However, the complexity of interactions between microbes require methods for observing population dynamics within the process and modern approaches such as modeling or automation for process development. After shortly discussing these interaction mechanisms, we aim to present a broad variety of successfully established co‐culture processes to display the potential of artificial microbial consortia for the production of biotechnological products.The application of artificial microbial consortia for biotechnological production processes is an emerging field in research as it offers great potential for the improvement of established as well as the development of novel processes. In this review, we summarize recent highlights in the usage of various microbial consortia for the production of, for example, platform chemicals, biofuels, or pharmaceutical compounds. It aims to demonstrate the great potential of co‐cultures by employing different organisms and interaction mechanisms and exploiting their respective advantages. Bacteria and yeasts often offer a broad spectrum of possible products, fungi enable the utilization of complex lignocellulosic substrates via enzyme secretion and hydrolysis, and microalgae can feature their abilities to fixate CO At first, these fermentations mainly focused on foods and beverages, including the production of beer, wine, cheese, or bread. During the last decades, as more knowledge about these procedures was gained, biotechnology became more important and new processes were designed and optimized, often inspired by nature. A recent example of this way of inspiration can be observed in the development of artificial co‐culture processes.Natural microbial consortia are mostly undefined groups of microorganisms from several different species collaborating, for example, for the degradation of lignocellulosic biomass. This feature is often used in environmental engineering for wastewater treatment or bioremediation , 2. In cCo‐cultivation may provide significant advantages as compared to the cultivation of pure cultures based on several different mechanisms. Process limitations caused by the metabolic burden of gene overexpression, accumulation of toxic and inhibiting byproducts or intermediates or thermodynamic limitations can be evaded by the principles of division of labor or provision and utilization of different substrates, resulting in increased productivity and product yields , 4, 5. ADespite these advantages, many challenges yet remain when using consortia instead of monocultures in bioproduction processes, and these challenges have limited implementation on a commercial scale. One of the main challenges is posed by the complex interactions between cells of different organisms. Although many consortia in nature work synergistically, combining non‐compatible strains can provoke competitive or even antagonistic behavior with unfavorable effects on process performance. Thus, the presence of more than one organism deem observation of population dynamics necessary in order to analyze and control growth and interactions within the consortium. Therefore, a variety of methods were developed for resolving population dynamics in co‐cultures . OfflineDue to these complex interactions and challenges, the development of co‐culture processes can become difficult and time‐consuming. In order to reduce the experimental efforts, computational methods were introduced. For instance, metabolic modeling approaches were developed to analyze and understand the inter‐species interactions . Other iThe number of publications on artificial microbial consortia is constantly increasing. To overcome the aforementioned problems, it is essential to consider many different microorganisms and process designs. This review is intended to summarize the possibilities for bioproduction and, by means of recent examples, to show the current progress in artificial co‐culturing approaches.2To design synthetic microbial consortia, it is important to understand the possible interaction mechanisms. Although the interaction mechanisms in microbial consortia are complex, they can be classified in few simplified types: mutualism, commensalism, parasitism, competition, amensalism, and neutralism.Ketogulonicigenium vulgare is, for example, supported by Bacillus megaterium by providing nutrients for improved growth and 2‐KGA production of K. vulgare without benefits for B. megaterium [In bioproduction processes, a cooperative relationship