Limited data describe outcomes on second‐line antiretroviral therapy (ART) among children globally. Our objective was to contribute data on outcomes among children living with HIV after initiation of second‐line ART in the context of routine care within a large global cohort collaboration.Patient‐level data from 1993 through 2015 from 11 paediatric HIV cohorts were pooled. Characteristics at switch and through two years of follow‐up were summarized for children who switched to second‐line ART after starting a standard first‐line regimen in North America, Latin America, Europe, Asia, Southern Africa (South Africa & Botswana) and the rest of sub‐Saharan Africa (SSA). Cumulative incidences of mortality and loss to follow‐up (LTFU) were estimated using a competing risks framework.3 in SSA to 828 cells/mm3 in North America. Improvements in CD4 counts were observed over two years of follow‐up, particularly in regions with lower CD4 counts at second‐line switch. Improvements in weight‐for‐age z‐scores were not observed during follow‐up. Cumulative incidence of LTFU at two years was <5% in all regions except SSA (7.1%) and Southern Africa (7.4%). Risk of mortality was <3% at two years of follow‐up in all regions, except Latin America (4.9%) and SSA (5.5%).Of the 85,389 children on first‐line ART, 3,555 (4%) switched to second‐line after a median of 2.8 years on ART ; 69% were from Southern Africa or SSA and 86% of second‐line regimens were protease inhibitor‐based. At switch, median age was 8.4 years and 50% had a prior AIDS diagnosis. Median follow‐up after switch to second‐line ranged from 1.8 years in SSA to 5.3 years in North America. Median CD4 counts at switch to second‐line ranged from 235 cells/mmChildren switched to second‐line ART experience CD4 count increases as well as low to moderate rates of LTFU and mortality within two years after switch. Severe immune deficiency at time of switch in some settings suggests need for improved recognition and management of treatment failure in children. The suc3 in mean CD4 counts after 48 weeks of follow‐up in the Ugandan study [3 in median CD4 counts after 3.3 years of follow‐up in the largest study conducted in Asia [Responses to first‐line ART among children have been evaluated in large randomized trials and observational studies , 11, 12.an study , and 463 in Asia . No deat in Asia , 20, 21.The studies described above were conducted while experience with second‐line ART among children was still limited in many settings. The Collaborative Initiative for Paediatric HIV Education & Research (CIPHER) global cohort collaboration provides a unique opportunity to further evaluate outcomes associated with second‐line ART in the context of routine care, as it reflects the world’s largest combined cohort of children living with HIV on ART.22.1The CIPHER cohort collaboration brings together existing paediatric HIV observational cohorts to address key knowledge gaps in the care and treatment of children and adolescents living with HIV globally. Eleven international networks contributed data from 1993 through 2015 from a total of 47 countries: Baylor International Pediatric AIDS Initiative (BIPAI), European Pregnancy and Paediatric HIV Cohort Collaboration (EPPICC), the International epidemiology Databases to Evaluate AIDS (IeDEA) Consortium , Central Africa, East Africa, West Africa and Southern Africa), International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) Protocols P219C and P1074, Optimal Models (ICAP at Columbia University), and the Pediatric HIV/AIDS Cohort Study (PHACS). All participating networks received local ethics approvals to transfer anonymized individual participant‐level data for this collaboration to the University of Cape Town  for data management using a standardized protocol. The pooling of data at the University of Cape Town was approved by the University of Cape Town Health Research Ethics Committee (UCT HREC (reference 264/2014)). The dataset was then sent to University College London  for analysis.Eligible children were less than 10 years of age at cohort enrolment as a proxy for perinatal HIV infection, were less than 18 years of age at initiation of a “standard” first‐line combination ART regimen, and were seen in clinic for at least one visit after initiating ART. Children documented as horizontally infected with HIV  and those enrolled in clinical trials of treatment monitoring, switch or interruption strategies were excluded.2.2NNRTI‐based ART regimen, the hierarchy was integrase strand transfer inhibitor (INSTI)>LPV/r>Other PI>efavirenz (EFV)>Other NNRTI. If first‐line was a PI‐based ART regimen, this was INSTI>EFV>nevirapine (NVP)>LPV/r>Other PI>Other NNRTI.“Standard” combination ART was defined as a regimen with at least three drugs, including at least two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) plus either a non‐nucleoside reverse transcriptase inhibitor (NNRTI) or a ritonavir‐boosted protease inhibitor (PI). Switch to second‐line was defined as: (i) change of at least one NRTI plus either change in drug class  or PI change; (ii) change from single to dual PI; or (iii) addition of a new drug class. Second‐line regimens including more than two drug classes were hierarchically classified based on whether they followed an NNRTI‐ or PI‐based first‐line ART. If first‐line was an Geographical region was categorized as: North America, Latin America , Europe, Asia, Southern Africa (South Africa and Botswana) and the rest of sub‐Saharan Africa (SSA). Southern Africa was considered separately from SSA because this region had earlier introduction of LPV/r‐based regimens as first‐line and earlier rollout of viral load (VL) monitoring. Immunologic classification of HIV disease was based on World Health Organization (WHO) guidelines, and AIDS was defined as a WHO Stage 3/4 or a Centers for Disease Control and Prevention (CDC) Stage C clinical diagnosis , 23, 24.2.3Outcomes of interest included CD4 counts and weight‐for‐age z‐scores (WAZ) at one and two years of follow‐up after switch to second‐line ART. Follow‐up was limited to two years based on the average duration of available follow‐up in SSA after switch to second‐line ART. Changes in CD4 counts and WAZ from switch to second‐line ART were also summarized. The British 1990 growth reference centiles were used to transform weight measures to WAZ for all regions due to the availability of standards across all age ranges . Additio2.4This analysis was an intent‐to‐treat analysis, meaning that children were not excluded from analyses due to subsequent discontinuation or change of regimen after initial switch to second‐line ART when summarizing outcomes. Demographic and clinical characteristics at start of second‐line ART as well as follow‐up duration were summarized by region. Clinical and laboratory outcomes, including CD4 counts and WAZ, at one and two years after start of second‐line ART were then compared descriptively by region. CD4 counts and WAZ were additionally compared descriptively over follow‐up by CD4 count at switch, age at switch, WAZ at switch and second‐line regimen type. Summary statistics included only those with available data. The proportion of children with missing measures, however, was noted. Cumulative incidences of mortality and LTFU at one and two years of follow‐up were estimated using a competing risks framework  with LTF33.1Of over 170,000 children included in the CIPHER global cohort collaboration from the 11 participating networks, 85,389 (50%) initiated a “standard” first‐line ART regimen between 1993 and 2015 and were followed for switch to second‐line. Of these, 3,555 (4%) initiated a second‐line regimen, and outcomes were assessed over two years of follow‐up from the time of switch Figure . Childre3, though this varied greatly across regions, from 3.6% of children in North America to 36% in Asia, 44% in SSA and 48% in Latin America. Of the 62% of children with VL measurements at start of second‐line, 82% had VLs > 1000 copies/mL. Median WAZs were below reference norms in all regions, with children in Asia and SSA frequently severely underweight at the start of second‐line ART (median (IQR): Asia, −1.9 ; SSA, −2.0 ).While 69% of clinics met our definition for having routine CD4 and VL testing, this varied greatly across and within regions, with 13% of sites in SSA defined as having routine VL testing and 33% having targeted VL testing. At start of second‐line ART, 41% of children had severe immune deficiency and 50% ever had an AIDS‐defining diagnosis. Of note, severe immune deficiency at switch to second‐line ART was close to 60% in the rest of SSA as compared to 26% in Southern Africa, where 100% of clinic sites had routine CD4 and VL monitoring. This disparity in HIV progression on ART was also evidenced by the proportion of children who progressed to an AIDS diagnosis after start of first‐line ART and prior to switch to second‐line ART in SSA compared to Southern Africa (20% vs. 0.6% respectively). Of the children with available CD4 counts at switch to second‐line ART (78%), over a quarter had CD4 counts <200 cells/mm3.2Among the 86% of participants who were on an NNRTI‐based first‐line regimen, the majority (89%) initiated an LPV/r‐based second‐line regimen, particularly in Southern Africa (99%) and SSA (94%) Figure . In the 3.33  and 199 cells/mm3  at one and two years of follow‐up respectively. Median CD4 counts were >500 cells/mm3 across all regions at one and two years after switch to second‐line ART  of 1.8 0.7, 3.3) in SSA, 2.2  in Southern Africa, 3.4  in Asia, 3.7  in Latin America, 4.0  in Europe, to 5.3  in North America. Children in almost all regions experienced improvements in median CD4 counts from switch to second‐line ART at one and two years of follow‐up, with more dramatic improvements in the regions with lower CD4 counts at start of second‐line  , though median WAZ was still less than three standard deviations below the mean two years after switch , 5%  and −3.8  respectively.The cumulative incidence of LTFU at two years was <5% in all regions except Southern Africa and SSA, where it was 7.1% : 5.7%, 8.8%) and 7.4%  respectively , Colette Smith† , Intira Jeannie Collins† , Ruth Goodall† , Elaine J Abrams , Annette H Sohn , Thahira J Mohamed , Russell B Van Dyke , Pablo Rojo , Kara Wools‐Kaloustian , Jorge Pinto , Andrew Edmonds , Irene Marete , Mary Paul , Harriet Nuwaqaba‐Biribonwoha , Valériane Leroy , UMR 1027 Université Toulouse 3, Toulouse, France), Mary‐Ann Davies , and Rachel Vreeman* . *Project co‐chairs; †Project statisticians/epidemiologists.Data Coordinating Team: Nicky Maxwell ,Venessa Timmerman , Charlotte Duff .Writing Team:CIPHER Executive Committee: Lynne Mofenson, Linda‐Gail Bekker, Marissa Vicari, Shaffiq Essajee, Martina Penazzato; CIPHER Project Oversight Group: Intira Jeannie Collins, Kara Wools‐Kaloustian, Mary‐Ann Davies, Valériane Leroy, Ruth Goodall, Kunjal Patel, Colette Smith, Rachel Vreeman, Amy Slogrove, Paige Williams, Siobhan Crichton, George Seage III; BIPAI: Lineo Thahane (Baylor College of Medicine Children's Foundation Lesotho), Peter N Kazembe , Bhekumusa Lukhele (Baylor College of Medicine Children’s Foundation‐eSwatini), Lumumba Mwita (Baylor College of Medicine Children's Foundation‐Tanzania), Adeodata Kekitiinwa‐Rukyalekere (Baylor College of Medicine Children's Foundation – Uganda), Sebastian Wanless , Mogomotsi S Matshaba ; EPPICC: Intira Jeannie Collins , Ruth Goodall , Colette Smith , Tessa Goetghebuer , Claire Thorne , Josiane Warszawski , Luisa Galli , Sybil Geelen , Diana M Gibb , Carlo Giaquinto , Magdalena Marczynska , Laura Marques , Filipa Prata , Luminita Ene , Liubov Okhonskaia , Pablo Rojo , Antoni Noguera‐Julian , Lars Naver , Christoph Rudin , Gonzague Jourdain , Ali Judd , Alla Volokha ; IeDEA‐CCASAnet: Jorge Pinto , Vanessa Rouzier , Regina Succi ; IeDEA Asia‐Pacific: Kulkanya Chokephaibulkit , Annette H Sohn , Azar Kariminia , Thahira J Mohamed ; IeDEA Central Africa: Marcel Yotebieng , Andrew Edmonds , Patricia Lelo ; IeDEA East Africa: Rita Lyamuya , Irene Marete , Eldoret, Kenya), Patrick Oyaro (Family AIDS Care and Education Services (FACES), Kenya Medical Research Institute (KEMRI), Kisumu, Kenya), Kara Wools‐Kaloustian ; IeDEA Southern Africa: Andrew Boulle , Kennedy Malisita , Geoffrey Fatti , Andreas D Haas , Mary‐Ann Davies ; IeDEA West Africa: Sophie Desmonde , Fatoumata Dicko , Valériane Leroy , UMR 1027 Université Toulouse 3, Toulouse, France); IMPAACT/PHACS: Mark J Abzug , Paige Williams , Murli Purswani , George Seage III , Russell Van Dyke , Ellen Chadwick ; ICAP‐Optimal Models: Elaine Abrams , Chloe Teasdale , Harriet Nuwagaba .Table S1. Clinical and laboratory outcomes at one year of follow‐up after start of second‐line ARTTable S2. Clinical and laboratory outcomes at two years of follow‐up after start of second‐line ARTFigure S1. Study population derivation.Figure S2. Median CD4 counts (cells/mm3) with interquartile ranges over two years of follow‐up by characteristics at switch to second‐line.Figure S3. Median weight‐for‐age z‐scores with interquartile ranges over two years of follow‐up by region.Figure S4. Median weight‐for‐age z‐scores with interquartile ranges over two years of follow‐up by characteristics at switch to second‐line.Click here for additional data file.


