC) models. To optimize the ROC model, we also used a combination of CRP and f‐calprotectin as a composite disease activity marker.Remission versus active disease. Based on albumin quartile analysis, we selected two different cut‐off values representing the limits toward the lowest (36.5 g/L) and the highest (41.5 g/L) albumin quartiles. We assumed that the lower albumin quartile levels included the patients with the most severe inflammation, while the upper albumin quartile levels represented the patients with the least inflammatory burden. These albumin cut‐offs were used to develop two different explorative composite/combined ROC models, including CRP, f‐calprotectin, and albumin.We also explored albumin as a surrogate marker for remission 3+‐labeled protein‐A tracer and time‐resolved fluorescence. The assay for serum ADL concentrations is fully automated on the AutoDELFIA®  immunoassay platform. ADAs to ADL were analyzed using in‐house inhibition assays that only measure neutralizing ADAs (antibodies that inhibit the TNF‐binding capacity of the drugs).Blood was drawn for the determination of serum concentrations of ADL and ADAs regardless of the injection time. The drug was measured using a validated in‐house assay in which biotinylated recombinant TNF‐α is used to trap ADL onto a streptavidin‐coated solid phase. The captured drug was then quantified using an EUThe normality of the data was tested using the Shapiro‐Wilk test. Medians and ranges were reported for continuous data as the data were not normally distributed. The Mann–Whitney test was used to test for differences between groups. Numbers and percentages were reported for categorical data, and the chi‐square test or Fisher's exact test were used to test for differences between groups as appropriate. To determine the lower ADL cut‐off concentrations, an ROC analysis was performed separately for CRP, f‐calprotectin, and for composite models , choosing the point closest to the  corner (maximizing Youden's index). Based on this, we calculated the sensitivity, specificity, and area under the curve (AUC) with standard error and 95% confidence intervals.p < 0.05 was considered statistically significant.Associations between inflammatory markers and drug levels were explored using multivariable regression analysis with CRP, f‐calprotectin , and albumin as dependent variables in three different models and serum adalimumab, age, and sex as independent variables. For all statistical analyses, All analyses were conducted using SPSS, version 23  or GraphPad Prism, version 7 .http://clinicaltrials.gov (NCT02134054).The study was approved by the regional ethics committee, REK Vest , and was conducted in compliance with the principles expressed in the Declaration of Helsinki. All participating patients provided written informed consent. The study was registered at The study included 101 of 108 eligible patients who were on ADL maintenance treatment. The study lost one patient to follow‐up at another center, one patient was considered ineligible for participation due to mental illness, and five patients declined to participate.The median age was 35 years, and 48 (47%) patients were male. The median time since diagnosis was 9 years, and the median duration of treatment with ADL was 32 months. In this cohort, 16 (15.8%) patients had been on at least one other biological agent before starting their current ADL treatment. Drug concentrations had been measured in roughly one‐fifth of the patients during the last 6 months prior to inclusion, and 13 (12.9%) patients used concomitant immunomodulators (CIMs). Ninety patients received a standardized treatment regimen for ADL (40 mg q2wk), 10 patients 40 mg weekly, and 1 patient 80 mg weekly  or between those who had measured drug concentrations before inclusion versus those who had not . Use of CIMs versus no use of CIMs did not affect the drug concentrations .For all patients, the median [range] drug concentration was 6.9 mg/L [0–24.6], with no sex difference. There were no differences in drug concentrations between patients who had been on previous biological medication The median [range] values were as follows: CRP, 2.9 mg/L [1–45]; f‐calprotectin, 72 mg/kg [20–1250]; and albumin, 39.5 g/L [24.9–47.6]. The levels of the inflammatory markers were not significantly influenced by previous exposure to biologics, previous drug concentration measurement, or CIM use.r2 = 0.10, P = 0.002), between f‐calprotectin and ADL levels , and a positive association between albumin and ADL levels   and > 5 mg/L . These subgroups had significantly different median [range] drug concentrations: 7.2 mg/L [0–24.6] versus 6.0 mg/L [0–20], P = 0.04  and > 50 mg/kg . These subgroups also had significantly different drug concentrations: 8.9 mg/L [2.4–24.6] versus 6.4 mg/L [0–20], P = 0.001  versus CRP > 5 mg/L and/or f‐calprotectin > 50 mg/kg . The drug concentrations in these two groups were significantly different, 8.9 mg/L [2.4–24.6] versus 6.5 [0–20], P = 0.001 . In terms of optimizing sensitivity and specificity, the optimal lower cut‐off value for therapeutic serum concentration was 5.7 mg/L, with a sensitivity of 70% and a specificity of 50% . In terms of optimizing sensitivity and specificity, the optimal lower cut‐off value for therapeutic serum concentration was 6.9 mg/L, with a sensitivity of 71% and a specificity of 58% . In terms of optimizing sensitivity and specificity, the optimal lower cut‐off value for therapeutic serum concentration was 6.8 mg/L, with a sensitivity of 74% and a specificity of 57% . In terms of optimizing sensitivity and specificity, the optimal lower cut‐off value for therapeutic serum concentration was 6.8 mg/L, with a sensitivity of 77% and a specificity of 56% . In terms of optimizing sensitivity and specificity, the optimal lower cut‐off value for therapeutic serum concentration was 7.0 mg/L, with a sensitivity of 71% and a specificity of 53%  and 7.0 mg/L . Thus, we demonstrated separate cut‐off values for ADL concentrations that were statistically significant using all three inflammation markers; dividing patients based on their levels of the selected disease activity marker appeared to be useful for developing ROC models. The significant associations between ADL and investigated disease activity markers supported these findings.Previous studies have also used conventional biomarkers of inflammation in Crohn's disease to examine ADL concentration thresholds with the aim of identifying the lowest drug concentration required to maintain disease remission. CRP has been widely used as such a biomarker,The f‐calprotectin protein is another well‐documented marker of disease activity in Crohn's disease.P = 0.44).Only one previous study explored a combined disease activity marker of CRP (< 5 mg/L) and f‐calprotectin (< 250 mg/kg), determining a lower ADL cut‐off of at least 9.5 mg/L. However, the referred study only consisted of 34 patients, and the result did not reach statistical significance  and in the selection of specificity and sensitivity, there are still consistent similarities with our threshold findings in the range of 5.8–7.0 mg/L.On the other hand, one recent study using a CRP level of 5 mg/L reported a considerably higher ADL threshold of 11.8 mg/L.A strength of our study was the large sample size of 101 patients, making it larger than previous studies. This study also has some limitations, including its cross‐sectional design. We did not perform colonoscopies to investigate endoscopic inflammation, so the true rate of remission, that is, mucosal healing, was therefore unknown. Blood samples to analyze ADL concentrations were drawn randomly during the treatment interval. Although ADL levels appear to be stable at different time points between injections,In conclusion, CRP and f‐calprotectin may be useful markers of clinical disease activity in order to identify a lower ADL threshold. Serum albumin appears to be a promising marker in this setting but needs further validation. A serum ADL concentration of at least 6.8 mg/L appears favorable for maintaining biochemical remission in Crohn's disease, supporting a proactive role of TDM in Crohn's disease patients on ADL treatment.