such as mutualism or commensalism is beneficial. Mutualism describes a strategy in which two or more species benefit from each other, for instance by exchanging metabolites (cross‐feeding). Another widely distributed example of mutualism can be found in syntrophic processes, where methanogenic organisms are dependent from hydrogen formed by their consortium partner, which in exchange profit from hydrogen accumulation being held off . In commgaterium . Parasitgaterium . In biop2.1Trichoderma reesei (A) and Ustilago maydis (B) to produce itaconic acid directly from cellulose [One big advantage of co‐cultures is the possibility of using low‐cost substrates like starch or lignocellulose for the bioprocesses. Since these substrates are composed of various kinds of linear or branched carbohydrates, their hydrolysis to soluble monomers is a complex process carried out in several steps. Consolidated bioprocesses with co‐cultures integrating enzyme production, hydrolysis and bioconversion into a single process are a promising approach to accomplish this task. Often fungi are used as the enzyme producer (A) as they are well known for their hydrolytic capabilities. The second strain (B) can subsequently utilize the released monomers for growth or conversion into the desired product Figure . This prellulose .2.2Escherichia coli strains [E. coli strains. The upstream strain produces butyrate, which is consequently reduced to butanol in the downstream strain [Another of the many possible mechanisms for using artificial microbial consortia in bioproduction processes is the division of the microbes into upstream and downstream strains. The upstream strain (A) is responsible for taking up the substrate, converting it into an intermediate product, and, finally, secreting it into the medium. The downstream microorganism (B) then produces the product by further processing the intermediate molecule Figure . This se strains . Anotherm strain .2.3Another advantage of using co‐cultures is the possibility of circumventing feedback inhibition during production. During the bioproduction process, one microorganism (A) might metabolize the substrate to a product, which may be inhibitory to its own growth. However, in this scenario a second microorganism (B) cannot metabolize the substrate, but it uses the product of strain A as a carbon source for growth. Consequently, the concentration of the intermediate product in the medium decreases, thus leading to a reduction of the inhibitory effect on strain A. This type of commensalism results in a higher yield of the final product because strain B removes the intermediate product continuously from the medium in order to synthesize the final product Figure .E. coli and improved oxygenation by Saccharomyces cerevisiae. Aside from the intermediate, the upstream E. coli forms acetate which acts inhibiting on its growth. This is however evaded by the utilization of acetate as substrate for the downstream yeast converting taxadienes to taxanes [This approach has been applied to the overproduction of taxanes, which are the precursor to the anticancer drug paclitaxel. A synthetic mutualistic co‐culture was formed in this specific approach where parts of the whole pathway were separated in different species cultured together for fast production of taxadienes in  taxanes . Another taxanes .2.42). The photoautotrophic bacterium uses sunlight to fixate CO2 through the Calvin cycle and produces soluble sugar molecules, which are secreted into the medium. The heterotrophic bacterium uses this substrate and synthesizes the desired product  fermentation and increase the productivity compared to the conventional ABE fermentation  Figure .T. reesei forms a biofilm on the surface of the membrane prevailing anaerobic condition in the bulk phase. At the same time, this fungus produces and secretes enzymes responsible for the breakdown of lignocellulosic material into glucose as substrate for the anaerobic partner, Lactobacillus. While the anaerobic cells are then shielded from the oxygen, lactic acid can be synthesized from the monosaccharides [Clostridium phytofermentans and a cellodextrin fermenting yeast (Candida molischiana or S. cerevisiae) for ethanol production. The aerobic yeast protected the anaerobic C. phytofermentans by removing the oxygen. In return, the anaerobic strain hydrolyzed cellulose to soluble cellodextrins, which can be used by the yeast for ethanol production [One recent study took advantage