The prognostic value of biomarkers in patients with heart failure (HF) and mid‐range (HFmrEF) or preserved ejection fraction (HFpEF) has not been widely addressed. The aim of this study was to assess whether the prognostic value of growth differentiation factor 15 (GDF‐15) is superior to that of N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) in patients with HFmrEF or HFpEF.P < 0.0001) and NT‐proBNP . A Cox multivariable model identified New York Heart Association Functional Class III (P = 0.04), systolic blood pressure (P = 0.01), left atrial diameter (P = 0.03), age >65 years (P < 0.0001), and GDF‐15 concentrations (P = 0.01) but not NT‐proBNP as independent predictors of all‐cause mortality. The area under the curve was 0.797 for the basic model including NT‐proBNP, and the area under the curve comparing the overall model was 0.819, P = 0.016 (DeLong's test). Integrated discrimination improvement index after the inclusion of GDF‐15 in the model with the mortality risk factors was 0.033; that is, the ability to predict death increased by 3.3% (P = 0.004). Net reclassification improvement was 0.548 (P < 0.001); that is, the capacity to improve the classification of the event  was 54.8%. GDF‐15 concentrations were divided in tertiles , and survival curves were evaluated using the Kaplan–Meier technique. Patients in the highest tertile had the poorest 5 year survival, at 16%, whereas the lowest tertile had the best survival, of 78% (P < 0.001).Heart failure patients with either HFpEF or HFmrEF were included in the study. During their first visit to the HF unit, serum samples were obtained and stored for later assessment of GDF‐15 and NT‐proBNP concentrations. Patients were followed up by the HF unit. The main endpoint was all‐cause mortality. A total of 311 patients, 90 (29%) HFmrEF and 221 (71%) HFpEF, were included. Mean age was 72 ± 13 years, and 136 (44%) were women. No differences were found in GDF‐15 or NT‐proBNP concentrations between both HF groups. During a median follow‐up of 15 months (Q1–Q3: 9–30 months), 98 patients (32%) died, most (71%) of cardiovascular causes. Patients who died had higher median concentrations of GDF‐15 (4085 vs. 2270 ng/L, Growth differentiation factor 15 was superior to NT‐proBNP for assessing prognosis in patients with HFpEF and HFmrEF. GDF‐15 emerges as a strong, independent biomarker for identifying HFmrEF and HFpEF patients with worse prognosis. GDF‐15 is weakly expressed in healthy human tissues, with the exception of the placenta. GDF‐15 expression is up‐regulated by p53, which in turn is a factor responding to daily‐life stressors, such as inflammation, hypoxia, and oxidative stress.The aim of our study was to assess the potential of GDF‐15, measured by a fully automated immunoassay, in predicting all‐cause mortality in a large group of HFmrEF and HFpEF patients.2Patients meeting HF diagnosis criteria according the European Society of Cardiology guidelines,During the first visit to the HFU, signs and symptoms were registered and blood was drawn. Serum samples were obtained after centrifugation and stored at −80 °C until analysis. NT‐proBNP and GDF‐15 were measured by electrochemiluminescence immunoassays on a Cobas e601 platform . The measurement ranges for NT‐proBNP and GDF‐15 were 5–35 000 and 400–20 000 ng/L, and precision was ≤3.5% and ≤4.9%, respectively, according to the manufacturer. Values reaching the top of the concentration ranges were equivalent to the maximum detectable value (i.e. 35 000 ng/L for NT‐proBNP and 20 000 ng/L for GDF‐15). Patients were followed in the HFU, and all‐cause mortality was registered. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki. All participants received information about the study and signed informed consent. The study was approved by the centre's ethics committee.2.1χ2 test for categorical variables and the Student's t‐test or the Mann–Whitney U test according to the Gaussian or non‐Gaussian distribution of the continuous variables. Survival analysis was performed using proportional hazards regression models dividing GDF‐15 into tertiles. The proportionality of the risks was tested using Schoenfeld residuals. The survival curves were also evaluated with the Kaplan–Meier technique for the values of GDF‐15 , and the differences in survival were tested with the log‐rank test. Several variables with known power or power determined in the univariate analysis to identify outcomes were entered in the multivariate analysis. Variables were age, HF aetiology, New York Heart Association (NYHA) functional class, systolic blood pressure, atrial fibrillation, left atrial diameter, estimated glomerular filtration rate, haemoglobin, NT‐proBNP, and GDF‐15 concentrations. A backward elimination method was then used to identify independent predictors of all‐cause mortality. To evaluate the potential value of measured biomarkers in a prediction model of mortality risk, patients with HFmrEF and HFpEF were considered together, given the similarities found between both groups. The potential value of measured biomarkers in a prediction model of mortality risk, which included the independent predictors of mortality found in our cohort, as a base risk multivariable model, in addition to NT‐proBNP, was evaluated by several methods. The Grønnesby and Borgan goodness‐of‐fit test was used to determine if the proposed model fitted the observed outcome with the expected calibration capacity of the model. The concordance index (C‐statistic) checked the discrimination capacity of the model. The improvement in the discrimination capacity of the model including the biomarkers was assessed by the integrated discrimination improvement index, which evaluated the changes in the prediction probabilities of mortality estimated. The net reclassification improvement, category‐free version, was used to test changes in the prediction of estimated mortality implying a change from one category to another.P < 0.05 was considered statistically significant. Statistical software SPSS Version 24.0  and R Version 3.3.2  were used to perform all statistical analyses.Categorical variables were expressed as frequencies and percentages. Continuous variables were expressed as mean ± standard deviation or median , according to their Gaussian or non‐Gaussian distribution. The statistical differences between groups were compared using the 3TableTableTableTableP < 0.0001, and NT‐proBNP: 3613 ng/L (±5629 ng/L) vs. 1835 ng/L (±3449 ng/L) expressed as median and standard deviation, P < 0.0001. Multivariable analyses identified NYHA Functional Class III (P = 0.04), systolic blood pressure (P = 0.01), left atrial diameter (P = 0.03), age >65 years (P < 0.0001), and GDF‐15 concentrations (P = 0.01) but not NT‐proBNP as independent predictors of all‐cause mortality (TableP = 0.016 (DeLong's test). Integrated discrimination improvement index after the inclusion of GDF‐15 in the model with the mortality risk factors was 0.033; that is, the ability to predict death increased by 3.3% (P = 0.004). Net reclassification improvement was 0.548 (P < 0.001); that is, the capacity to improve the classification of the event  was 54.8%. GDF‐15 concentrations were divided in tertiles  and the respective survival compared by Kaplan–Meier survival curves. Statistically significant differences in 5 year survival were found among the three groups. Patients in the highest tertile had the poorest 5 year survival, at 16%, whereas in the lower tertile, survival was 78% (P < 0.001); survival among patients in the intermediate tertile (39%) differed statistically from the lower (P = 0.006) and higher (P < 0.001) tertiles .