Thitarodes xiaojinensis transcriptome. According to their domain structures, six CTLDPs with one carbohydrate‐recognition domain (CRD) were classified into the CTL‐S subfamily. The other 23 CTLDPs with two CRDs were grouped into the immulectin (IML) subfamily. The remaining three with extra regulatory domains were sorted into the CTL‐X subfamily. Phylogenetic analysis showed that CTL‐S and CTL‐X members from different insects could form orthologous groups. In contrast, no T. xiaojinensis IML orthologues were found in other insects. Remarkable lineage‐specific expansion in this subfamily was observed reflecting that these CTLDPs, as important receptors, have evolved diversified members in response to a variety of microbes. Prediction of binding ligands revealed that T. xiaojinensis, a cold‐adapted species, conserved the ability of CRDs to combine with Ca2+ to keep its receptors from freezing. Comparative analysis of induction of CTLDP genes after different immune challenges indicated that IMLs might play critical roles in immune defenses. This study examined T. xiaojinensis CTLDPs and provides a basis for further studies of their characteristics.Insects have a large family of C‐type lectins involved in cell adhesion, pathogen recognition and activation of immune responses. In this study, 32 transcripts encoding C‐type lectin domain proteins (CTLDPs) were identified from the  Their signal peptides and transmembrane regions were predicted through CBS prediction server (http://www.cbs.dtu.dk/services/). Their domain architectures were visualized by software DOC  along with the I‐TASSER server  for 12 h, Ophiocordyceps sinensis for 12, 48, 72 h, 1 year, and Cordyceps militaris for 12, 48, 72 h, were constructed and separately sequenced on the Hiseq 2000 . Following this, values of log2‐fold change for 32 T. xiaojinensis CTLDP genes were used to draw a heatmap using heatmap.2 function in R environment. To validate the results of differentially expressed genes (DEGs), specific primers  libraries, referring to messenger RNA (mRNA) samples from the fat body of larvae without treatment (control group) and larvae exposed with  primers  for six  et al., . The acqT. xiaojinensis transcriptome  residues, which may form three disulfide bridges for stability, are conserved in nearly all of the CTLDs belonging to the IML‐A group Fig. . The disT. xiaojinensis CTLDPs, potential binding sites and corresponding ligands in the 53 CTLDs were detected by COACH server combining with I‐TASSER  had a typical CTLD structure model presenting double loops similar to those in DC‐SIGNR (black)  form the second β‐sheet located at the top of the structures , alpha‐L‐fucopyranose and NGA, respectively. It indicates that the second loop is structurally flexible among CTLDPs and is the key component of binding specificity. Some T. xiaojinensis CTLDs , had predictions for sugar ligands that were inconsistent with the rule referring to EPN and QPD motifs. Therefore, more evidence will be needed to confirm these predictions.To predict the functions of  al., 2+ . In partith Ca2+ . CTLDs p et al., . In T. xalactose . In addi et al., , to deteck) Fig. . The N‐ res Fig. . The secdination . Its 3D T. xiaojinensis CTLDP genes, we searched their FPKM values in ten libraries , respectively  and CTL‐S along with the CTL‐X family (monophyletic group) indirectly reflects their potential functions in the ghost moth. It seems that members in the IML family have undergone significant evolutionary pressure leading to duplication and divergence, indicating that they are probably targets for diverse foreigners. In contrast, conservation was observed in T. xiaojinensis CTL‐Ss and CTL‐Xs, the orthologues of which could be found in other species, indicating that they might deal with endogenous glycans or act in cell‐cell adhesion and tissue integration.In this study, 32 CTLDP genes were annotated from the T. xiaojinensis . Two well‐known CTLDs (AgCTL4 and MA2) in A. gambiae have been reported to protect Plasmodium parasites from melanization  and dengue virus‐2 (DENV‐2) invasion, respectively  experiments  formed an orthologous group and so did B. mori IML4, M. sexta IML19, Danaus plexippus CTL18 and P. xuthus XP_013176126.1  to CTL‐X2, 4 and 6 from M. sexta. The phylogenetic tree in Figure D. melanogaster furrowed gene in CTL‐X2 group encodes a protein, similar to vertebrate selectins, and mutation of complement control protein regions in the protein interrupted development of sensory organs  were studied by Faivre‐Sarrailh et al.  is homologous to CTLDP and its antifreeze activity was responsive to Ca2+  until Ca2+ removes it from the binding site  of very low . Consided larvae , indicatT. xiaojinensis were divided into three subfamilies and renamed. Phylogenetic analysis revealed evolutionary diversification of these genes. Gene duplication and merging may have resulted in IMLs possessing two CTLDs and natural selection‐based expansion of this subfamily in T. xiaojinensis. In addition, most of the identified CTLDPs in T. xiaojinensis had Ca2+ affinity possibly to regulate interactions of these receptors with other ligands and to protect them from freezing. Structural comparisons revealed that the structure of the second loop could also affect the specificity of binding ligands. CTLDP gene expression profiles in response to different immune challenges provide useful information for future functional studies in species of primitive Lepidoptera.In conclusion, 32 CTLDP genes identified from The authors declare no conflicts of interests.Fig. S1. Structure‐based sequence alignment of Thitarodes xiaojinensis C‐type lectin domains (CTLDs) and the CTLD in human DC‐SIGNR. Multiple sequence alignment was carried out by MUSCLE, a module in MEGA 6.0, and depicted by ESPript. Identical residues are marked in red and similar residues are in yellow. The carbohydrate‐recognition motifs are indicated by the box enclosed with a red line.Click here for additional data file.Table S1. Functions of the C‐type lectin domain proteins (CTLDPs) with one carbohydrate‐recognition domain (CRD) in Dipteran.Table S2. Functions of the C‐type lectin domain proteins (CTLDPs) with two carbohydrate‐recognition domains (CRDs) in Lepidoptera.Table S3. Features of 32 Thitarodes xiaojinensis C‐type lectin domain proteins (CTLDPs).Table S4. Primers for 6 genes encoding C‐type lectin domain proteins (CTLDPs).Table S5. Structural characteristics of 53 C‐type lectin domains (CTLDs) in Thitarodes xiaojinensis.Table S6. FPKM values of 32 Thitarodes xiaojinensis genes encoding C‐type lectin domain proteins (CTLDPs) in ten libraries.Click here for additional data file.


Mesenchymal stem cells (MSCs) have immunomodulatory properties and support hematopoiesis in the bone marrow (BM). To develop a new strategy to not only prevent graft‐vs‐host disease (GVHD) but also to enhance engraftment, a phase I trial of cord blood transplantation (CBT) combined with intra‐BM injection of MSCs (MSC‐CBT) was designed. Third‐party BM‐derived MSCs were injected intra‐BM on the day of CBT. The conditioning regimen varied according to patient characteristics. GVHD prophylaxis was tacrolimus and methotrexate. The primary endpoint was toxicity related to intra‐BM injection of MSCs. Clinical outcomes were compared with those of six controls who received CBT alone. Five adult patients received MSC‐CBT, and no adverse events related to intra‐BM injection of MSCs were observed. All patients achieved neutrophil, reticulocyte, and platelet recoveries, with median times to recoveries of 21, 35, and 38 days, respectively, comparable with controls. Grade II‐IV acute GVHD developed in three controls but not in MSC‐CBT patients. No patients developed chronic GVHD in both groups. At 1 year after transplantation, all MSC‐CBT patients survived without relapse. This study shows the safety of MSC‐CBT, and the findings also suggest that cotransplantation of MSCs may prevent GVHD with no inhibition of engraftment. This trial was registered at the University Hospital Medical Information Network Clinical Trials Registry as number 000024291. Mesenchymal stem cells (MSCs), which were derived from bone marrow (BM) of third‐party donor, were injected intra‐BM of recipient 4 hours before cord blood transplantation (CBT). This study shows the safety of CBT combined with intra‐BM injection of MSCs, and also suggests that co‐transplantation of MSCs may prevent graft‐vs‐host disease without inhibition of engraftment. Mesenchymal stem cells (MSCs) support hematopoiesis in the bone marrow and have immunomodulatory properties.MSCs have potencies to enhance engraftment and to prevent graft‐versus‐host disease (GVHD) after allogeneic hematopoietic cell transplantation.This study shows the safety of intra‐bone marrow co‐transplantation of MSCs in cord blood transplantation.All patients achieved engraftment without clinically important GVHD.Co‐transplantation of MSCs may prevent GVHD without inhibition of engraftment.Mesenchymal stem cells (MSCs) support hematopoiesis in the bone marrow and have immunomodulatory properties.MSCs have potencies to enhance engraftment and to prevent graft‐versus‐host disease (GVHD) after allogeneic hematopoietic cell transplantation.This study shows the safety of intra‐bone marrow co‐transplantation of MSCs in cord blood transplantation.All patients achieved engraftment without clinically important GVHD.Co‐transplantation of MSCs may prevent GVHD without inhibition of engraftment.Mesenchymal stem cells (MSCs), which were derived from the bone marrow of third‐party donors, were injected into the bone marrow of the recipient 4 hours before cord blood transplantation. This study showed the safety of cord blood transplantation combined with intra‐bone marrow injection of MSCs and also suggested that cotransplantation of MSCs may prevent graft‐vs‐host disease without inhibition of engraftment. This strategy may be applicable not only to cord blood transplantation but also to bone marrow transplantation or peripheral blood stem cell transplantation, leading to the prevention of severe graft‐vs‐host disease, especially in human leukocyte antigen‐mismatched settings, and reduction of the burden imposed on hematopoietic stem cell donors by decreasing the required stem cell number.1Cord blood transplantation (CBT) is a curative treatment for various hematologic disorders. Previous studies have reported comparable outcomes of CBT and human leukocyte antigen (HLA)‐matched unrelated donor transplantation in adult patients.MSCs are a heterogeneous population of stromal stem cells that can be isolated from many tissues, such as BM, adipose tissue, CB, and placenta. MSCs have the capacity for self‐renewal and can differentiate into mesodermal lineage cells.In previous clinical studies, the feasibility and safety of CBT with intravenous cotransplantation of MSCs were observed in pediatric patients.Based on these properties of MSCs and experimental and clinical findings, to develop a new strategy not only to enhance engraftment