of this mechanism to produce lactic acid from cellulose using a membrane reactor, which ensured locally defined aeration through an oxygen permeable membrane. During cultivation, the aerobic consortia member charides . Anotheroduction .33.1E. coli has become one of the most widely used microorganisms in the biotech sector due to its ability to grow quickly with cheap carbon sources. E. coli is used to synthesize a wide variety of products. Additionally, recent advances in metabolic engineering and systems biotechnology have greatly advanced research on microbial biosynthesis in general. Given that the implementation of microbial consortia is assuming an increasingly important role, it seems clear that the use of single‐species E. coli consortia is also on the rise. Generally, the mechanism of choice when using E. coli co‐culture is the upstream‐strain/downstream‐strain mechanism, thus splitting complex production pathways and reducing the metabolic burden for each strain.E. coli co‐culture in shake flasks. RA is generated by a condensation reaction of the two precursors caffeic acid (CA) and salvianic acid (SSA). In first co‐culture experiments consisting of only two E. coli strains, the synthesis of one of the main precursors was performed using the upstream strain, whereas the production of the second precursor and the final product took place in the downstream strain. As both precursors compete for the carbon flux from the tyrosine biosynthetic pathway, the production of the precursors was afterwards divided to two different strains. By further separating the synthesis by implementing a third E. coli strain, CA and SSA were produced by two different upstream strains and the final product RA, generated by the third (downstream) strain, was produced with a 38‐fold increased final concentration of 172 mg L–1 compared to a monoculture of E. coli [E. coli strains. This co‐culture sought to overcome a slow reaction step by either adding a second strain harboring the respective reaction, or by splitting the production pathway and increasing the share of the downstream strain. Using the latter strategy, they achieved a final concentration of 2 g L–1 muconic acid from glycerol in a batch bioreactor [E. coli co‐culture growing on a glucose/xylose mixture, with the upstream strain consuming only glucose and the downstream strain depleting xylose. They achieved a highly efficient utilization of a sugar mixture and a final concentration of 4.7 g L–1 muconic acid [For example, Li et al. showed how to efficiently produce the complex natural product rosmarinic acid (RA) using an  E. coli . Zhang eoreactor . In the nic acid , which inic acid , 32, 33.nic acid , 35.E. coli co‐cultivation approaches used to produce a wide variety of flavonoids. The following paragraphs describe some of the recent findings in this field.Recently, scientists have also focused on the production of flavonoids with bacteria. Flavonoids can be found naturally in fruits, vegetables, wine or tea, etc. This product class is particularly interesting given its high pharmaceutical and nutritional value. Many flavonoids exhibit antioxidant and anti‐inflammatory activity and act as anticancer agents , 37. It E. coli strains from glucose as a carbon source. The synthesis of the molecule was divided into the production of p‐coumaric acid from the central metabolism with the upstream strain (11 biosynthetic steps), and the conversion of p‐coumaric acid into sakuranetin by way of the downstream strain (six biosynthetic steps). In the end, 79.0 mg L–1 sakuranetin was obtained in a fed‐batch process, which is (to the authors’ knowledge) the highest concentration ever obtained with de novo biosynthesis in E. coli [In one study by Wang et al., the flavonoid sakuranetin was produced using two  E. coli .p‐coumaric acid to the co‐culture, so the upstream E. coli strain converted the acid to apigenin (four biosynthetic steps), from which the downstream E. coli strain synthesized apigetrin via a glycosyltransferase reaction. They achieved a final concentration of 16.6 mg L–1 apigetrin, which was 2.5 fold higher than the results achieved with an E. coli monoculture [Thuan et al. worked on the production of apigetrin. In contrast to the previously described mechanism, these researchers added oculture .E. coli strain (phenylpropanoic acids to flavanones) was combined with a NADPH requiring a downstream E. coli strain (flavanones to flavan‐3‐ols). The maximum concentration