European countries face fiscal pressure regarding the long-term sustainability of their healthcare system due to increasing levels of public health expenditures and mounting demographic pressures. The promotion of generic drugs is considered to be an efficient means to tackle these challenges; however, market diffusion remains slow. The aim of this study was to investigate the impact of price and brand cues on purchase intentions by means of Direct-to-Consumer (DTC) advertising, and to build on the market cue evaluation model by Dodd et al.Participants rated purchase intentions on six DTC adverts varying in price and brand information, followed by self-reports on purchase intentions, attitudes towards generics, brand loyalty, price consciousness, as well as perceptions of quality, risk and value. Open-ended questions explored attitudes toward generic drugs.Brand information and purchase intentions were mediated by perceived risk and perceived quality, while price information influenced purchase intention through perceptions of quality, risk and value. Consumers’ purchase behaviour was furthermore  influenced by unawareness and misconceptions, past experiences, and advertising as a decision-making tool.Advertisements, including price and brand information, are an important tool to improve consumers’ awareness of the availability of different OTC drugs. Practical and theoretical implications are discussed. Increasing needs to curb healthcare cost and growing public demands for self-medication have led to a major expansion of Europe’s Over-the-Counter (OTC) drug market . Within Generics, in particular, are regarded as the best way for patients to receive similar treatments at lower costs . They enStrategies to promote the use of OTC drugs vary across Europe , rangingEconomic theory suggests that a perfectly rational consumer would choose the least costly product in the pharmaceutical market , 13. IndMore recent conceptual models argue that consumers do not simply perceive price as the cost of a product but also as a cue for various intervening external and internal constructs, including brand , 17, priLastly, and building on the above, Dodds, Monroe and Grewal’s market cue—product evaluation model  assumes Empirical findings and theoretical conceptualizations appear to agree that price and brand information reflect important extrinsic cues which exert their influence on purchase intention through a range direct and indirect influencing factors, including brand, brand loyalty, and perceived quality, risk, and value .According to the current state of our knowledge, however, no previous research has aimed to explain the relationship between extrinsic cues in advertising, potentially intervening variables, and their impact on the purchase of OTC drugs , 31. FurThe present study addressed basic effects of OTC drug advertisements (pain medication), including price and brand cues, on consumers’ purchase intention. Secondly, at a theoretical level, a modified version of Dodd et al.’s market cue evaluation model was tested to explain how price and brand information shapes purchase intentions through a number of intervening constructs, including: brand loyalty; price consciousness; attitude towards generics as well as the products’ perceived risk; and, quality, value and efficacy. Specifically, four main hypotheses are proposed  cf. Tab.Table 1RIn line with previous literature on  advertising and consumer behaviour , 35, an An open online questionnaire on Qualtrics was designed run between January 2019 and July 2019. Participants from the German general public were recruited using social media, company mailings and Internet forums. An online advertisement briefly outlining the study aims and procedure was used to invite participants to take part in the online questionnaire. The advert included an embedded link to the questionnaire. Written informed consent was sought from each participant prior their participation. A data protection statement was also provided. Eligible participants were participants aged 18 or over without cognitive or linguistic impairment. Participants received no financial reimbursement and were free to withdraw active involvement in the study at any time of the data collection. All data was anonymised for storage and analysis.The questionnaire presented participants with one of six pictorial advertisements showing either a well-known OTC brand or a generic alternative. The advertisements were followed by several questions assessing the influence of various factors on participants’ decision-making process. Open-ended questions were added to give participants the opportunity to expand on their response and to gain rich, in-depth information regarding factors influencing participants’ opinion and their decision-making process.Six pictorial advertisements were created showing either a well-known OTC-brand or a generic alternative. The design of the advertisements was inspired by existing pharmaceutical advertisements and used an identical background and promotional slogan across conditions (”the pill against pain and fever”). As per definition, the generic alternative had the same indications and active pharmaceutical agent varying only in some auxiliary agents. Both drugs are used to treat fever, inflammation, mild or chronic pain and are available in most German pharmacies and online stores.Generics, OTC-drug and the active pharmaceutical agent was explained on a separate information sheet. The stimuli and the information sheet were pre-assessed by a group of nine medical marketing experts from an unrelated German pharmaceutical company. Lastly, manipulation checks were embedded which assessed the attention paid to the presented stimuli advertisements. Participants were asked to select whether they saw a generic or a brand, state the name of the drug they saw and either rate the price-level from very low to very high or to write down how much they would pay for the seen drug. The latter question was asked when the advertisement showed no price information.Four of the six advertisements showed price information, presenting a high or a low price (6.18€ vs. 2.18€). To increase ecological validity, price levels were established by calculating the average price for which each drug is sold in German pharmacies (online and in retail stores). To ensure that participants had the same basic knowledge about the stimuli they were presented with, the terms Questionnaires addressed participants’ (1) demographics; (2) brand loyalty; (3) price consciousness; (4) attitude towards generics as well as the products’ perceived (5) risk; and, (6) quality, value and efficacy. The main outcome variable was (7) purchase intention. Except for the demographics, all items were rated on a 7-point Likert Scale (1 = “strongly disagree” to 7 = “strongly agree”), with higher scores indicating higher levels of perceived risk, quality, etc. Lastly, (8) open-ended questions at the end of the survey enquired about general attitudes towards generics as opposed to branded OTC drugs, as well as general comments participants wished to make .(1) DemographicsParticipants' demographic profile was captured using a multiple-choice response format and asked them to report their age, sex, net income, highest level of education, type of job and health insurance.(2) Brand loyaltyα = 0.78.Eight items developed by Lodorfos et al. (2006) were used to measure participants’ brand loyalty . Example(3) Price consciousnessα = 0.80).Price consciousness was measured to investigate the role of individual differences in the utilisation of price cues in consumer purchasing patterns . Price c(4) Attitude towards genericsAttitude towards generics was assessed based on Hakonsen et al. 2018. Example items are ‘I don’t like the thought of generics’ and ‘Generics are often associated with more side-effects than brand-name drugs’ .(5) Perceived riskPerceived risk was assessed using Stone and Grønhaug nine-item scale of perceived risk dimensions, including performance, physical and financial risk . Interna(6) Perceived quality, value and efficacyThree items on perceived quality indicators and five value indicators were used to measure participants’ perceptions , 44. The(7) Purchase Intentionα = 0.96). Participants were also asked to rate the following question ‘The presentation of prices in advertisements would affect whether I buy generic or branded OTC drugs.’ on a scale ranging from strongly disagree [Purchase intention was measured using a four-item Likert scale , and incdisagree  to strondisagree  and to e(8) Open-ended questionsLastly, participants were asked to state their general attitudes towards generic drugs in an open-ended text box, as well as encouraged to provide any additional feedback or comments they found important for the research team to consider.All items were translated into German and revalidated. Following recent guidelines for translating questionnaires, a bilingual researcher and a naïve bilingual translator, who was unaware of the objective of the study, translated the items into their mother tongue to best reflect the nuances of the German language. After the data collection, reliability checks were conducted to assess for internal consistencies.Questionnaire responses were securely stored online in a password protected Qualtrics account, which allocated a unique identifier code to the data of each participant. The data was imported into Microsoft Excel and IBM SPSS (Version 25) for further analysis. Participants’ responses to all Likert-scale items, apart from those assessing demographics, were calculated to an average score for each variable. The data was tested for normal distribution before statistical analysis was applied . In the First, a one-way analysis of variance (ANOVA) was used to investigate whether advertisements price–no price versus low price versus high price-, and, brand–brand versus generic–information, led to different purchase intentions between groups. The main objective of this empirical study was to explore the effect of different OTC advertisements on consumers’ purchase intention.To examine the influence and predictive value of all variables  on consumers’ purchase intention, a regression analysis was run. It allowed to determine the overall variance explained by the predictors (fit of the model) and their relative contribution . Only daA and B, were proposed and tested based on Dodd et al.’s market cue evaluation model, using Hayes’ PROCESS Plugin for SPSS [X → Y). Secondly, the regressions of the mediators on the independent variable should be significant (X → M1 and M2). Thirdly, the regressions of the dependent variable on the mediators, controlling for the independent variable, should be significant (M|X → Y). Fourthly, the regression of the dependent variable on the independent variable, controlling for the mediators is non-significant and nearly zero (X|M → Y) [Subsequently, two parallel mediation models, for SPSS . Mediatifor SPSS . Four coX|M → Y) . PROCESSA, depicted in Fig. B examined the effect of price on perceived value, in the presence of two parallel mediators: perceived risk and perceived quality  were considered to be incomplete due to missing responses. Additional file In total 253 participants completed the online survey. Of those, 27.6%  = 10.238, p < 0.001), with post-hoc tests revealing that participants were least likely to purchase high-priced generic as opposed to low and high-priced brand, as well as a brand without a price. Participants were also found to be more likely to purchase the low-priced generic and the low-priced brand than the generic without a price, suggesting that the display of low-price information may have had an effect on consumers’ purchase intention. All other comparisons were found to be insignificant. Hence, hypothesis 1a could not be confirmed while and hypothesis 1b could be confirmed. Descriptive and post-hoc tests can be found in Additional file The analysis of variance showed significant difference between groups  from the predictor variables . Prior to regression analysis, correlations between the various variables and purchase intention were tested using Pearson’s correlation analysis. A summary of all correlation coefficients is displayed in Additional file  R2 = 0.160, F = 12.562, p < 0.001), indicative for a moderate goodness-of-fit according to Cohen. It was found that price significantly predicted purchase intention  =  − 4.502, p < 0.001), as did brand  =  − 2.261, p < 0.05), confirming hypothesis 2.The regression analysis consisted of two steps. Because price and brand information were the main focus of the study, these were entered first into the model. Then a forced entry method (one step) was applied to calculate the predictive value of all other variables. The results of the first multiple regression indicated that the two predictors, price and brand, explained 17.4% of the variance  = 17.832, p < 0.001) and explained 58,9% of variance (adjusted R2 = 0.566).The second multiple regression analysis including all possible predictors  = 2.983, p < 0.01), perceived risk  = − 3.346, p < 0.001) and perceived value  = 5.048, p < 0.001).Results indicate a 41.5% increase in explanatory power compared to the first model. Three variables significantly predicted purchase intention, perceived quality , b = − 0.664, t(120) =  − 2.031, p < 0.05 (β = − 0.363). The second step indicated that the regression of brand information on both mediators was also significant, for perceived risk b = 0.492, t(120) = 2.080, p < 0.05 (β = 0.371) and for perceived quality b = − 0.715, t(120) =  − 3.941, p < 0.001 (β = − 0.674). The third step of the mediation process confirmed the relationship between