but also to prevent GVHD after CBT, a phase I trial of CBT combined with intra‐BM injection of ex vivo expanded MSCs (MSC‐CBT) was designed.2The study protocol has been described in detail previously.2.17 cells per kg or higher. Additionally, patients had to have at least one potential MSC donor aged 20‐74 years from a spouse or relative within the fourth degree of relationship. The inclusion and exclusion criteria of the MSC donors are listed in the study protocol in detail.This was a single arm, nonrandomized, open‐label, single‐center, phase I trial at Nagoya University Hospital. The target sample size was five patients. Eligible patients were aged 20 years or older; had a hematologic disorder with an indication for CBT; did not have malignant cells accounting for 70% or more of all nucleated cells in the BM; had an Eastern Cooperative Oncology Group performance status of 0‐2; had adequate organ function as defined by an ejection fraction of 40% or greater, forced vital capacity of 50% or greater, forced expiratory volume in 1 second of 60% or greater, aspartate aminotransferase and alanine aminotransferase concentrations less than 5 times the upper limit of normal, and serum creatinine less than 3 times the upper limit of normal; and they had available CB units with serological HLA‐A, B, and DR ≥4/6 matched and with a total nucleated cell (TNC) dose of 1.5  ×  10Patients were excluded if they had history of allogeneic HCT in the 1 year prior to enrollment, exposure to gemtuzumab ozogamicin in the 6 months prior to enrollment, and allergy to the drugs used for transplant preconditioning or GVHD prophylaxis. Exclusion criteria also included positive for HIV antibody, pregnancy or lactation, and uncontrolled psychiatric disorder or infection.The Japanese Ministry of Health, Labour, and Welfare confirmed that this study complied with the Act on the Safety of Regenerative Medicine . The study was conducted in accordance with the principles outlined in the Declaration of Helsinki, and all patients and donors provided written, informed consent before registration. Patients and donors were registered in this study after independent review by the data center in the Department of Hematology and Oncology, Nagoya University Graduate School of Medicine.2.2Human platelet lysates were prepared from single‐donor platelet concentrate provided by the Japan Red Cross Blood Center by the Application for the use of blood donated in Japan based on the “Guidelines on the use of donated blood in R&D, etc.” Platelet concentrate was frozen at −30°C and thawed twice and then stored at −30°C. The frozen platelet concentrate was thawed at 4°C and centrifuged to obtain supernatant as platelet lysate.6 cells per kilogram of patient weight. The volume of BM aspirate was determined according to patient weight; if the patient weight was <35, 35‐50, or ≥50 kg, the volume of BM aspirate was 10, 15, or 20 mL, respectively. Mononuclear cells were isolated by centrifugation of BM using Ficoll‐Paque PREMIUM . The separated mononuclear cells were seeded in T‐25 cell culture flasks at 1.0‐2.0 × 107 cells per flask in Dulbecco's modified Eagle's medium  containing 5% human platelet lysate and 2 IU/mL heparin  (referred to as culture medium) and cultured at 37°C in a humidified incubator containing 5% CO2. After culturing for 3 or 4 days, nonadherent cells were removed, and the adherent cells were further cultured. Cells were harvested at subconfluent using TrypLE Select . Cells at passage 1 were seeded in the same number of T‐75 culture flasks from T‐25. Cells at passage 2 were seeded in the same number of T‐225 culture flasks from T‐75. Cells at passage 3 or 4 were seeded in a 3‐fold number of T‐225 flasks. MSCs were harvested after passage 3 or 4 according to the cell count, sampled, and cryopreserved at −150°C in CP‐1  until the day of CBT.BM was harvested from the posterior iliac crest of the MSC donor with local anesthesia by the standard procedure of BM aspiration. The target MSC dose was 0.5 × 106 cells per kilogram of patient weight, absence of contamination by pathogens  test, and viral PCR tests for hepatitis B and C viruses, HIV type 1, parvovirus B19, herpes simplex virus, varicella‐zoster virus, human herpesvirus‐6, cytomegalovirus, Epstein‐Barr virus), and immune phenotype characterized by the expression of CD73, CD90, and CD105 surface molecules (≥90%) and the absence of CD14, CD19, CD34, CD45, and HLA‐DR expressions (≤10%).Criteria for release of MSCs for clinical use were as follows: viability ≥70%, viable cell count ≥0.2 × 102.3The conditioning regimen was not defined in this study. in vivo purging of T cells using treatments such as anti‐thymocyte globulin was prohibited. GVHD prophylaxis consisted of the combination of tacrolimus and short‐term methotrexate.2.4On the day of CBT, MSCs were thawed, washed, and resuspended in 2‐10 mL of a saline solution. Premedication with hydrocortisone 100 mg and chlorpheniramine 10 mg was administered approximately 30 minutes before injection of MSCs. After local anesthesia, a standard BM aspiration needle was inserted into the iliac bone on one side. To ensure that the needle was securely inserted into the BM cavity, aspiration of <0.5 mL BM was done. Then, approximately 5 mL of MSC suspension were injected slowly. This procedure was repeated on the iliac bone on the contralateral side. Four hours after MSC injection, CB was infused intravenously with the standard procedure. Granulocyte colony‐stimulating factor (G‐CSF) was administered from 7 days after transplant to neutrophil engraftment.2.5Adverse events were graded by Common Terminology Criteria for Adverse Events version 4.0. Safety was assessed by monitoring and recording of all adverse events and serious adverse events. The study was monitored by an independent data and safety monitoring committee, and serious adverse events were reviewed and judged to determine whether an adverse event was attributable to treatment. Periodic monitoring was done according to the Japanese clinical trial guideline at least annually. The study stopping rules included graft failure, transplant‐related mortality before engraftment, or grade 4‐5 adverse event in three patients.Patients had routine clinical assessments and laboratory investigations such as blood cell counts, tacrolimus levels, and cytomegalovirus antigenemia. Patients were planned to be followed up for at least 1 year after transplant or less if they satisfied one of the discontinuation criteria. Chimerism analyses were done at the National Hospital Organization Nagoya Medical Center using short tandem repeats by PCR assay in peripheral CD3+ T cells on days 14, 28, and 56 after transplantation as previously described.To evaluate immune reconstitution, lymphocyte subsets were measured at days 28, 42, 56, and 84 after transplantation by immunophenotyping of peripheral blood. Peripheral blood mononuclear cells (PBMCs) were stained with the following fluorochrome‐conjugated monoclonal antibodies: anti‐human CD3, CD4, CD8, CD16, CD19, CD25, CD27, CD56, and CD127 . To stimulate interferon (IFN)‐γ, interleukin (IL)‐4, and IL‐17 production, the PBMCs were stimulated for 5 hours with 50 ng/mL phorbol myristate acetate and 1000 ng/mL ionomycin in the presence of brefeldin A . Subsequently, the cells were fixed and permeabilized with Cytofix/Cytoperm Solution and Perm/Wash Buffer (BD Biosciences). After fixation, the cells were stained with IFN‐γ, IL‐4, IL‐17, and CD4 antibodies. Data acquisition and analyses were performed with a FACSAria (BD Biosciences) instrument.To evaluate cytokine and chemokine kinetics, serum concentrations of IL‐1α, IL‐1β, IL‐2, IL‐4, IL‐5, IL‐6, IL‐10, IL‐12, IL‐13, IL‐17, IL‐21, IFN‐γ, tumor necrosis factor, IP‐10/CXCL10, and MCP‐1/CCL2 through pre‐ and post‐transplant  were measured using a Cytometric Bead Array Flex Set System (BD Biosciences), according to the manufacturer's instructions. On day 0, serum was obtained twice, before the infusions of MSCs and of CB cells. Samples were run on FACSCanto II (BD Biosciences), and data were analyzed using FCAP Array software (BD Biosciences). The changes in cytokine and chemokine levels from day 0 were evaluated.2.6The primary endpoint of this study was toxicity related to intra‐BM injection of MSCs within 14 days after transplantation, which was defined as adverse events that could not be explained by other complications, such as regimen‐related toxicity or infection, that generally occur after transplantation. Secondary endpoints included the rate of engraftment, the time to hematopoietic recoveries, the incidences and severities of acute and chronic GVHD, the incidences of regimen‐related toxicities and infection, and the probabilities of nonrelapse mortality (NRM), relapse, disease‐free survival, and overall survival at 1 year after transplantation.2.7The study patients were compared with a control group of six patients who received CBT without MSCs during the same time period, between May 2017 and May 2018, in Nagoya University Hospital with respect to hematopoietic recoveries, clinical outcomes, lymphocyte subsets, and cytokine/chemokine kinetics. The control patients did not join this study because of patient decisions (n = 1), not enough time to prepare MSCs (n = 1), the difficulty of BM aspiration due to BM fibrosis (n = 1), not meeting the criteria for release of MSCs (n = 1), or the close of registration for this study (n = 2).2.89/L for 3 consecutive days. The time to neutrophil engraftment was defined as the first day of achieving an absolute neutrophil count greater than 0.5 × 109/L for 3 consecutive days. The times to platelet and reticulocyte recoveries were defined as the first days of achieving a platelet count greater than 20 × 109/L or 50 × 109/L and a reticulocyte count greater than 1% for 3 consecutive days without transfusions. Primary graft failure was defined as lack of neutrophil engraftment in patients surviving at least 60 days, and secondary graft failure was defined as neutrophil engraftment followed by a decline in the neutrophil count to less than 0.5 × 109/L for 3 consecutive days. Acute GVHD was diagnosed and graded according to the consensus criteria.Engraftment was defined as neutrophil recovery to greater than 0.5 × 10P values were two‐sided, and values of P < .05 were considered significant. Statistical analyses were performed with Stata software version 15.1 , GraphPad Prism software version 6.03 , and EZR software version 1.33.Mann‐Whitney tests and Fisher's exact tests were used to compare baseline characteristics and outcomes between the MSC‐CBT group and the control group. Mann‐Whitney tests were also used for the comparisons of lymphocyte subsets and cytokine/chemokine kinetics between the two groups. The probabilities of hematopoietic recoveries and GVHD were estimated on the basis of cumulative incidence curves and compared using Gray's test or the Fine and Gray competing risk regression model. Regarding hematopoietic recoveries, death and relapse were the