achieved was 41 mg L–1 flavan‐3‐ols  by artificially adding p‐coumaric acid as a precursor [E. coli strains by adding a strain for the production of p‐coumaric acid and caffeic acid from glucose, on the one hand, and adding a strain for production of anthocyanidin‐3‐O‐glucosides from flavan‐3‐ols on the other hand, resulting in the de novo production of flavan‐3‐ols and anthocyanidin‐3‐O‐glucosides solely from glucose [E. coli co‐cultures are icariside D2 [The microbial production of flavonoids might also reach a very high level of complexity. This was shown first by Jones et al., who chose an experimental approach together with a computational optimization in order to increase final product concentrations in the microbial production of flavan‐3‐ols afzelechtin and catechin. A malonyl‐CoA requiring an upstream recursor . This apiside D2  and resviside D2 .E. coli co‐culture in which one strain was used to produce p‐coumaric acid from glucose, and the other strain was used for its conversion to the final curcuminoid product in a lab‐scale bioreactor. After various optimization steps, Fang et al. achieved a final concentration of 6.28 mg L–1 bisdemethoxycurcumin. Nevertheless, the final concentrations were still twice as high with an alternatively implemented two‐stage, single‐species E. coli process [–1 of curcumin and a total curcuminoid concentration of 41.5 mg L–1 using an E. coli co‐culture. These concentrations are, to the authors’ knowledge, the highest concentrations of curcumin/curcuminoids ever obtained by means of microbial production [Curcuminoids, similar to flavonoids, also exhibit antioxidant, anticancer, and antitumor activity. Curcuminoids were produced in an  process . Two yeaoduction .E. coli strains to circumvent carbohydrate catabolite repression (CCR) during n‐butanol production from glucose and xylose, which account for the majority of monosaccharides in plant biomass. CCR prohibits the uptake of less preferable carbon sources like xylose in presence of glucose, resulting in incomplete utilization of the available substrates. By applying a glucose‐selective and a xylose‐selective strain they achieved a n‐butanol concentration of 4 g L–1 or 50% of the theoretical yield. Furthermore, the highly NADH‐intensive n‐butanol synthesis pathway was distributed into the two strains with the glucose‐selective strain producing and secreting butyrate, which is subsequently converted by the xylose‐selective strain to butanol with the byproduct acetate, which is necessary for butyrate formation of the former strain. Using this strategy a final n‐butanol concentration of 5.2 g L–1 was achieved, accounting for 63% of the theoretical yield [Saini et al. designed a consortium of two al yield .3.2Clostridia are also well‐known production hosts in the biotech sector. However, their cultivation is more demanding than the cultivation of E. coli because Clostridia are obligate anaerobes. Clostridium co‐cultures can be used to improve the production of butanol (and butanol derivatives) or hydrogen and fatty acids, or to simply expand the substrate spectrum in a production process [ process .Clostridia are often used for ABE fermentation. Co‐cultures are introduced to maximize the resulting yield of acetone, butanol, and ethanol. In ABE fermentation with Clostridium consortia, scientists have focused on numerous different production aspects using a wide variety of bacterial strains and substrates. Many scientists work with a co‐culture in which one strain has lytic properties on the substrate, and the other (non‐lytic) strain exhibits high activity in producing ABE. For example, Kiyoshi et al. produced butanol from rice straw by culturing C. thermocellum and C. saccharoperbutylacetonicum [C. beijerinckii and C. tyrobutyricum to produce butanol from cassava starch [Clostridium co‐cultures, 5‐fold increased amounts of butanol of 3.94 g L–1 compared to the wild‐type consortia can also be produced from lignocellulose [–1 butanol from crystalline cellulose [Clostridium‐only consortium consisting of C. cellulovorans and C. beijerinckii [etonicum . Furthera starch . Using Cellulose  and 7.9 ellulose . Wen et erinckii .Clostridium co‐cultures, with the aim to produce biohydrogen. Using C. thermocellum and C. thermosaccharolyticum growing on sweet sorghum stalks, they obtained a hydrogen production of 5.1 mmol gsubstrate–1. In this case, C. thermocellum was breaking down cellulose and hemicellulose to soluble sugars that the