both mediators and purchase intention, controlling for brand information, with perceived risk b = − 0.620, t(118) =  − 5.328, p < 0.001 (β = − 0.449) and perceived quality b = 0.508, t(118) = 3.346, p < 0.001 (β = 0.294). Lastly, step four of the analysis revealed that, controlling for both mediators, brand information was not a significant predictor of purchase intention, b = 0.004, t(118) = 0.015, p = 0.988 (β = 0.002). Thus, perceived quality and perceived risk fully mediated the relationship between brand information and purchase intention, confirming hypothesis 3.Step one of mediation Model A reveals that brand information indirectly impacts purchase intention through both perceived risk  as well as perceived quality . The mediations coexist in parallel and do not differ significantly in size , suggesting neither of the mediators play a greater role in explaining the effect of brand information on purchase intention. The model reveals that the branded drug increases perceptions of quality whilst decreasing levels of risk.The analysis of Model B indicated that price information significantly predicted perceived value, ignoring both mediators , b = − 1.976, t(120) =  − 10.833, p < 0.001 (β = − 0.703). The second step revealed that the regression of price information on both mediators was also significant, for perceived risk b = 0.513 t(120) = 2.174, p < 0.05 (β = 0.195) and for perceived quality b = − 0.443, t(120) = − 2.349, p < 0.05 (β = − 0.210). However, the third step of the mediation process only confirmed the relationship between perceived risk and perceived value, controlling for price information, b = − 0.347, t(118) = − 4.595 p < 0.001 (β = − 0.326), suggesting that perceived risk might acted as a mediator whereas perceived quality did not, b = 0.033, t(118) = 0.350, p = 0.727 (β = 0.025). Finally, step four of the analysis showed that, controlling for both mediators, price information was still a significant predictor of perceived value, b = − 1.783, t(118) = − 10.689, p < 0.001 (β = − 0.634).Step one of mediation Model Thus, perceived quality and perceived risk did not fully mediate the relationship between price information and perceived value, only partly confirming hypothesis 4. The results suggest that perceived risk partially mediated the effect of price information on perceived value . The results indicate that low price increases perceived quality and decreases perceived risk.B, we tested for a serial mediation to predict purchase intention from price. Therefore, a new Model C was proposed, which represents a serial mediation between price and purchase intention through perceived quality, perceived risk and perceived value, as depicted in Fig. In light of the previously outlined multiple regression and correlation analysis, as well as findings from Model b = 0.427, t(117) = 3,369 (β = 0.248), p < 0.001; perceived risk: b = − 0.367, t(117) = − 3.339, p < 0.001 (β = − 0.265); perceived value: b = 0.626, t(117) = 5.087, p < 0.001 (β = 0.483). However, controlling for all three mediators, the regression of price information on purchase intention was no longer significant  = 0.828 p = 0.409; β = 0.142), suggesting that mediation had taken place.All mediators predicted purchase intention whilst controlling for price information , as was the indirect path through perceived quality  and perceived value . In contrast, the indirect effect of price information through perceived risk was insignificant (95% CI: − 0.222 to 0.088) and so where all other indirect paths between the variables. The findings show that low prices positively affected perceived quality. Taken together, the data support the serial mediation hypothesis: as price decreases perceived quality of the OTC drug increases, this then decreases perceived risk, which in turn increases perceived value and ultimately affects purchase intent. In addition, perceived risk does not act as an independent mediator but rather is part of a longer causal chain..Unawareness and misconceptionsParticipants showed limited awareness regarding the comparability of generics and branded OTC drugs and expressed concerns regarding the efficacy and safety of generic alternatives. Consequently, price information in advertising appeared to play a minor role in the purchase intention of consumers that have negative perceptions about generic OTC drugs. There was also evidence that this understanding might result from lacking information about the benefits and bioequivalence of generic alternatives, suggesting that increased awareness may alter consumers’ purchase intention.Past experienceParticipants stated to be more likely to buy a branded drug that has been on the market for years than a newer and less advertised generic alternative, regardless of the price. Thus, past experiences with a branded or a generic drug appeared to have a decisive impact on consumers’ purchase intention with health professionals as important initiators of OTC drug use.Advertising as a decision-making toolParticipants expressed mixed views about the value of drug advertisements. While some participants perceived OTC drug advertisements as important and helpful, others believed that they are inauthentic and untrustworthy. Overall, however, advertisements were assumed to increase transparency and competition with some respondents explicitly questioning the association between higher prices and better quality for OTC drugs.To gain deeper insight about whether consumers thought that the presentation of prices in OTC advertisements the surveys’ open-ended data emerged into the following three themes , participants were more likely to purchase low-priced generic OTC drug compared to the high-priced branded drug when the price was reported (price awareness: H 1b).Findings also provide critical insights into the processes and factors that underlie consumer purchasing patterns of OTC drugs (cf. hypotheses 2–4). It was shown that price and brand information significantly predicted participants’ purchase intention in the absence of other potential predictors, explaining 17.4% of the variance, confirming hypothesis 2. Adding other predictive variables showed a 41.5% increase in explanatory power. Three variables significantly predicted purchase intention, including perceived quality, perceived risk, and perceived value.A). While the brand information led to a decreased perception of risk and increased perception of quality, the opposite was found for the display of a generic drug. In other words, perceived quality and perceived risk fully mediated the relationship between brand information and purchase intention, confirming hypotheses 3(a–c). These findings are in agreement with previous research [It was, furthermore, demonstrated that the relationship between price/brand information and participants’ purchase intention was significantly mediated by perceived risk and quality . While there was a significant inverse relationship between perceived risk and perceived value (cf. H4(c)), there was none for perceived quality and perceived value (cf. H4b). The exposure to high-priced drug advertisements did not increase perceptions of quality and decrease perceptions of risk (cf. H4(a)); instead low price increased perceived quality and decreases perceived risk. At first glance these results appear counterintuitive; however, recent research has shown that cost savings gained from the use of generic prescription drugs can create a positive appeal to consumers who had previous experience with generics [In relation to hypothesis 4, findings showed that perceived quality and perceived risk did not fully mediate the relationship between price information and perceived value, which, in turn, is expected to predict purchase intention , where perceived value, risk and quality acted as part of a serial mediation. Results confirmed that price information and purchase intentions were predicted through consumers’ perceptions of quality, risk and value, and that perceived risk had an inverse relationship with perceived value and perceived quality. In other words, higher perceived quality reduced perceived risk, which, in turn, increased perceived value and purchase intention. While a link between price and brand information, as well as between perceived risk and perceived quality was established in previous research [Because of the findings from our regression analysis and Model research , 59, 60,The simplified thematic analysis demonstrated that consumers perceived the display of prices and OTC advertising as a trigger to gather more information about medications, and that past experiences with either a generic or branded drug had an important effect on consumers’ purchase intention. They also highlighted that they would rely on pharmacists’ recommendations or seek their advice when purchasing an OTC drug, transforming the purchase into an active act of decision making. Overall, it appears that having awareness about different OTC drugs and their benefits becomes embedded in consumers’ decision-making process, making individuals more open to the influence of external cues such as price information in advertising. Since existing research demonstrated that price cues are particularly effective in promoting products to those consumers that have more knowledge about a product category , 62, curFrom a policy and commercial standpoint, it has several noteworthy implications for marketers and public policy makers.In terms of pharmaceutical marketing, advertisement of actual prices may not be sufficient to incentivise consumers to switch from a branded OTC drug to a generic one. Yet, price advertising campaigns appear to contribute towards the broader objective of creating awareness of generic drugs’ (economic) benefits among consumers . This grPromotional and educational efforts should be targeted specifically at mitigating consumers’ perceptions of risk while improving their trust and confidence in the quality of generic drugs . The comThe qualitative data analysis also highlighted the need for policymakers to make use of the direct contact between consumers and pharmacists (or physicians) as a key communication channel. In Germany, pharmacies remain the first port of call when purchasing OTC drugs, and have considerable potential to influence consumer beliefs about generic drugs and their use. For this, it is important that measures are taken to ensure that this cohort is appropriately trained and willing to inform consumers about generic medications, in order to help broaden consumers’ acceptance of generic alternatives .The present study did not assess whether participants had a medical background or more advanced levels of knowledge about generic medicines prior to the experiment. Health professionals, pharmacists and other more knowledgeable individuals commonly hold more favourable attitudes towards generics and are, thus, more likely to purchase generic alternatives .The artificial nature of the experiment may have limited the study’s external validity and have prompted behaviour that is absent under more realistic conditions . DespiteConcomitantly, it is important to note that the study relied on consumers’ self-reported purchase intention rather than on actual sales data. Thus, the study had to rely on the participants’ integrity to respond honestly to the questionnaires. While observational studies are a better means to observe participants’ actual choices , and futOur findings are limited to print media; contemporary marketing, however, utilises a broad range of communication channels and formats to promote medicines, such as television, social media and drug packaging. Different channels might reach different target groups, e.g. the older generation, which is less well represented in the present study. Investigating the synergistic and different effects of these various advertisement approaches would likely increase the generalisability of the present results and provide insights into the most powerful way to promote the use of generic OTC drugs.Finally, the current study only addressed one therapeutic area of OTC drugs: pain medicines. Although these drugs are the most frequently consumed type of OTC drug, potentially varying perceptions associated with different therapeutic areas should be explored. Additionally, scholars may wish to investigate the role of different health-related consumer characteristics.Increasingly more European countries struggle with rising healthcare costs and the assurance of a sustainable healthcare system in the face of mounting demographic pressures and increasing levels of public expenditure. The promotion of generic OTC drugs for self-medication purposes is considered to represent an effective means to tackle these challenges. Two main recommendations emerge from these conclusions: (1) authorities should allocate budgets and invest in interventions to educate consumers and healthcare professionals about the bioequivalence of different available OTC drugs; and, (2) effective extrinsic marketing cues should be posited along with intrinsic product cues, such as the active ingredient of a drug, for products to occupy a meaningful and distinct competitive position in consumer’s purchase environment.Additional file 1: Table S2. Participants’ characteristics (N=183).Additional file 2: Table S3. Mean and standard deviations of purchase intention by advertisement group. Table S4. Post hoc results for purchase intention by advertisement group.Additional file 3: Table S5. Correlation coefficients between study variables.Additional file 4: Table S6. Predictors of purchase intention of OTC drugs.Additional file 5: Table S7. Examples of comments made by participants in response to the open-ended question.