competing events; for GVHD, death without GVHD and relapse were the competing events. All 33.17/kg  and 0.99 × 105/kg , respectively. No patients had donor‐specific HLA antibodies. All patients received a myeloablative conditioning regimen. MSC donors were HLA‐haploidentical in four cases (patient's son in three cases and mother in one case), and HLA‐mismatched in one case (patient's wife). The median number of infused MSCs was 1.35 × 106/kg .Between February 2017 and June 2018, six patients were enrolled in this study, but one patient did not receive protocol treatment because the MSC product did not meet release criteria because of insufficient cell counts  were observed. Regimen‐related toxicities within 28 days after transplantation are summarized in Table 3.39/L, reticulocytes ≥1%, platelets ≥20 × 109/L, and platelets ≥50 × 109/L, with median times to recovery of 21 , 35 , 38 , and 52  days after transplantation, respectively , the differences in hematopoietic recoveries between with and without cotransplantation of MSCs were thought to be minimal. In the present study, all five adult patients achieved both neutrophil and platelet recoveries with relatively lower cell doses of CB graft compared with pediatric patients, including a unit with TNCs <2.0 × 107/kg. Although there was no difference in the time of hematopoietic recoveries, the present study indicated the potential of intra‐BM injection of MSCs to support sustained engraftment. Further study is required to determine whether intra‐BM injection of MSCs improves engraftment in CBT for adult patients.Four clinical studies of cotransplantation of MSCs in CBT for pediatric patients have been reported. One study, in which G‐CSF was used only for 23% of the patients, reported a rate of neutrophil engraftment of 85%, with a median time of 30 days after transplantation and no reduction of the risk of graft failure.In the present study, the engraftment of cotransplanted MSCs was analyzed by chimerism analysis using short tandem repeats with a detection limit of 0.1%. The chimerism of MSCs derived from recipient BM after transplant remained of recipient origin and the fraction of the MSC donor was not detected. In the BM, MSCs differentiate into BM stromal cells, osteocytes, osteoblasts, and endothelial cells, all of which constitute the BM microenvironment, known as the HSC niche, and they support hematopoiesis by controlling maintenance, self‐renewal, proliferation, differentiation, and mobilization of HSCs.Several inflammatory cytokines , which play important roles in the pathogenesis of GVHD, were lower in MSC‐CBT patients than in controls in this study. However, the comparison of cytokine levels has a limitation in the present small‐sample study. The observed differences in cytokine levels after transplant could be not the reason for, but rather the result of the lack of acute GVHD. Although all MSC‐CBT and control patients received similar myeloablative conditioning regimens, the observation could also be explained by differences in the actual damage caused by conditioning regimen. The effect of cotransplantation of MSCs on cytokine production and its association with the development of GVHD should be analyzed by further studies with larger cohorts of patients and controls.In adult patients undergoing CBT in Japan, the incidences of grade II‐IV and grade III‐IV acute GVHD were reported to be 13%‐41% and 8%‐12%, respectively.5CBT combined with intra‐BM injection of MSCs was found to be a safe and feasible therapeutic strategy. Furthermore, the present findings suggest the potential that intra‐BM injection of MSCs may prevent the development of GVHD, accompanied by a decrease in some inflammatory cytokines, with no inhibition of engraftment and immune reconstitution. This strategy might be applicable not only to CBT but also to BMT or PBSCT, leading to prevention of severe GVHD, especially in HLA‐mismatched settings and reduction of the burden imposed on HSC donors by decreasing the required stem cell number. Further clinical trials are needed to confirm the efficacy of intra‐BM injection of MSCs.T.M. received educational and investigational support from Chugai Pharmaceutical Co., Ltd. and Novo Nordisk Pharma Ltd.; honoraria from Shire/Takeda Pharmaceutical Co., Ltd., Bayer Pharmaceutical Co., Ltd., Bioverativ/Sanofi Co., Ltd., Chugai Pharmaceutical Co., Ltd., CSL Behring Co., Ltd., and Novo Nordisk Pharma Ltd.; serves on advisory boards for Baxalta/Shire/Takeda Pharmaceutical Co., Ltd., Bayer Pharmaceutical Co., Ltd., Novo Nordisk Pharma Ltd., Chugai Pharmaceutical Co., Ltd., and Pfizer Co., Ltd. H.K. received research funding from FUJIFILM Corporation, Kyowa Hakko Kirin Co., Ltd., Otsuka Pharmaceutical Co., Ltd., Perseus Proteomics Inc., Daiichi Sankyo Co., Ltd., AbbVie GK, Astellas Pharma Inc., Zenyaku Kogyo Co., Ltd., Nippon Shinyaku Co., Ltd., Eisai Co., Ltd., Chugai Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Sumitomo Dainippon Pharma Co., Ltd.; honoraria from Bristol‐Myers Squibb, Ltd. and Astellas Pharma Inc.; served as the Consultant/Advisory role Astellas, Daiichi Sankyo, received honoraria from Astellas, and received research funding from Chugai, Kyowa Hakko Kirin, Zenyaku Kogyo, FUJIFILM, Daiichi Sankyo, Astellas, Otsuka, Nippon Shinyaku, Eisai, Pfizer, Takeda, Novartis, Sumitomo Dainippon, Sanofi, Celgene. These companies were not directly involved in any part of this study. The other authors indicated no potential conflicts of interest.T.G.: conception and design, provision of study material or patients, collection and/or assembly of data, data analysis and interpretation, manuscript writing, final approval of manuscript; M.M.: conception and design, financial support, provision of study material or patients, collection and/or assembly of data, data analysis and interpretation, manuscript writing, final approval of manuscript; T.N.: conception and design, provision of study material or patients, collection and/or assembly of data, data analysis and interpretation, final approval of manuscript; S.T., Y.I., Y.U., and Y.A.: provision of study material or patients, collection and/or assembly of data, final approval of manuscript; S.K.: collection and/or assembly of data, data analysis and interpretation, final approval of manuscript; S.S.: conception and design, provision of study material or patients, collection and/or assembly of data, final approval of manuscript; K.K., A.H., S.N., N.N., and Y.T.: conception and design, administrative support, final approval of manuscript; Y.K. and T.M.: administrative support, final approval of manuscript; H.K.: conception and design, financial support, administrative support, final approval of manuscript.Figure S1. Supporting information.Click here for additional data file.Figure S2. Supporting information.Click here for additional data file.Table S1. Chimerism analysis.Table S2. Characteristics and outcomes of control patients receiving cord blood transplantation alone.Table S3. Lymphocyte subset analysis.Click here for additional data file.


Chronic kidney disease (CKD) patients, especially those with end stage renal disease (ESRD) undergoing hemodialysis (HD), exhibit high prevalence of periodontitis. This cross-sectional study aimed to investigate the periodontal status of HD patients and its relationship with salivary microbiome.One hundred eight HD patients and one hundred healthy control individuals were recruited. They were subjected to periodontal examination followed by saliva samples collection for 16S rRNA gene sequencing.Lachnospiraceae [G-2] sp. |HMT_096| is positively correlated with the duration of HD and the community periodontal index (CPI). Five OTUs  belonging to the phyla Firmicutes were enriched as the duration prolonged, and four OTUs originated from the phyla Proteobacteria were negatively related with the CPI index. ESRD patients undergoing HD exhibited microbiota structural, compositional and functional differences compared with the healthy controls. And the species changed as the duration of hemodialysis prolonged.The HD patients were with worse periodontal health status, and exhibited higher salivary microbial diversity and lower richness. The periodontal pathogens were significantly enriched in the HD patients. The inferred functional analyze showed microbes enriched in the HD patients were mainly related to metabolism. Despite the periodontal status and overall structure of the microbiome were not significantly altered as the HD duration prolonged, the abundance of End stage renal disease changes salivary microbiome and is a risk factor for oral dysbiosis. Chronic kidney disease (CKD) is characterized by a presence of injury and/or a progressive loss of renal function over a period of months or years culminating with end stage kidney disease (ESKD) . Due to CKD is a risk factor for chronic periodontitis –6. For pA complex community of bacteria, archaea, protozoa, fungi and viruses colonize our human body, which encompasses 10 times more cells and 100 times more genes than the host . The oraGut dysbiosis has already been well described in CKD patients , 21 and In this study, we aimed to compare the periodontal status and saliva microbiota between HD patients and healthy persons, and further investigated the association between the salivary microbiome and the duration of HD treatment. These results enrich our understanding of the relationship between general disease state, oral microbiome changes and oral health status.This study was approved by the Institutional Review Board of the Sichuan University Hospital. The case group comprised 108 patients undergoing HD three times per week at the West China Hospital, Sichuan University, Chengdu, China. They were in stable clinical conditions for at least 3 months. Patients with diabetic nephropathy or kidney transplantation, or patients who had been on absorbable antibiotics or undergoing periodontal disease treatment within the preceding 3 months or have smoking habits were excluded. 