higher hydrogen‐yielding C. thermosaccharolyticum could consume [C. thermocellum and C. thermopalmarium [Islam et al. worked with  consume . Geng etalmarium .Clostridia can be used to further process CO or the CO fraction of synthesis gas (syngas) in order to produce useful chemicals from (waste) gas. In general, carboxydotrophic bacteria, like Clostridium, exhibit a higher product selectivity than chemical catalysts. Diender et al. worked with a co‐culture consisting of C. autoethanogenum and C. kluyveri to produce medium‐chain fatty acids (butyrate and caproate) and higher alcohols (butanol and hexanol) from syngas. During the co‐cultivation process, C. autoethanogenum utilized the CO to produce acetate and ethanol, which were converted by C. kluyveri to form medium chain fatty acids by chain elongation [C. autoethanogenum by blocking either acetaldehyde dehydrogenase or formate dehydrogenase (ferredoxin) activity [C. ljungdahlii and C. kluyveri to demonstrate the production of butanol, hexanol, and traces of octanol from syngas [C. kluyveri and C. carboxidivorans in co‐culture, respectively [C. kluyveri acted as the chain elongator [2 in the aforementioned co‐cultures, Haas, et al. implemented a CO2 electrolyzer to produce CO from CO2 and H2O [Recent publications have shown that ongation . Furtherongation . Benito‐activity . Alternam syngas . To gainectively . Buildinectively . This halongator . In orde and H2O .3.3E. coli or Clostridium co‐cultures, but also with mixed bacterial consortia. In addition to those already mentioned with respect to bacteria, this allows the use of mechanisms that have not been widely investigated before. Additionally, the specific strengths of every single chosen species can be exploited. Eventually, this will lead to both the production of a higher number of various products and the ability to use an extended variety of substrates.Scientists today are working not only with pure Gluconobacter oxydans produces L‐sorbose from D‐sorbitol, and Ketogulonicigenium vulgare forms 2‐KGA from L‐sorbose accompanied by Bacillus spp. for the promotion of growth and production efficiency by releasing active substances. In 2016, Wang et al. implemented a one‐step fermentation using only two different species instead of the two‐step fermentation. After optimizing and engineering the co‐culture consisting of G. oxydans and K. vulgare by deleting genes involved in the sorbose metabolism of G. oxydans, therefore alleviating competition between both strains, their final yield was comparable to the conventional 2‐step fermentation [G. oxydans, K. vulgare and Bacillus endophyticus. The co‐existence of G. oxydans together with B. endophyticus supplied additional nutrients, hence promoting growth and the 2‐KGA production of K. vulgare. Simultaneously, the growth of the both first strains was decreased due to substrate competition with K. vulgare, resulting in increased 2‐KGA production [Bacillus megaterium, growth and metabolism of K. vulgare and the enzyme activity of the L‐sorbitol dehydrogenase as there are different temperature optima [B. megaterium with lysozyme for release of intracellular components for increased 2‐KGA production by K. vulgare [One famous product of mixed bacterial consortia is 2‐keto‐L‐gulonic acid (2‐KGA), a precursor of vitamin C. Conventionally, vitamin C is produced in a two‐step fermentation process using three different bacterial species, in which case entation . Also, Moduction . Many ape optima  or the r vulgare .Clostridium co‐cultures described above, mixed species consortia can be applied in ABE fermentation processes. For example, Cui et al. implemented a co‐culture for increased butanol production using the aerobic‐anaerobic‐mechanism. During the fermentation, Bacillus subtilis depleted oxygen to enable the growth of the obligate anaerobe Clostridium beijerinckii. The key advantage of this approach is the dispensable genetically modification of C. beijerinckii. After optimizing the process, 6.4 g L–1 butanol and 3.5 g L–1 butyrate could be obtained, proofing a successful co‐culture with feeding and protection between both strains [Bacillus subtilis in a co‐culture with Clostridium butylicum by using starch as substrate for ABE production [Bacillus toyonensis and Stenotrophomonas rhizophila to reduce the oxygen demand in the aerobic fermentation of palm oil mill effluent (POME). The introduction of the aforementioned co‐culture  significantly decreased the oxygen demand