Cases of chronic kidney disease (CKD), including CKD in pregnant women, have increased globally in recent years. CKD during pregnancy is associated with a higher risk of adverse outcomes, including gestational hypertension, preeclampsia, intrauterine growth restriction, and preterm birth, among others. Nutrition plays a significant role in many metabolic and physiological changes during pregnancy. Women with CKD are at increased risk of nutrition deficiencies and metabolic issues than women without CKD. Currently, we lack evidence regarding metabolic and nutritional adaptations during pregnancy in women with CKD and how these adaptations relate to perinatal outcomes. In this review, dietary and supplementation recommendations for CKD in adults and pregnant women are summarized from current clinical guidelines. We present the main nutrition care practices that have been studied in CKD pregnancies. This review will be helpful to health professionals as a preliminary reference for nutrition assessment and therapy in pregnant women with CKD. The frequency of chronic kidney disease (CKD) during pregnancy has increased. This could be related to the higher prevalence in CKD reported in recent years, the improvement of medical treatment in CKD adults, and a better kidney function assessment during pregnancy –3.Pregnant women with CKD have specific nutritional needs and are at higher risk of adverse perinatal outcomes. There are currently no established guidelines to address nutrition therapy in this group. In this review, we aim to summarize established nutritional recommendations for nonpregnant individuals with CKD –6 and thNutrition therapy goals for pregnant women with CKD include to meet energy and nutrient needs for optimal fetal growth and development while promoting adequate metabolic control; to make individual recommendations for vitamin and mineral supplementation; and to promote a healthy lifestyle to improve maternal and fetal health.Resting energy expenditure (REE) appears to be higher in adults with CKD due to renal replacement therapy, poorly controlled diabetes mellitus (DM), severe hyperparathyroidism (HPT), and inflammation. In nondialyzed patients, REE tends to be equal or even lower than that of healthy individuals .In stages 3–4 of CKD, the recommended energy intake is 96.2–146.4 kJ/kg/day  using current weight . Lipid profile in patients with PD tends to be more atherogenic , 25.Lipid and saturated fat intakes for individuals with CKD should be maintained below 30 and 10% of total energy intake (TEI), respectively . In hypeLipid metabolism during pregnancy is characterized by an accumulation of fat in maternal depots during early pregnancy and the later development of hyperlipidemia due to increasing lipolysis and mobilization of TG .n = 48) (unpublished data).No lipid status has been reported in CKD pregnant women. In our case series of pregnant women with CKD , mean serum cholesterol and TG were 246.6 ± 116.7 mg/dL and 277.0 ± 187.0 mg/dL, respectively, in the second trimester, and 277.1 ± 129.3 mg/dL and 341.1 ± 190.6 mg/dL, respectively, in the third trimester  .Early pregnancy is characterized by an increase in insulin sensitivity, while an insulin resistance state develops during late pregnancy to prioritize the use of fats for energy, sparing carbohydrates for the fetus . If CKD In a healthy pregnancy, acceptable carbohydrate recommended intake is 45–65% of TEI , while fCKD is associated with hydroelectrolytic disturbances. When GFR is below 20 mL/min, the kidney loses its capacity to concentrate or dilute the urine . Sodium In early CKD stages, micronutrient intake recommendations are similar to those for a healthy pregnancy. Specific recommendations are now needed for those at more advanced stages of CKD and pregnant women on dialysis. Table CKD is characterized by disturbances in mineral, vitamin D, and parathyroid hormone (PTH) metabolism . As GFR KDIGO recommends measuring serum 25-OH-D, calcium, phosphorus, PTH, and alkaline phosphatase activity at least once in adults with CKD stage 3 and above, and then annual reassessment if levels are within normal parameters .During stages 3–5 and HD, the Academy of Nutrition and Dietetics suggests a total elemental calcium intake  <2 g/day in CKD patients [Dietary phosphorus should be restricted to 800–1000 mg/day when serum phosphorus levels are >4.6 mg/dL (stages 3–4) or >5.5 mg/dL (stage 5) .Vitamin D supplementation with 800–1000 IU of cholecalciferol is indicated when serum 25-OH-D is below 30 ng/ml or in stages 4–5 with severe and progressive HPT .In stages 3–4, active oral supplementation with calcitriol or vitamin D analogs is indicated when plasma PTH is high and in patients with serum corrected total calcium <9.5 mg/dL and serum phosphorus <4.6 mg/dL [2D secondary to 1-alpha-hydroxylase placental activity is observed. Vitamin D homeostasis is characterized by an increase in maternal calcitriol, enhanced availability of maternal 25-OH-D, and increase of maternal vitamin D-binding protein concentrations [During a healthy pregnancy, calcium absorption is stimulated to meet increased requirements . Increastrations . The Ametrations .n = 8/36) and 19% (n = 5/26) of women had low 25-OH-D (<20 ng/mL), respectively. We observed a positive correlation between PTH net change from the second to the third trimester with plasma phosphorus concentration in the third trimester  (unpublished data). Table There are no reports of serum PTH and 25-OH-D concentrations in CKD pregnant women. In our case series of pregnant women with CKD , we observed PTH levels in the second and third trimesters of 55.3 ± 107.6 pg/ml and 47.7 ± 36.9 pg/ml, respectively. These concentrations exceed normal ranges for a healthy pregnancy but are within normal ranges reported in CKD adults , so in most cases, anemia is characterized as being hyperproliferative, normochromic, and normocytic . BesidesKDIGO recommends IV or oral iron trials in adults with or without ESA therapy if the goal is to increase Hb without starting ESA treatment, or to decrease ESA dose, and if transferrin saturation is <30% and ferritin are <500 ng/ml . For HD The World Health Organization (WHO) defines anemia during pregnancy as Hb < 11 g/dL or hematocrit < 33% at any time during the pregnancy . PhysiolInadequate intake of folic acid is associated with a higher risk of neural tube defects, LBW, and SGA. Maternal vitamin B12 status affects fetal growth and development, and its low levels are associated with some metabolic alterations and impaired neurodevelopment . In CKD The WHO recommends supplementing 30–60 mg/day of elemental iron daily and 400 µg/day of folic acid starting 3 months before pregnancy. In the case of anemia, 120 mg/day of oral iron is recommended , 46. IroOral iron supplementation is safe in CKD pregnancies under HD. IV iron might be used in dialysis during pregnancy with caution. Cabiddu suggests to use 20–30 mg/day of IV elemental iron (iron gluconate) until transferrin saturation reaches 30% and serum ferritin 200–300 ng/mL . Folic aIn CKD adults, sodium and potassium recommendations should be individualized based on serum concentrations, blood pressure, medications, hydration status, and kidney function. Clinical signs and symptoms of hyperkalemia  should be assessed and monitored. In hyperkalemic adults with CKD, dietary intake of potassium <2.4 g/day is recommended. Restriction of some fruits, vegetables, and other foods rich in potassium  might be needed .In CKD, sodium intake recommendation should be maintained at <2.4 g/day by limiting the consumption of processed meats, smoked foods, ready-to-use seasonings and dressings, instant soups, preservatives, and salt additives .In a group of pregnant women under HD (18–24 h/week), Vidal et al. offered 3–4 g/day of salt and 3 g of potassium, among other recommendations, reporting positive perinatal outcomes .Given the lack of specific research on this population, it is possible to make adaptations to the guidelines used for healthy pregnant and for nonpregnant individuals with CKD. The role of the renal nutritionist is key in tailoring energy and nutrient intakes to promote maternal and fetal health and metabolic control. More research is urgently needed to develop nutritional guidelines for this population.


Anti‐programmed cell death protein 1 (PD‐1) antibodies are a standard treatment for metastatic melanoma patients. However, the understanding of the efficacy of anti‐PD‐1 for acral melanoma (AM) and mucosal melanoma (MM) is limited as these subtypes are relatively rare compared to cutaneous melanoma (CM).This single institution, retrospective cohort study included patients with advanced AM and MM who underwent anti‐PD‐1 therapy for metastatic melanoma between 2012 and 2018. Objective responses were determined using the investigator‐assessed Response Evaluation Criteria in Solid Tumors version 1.1. Progression‐free survival (PFS) and overall survival (OS) were assessed using the Kaplan–Meier method. A Cox regression analysis was performed to identify the factors associated with survival outcomes.p = 0.03, MM: HR, 0.20; 95% CI, 0.08–0.53; p = 0.001) was significantly associated with shorter OS for both subtypes.Ninety‐seven patients were identified, 38 (39%) with AM and 59 (61%) with MM. The objective response rates (ORRs) were 21.0% and 15.2% in patients with AM and MM, respectively. The median PFS and OS were 3.6 and 25.7 months for AM patients, and 3.0 and 20.1 months for MM patients, respectively. Elevated serum lactate dehydrogenase (LDH) (AM: hazard ratio [HR], 0.22; 95% confidence interval [CI], 0.06–0.87; The ORR, PFS, and OS with anti‐PD‐1 therapy were poor in patients with AM and MM compared to those previously reported clinical trials for nonacral CM. High serum LDH was associated with significantly shorter OS. Melanocytes also develop within the mucosal surfaces of the body and can give rise to mucosal melanoma (MM). Melanocytes in glabrous skin, including the palms of the hands and soles of the feet, can become acral melanoma (AM). Antibodies against programmed cell death receptor 1 (PD‐1) constitute a standard therapy for the management of patients with metastatic melanoma of all subtypes. Recently, the data regarding activity of anti‐PD1 treatment in AM and MM has grown significantly. Shoushtari et al. first described an objective response rate (ORR) of 32% in patients with AM (n = 25) and 23% in those with MM (n = 35).Thus, we studied the patient characteristics and survival outcomes of a retrospective cohort of patients from a single U.S. institution diagnosed with AM or MM who received treatment with FDA‐approved single‐agent anti‐PD‐1 (nivolumab or pembrolizumab) therapy as the standard of care for metastatic or unresectable disease.22.1BRAF, neuroblastoma rat sarcoma viral oncogene homolog (NRAS), or proto‐oncogene receptor tyrosine kinase (KIT) mutations; the number and characteristics of prior and subsequent systemic therapies; treatment‐related variables ; and survival status.Under an Institutional Review Board‐approved protocol, patients at the MD Anderson Cancer Center with AM and MM who received at least one dose of single‐agent nivolumab or pembrolizumab between 2012 and 2018 for metastatic or unresectable disease melanoma were identified. Clinical information was retrieved from electronic medical records, including sex; age; ethnicity; disease stage; Eastern Cooperative Oncology Group performance status (PS); primary site; sites of metastatic disease at the initiation of anti‐PD1 therapy; the presence of 2.2Objective response to therapy was determined using the investigator‐assessed Response Evaluation Criteria in Solid Tumors version 1.1.PFS and OS were assessed using the Kaplan–Meier method. PFS was assessed from the date of anti‐PD‐1 treatment initiation to the date of radiologic progression, change in therapy, death, or last follow‐up. The OS was assessed from the date of treatment initiation to the date of death or last follow‐up. Patients who were alive at the last follow‐up were censored. The log‐rank test was used to compare categorical variables. A Cox regression analysis was performed to identify factors associated with outcomes. All statistical analyses were performed using EZR , which is a graphical user interface for R .33.1BRAF, KIT, or NRAS was identified in 14% (5/37), 10% (4/37), and 10% (4/37) of the patients with AM and 3% (2/55), 19% (11/55), and 10% (6/55) of the patients with MM, respectively.The demographic characteristics of the study cohort are shown in Table 3.2BRAF mutation status, brain metastasis, sex, LDH level, liver metastasis, ethnicity, prior immunotherapy, or number of metastases  and a disease control rate (DCR) of 52.6% (Table p = 0.03) was associated with shorter OS. No significant associations were observed for OS with gender, ethnicity, BRAF mutation status, prior immune therapy, CNS involvement, liver involvement, or number of metastases  and a DCR of 35.6% Table .p = 0.001). However, no significant associations were observed between OS and gender, ethnicity, prior immune therapy, CNS involvement, liver involvement, or more than three organs of metastases  received postprogression therapy. Immunotherapy was the most common treatment , followed by cytotoxic chemotherapy n = 15, 15%) and targeted therapy . Only three patients received ipilimumab and nivolumab combination therapy  and MM (15.2%) was observed in this study to be relatively low compared to previously reported data in patients with CM,p = 0.55] or MM . However, as this study was an interracial comparison within the United States, and included very few patients of Asian ancestry, we cannot determine if the efficacy of anti‐PD‐1 differs by ethnicity. Future studies should further explore outcomes by ethnicity with immune check point inhibitors, particularly for subtypes that are enriched in specific ethnic subgroups. Although AM and MM fundamentally differ from nonacral CM in their pathogenesis and therapeutic targets,Recently, it was reported that anti‐PD‐1 antibodies have limited survival benefit among patients with AM  in Japanese patients.In the present study, we did not identify a factor significantly associated with ORR in either AM or MM patients. We did observe that elevated serum LDH level was prognostic in our cohort of AM and MM patients treated with anti‐PD‐1. Though AM patients constituted a relatively small proportion and MM patients were not included in the eighth edition of the American Joint Committee on Cancer manual, Limitations of this study include its retrospective nature and the small sample size. Although we included both treatment‐naive and previously treated subjects in our study, we observed a lower efficacy of anti‐PD‐1 antibodies in AM and MM patients, and no significant difference based on prior treatment. Our results suggest that because treatment with both ipilimumab and nivolumab is often used for metastatic melanoma, analysis of the outcomes of these rare subtypes using combination therapy should be addressed in the future along with the development of novel immunotherapy strategies.In conclusion, our cohort of patients with AM and MM treated with anti‐PD‐1 demonstrated worse ORR and OS compared to reported data for nonacral CM patients. Thus, the efficacy of anti‐PD‐1 differs by disease subtype, and perhaps by ethnicity. Moreover, elevated serum LDH level was associated with shorter OS in both AM and MM patients. Therefore, there is a need to develop new targeted or combination therapies for patients with AM and MM that could enhance the efficacy of immune checkpoint inhibitors.The authors have no conflicts of interest to declare.Study concept and design: Dai Ogata, Suhendan Ekmekcioglu, Lauren E. Haydu, Michael A. Davies and Rodabe N. Amaria; provision of study materials or patients: Isabella C. Glitza, Sapna P. Patel, Hussein A. Tawbi, Jennifer L. McQuade, Adi Diab, Michael K. Wong, Michael A. Davies and Rodabe N. Amaria; collection and assembly of data: Lauren E. Haydu; data analysis and interpretation: Dai Ogata; writing–original draft: Dai Ogata; writing–review and editing: Dai Ogata, Lauren E. Haydu, Michael A. Davies and Rodabe N. Amaria.Table S1‐S2Click here for additional data file.