100 healthy matched subjects were recruited as controls. All participants gave a written informed consent before participation, and the study was carried out in accordance with those ethical standards in the Declaration of Helsinki.One trained dentist performed all the clinical measurements. The Community Periodontal Index (CPI) was used to determine the oral periodontal health status, with the score of 6 sites for 10 World Health Organization index teeth . The num− 1, 1.5 h) treatment step to lyse the bacterial cell.After the oral examination, saliva samples were collected by the same dentist. All participates were instructed not to eat or brush their teeth at least 2 h before sampling. A Salivette  collection swab with hard pack was used for the saliva collection and storage. Whole unstimulated saliva was collected using the swab in floor of the mouth. The swab was placed back into the collection tube, and stored at − 80 °C before subsequent analysis. Total DNA was isolated from saliva using the QIAamp DNA micro Kit  per the manufacturer’s recommendations, with minor modification by adding an extra lysozyme  treatment step for lysing the bacterial cell. The V3-V4 regions of the bacterial 16S rRNA gene were PCR amplified using barcoded 338F and 806R. Amplicons were extracted from 2% agarose gels and purified using the AxyPrep DNA Gel Extraction Kit  and quantified using QuantiFluor™ -ST . Purified amplicons were pooled in equimolar and paired-end sequenced (2 × 250) on an Illumina MiSeq platform  according to the standard protocols.Total DNA was extracted from saliva using the QIAamp DNA micro Kit  per the manufacturer’s recommendations, with minor modification by adding an extra lysozyme (3 mg mlP < 0.05), and Kruskal-Wallis test was used for comparation among three groups (P < 0.05). X2 test or Fisher’s exact test was used to compare the categorical variables in the contingency tables (P < 0.05). Principal co-ordinates analysis (PCoA) and supervised Partial least squares-discriminant analysis (PLSDA) analysis were assessed using the SimcaP software . Linear discriminant analysis (LDA) effect size (LEfSe) method was implemented with LEfSe (version 1.0). The functionality of the microbiota was performed using PiCRUST and compared between the two groups. Cytoscape (version 3.6.0) was used to visualize the correlations between the microbiota and duration of HD and other clinical index, with a Spearman’s correlation coefficient .The raw fastq files were first quality-filtered by Trimmomatic and then merged by FLASH. OTUs were clustered by 97% cutoff using UPARSE (version 7.1). To determine the species name and HOT , sequences were characterized based on the HOMD database. The relative abundance of each bacterial taxon was calculated and typically presented as “Mean ± SD”. The core microbiome of salivary community was analyzed based on previous study . Mann-WhP = 0.013).One hundred eight HD patients and one hundred healthy subjects were recruited. The two groups matched in age, gender and body mass indices (BMIs) Table . For theP = 0.012), and a higher diversity index . Uncultivated phylotypes did not significantly differ between the two groups (P = 0.610). We generated PCoA plots to investigate the relationship of the composition. The unweighted UniFrac plot showed a distinct separation of the HD samples and the healthy controls based on PC1 (13.28%) and PC2 (8.91%)  in both groups. The relative abundances of Firmicutes (P = 0.008), Bacteroidetes (P = 0.002), Spirochaetae (P = 0.001), Synergistetes (P < 0.001), Tenericutes (P < 0.001), Gracilibacteria (P < 0.001), and the total relative abundance of the other 21 phyla (P < 0.001) were significantly higher in the HD patients, whereas the abundances of Proteobacteria (P = 0.074) and Actinobacteria (P < 0.001) decreased , Capnocytophaga (P < 0.001), Porphyromonas (P = 0.001), Veillonellaceae (P < 0.001), Granulicatella (P < 0.001) and other 9 genera were significantly enriched in the HD samples. In contrast, Lautropia (P = 0.031), Prevotella [G-7] (P < 0.001), Actinomyces (P < 0.001), Veillonella (P < 0.001), Rothia (P = 0.031) and Leptotrichia (P = 0.027) showed significant overabundance in the healthy controls.Next, we evaluated the oral microbial community characteristics of the two niches. The taxonomic compositions at the phylum level varied widely between groups Fig. a. Firmic P = 0.00, Spiroch P = 0.00, SpirochRothia aeria (P < 0.001), Actinomyces odontolyticus (P < 0.001), Fusobacterium periodonticum (P = 0.001), Oribacterium asaccharolyticum (P = 0.033) were unique with relative abundances > 1% to the healthy group. On the contrary, Porphyromonas gingivalis (P < 0.001), Neisseria elongate (P < 0.001), Catonella morbi (P = 0.008), Porphyromonas endodontalis (P < 0.001) and Capnocytophaga leadbetteri (P < 0.001) were only detected in the HD group as core salivary microbiome with a mean relative abundance > 1%.The core microbiome with average relative abundance > 1% or species with statistically difference were charted in Fig. Prevotella nigrescens (P = 0.147) , and the supplementary Table SLachnospiraceae [G-2] sp. | HMT_096 | was positively correlated with both the duration of HD and the CPI index of the patients. Agrobacterium tumefaciens, Pseudomonas marincola, Vibrio gigantis, Streptococcus anginosus, Pseudomonas orientalis and Arthrospira platensi showed moderate correlations (|correlation ρ| > 0.4) with CPI index, were negatively correlated with that periodontal indicator. In addition, there were another 6 species exhibiting weak positive correlations with the duration of HD therapy .Next, we performed a correlation analysis of the differential microbiota at the OTU level with the duration of HD therapy and oral clinical indices. Figure n = 23): 3 m < duration of HD ≤1y; (ii) HD2 group (n = 61): 1y < duration of HD ≤5y and (iii) HD3 group (n = 24): duration of HD >5y. All the patients in the HD3 group were with periodontitis and the percentage of individuals with CPI 3 and CPI 4 was slightly higher than the other two groups  HD1 group , to a dysbiotic microbial community of anaerobic microbes belonging to the phyla essentially comprised of Firmicutes, Spirochaetes, Synergistetes, and Bacteroidete  sp. | HMT_096 |, from the genera Firmicutes, was enriched as the extension of the duration of HD and was more abundant in the patients with severe periodontitis. The duration may not change the overall composition and structure of the salivary microbial community significantly, but contribute to changes of some specific species that may further stimulate a bad effect on the patients’ periodontal status. Considering that the available data about oral microbiota of HD patients remain limited, all these correlated nods may be helpful in finding potential periodontal pathogens or probiotic bacteria and new reasonable periodontal treatment with the HD population in the future.The severity of periodontal disease slightly worsened as the HD duration prolonged. Further, we found that OTUs, positively related with the duration of HD, were mainly originated from the phyla ESRD patients undergoing HD exhibited more severe periodontal health status, and had microbiota structural, compositional and functional differences compared with the healthy controls. Furthermore, we identified the species changed as the duration of hemodialysis prolonged. End stage renal disease changes salivary microbiome and is a risk factor for oral dysbiosis.Additional file 1: Table S1. Dissimilarity Tests between the Healthy Controls and the HD Patients. Table S2. Relative Abundance of the Top 30 Bacterial Genera. Table S3. Relative abundance of the top 30 bacterial genera with significant difference between the groups. Table S4. Relative Abundance of the Species Associated with Diseases in the Healthy Controls and the HD Patients. Table S5. The detailed information of the Cytoscape analyzation. Table S6. Demographics and Clinical Parameters of Patients in the Three Groups. Table S7. Comparison of Bacterial Diversity, Richness, Observed Operational Taxonomic Units (OTUs) and Uncultured Species among the Three Groups. Table S8. Relative Abundance of the Top 10 Bacterial Phyla. Table S9. Relative Abundance of the Species Associated with Diseases in the Three Groups. Figure S1. PLS-DA discriminant analysis plot. PLS-DA: Partial least squares-discriminant analysis; HD1 group (N = 23): 3 m < duration of HD ≤1y; HD2 group (N = 61): 1y < duration of HD ≤5y; HD3 group (N = 24):5y < duration of HD.


Here, we report a case of haemangioma on middle mediastinum accompanied by unilateral pleural effusion, which was initially suspected to be lung cancer and pleurisy. During annual check‐up, chest radiography of a 30‐year‐old female showed homogeneous opacity in the left lower pulmonary field. Excision was performed, and the mass was pathologically diagnosed as benign mediastinal vascular tumour with exudative pleural effusion. To our knowledge, this presentation occurs in <0.5% of tumours of the mediastinum, and furthermore, the presence of pleural fluid is extremely rare, and the underlying mechanism is unknown. Although mediastinal haemangioma is hard to diagnose without surgery, we should include it in the differential diagnosis of a tumour with unilateral pleural effusion. Here, we report a case of haemangioma on middle mediastinum accompanied by unilateral pleural effusion, which was initially suspected to be lung cancer and pleurisy. Although mediastinal haemangioma is hard to diagnose without surgery, we should include it in the differential diagnosis of a tumour with unilateral pleural effusion. Mediastinal haemangioma is a very rare neoplasm, present in <0.5% of mediastinal masses. Here, we report a rare case of a mediastinal mass accompanied by unilateral pleural effusion impossible to be diagnosed without excision.A 30‐year‐old non‐smoker female was referred to our outpatient clinic with left‐sided limited pleural effusion on X‐ray radiography, detected at an annual health check‐up. She had a past medical history of endometriosis, ovarian cyst, and fibroadenomas of the left breast, which were all treated two years ago by polypectomy of the uterine cervix and hormone therapy. For the past eight years, she has been travelling abroad once a month for business, from east Asia to Europe, and had been to a coal mine in Indonesia for more than 15 times. She had been followed up since the last eight years, with no definitive diagnosis; moreover, she had no cough, sputum, or breathing difficulty.At our clinic, the patient appeared generally good and conscious, with a body temperature of 37.1°C, blood pressure of 108/70 mmHg, and heart rate of 70 beats/min. Her respiratory rate was 16 cycles/min and oxygen saturation was 96% on room air. Cardiopulmonary examination revealed diminished breath sounds on the left lower lung lobe and dullness on percussion was also noted. All other findings on physical examination were unremarkable. Laboratory tests showed normal blood levels , C‐reactive protein (<0.04 mg/dL), interleukin‐2 receptor (293 U/mL), and tumour markers (carcinoembryonic antigen (CEA): 0.5 ng/mL, stage‐specific embryonic antigen‐1; (SSEA‐1) sialyl Lewis X‐i antigen (SLX): 34.9 U/mL, carbohydrate antigen 19‐9 (CA 19‐9): 7.9 U/mL).Chest radiography showed a homogeneous opacity in the left lower pulmonary field. On high‐resolution computed tomography (HRCT), multiple mass lesions on the medial side of the left lower lobe appeared to be scattered, which are supposed to be pleural in origin. They showed strong and non‐uniform contrast enhancement, with the largest one being 27 × 15 × 33 mm, which appeared to be nourished by the musculophrenic branch of the left internal thoracic artery  was performed and indicated no 18F‐fluorodeoxyglucose (FDG) uptake, and the pleural effusion had increased Fig. . After aPleural effusions are a common medical problem with over 50 recognized causes . MediastAppropriate written informed consent was obtained for publication of this case report and accompanying images.


Patients with advanced‐stage follicular lymphoma (FL) who progress early after receiving first‐line therapy have poor overall survival (OS). Currently applied clinical prognostic models such as FL International Prognostic Index [FLIPI], FLIPI‐2 and PRIMA‐Prognostic Index [PRIMA‐PI] have suboptimal sensitivity and specificity to predict this poor prognosis subgroup. The primary objective was to develop a novel prognostic model, the FL Evaluation Index (FLEX) score, to identify high‐risk patients and compare its performance with FLIPI, FLIPI‐2 and PRIMA‐PI. Progression‐free survival (PFS) after first‐line immunochemotherapy was the key endpoint, while OS and progression of disease within 24 months (POD24) were also assessed. The model, which includes nine clinical variables, was developed using a cohort of patients with previously untreated advanced‐stage FL from the phase 3 GALLIUM trial (NCT01332968). The performance of the model was validated using data from the SABRINA trial (NCT01200758). In GALLIUM , FLEX increased the intergroup (low‐risk/high‐risk) difference in 2‐year and 3‐year PFS rates and demonstrated superior intergroup differences in 2‐year and 3‐year OS rates compared with FLIPI, FLIPI‐2 and PRIMA‐PI. Sensitivity for a high‐risk score to predict POD24 was 60% using FLEX compared with 53% for FLIPI and FLIPI‐2, and 69% for PRIMA‐PI, while specificity was 68% for FLEX compared with 58% for FLIPI, 59% for FLIPI‐2 and 48% for PRIMA‐PI. The prognostic value of FLEX in SABRINA was similar to FLIPI. Therefore, FLEX appears to perform better than existing prognostic models in previously untreated FL, in particular for the newer treatment regimens. These measures have important prognostic value but still have suboptimal sensitivity and/or specificity for POD24. For example, the m7‐FLIPI risk score, which integrates FLIPI with the Eastern Cooperative Oncology Group performance status (ECOG PS) and the mutation status of seven genes,Here, we have developed a new prognostic model — the Follicular Lymphoma Evaluation Index (FLEX) — based solely on clinical variables , that is able to identify high‐risk patients by predicting both PFS (key endpoint) and POD24 following first‐line immunochemotherapy for FL with current recommended regimens. The aim was to develop a simple prognostic model that is easy to interpret. In developing this model, we used patient‐level data from the phase 3 GALLIUM trial.22.1Data for the training cohort were derived from an updated efficacy analysis of all 1202 patients with FL enrolled in the randomized phase 3 GALLIUM trial .The study was conducted in accordance with the principles set out in the updated Declaration of Helsinki, the International Conference on Harmonisation Guideline for Good Clinical Practice and all applicable local laws and regulations. The study protocol and its amendments and other study‐related materials were approved by the institutional review boards/ethics committees at participating centers. Written informed consent was provided by all patients.2.2Based on data availability in GALLIUM and prior evidence of biological plausibility , 17 clinical variables were identified as potential model inputs before initiating the analysis, and were included in the primary evaluation Table . ContinuOf note, the impact of dichotomization of input variables has been assessed to be very small, in a sensitivity analysis Figure , compareTreatment variables were used for model fitting but were excluded from the final construct as the aim of the study was to establish a general prognostic model that performs well independently of treatment.2.3The FLEX model was validated using an independent dataset from the SABRINA trial: a randomized phase 3 study (NCT01200758) investigating the pharmacokinetic non‐inferiority, efficacy and safety of subcutaneous vs intravenous rituximab plus 6‐8 cycles of chemotherapy, followed by rituximab maintenance for 2 years (in responders), for the first‐line treatment of patients with FL.2.4The FLEX prognostic model was built using penalized multivariable Cox regression methodology with elastic net regularization.The performance of the FLEX score was tested by assessing the effect of risk categorization (high‐risk vs low‐risk) on PFS and overall survival (OS), and then comparing these data with those obtained using established prognostic indices . For each prognostic tool, intergroup differences in estimated 2‐year and 3‐year PFS and OS rates between patients classified as high‐ and low‐risk were calculated. All survival outcomes were estimated using Kaplan‐Meier methodology. To test the robustness of the FLEX model, sensitivity analyses were undertaken to assess the effect of chemotherapy backbone, exclusion of CVP‐treated patients (as CVP is used less often in current practice), additional risk stratification and increasing the cut‐point for defining high risk on PFS. Additionally, Cox proportional‐hazards analysis of PFS (based on HRs and 95% CIs) evaluated the effects of treatment regimen and the nine components of the FLEX score on the results. The effects of treatment regimens on the PFS data were also determined for FLIPI and PRIMA‐PI.The sensitivity and specificity of a high‐risk score to predict POD24 were calculated for each prognostic tool, and were used as a measure of accuracy for predicting POD24, which was defined as progressive disease (PD) or death due to disease within 24 months of randomization (noPOD24 = no PD or lymphoma‐related death in that period).In addition, we performed a time‐dependent area under the ROC curve (AUROC) analysis to have a more global assessment of discrimination ability of the different scores examined.33.12 microglobulin >institutional upper limit of normal [ULN], peripheral blood absolute natural killer [NK] cell count <100/μL and serum lactate dehydrogenase [LDH] > ULN) were retained by the methodology and selected for inclusion in the final model based on their HRs for PFS (Table 2 microglobulin and hemoglobin); novel variables included SPD, gender and NK cell count.Nine clinical variables  or “high‐risk” if they scored 3‐9 (n = 359/1004 patients). The cutoff‐point of 3 for risk categorization reflected the number closest to the  point on both the ROC curves for predicting PFS events at the 3‐year landmark and POD24 event, in the training (GALLIUM) cohort. This cut‐point provided the best balance between true‐positives and false‐positives for POD24.3.2The performance of the FLEX model was assessed in a training cohort of 1004 patients from the GALLIUM trial; these patients were those with complete data for all nine components of the FLEX score. Applying the established risk categorization to the GALLIUM data, 2‐year and 3‐year PFS rates of 91% and 86%, respectively, were observed in FLEX low‐risk patients compared with 74% and 68%, respectively, in high‐risk patients Figure . Two‐yeaThe intergroup (low‐risk to high‐risk) differences in 2‐year and 3‐year PFS rates in the training cohort (GALLIUM) were numerically higher with FLEX than with FLIPI, FLIPI‐2 or PRIMA‐PI  resulted in a small decrease in the performance of the FLEX score (not shown) but, notably, additional less relevant variables like geographical region, which may be correlated with disease burden, were retained by the procedure. Without SPD or bulky disease the performance of the FLEX model for predicting prognosis was diminished relative to other clinical scores.3.3We conducted various post‐hoc analyses to assess if the performance of the FLEX model was consistent. These included analysis in the various chemotherapy backbone groups (excluding patients receiving CVP), assessing the impact of an intermediate risk category and also the impact of using a higher cut‐off for “high‐risk” patients. The performance of the FLEX model for PFS was consistent across backbone chemotherapy groups, with the greatest separation in the PFS curves for low‐risk vs high‐risk patients observed among bendamustine‐treated patients Figure . ExcludiSplitting patients into three FLEX risk categories , instead of two, provided additional risk stratification with 2‐year PFS rates of 93%, 88% and 74%, and 3‐year PFS rates of 88%, 82% and 67%, respectively. Using a higher cut‐point of ≥4 to define FLEX high‐risk instead of ≥3  resulted in fewer high‐risk patients , but increased the intergroup (low‐high risk) differences in 2‐year and 3‐year PFS rates to 24% and 25%, respectively.Cox proportional‐hazards analysis of PFS showed that FLIPI and PRIMA‐PI had a lower prognostic value across treatment regimens than the FLEX score Figure . NotablyAs an additional sensitivity analysis, we assessed the impact of categorization performed on some of the variables in the initial search list. Figure P = .40). From additional modeling of the propensity of missingness (not shown), we could only observe some geographical differences  and, more importantly, there was no apparent impact of missing vs non‐missing FLIPI data.Moreover, the survival profile of patients with missing data on FLEX components appears similar to that of complete cases, with a PFS HR for “incomplete” vs “complete” FLEX data of 0.89 . Specificity for POD24 was 68% with FLEX compared with 59% for FLIPI and FLIPI‐2, and 47% for PRIMA‐PI  is a popular choice among physicians.Ideally, physicians would like to use a prognostic score that is both easy to calculate and has variables that are readily available. Due to its simplicity, PRIMA‐PI ; genes that may be prognostic in one treatment subgroup may not therefore be prognostic in others.To conclude, in the GALLIUM study, our new clinical prognostic model, FLEX, was more accurate at discriminating patients likely to have poor PFS and OS than either FLIPI, FLIPI‐2 or PRIMA‐PI. In contrast to existing clinical models, the prognostic value of the FLEX score was observed consistently across chemotherapy backbones and anti‐CD20 antibody treatment arms.A.K., Fe.Ma.: Employed at F. Hoffmann‐La Roche Ltd.A.G.: Advisory boards for MSD, AbbVie, Takeda and Janssen.C.B.: Employed at Genentech, Inc. and has equity ownership interests (including stock options) in F. Hoffmann‐La Roche Ltd.C.C.: Research funding, Celgene; honoraria and travel support, Gilead; travel support, F. Hoffmann‐La Roche Ltd.F.M.: Previous employment, F. Hoffmann‐La Roche Ltd.J.F.S.: Honoraria and consulting or advisory fees, AbbVie, Celgene, Genentech, Gilead, Janssen, F. Hoffmann‐La Roche Ltd and Takeda; research funding, AbbVie and Janssen; travel support, Celgene and F. Hoffmann‐La Roche Ltd.M.H.: Research funding, F. Hoffmann‐La Roche Ltd.; membership on an entity's Board of Directors or advisory committees, Celgene, F. Hoffmann‐La Roche Ltd., Gilead, Janssen.R.M.: Consultancy, Gilead; honoraria and speaker's bureau, F. Hoffmann‐La Roche Ltd. / Genentech, Inc.T.N.: Employed at F. Hoffmann‐La Roche Ltd. and has equity ownership interests (including stock options) for F. Hoffmann‐La Roche.W.H.: Consultancy, honoraria and research funding, F. Hoffmann‐La Roche Ltd., Janssen; consultancy and honoraria, Celgene, Gilead, Vector Therapeutics; research funding, Bayer.Study design: C.C., C.R.B., T.N., Fe.Ma., M.H., R.M.Study conduct: A.G., A.K., C.C., C.R.B., T.N., Fe.Ma., J.F.S., M.H., R.M.Data collection: A.G., T.N., W.H.Data analysis: A.K., C.C., C.R.B., T.N., Fe.Ma., W.H. F.M.Data interpretation: A.K., A.G., C.C., C.R.B., T.N., Fe.Ma., F.M., J.F.S., W.H.Manuscript writing: Fe.Ma., F.M.Manuscript review: All authors.Appendix S1. Supplementary Material.Click here for additional data file.