The majority of patients with advanced cancer develop cachexia, a weight loss syndrome that severely reduces quality of life and limits survival. Our understanding of the underlying mechanisms that cause the condition is limited, and there are currently no treatment options that can completely reverse cachexia. Several tumour‐derived factors and inflammatory mediators have been suggested to contribute to weight loss in cachectic patients. However, inconsistencies between studies are recurrent. Activin A and interleukin 6 (IL‐6) are among the best studied factors that seem to be important, and several studies support their individual role in cachexia development.We investigated the interplay between activin A and IL‐6 in the cachexia‐inducing TOV21G cell line, both in culture and in tumours in mice. We previously found that the human TOV21G cells secrete IL‐6 that induces autophagy in reporter cells and cachexia in mice. Using this established cachexia cell model, we targeted autocrine activin A by genetic, chemical, and biological approaches. The secretion of IL‐6 from the cancer cells was determined in both culture and tumour‐bearing mice by a species‐specific ELISA. Autophagy reporter cells were used to monitor the culture medium for autophagy‐inducing activities, and muscle mass changes were evaluated in tumour‐bearing mice.P = 0.0048, and 48% reduction on mRNA level, P = 0.0308). Significantly reduced IL‐6 secretion (P < 0.05) from the cancer cells is consistently observed when using biological, chemical, and genetic approaches to interfere with the autocrine activin A loop. Inhibiting activin signalling also reduces the ability of the cancer cells to accelerate autophagy in non‐cancerous cells . Coherent to the in vitro data, the use of an anti‐activin receptor 2 antibody in cachectic tumour‐bearing mice reduces serum levels of cancer cell‐derived IL‐6 by 62% , and, importantly, it reverses cachexia and counteracts loss of all measured muscle groups (P < 0.0005).We show that activin A acts in an autocrine manner to promote the synthesis and secretion of IL‐6 from cancer cells. By inhibiting activin A signalling, the production of IL‐6 from the cancer cells is reduced by 40–50% (up to 42% reduction on protein level, Our data support a functional link between activin A and IL‐6 signalling pathways and indicate that interference with activin A‐induced IL‐6 secretion from the tumour has therapeutic potential for cancer‐induced cachexia. Cancer cachexia (hereafter referred to as cachexia) severely compromises quality of life and limits survival of up to 80% of patients with advanced cancer.Several inflammatory and tumour‐derived factors are suggested to drive development of cachexia. One of these is activin A, a member of the transforming growth factor beta (TGFβ) superfamily of proteins. Activin A administration alone is sufficient to cause weight loss (including muscle loss) in mice.It has been suggested that several members of the TGFβ superfamily, including activin A, can affect skeletal muscle by limiting the differentiation of myoblasts.Several studies point to tumour‐derived interleukin 6 (IL‐6) as a central driver of cachexia. We have shown that IL‐6 is secreted from cancer cells, and, via trans‐signalling, it can accelerate the catabolic process autophagy in muscle cells, thereby contributing to cachexia.The existence of convincing data with regard to the cachexia‐causing ability of both activin A and IL‐6 could be due to different mechanisms operating in different contexts and patients but could also be due to a functional relationship between activin A and IL‐6. In order to investigate this, we have used the ovarian carcinoma cell line TOV21G. These cells secrete high amounts of activin A and cause a rapid development of cachexia at a low tumour burden in mice.in vitro cell culture experiments, the following reagents were used as specified: Recombinant (r) human/mouse/rat activin A , rHuman IL‐6 , rHuman Activin RIIB Fc Chimera (R&D Systems 339RB/CF), human/mouse/rat activin A (beta A subunit) antibody , ALK4/5/7 inhibitor , 3‐methyladenine , bafilomycin A1 , Torin 1 , and Hanks' Balanced Salt Solution .During CDD866 is a chimeric murinized version of BYM338/bimagrumab, an anti‐ActRII antibody, where the human Fc region of the antibody has been replaced by a mouse Fc (IgG2a Leu234Ala/Leu235Ala), provided by the Novartis Biologic Units.2 and 95% air at 37°C. TOV21G cells from ATCC (CRL‐11730) were cultured in 42.5% medium 199 + GlutamaxTMI (Gibco 41150) and 42.5% medium MCDB 105 , supplemented with foetal bovine serum  and gentamicin (0.05 mg/mL). HEK293 green fluorescent protein (GFP)‐p62 cells (a kind gift from Prof. T. Johansen and colleagues) were cultured in DMEM (Sigma D5796) supplemented with FBS (10%) and gentamicin (0.05 mg/mL).Cells were maintained in a humidified atmosphere of 5% COFor inhibin beta A (INHBA), activin receptor 2A (ACVR2A), activin receptor 2B (ACVR2B), KRAS, and SMAD3 downregulation, TOV21G cells were transfected using 20 nM siRNA , and DharmaFECT transfection reagent 1 (Dharmacon) was diluted in Opti‐MEM 1 Reduced Serum Medium . After 24 h, the transfection medium was exchanged for normal growth medium, and the cells were incubated for 1 or 3 days before conditioned medium (CM) was harvested and protein and RNA were isolated. At this time, cultures were approximately 80% confluent. The following siRNA oligonucleotides were obtained from Dharmacon: L‐011701‐00‐0010 ON‐TARGETplus SMARTpool human INHBA, L‐004926‐00‐0010 ON‐TARGETplus SMARTpool human ACVR2A, L‐004927‐00‐0010 ON‐TARGETplus SMARTpool human ACVR2B, L‐020067‐00‐0005 ON‐TARGETplus SMARTpool human SMAD3, and D‐001210‐01‐20 non‐targeting siRNA. Two siRNA oligonucleotides targeting KRAS were obtained from Ambion: cat. no. 4390824 (ID s7939 and ID s7940).HEK293 autophagy reporter cells were exposed to 50 μg/mL recombinant activin A for 5 min at the end of 2 h incubation in normal growth medium containing 0.1% FBS. Cell were lysed by cell scraping on ice in a buffer containing 8 M urea, 0.5% (v/v) Triton X‐100, 100 mM DTT, 1xComplete® protease inhibitor, and 8% phosphatase inhibitor cocktail I and III (Sigma). Protein concentration was determined by BioRad protein assay (BioRad). Equal amounts of proteins were separated using NuPAGE® Novex® 4‐12% Bis‐Tris Gels (Invitrogen) and dry blotted on nitrocellulose membranes. The membrane was blocked, and antibodies were diluted in a 1:1 mixture of Odyssey blocking buffer (Li‐Cor) and TBST . Bound antibodies were imaged by near infrared fluorescence using appropriate fluorescent dye labelled secondary antibodies and an Odyssey NIR scanner (Li‐Cor Biosciences). Images were processed using the Li‐Cor Odyssey software image studio 2.0. The antibodies used for immunostaining were pSMAD3 (Ser423/Ser425) , diluted 1:1000, and beta‐tubulin , diluted 1:5000.TOV21G cells were transfected with siRNA as described earlier. Three days after removal of transfection reagents, the cells were harvested in urea buffer, and extracts were applied on gels, blotted, and used for western detection as described earlier. Antibodies used for immunostaining were pNF‐κB p65 (Ser536) , phospho‐p38 MAP kinase (Thr180/Tyr182) , and Erk1/2 , all diluted 1:1000.Autophagy was quantified using flow cytometry measuring GFP fluorescence in live HEK293 cells expressing GFP‐sequestosome 1 (SQSTM1) fusion gene, as previously described.The levels of IL‐6 and activin A in CM from TOV21G cells were determined using human IL‐6 OptEIA ELISA kit  and a human/mouse/rat activin A Quantikine ELISA kit , respectively. All analyses were performed according to the manufacturer's protocols.The levels of human IL‐6 and murine IL‐6 in serum from mice were determined using the U‐PLEX Human IL‐6 Assay  and the U‐PLEX Mouse IL‐6 Assay  according to the protocols provided by the manufacturer. The levels of activin A in serum from mice were determined using a self‐made activin A ELISA, which was established according to the protocol of Meso Scale Discovery. The following antibodies were used for this ELISA: anti‐activin A primary antibody ; biotinylated anti‐activin A secondary antibody ; for detection, Sulfo‐TAG streptavidin ; and for the titration of the standard curve, recombinant human activin A . The antibodies in this sandwich ELISA are directed against the same epitope of the INHBA subunit and thus will detect only the homodimer (activin A). They do not recognize the inhibin beta B subunit, and accordingly, there is no cross reactivity towards activin AB. Due to low homology (18%) between INHBA and the alpha subunit found in inhibin A, any cross reactivity towards inhibin A is considered unlikely.FigureAll presented ELISA data are within the range of the respective standard curves Figure. When ne−ΔΔCt.TOV21G cells transfected with NT, INHBA, ACVR2A, ACVR2B, KRAS, or SMAD3 siRNA were left for 1 or 3 days post‐transfection (as explained