Dear Editor,The standard care of glioblastoma multiforme (GBM), which is surgery followed by temozolomide concurrent radiotherapy (RT/TMZ), confers limited survival benefit for patients.6 fresh G422 cells led to 100% tumor formation, and the tumors reaching 1 cm3 on day 7–9 postimplantation (p.i.) were used for further experiments , were selected for establishing the orthotopic model. We then determined the pathology and molecular characters of G422‐tumors. The brain slices showed rapid G422‐tumor development during day 7–15 p.i. . The G422‐tumors were GFAP+Vimentin+CD3− and infiltrated into distant brain areas   and RT/TMZ , but did not synergize with RT   Figure . In addiP = .0037) and there was no statistical difference between the RT/TMZ and RT/TMZ/Man/Mol groups . Lastly, we explored the molecular mechanisms through which RT/TMZ/Man cures the G422‐mice by metabolomic analysis. The identified metabolites that are significantly differentially expressed between the RT/TMZ/Man and the RT/TMZ, Man, or untreated‐subcutaneous G422 gliomas were listed in the heat maps Figure . WesternTN‐GBM mouse model that faithfully recapitulates the aggressiveness and therapeutic responses of human GBM, which still requires further verification. We discovered that the RT/TMZ/Man could offer disease cure for GBM in our model through metabolically abolishing the HIF‐1‐mediated resistance. Our work highlights a novel and superior preclinical mouse model for drug screening and the potential therapeutic value of the RT/TMZ/Man regimen for GBM.In conclusion, we established a highly reproducible syngeneic G422The authors declare that they have no conflict of interest.All animal handling and experiments were performed in accordance with the NIH guidelines and approved by the Institutional Ethics Committees of Huazhong University of Science and Technology.Feng Liu performed experiments, analyzed data, and wrote the manuscript. Xiaohong Xu, Chunyang Li, and Songlin Yin assisted with animal experiments. Yuanjun Li and Chunyan Li assisted with PET/CT experiments. Shangbin Yu assisted with experimental design. Xiao Qian Chen designed the scheme of the study and wrote the manuscript.Supporting informationClick here for additional data file.


Patients with non‐ST‐segment elevation myocardial infarction (NSTEMI) have a generally poor prognosis and antithrombotic management patterns (AMPs) used post‐acute coronary syndrome (ACS) remain unclear. Duration of dual antiplatelet therapy (DAPT) and patient characteristics was evaluated in NSTEMI patients enrolled in EPICOR Asia.Patients stopping DAPT early may benefit from more intensive monitoring.EPICOR Asia was a prospective, real‐world, primary data collection, cohort study in adults with an ACS, conducted in eight countries/regions in Asia, with 2 year follow‐up. Eligible patients were hospitalized within 48 hours of symptom onset and survived to discharge. We describe AMPs and baseline characteristics in NSTEMI patients surviving ≥12 months with DAPT duration ≤12 and > 12 months post‐discharge. Clinical outcomes  were also explored.At discharge, 90.8% of patients were on DAPT . At 1‐ and 2‐year follow‐up, this was 79.2% and 60.0%. Patients who stopped DAPT ≤12 months post‐discharge tended to be older, female, less obese, have prior cardiovascular disease, and have renal dysfunction. While causality cannot be inferred, the incidence of the composite endpoint over the subsequent 12 months was 10.6% and 3.1% with shorter vs longer use of DAPT, and mortality risk over the same period was 8.4% and 1.6%.Over 90% of NSTEMI patients were discharged on DAPT, with 60% on DAPT at 2 years. Patients stopping DAPT early were more likely to have higher baseline risk and may therefore benefit from more intensive monitoring during long‐term follow‐up. Full details of the study design have been published previously.EPICOR Asia  and major bleeding events during the second year post‐discharge by DAPT duration ≤12 vs >12 months is also described. In practice, final interviews were conducted within ±2 weeks of the 24‐month time point. Outcomes data are provided based on cumulative summary at pre‐defined intervals during follow‐up.2.3P values were calculated using the chi‐square test for categorical variables, two‐sample t‐test for comparison of means, and Wilcoxon test for comparison of medians. Patients on DAPT at discharge include all those discharged on two or more antiplatelets  from the index hospitalization, and DAPT duration is defined as the time from discharge to the last use of two or more antiplatelets, not accounting for interruptions.Baseline demographics and characteristics were compared according to post‐discharge DAPT duration ≤12 months vs >12 months up to 2 years among NSTEMI patients discharged on DAPT who survived ≥12 months post‐discharge. In NSTEMI patients who survived at least the first 12 months post‐discharge, the incidence of major adverse cardiovascular events, death as an individual item, and major bleeding events during the second year of follow‐up was also explored according to DAPT duration ≤12 months vs >12 months. A major caveat is that causality cannot be inferred between outcomes and DAPT duration since it was not a randomized study; DAPT duration is not a baseline variable but an outcome, and there are multiple possible confounders, particularly regarding the nonspecified selection processes determining which patients stop or continue on DAPT at any time point. Thus, patients with DAPT duration ≤12 or > 12 months should not be considered treatment groups, but rather as different patient groups with different clinical characteristics and risk profiles.33.1Of the 13  005 ACS survivors enrolled in EPICOR Asia, 12  922 met the inclusion/exclusion criteria, of whom 6306 (48.8%) had a final diagnosis of NSTE‐ACS at discharge, including 2549 (19.7%) with NSTEMI. The mean age of NSTEMI patients was 62 years, 73.9% were male, 83.9% had at least one CV risk factor, 29.5% had prior CVD, and the majority (76.5%) were of Asian ethnicity, as reported previously.3.2P < .05), less likely to be male (P < .01), and were more likely to have diabetes (P < .01), a history of CVD (P < .05), or chronic renal failure (P < .0001)  were discharged on DAPT, of whom 490 (21.2%) stopped DAPT within the first year, and 1832 (79.1%) continued. Among those discharged on DAPT, 2124 (91.7%) survived for at least 12 months thereafter: 299 (14.1%) of these patients stopped within the first year, and 1825 (85.9%) continued. Compared with patients who remained on DAPT for more than 12 months, those who stopped DAPT sooner were older (12 receptor inhibitor (99% clopidogrel)  (Table P < .0001 in each case). There were no significant differences in in‐hospital CV complications, degree of dependence at discharge, or EuroQol‐5 Dimensions score between those who stopped DAPT early or continued beyond 12 months.Among patients who survived ≥12 months post‐discharge, no significant differences were evident in time from symptom onset to admission, or from symptom onset or admission to reperfusion by DAPT duration of use, although patients who stopped DAPT early had a longer median length of hospital stay  Table . Patient3.3In the NSTEMI population who survived at least 12 months post‐discharge, the median (interquartile range) duration of DAPT in patients who received it for ≤12 months and > 12 months was 219 80‐347) and 718 (589‐725) days, respectively. The incidence of the composite endpoint, death, MI, and stroke, over the next 12 months was 10.6% with DAPT ≤12 months and 3.1% with DAPT >12 months, and the mortality rate was 8.4% and 1.6%, respectively (Table 7 and 7184P < .001 for trend). The authors also reported a higher incidence of a composite primary outcome  in patients who discontinued DAPT in less than 6 weeks (P < .0001), and 6 weeks to <6 months (P = .02), but not for 6 months to <12 months (P = .06) compared with DAPT ≥12 months, indicating that the highest risk of events is in the earliest stages following an acute MI. This appears to be reflected in the EPICOR Asia data, since most of the significant differences in baseline characteristics between the shorter vs longer DAPT duration populations either diminished or disappeared when only the ≥12‐month survivors were included in the analysis, with the exception of male sex and chronic renal failure.The results of this analysis of NSTEMI patients included in the EPICOR Asia study showed that the majority (90.8%) were discharged on DAPT, 78.8% continued it for over 12 months, and 60.0% remained on DAPT at the final 2‐year follow‐up visit. Patients who discontinued DAPT within the first year appeared to be a higher‐risk population, as they were older, and more likely to have a history of CVD or renal dysfunction. Conversely, patients treated with DAPT beyond 1 year appeared to be at lower CV risk. This reflects the observed paradox that higher‐risk patients post‐MI are less likely to persist with prescribed medication.P < .01 by log rank test).Recent observational studies have also examined DAPT duration in NSTEACS patients in Asia, but their follow‐up periods typically did not exceed 1 year.Low adherence to guideline‐based DAPT use was demonstrated in a further study in Malaysia of 525 high‐risk survivors of NSTE‐ACS . Here, more than 80% of patients were managed medically following hospitalization with 48% discharged on DAPT; this declined to 32% and 16% at 3 and 12 months, respectively.In fact, the high‐risk population should be given longer duration of DAPT than others, which was verified in THEMIS .In EPICOR Asia, the “real‐world” trial, the incidence of major adverse CV events, including mortality, during the second year of follow‐up among patients who survived at least the first year was higher with ≤12 months of DAPT compared with >12 months of DAPT. Furthermore, the higher incidence of the composite endpoint in patients who received DAPT for up to 12 months appeared largely driven by cumulative mortality. As stated earlier, however, a causal relationship cannot be inferred between earlier DAPT discontinuation and increased risk of subsequent events. In the “real‐world” setting, the reasons contributing to DAPT use and duration will be multifarious. It is possible that at least some cases of early DAPT discontinuation are driven by bleeding events, and patients at increased risk of bleeding are also often at increased risk of ischemic events, and vice versa.4.1Limitations of the present analysis include those usually applicable to observational studies, such as the nonrandomized nature of the study population. There is also the risk of immortal time bias; that is, bias introduced by the study design in which an outcome cannot occur during the specified period of follow‐up.Finally, while the reasons for DAPT discontinuation were not reported, some may be suggested. For example, baseline data showed that patients who were older, female, with low body mass index (BMI), previous CVD, or renal insufficiency tended to stop DAPT treatment soon after discharge. The early cessation of DAPT in the older, low‐BMI patients may be associated with bleeding, such as epistaxis and gingival bleeding. Although such bleeding is usually mild, the patient may be very nervous and likely to stop DAPT as soon as possible. Early discontinuation of drugs in women may be related to lack of awareness of ACS disease, low family and social status, and insufficient attention. In patients with previous CVD or renal insufficiency, early withdrawal of medication may be associated with too many concomitant drugs or treatment with DAPT for a period prior to study enrollment. Furthermore, in some cases, taking too much medicine can cause stomach discomfort or ulcers. Sometimes, for example, aspirin therapy may be stopped, either under the guidance of a doctor or by the patient him/herself. As premature cessation of DAPT can increase the risk of CV events, additional attention should be paid to these groups, including patient education, increased follow‐up frequency, and close guidance on antiplatelet therapy and other treatments.5In summary, the majority of NSTEMI patients in EPICOR Asia were discharged on DAPT, and nearly two‐thirds remained on it at 2 years. NSTEMI patients in whom DAPT treatment is stopped earlier than 12 months post‐discharge appear to represent a vulnerable group in terms of baseline risk factors and may benefit from more intensive monitoring during long‐term follow‐up.Yanan Zou, Shuang Yang, Shipeng Wang, Bo Lv, Lili Xiu, Lulu Li., Stephen W.‐L. Lee, Yong Huo, and Bo Yu have nothing to disclose. Chee Tang Chin has received research support from Eli Lilly; honoraria from Medtronic, and has been a consultant or advisory board member for AstraZeneca. Stuart J. Pocock receives research funds from AstraZeneca.