earlier) before RNA was isolated using RNeasy Mini Kit  according to the protocol from the manufacturer. Purity, quality, and concentration of isolated RNA were confirmed using Nanodrop. cDNA for qPCR analysis was made by using the QuantiTect Reverse Transcription Kit  according to the manufacturer's protocol. mRNA levels were normalized against GAPDH. qPCR was performed in parallel 20 μL reactions containing 10 μL Perfecta qPCR Fast‐Mix ROX , 1 μL of the respective primer set, and 9 μL template . The following TaqMan primer sets from Life Technologies were used: human INHBA , human AVCR2A , human ACVR2B , human IL‐6 , human KRAS , human SMAD3 , and human GAPDH . The cycling conditions for the StepOne plus system  were 45°C for 2 min, 95°C for 30 s, and 40 cycles of 95°C for 1 s and 65°C for 20 s. Relative RNA transcription levels were transformed into linear form by 2Foxn1nu) were purchased from Harlan Laboratories , acclimated for 7 days housed at 25°C with a 12:12 h light–dark cycle, and provided ad libitum water and a standard laboratory diet containing 18.2% protein and 3.0% fat with an energy content of 15.8 MJ/kg .The animal experiment was performed according to the regulations effective in the Canton of Basel City, Switzerland, under the license number BS‐2186. Eight‐week‐old female mice  using a Station anaesthesia minihub . When tumours were palpable, length and width of tumours were measured through skin, and tumour volumes were calculated according to the formula (length × width2)/2. Seven days after cell inoculation, mice bearing tumours with acceptable morphology and size (mean volume of approximately 130 mm3) were randomized to groups containing 10 mice per group, and the treatments were initiated on the day of randomization (Day 0). CDD866 was administered at 20 mg/kg s.c., once weekly in a volume of 5 mL/kg. Body weight and tumour volume were measured two to three times per week. At the end of the experiment (Day 35), the mice were euthanized with CO2. In the group of vehicle‐treated mice, three mice had to be sacrificed at Days 28, 30, and 32, respectively, for animal welfare reasons. For all animals, tumour, tibialis anterior, gastrocnemius–soleus–plantaris complex, quadriceps, heart, liver, kidney, perigonadal white adipose tissue, spleen, and brain were collected and weighed. The brain weight was measured for normalization of organ weights.TOV21G cells were harvested by trypsin treatment and suspended in a solution containing 50% PBS and 50% BD Matrigel™ matrix without phenol red  at a density of 3 × 10Before performing our analyses, we omitted three mice from each of the two groups inoculated with TOV21G cells due to very large or small tumours .http://www.cbioportal.org/) is an open‐access database that allows visualization and analysis of large‐scale cancer genomics data sets.cBioPortal .We have previously found that weight loss in cancer patients is associated with autophagy‐inducing bioactivity in the blood stream.FigureFigurein vivo but in an indirect manner by influencing the abundancy of other autophagy‐inducing factors.To quantify autophagic flux, we utilized an autophagy reporter cell system,In mice, cachexia is reversed by activin receptor antagonists.FigureFigureFigureFigureTOV21G ovarian cancer cells have been shown to secrete high amounts of activin A.FigureFigureFiguresFiguresFiguresWe have previously found that the CM from TOV21G cells accelerates autophagy in other cells and have largely attributed this effect to their secretion of IL‐6.FiguresFiguresFiguresConsistent with an autocrine function of activin A in the regulation of IL‐6 secretion from the cancer cells, an activin A neutralizing antibody reduced the level of IL‐6 in CMs by 22% from 6.1 ng/mL in untreated cells FiguresB and S3.FigureFigureFigureFigureFigureBecause autocrine activin A signalling clearly stimulates IL‐6 secretion from the cancer cells, we asked if this involved increased transcription of the IL‐6 gene. qPCR analysis of NT, INHBA, ACVR2A, and ACVR2B siRNA‐treated TOV21G cells demonstrated that all siRNAs targeting activin A signalling caused reduced mRNA level of IL‐6, supporting that autocrine activin A signalling promotes IL‐6 transcription FigureE. In accOur results clearly demonstrate that autocrine activin A signalling in the cancer cell culture promotes the release of IL‐6. Thus, we tested whether activin A antagonism is able to reduce the systemic (serum) level of IL‐6 in tumour‐bearing animals and whether a putative reduction in IL‐6 level is associated with reversal of cachexia. We treated TOV21G tumour‐bearing mice with an ActRII neutralizing antibody (CDD866). CDD866 efficiently inhibits the binding of ligands, including activin A and myostatin, to both ActRIIA and ActRIIB.FigureFigureFigureFigureP = 0.06) .As expected, the TOV21G tumour‐bearing mice rapidly developed cachexia, evident as loss of body weight, muscle , and white adipose tissue FigureA–4I. ImpFigureFigureFigurein vitro, we tested whether the ActRII neutralizing antibody (CDD866) could reduce the level of IL‐6 in sera from TOV21G‐bearing mice. In accordance with our in vitro findings, inhibition of ActRII caused a significant reduction of cancer‐derived human IL‐6 in serum from the tumour‐bearing mice  using the cBioPortal website, we found a significant association between the expression of these genes . Surprisingly, we found that although host IL‐6 levels increased in sera of cachectic tumour‐bearing mice, the levels were not significantly affected by interference with activin A signalling. It should, however, be noted that we used immune‐compromised nude mice with subcutaneous flank implantation of TOV21G, similarly to Zhou et al. who reported the ability of TOV21G to cause cachexia in an activin A‐driven mechanism.Our et al. used another ovarian clear cell carcinoma cell line, ES‐2, and argued that this is more similar to human ovarian cancer.In this study, we used TOV21G cells to induce cancer cachexia. In a recent paper, Pin In our mouse model, we find that treating tumour‐bearing mice with an ACVR2 neutralizing antibody not only reverts muscle mass to normal level but also causes a significant increase in muscle mass. Possibly, this relates to the ability of this antibody to block the binding of both activin A and myostatin to the ACVR2.in vitro, we show that there is a direct effect of activin A signalling on IL‐6 gene transcription and IL‐6 protein secretion from the cancer cells. It is likely that this mechanism also is of relevance in the in vivo model.A complicating factor when interpreting the reduced hIL‐6 levels in circulation after interfering with the ACVR2 is that the tumour size is significantly influenced. The reduced levels of tumour‐derived IL‐6 in circulation could thus, to an unknown extent, be a result of reduced number of IL‐6‐producing TOV21G cells. Regardless, Based on results from murine models, recent clinical trials have aimed to unravel the efficiency of blocking activin signalling in patients with cachexia or muscle dystrophy. Clinical trials involving ACVR2B decoy receptors, however, were terminated due to severe adverse effects, including bleeding.The present study provides novel insights into the interplay between activin A and IL‐6 secretion from cancer cells that may be important for the development of future therapeutic strategies to reverse cancer cachexia.None declared.This study was financially supported by grants from The Norwegian Cancer Society, The Research Council of Norway through its Centres of Excellence funding scheme (223255/F50), and The Research Council of Norway (139610/300).Figure S1. Standard curves from activin A and IL‐6 ELISA. Standard curve for activin A (A) and IL‐6 (B) ELISA used when analyzing TOV21G conditioned medium, and for activin A ELISA used for analyzing serum samples (C).Click here for additional data file.Figure S2. Autophagy flux in autophagy reporter cells treated with autophagy effectors. Autophagy flux in autophagy reporter cells treated for 17 hours with 3‐methyladenine , bafilomycin A1 , Hanks' Balanced Salt Solution (HBSS) or Torin 1 (150 nM).Click here for additional data file.Figure S3. IL‐6 protein level in conditioned medium (CM) from TOV21G cells. Level of IL‐6 in CM from untreated TOV21G cells and TOV21G cells treated with non‐targeting (NT) siRNA. CM from 1 or 3 days post‐seeding (untreated) or post‐transfection (NT siRNA treated).Click here for additional data file.Figure S4. In TOV21G tumor‐bearing mice, injection of the ActRII neutralizing antibody does not affect the weight of the spleen but display an anabolic effect on kidney and liver. Mean relative weight change of spleen, kidney and liver, respectively ±SEM of vehicle‐treated (n = 7) and CDD866‐treated (n = 7) TOV21G tumor‐bearing mice relative to non‐tumor, vehicle‐treated control mice (n = 5). *p < 0.05, ***p < 0.0005 (Student t‐test), n.s. = non‐significant.Click here for additional data file.


The adverse pregnancy outcomes caused by teenage pregnancy are major public health problems with significant social impact. While China is the most populous country in the world, and 8.5% of the women aged 10–50 years are adolescent women, we aimed to analyze the adverse maternal and perinatal outcomes of the adolescent pregnancy in Hebei Province, China.There were 238,598 singleton pregnant women aged 10–34 years from January 1, 2013 to December 31, 2017 in the database of Hebei Province Maternal Near Miss Surveillance System (HBMNMSS). The 238,598 pregnant women were divided into two groups: adolescent group (aged 10–19 years) and adult group (aged 20–34 years). The adolescent group was divided into two subgroups , the adult group was divided into two subgroups . We compared the risk of adverse pregnancy outcomes using univariate and multivariate logistic regression. We also made a stratified analysis of nulliparous and multiparous adolescent pregnancy.Compared with women aged 20–34 years, women aged 10–19 years had lower risk of cesarean delivery , gestational diabetes mellitus (GDM) . Women aged 10–19 years had higher risk of preterm delivery , small for gestational age (SGA) , stillbirth , neonatal death . The adolescent women aged 10–17 years had significantly higher risk of stillbirth  and neonatal death  compared with the women aged 25–34 years. Younger adults (20–24 years) also had higher risks of preterm delivery , stillbirth , and neonatal death  compared with women aged 25–34 years. The structural equation model showed that preterm delivery and cesarean delivery had an indirect effect on neonatal death in adolescent pregnancy.The adolescent pregnancy was related to adverse perinatal  outcomes, such as preterm delivery, stillbirth and neonatal death, especially in younger adolescent pregnancies. Adolescent pregnancy is defined as pregnancy of teenagers at the age of 10–19 years . CompareThe adverse pregnancy outcomes caused by teenage pregnancy are major public health problems with significant social impact , 7. AdolThe World Health Organization (WHO) reported that the global adolescent pregnancy rate was 10.3% in 2014, the highest rate was 28.8% in Nicaragua, whereas the lowest rate was 0.7% in Japan, an economically developed country . In AfriChina is the most populous country in the world. According to China’s 2010 census data , 8.5% ofHBMNMSS is the sub-database of China’s National Maternal Near Miss Surveillance System (NMNMSS), 22 hospitals  were enrolled from Hebei Province on the basis of random stratified cluster sampling, with 289,895 registered pregnant women who gave birth during the period from January 1, 2013 to December 31, 2017. We had a permission to access the database of HBMNMSS with Hebei Women and Children’s Health Center. Detailed sampling strategy was described in the previous paper .From this database, data was collected in each hospital using a specially designed data collection form by trained doctors, inputted and sorted out by special personnel. This form included sociodemographic characteristics, obstetric history, place and mode of delivery, pregnancy outcomes, complications during pregnancy, delivery, and in the postpartum period.Adolescent pregnant women (aged 10–19 years) were 4125 (1.4%), adult pregnant women (aged 20–34 years) were 250,522 (86.4%), pregnant women of advanced maternal age (≥35 years old) were 27,140 (9.4%), and pregnant women with missing data of age were 8108 (2.8%). We enrolled 238,598 singleton pregnant women aged 10–34 years, who were divided into two groups, adolescent group (aged 10–19 years) and adult group (aged 20–34 years). The adolescent group was divided into two subgroups: younger adolescent group (10–17 years) and older adolescent group (18–19 years), and adult group was divided into two subgroups: younger adult group (20–24 years) and older adult group (25–34 years).+ 6 gestational weeks [The maternal and perinatal outcomes in our study pertained to the latest pregnancy. The adverse maternal outcomes were defined as: cesarean section delivery (CS), anemia, gestational diabetes mellitus (GDM), pre-eclampsia (PE), HELLP syndrome , placenta previa, placental abruption, postpartum hemorrhage, maternal death. The adverse perinatal outcomes were defined as: small for gestational age (SGA), preterm delivery, neonatal low Apgar score, stillbirth, and neonatal death. The CS included emergency CS and elective CS. Anemia was defined as hemoglobin value below 110 g/L. GDM was diagnosed that fasting ≥5.1 mmol/L, one-hour post-prandial ≥10.0 mmol/L, two-hour post-prandial ≥8.5 mmol/L in 75 g oral glucose tolerance test . Pre-eclal weeks ; Low Apg2) test. Two groups were compared using univariate and multivariate logistic regression to evaluate the effect of adolescent group on the risk of adverse pregnancy outcomes, considering the adult group as the reference group. We made the subgroup analysis using logistic regression. The structural equation model mapped out the correlation to each other. Multivariate logistic regression was used to adjust the confounding factors such as: maternal education time, marital status, place of residence, delivery place, parity, history of cesarean delivery. The result was presented as risk ratio (RR) or adjusted risk ratio (aRR) and 95% confidence interval (CI). P < 0.05 was considered statistically significant, and all statistical tests were two-tailed. All data were analyzed using SPSS Version 17.0 (RRID: SCR-002865). Stata Version 15.0 (RRID: SCR-012763) was used to generate forest plots.First, we compared the basic data between the two groups of maternal age using T-test or Chi-square test. The counting data were described as n (%) using Chi-square test, and the measurement data were described as mean ± standard deviation (mean ± SD) using T-test. Next, we compared the incidence of adverse pregnancy outcomes between the adolescent group and adult group by Chi-square (휒n = 4482), gestational weeks missing or < 28 weeks , birth weight missing or < 1000 g (n = 932), maternal age missing or ≥ 35 years old . Our study analyzed 238,598 singleton pregnant women aged 10–34 years. These pregnant women were divided into two groups, the adolescent group  and the adult group . The flow chart of case selection was shown in Fig. The data of 289,985 pregnant women were collected from HBMNMSS, covering the period from 2013 to 2017; excluding multiple pregnancies (P < 0.001), meanwhile adolescent pregnant women had lower education than adult pregnant women, with education period ≤6 years (6.1% versus 1.8%) and 7–9 years (62.2% versus 34.3%) (P < 0.001). The proportion of adolescent pregnant women that made delivery in secondary hospitals and at home was more than that of the adult pregnant women (P < 0.001). Number of prenatal cares in the adolescent group (5.6 ± 2.2) was less than that in the adult group (6.8 ± 2.4) (P < 0.001). Birth weight of adolescent pregnant women was lower than that of the adult pregnant women (3204 ± 509 g versus 3344 ± 491 g) (P < 0.001) (Table P < 0.05)  (2 = 0.33). Compared with women aged 20–34 years, nulliparous women aged 10–19 years had higher risks of anemia, preterm delivery, SGA, stillbirth and neonatal death , GDM . And adolescent pregnancy had a significantly higher risk of preterm delivery , SGA , stillbirth , neonatal death . There had lower risk of anemia  in adolescent group, and higher risk of maternal death , but there were no statistically significant difference in the effects of anemia  and maternal death  after adjusting the confounding factors. There was no difference in the risk of, PE, HELLP syndrome, placenta previa, placental abruption, and low Apgar at 5 min in 10–19 years old adolescent pregnancies. Compared with adult group (aged 25–34 years), there were some differences in the subgroup of younger adolescents (aged 10–17 years) and older adolescents (aged 18–19 years) in the risks of adverse pregnancy outcomes. There was no statistical difference between the pregnant women aged 10–17 years and adult group in terms of GDM , and SGA . However, the pregnant women aged 10–17 years had significantly higher risk of stillbirth  and neonatal death . The pregnant women aged 18–19 years had a significantly higher risk of HELLP syndrome . Younger adults (20–24 years) had higher risks of preterm delivery , stillbirth , and neonatal death  than women aged 25–34 years (Table The rate of adolescent pregnancy (aged 10–19 years) was 1.4% in Hebei Province, China from 2013 to 2017, lower than 4.3% from 2010 to 2011 reported by Ganchimeg, T. et al. [Consistent with several previous studies worldwide , 24–26, The risk of cesarean delivery in adolescent pregnancy reduced by 25% than adult pregnancy, which was consistent with the previous found, with aRR (95%CI) varying from 0.49 (0.42–0.59) to 0.79 (0.75–0.89) , 28, 29.The endocrine regulating system of adolescents is functions differently from that of adults or is not fully developed , with hiWe found that the risk of stillbirth and neonatal death in adolescent pregnancy aged 10 to 19 years was 2.58 times and 2.63 times of that in adults pregnant women, in the younger pregnant women aged 10 to 17 years, the risk was higher . We got the similar results on stillbirth as Ganchimeg, T. et al. , with aRThe adverse maternal outcomes of the adolescent pregnant had no difference from those of adult pregnant in our study, such as in PE, placenta previa, placental abruption, postpartum hemorrhage, and some studies were consistent with our findings , 26, 29.We used the government-funded HBMNMSS as our data source, the data covered 10 cities, with large sample size and representative population. The data was collected not only from tertiary hospitals, but also from secondary and primary hospitals, which could truly reflect the situation of adolescent pregnancy in Hebei Province. But there were some limitations in our research, vast majority of adolescent pregnant women were 18–19 years old, the conclusion was mainly based on the older adolescent pregnant women. The database did not contain the information about smoking and maternal BMI and economic status. These confounding factors might affect the adverse pregnancy outcomes. The diagnosis system was not widely used in Hebei Province, which might lead to some bias in our study.The adolescent pregnancy was related to adverse perinatal  outcomes, such as preterm birth, stillbirth and neonatal death, especially in younger adolescent pregnancies, but it was a protective factor for cesarean delivery and GDM. Adolescence was not the best period for pregnancy. Health education and health care should be strengthened to improve the outcomes of adolescent pregnancy.


Female urinary retention is rare.Case 1, a 35‐year‐old nulliparous woman, and case 2, a 47‐year‐old nulliparous woman, had transient urinary retention. A urodynamics revealed increased bladder sensation in case 1 and detrusor underactivity with a large post‐void residual in cases 1 and 2. Both women had a uterine leiomyoma of >10 cm in diameter. Soon after extraction of the tumor, retention episodes disappeared completely in case 1.Although rare, uterine leiomyoma should be listed as a cause of female detrusor underactivity. CICclean, intermittent self‐catheterizationEMGelectromyographyMRImagnetic resonance imagingPabdabdominal  pressurePdetdifferential detrusor pressure (Pves − Pabd)Pvesvesical (bladder) pressurePVRpost‐void residualULuterine leiomyomaUL may cause urinary retention. We report on two cases with retention, in whom urodynamics revealed detrusor underactivity. Although rare, UL should be listed as a possible cause of female detrusor underactivity.et al.et al.et al.Only two urodynamics reports of ULA 35‐year‐old nulliparous woman began to have transient acute urinary retention monthly at age 30 at the onset of her menstrual cycle. She visited a gynecology clinic and was found UL (details unknown), but without bladder management. Five years later she visited a urology clinic. She was catheterized of 830 mL PVR. Cystoscopy revealed no abnormalities. She was started on CIC three times a day with 30 mg/day urapidil (soon discontinued), which enabled her to void but still had voiding difficulty, which brought her to our clinic. In between retention episodes she had urinary urgency more than once a month; and voiding difficulty more than once a week. We did not perform a bladder diary. Blood test and urinalysis were normal. A MRI showed no abnormalities in the lumbar vertebra, but revealed a UL 13 cm in diameter . She experienced episodes three times before being referred to us by a local urologist. On arrival, she was on 30 mg/day urapidil, and no CIC was performed. In between urinary retention, she had stress urinary incontinence (more than once a month); but no voiding difficulty. We did not perform a bladder diary. However, ultrasound echography revealed 68 mL of PVR. Blood test and urinalysis were normal. An MRI revealed UL 10 cm in diameter .et al.2O, suggesting outlet obstruction . In contrast, Andrada et al.et al.UL may cause either overactive bladder or retention.Previous authors reported that urinary retention due to UL commonly occurs in early morning (early‐morning voiding difficulty or urinary retention).We reported detrusor underactivity in two UL cases. Although rare, UL should be listed as a cause of female detrusor underactivity.This study was approved by the Ethics Committee in Toho University.Ayami Shimizu contributed to acquisition of subjects and/or data, data analysis and interpretation. Ryuji Sakakibara contributed to study concept and design, acquisition of subjects and/or data, data analysis and interpretation, and preparation of manuscript. Maki Nakata contributed to critical review of the manuscript. Akiko Takashima, Naoki Takeshita, Yosuke Aiba, Fuyuki Tateno, Yuuka Sugisaki, Hiroyoshi Suzuki, and Masashi Yano contributed to acquisition of subjects and/or data.The authors declare no conflict of interest.