Due to its abnormal morphology and ultrastructure, discoid lateral meniscus (DLM) is prone to tear and degeneration, leading to clinical symptoms. Arthroscopy is the main treatment for symptomatic DLM; however, postoperative outcomes vary widely due to the effects of diverse factors. This research aims to explore the factors influencing postoperative outcomes of symptomatic DLM.P < 0.05 was considered statistically significant.Patients with DLM who underwent arthroscopic surgery at our hospital from 9/2008 to 9/2015 were enrolled according to the inclusion and exclusion criteria. Fourteen variables, including sex, body mass index (BMI) and other variables, were chosen as factors for study. Knee function was assessed using the International Knee Documentation Committee (IKDC) score. Univariate analyses  and multivariate analyses  were used to identify the factors that influenced postoperative outcomes. P < 0.001). Male sex was predictive of a higher IKDC score . Compared with BMI ≥25 kg/m2, < 18.5 kg/m2 was associated with better IKDC score . Contrasting with age of onset ≥45 years, ≤14 years  and 14 ~ 25 years  were associated with better IKDC score. In comparison with symptoms duration> 24 months, IKDC scores for patients with symptoms duration ≤1 month , 1 ~ 6 months  and 6 ~ 24 months  were significantly elevated. Compared to Outerbridge grade III ~ IV, no injury  and grade I  were associated with higher IKDC score.A total of 502 patients, including 353 females (70.3%) and 149 males (29.7%), were enrolled. The median IKDC score postoperatively  was higher than that preoperatively   and symptoms duration < 24 months are conducive to good postoperative outcomes. However, combined articular cartilage injury (Outbridge grade ≥ 2) reduces postoperative effect.Arthroscopic treatment of symptomatic DLM is safe and effective, but its clinical efficacy is affected by many factors. Specifically, male sex, BMI < 18.5 kg/m The discoid meniscus is a congenital variation of the knee meniscus. Morphologically, the discoid meniscus is wider and thicker than the normal meniscus, resulting in potential instability. In the ultrastructure of the discoid meniscus, the radial and circular collagen fibre systems are reduced and disorganized, and the circular collagen fibres are insufficient in strength and show increased brittleness. These morphological and histological abnormalities make the discoid meniscus liable to tearing and degeneration –3.Clinically, discoid lateral meniscus (DLM) is common. The reported incidence of DLM is 13% in china , 16.6% iSymptomatic DLM, characterized by pain, swelling, snapping, locking, knee instability and limited mobility , 10, is This study was approved by the institutional review board of our institution. The inclusion criteria were as follows: DLM patients with symptoms  who underwent arthroscopic surgery at the Sports Medicine Center of West China Hospital of Sichuan University from September 2008 to September 2015. The exclusion criteria were as follows: patients with missing data; patients lost to follow-up; patients with bilateral symptomatic DLM who underwent bilateral knee operation; patients with symptomatic discoid medial meniscus, knee ligament injury or knee fracture; patients with rheumatoid arthritis or gouty arthritis of the knee; and patients with knee infections. A flow chart of the study is shown in Fig. 2); work intensity  and interquartile range (IQR) and by the number of cases (percentage), respectively. The differences between the preoperative and postoperative knee function scores were analysed using the Wilcoxon rank-sum test. In the univariate analysis, the Mann-Whitney U test and the Kruskall-Wallis rank sum test were used to analyse the differences in rank data between two groups and among multiple groups, severally. The model meets the parallelism through parallel test, and multivariate analysis was conducted using the ordinal logistic regression. P < 0.001).  and 149 males (29.7%), 252 (50.2%) left knees and 250 (49.8%) right knees. The median age of onset and the median duration of symptoms were 32.0 years  and 10.0 months , respectively. Other baseline information on the patients is shown in Table P < 0.05). Involved knee joint (left or right), Watanabe type, O’Connor tear type and follow-up time did not correlate with the IKDC classification (P > 0.05). Table Factors such as sex, BMI, work intensity, trauma history, age of onset, symptoms duration, medial meniscus tear, Outerbridge grade, K-L grade and type of surgery were associated with the IKDC classification  = 1.702, 95% confidence interval (CI):1.076–2.697). Compared with BMI ≥ 25 kg/m2, BMI < 18.5 kg/m2 was associated with better IKDC score , while no difference was found between 18.5 kg/m2 ≤ BMI < 25 kg/m2 and BMI ≥ 25 kg/m2 regarding IKDC score . In contrast to age of onset ≥45 years, ≤14 years  and 14 ~ 25 years  were predictive of obtaining a good IKDC score, whereas there was no significant difference between the IKDC score of 25 ~ 45 years and ≥ 45 years . In comparison with symptoms duration> 24 months, the odds of better postoperative IKDC score for symptoms duration ≤1 month , 1 ~ 6 months  and 6 ~ 24 months  were significantly elevated. Compared to the Outerbridge grade III ~ IV, no injury  and Outerbridge grade I  were favourable factors for acquiring higher IKDC score, while no difference was found between grade II and grade III ~ IV in terms of IKDC score . Work intensity, history of trauma, medial meniscus tear, K-L grade and type of surgery were not significant predictors of IKDC score . . Compared with males, on one hand, females have increased rates of cartilage loss and progression of cartilage defects at the knee [n = 39 cases, n = 48 cases, respectively).Male sex is a favourable factor in many orthopaedic diseases, but its correlation with postoperative efficacy in patients with DLM is controversial. Ahn  et al. dthe knee . On the the knee , 25, 26.the knee  and beinthe knee  and Kosethe knee  found thP < 0.001, OR = 37.069; 95% CI: 7.822–55.147), and the symptoms duration < 24 months  are advantageous for postoperative efficacy. It has been reported that the younger age of onset and a shorter course of the disease are correlated with a lower risk of articular chondromalacia and damage caused by DLM lesions [For symptomatic DLM, numerous studies have found that the earlier the age of onset is, the shorter is the duration of symptoms  and that the earlier the surgical intervention is performed, the better is the prognosis , 23, 27. lesions , 13, 28. lesions , 14, 29. lesions , 30, 31.2 is associated with a higher likelihood of obtaining better postoperative results . Fu [2 were more likely to suffer from articular cartilage lesions. High BMI has been shown to be the main risk factor for knee osteoarthritis, as obesity can lead to excessive compression of the meniscus and to loss of and pathological changes in the articular cartilage [P > 0.05); this may be because that work intensity is more reflects the activity of entire body rather than the pressure on the meniscus and cartilage of the knee.This study found that BMI < 18.5 kg/martilage –34. HencP < 0.001, OR = 6.379; 95% CI:2.545–15.975) and Outerbridge grade I  are beneficial factors for postoperative recovery of knee function. Outerbridge grade ≥ II is an unfavourable factor for postoperative outcome . The clinical manifestations of an articular cartilage lesion may not be obvious in the short term, but most patients will eventually have knee degeneration associated with cartilage damage, which leads to irreversible severe osteoarthritis drastically affecting knee function [The results of this study indicate that the absence of articular cartilage lesions , saucerization with repair and total meniscectomy , 38–40. Similar to the results of other studies , 12, 17,Regarding DLM tear, some studies reported that DLM tears could lead to degeneration of the articular cartilage and osteoarthritis in the long term , 47, thuConcerning the influence of O’Connor tear type on the postoperative result, Chen et al.  and BadlLonger follow-up is believed to be associated with more severe articular cartilage degeneration and clinical symptoms and worse knee joint function , 44. In We acknowledge that our study has some limitations. At the final follow-up, the assessment of postoperative efficacy didn’t analyse the imaging changes but only evaluated the subjective functional parameters; thus, there was no objective evaluation index that corresponded to the postoperative outcome. Moreover, this study is only a retrospective multivariate analysis, and the conclusions obtained should be further confirmed by prospective studies.2, age of onset < 25 years  and symptoms duration < 24 months are conducive to good postoperative outcomes. Combined articular cartilage injury (Outerbridge grade ≥ 2) is more likely to lead to poor postoperative effect. However, complicating medial meniscus injury, K-L grade, preoperative work intensity, DLM type, DLM tear and its O’Connor type, type of surgery, and postoperative follow-up time did not significantly affect the postoperative result.Arthroscopic treatment of symptomatic DLM is safe and effective, but its clinical efficacy is affected by many factors. Specifically, male sex, BMI < 18.5 kg/m