together with increased methane production [Aside from the  strains . A similoduction . Later ooduction .Geobacter taking advantage of Geobacter’s ability to perform direct interspecies electron transfer (DIET) [Geobacter sulfurreducens acting as electron donor provides electrons for C. pasteurianum as electron acceptor to favor the formation of reduced products. Glycerol served as fermentation substrate for C. pasteurianum and acetate as electron donor for G. sulfurreducens. The batch experiments performed in serum bottles showed a clear metabolic shift towards improved 1,3‐propanediol and butyrate production caused by the electron transfer, while the concentrations of ethanol and butanol decreased. The authors would like to point out that this effect opens possibilities for controlling product specificities in mixed cultures [Another approach is a co‐culture using organisms of the genus r (DIET) . This mer (DIET) . By formr (DIET) . Geobactcultures .44.1S. cerevisiae. However, this species is originally not able to metabolize pentoses such as xylose [S. cerevisiae with pentose‐converting yeasts is a promising approach to achieve complete utilization of hydrolyzed plant biomass.A common way of producing bioethanol from agricultural residues is the hydrolysis of the plant material followed by fermentation with yeasts, mainly s xylose . TherefoS. cerevisiae together with Spathaspora passalidarum, Farias et al. increased the ethanol production in shake flasks from 50% sugarcane molasse and 50% hemicellulosic bagasse hydrolysate up to 30.2 g L‐1 with depletion of all available sugars [Using e sugars .S. cerevisiae, Pichia barkeri, and Candida intermedia on hydrolyzed rice waste, resulting in almost complete consumption of the sugars contained and an ethanol yield of 0.167 g g–1 or 96% of theoretically possible conversion, compared to 74.3 – 80.3% with respective monocultures using a 7 L bioreactor [S. cerevisiae and Scheffersomyces stipitis to produce 34.46 g L–1 ethanol, which was further improved by immobilization to a maximum of 44.46 g L‐1 [Hashem et al. cultivated a consortium of oreactor . Similar46 g L‐1 .S. cerevisiae and Pichia angophorae to obtain ethanol from seaweed hydrolysate primarily consisting of glucose, galactose, and mannitol. Glucose can be utilized by both strains, whereas galactose and mannitol are solely converted by S. cerevisiae or P. angophorae, respectively. Using this consortium with a preceding substrate adaption phase, a final ethanol yield of 0.45 g g–1, and a conversion rate of 94% was achieved after 120 h [S. cerevisiae to selectively ferment glucose, xylose, and arabinose, respectively. In repeated anaerobic batch cultivation they achieved a three strain consortium demonstrating stable fermentation performance. [Sunwoo et al. used a consortium of er 120 h . Verhoevormance. .S. cerevisiae strain expressing three cellulases and a recombinant Pichia pastoris strain expressing two xylanases [–1 and a final concentration of 32.6 g L–1 was achieved in shake flasks after 70 h directly from wheat straw. A consortium established by Qadir et al. consisting of a S. cerevisiae strain natively producing cellulases and pectinase and the pectinase producer Geotrichum candidum was immobilized on corn cob pieces and produced 17.89 U ml–1 pectinase activity with orange peels. [In order to enable direct ethanol production from biomass, yeasts can be recombinantly equipped with hydrolytic enzymes for simultaneous saccharification and fermentation. Such a co‐culture was created with a recombinant ylanases . This wae peels. .P. pastoris strains overexpressing genes from Aspergillus terreus. In bioreactor experiments concentrations of 593.9 mg L–1 monacolin J and 250.8 mg L–1 lovastatin could be reached with methanol and 2.2 g L–1 monacolin J with ethanol. A pathway splitting co‐culture platform for the production of various flavonoids with different strains of S. cerevisiae was developed by Du et al. [Aside from genes coding for hydrolytic enzymes, genes for heterologous production of complex molecules can be introduced into yeast cells, which can be applied in co‐cultures using the mechanism of pathway splitting. Liu et al. produced the pharmaceuticals lovastatin and monacolin J with either methanol , or ethau et al. . Combini4.2T. reesei and Aspergillus niger complement each other in the degradation of cellulose. T. reesei forms high cellobiohydrolase activity, while A. niger produces higher β‐glucosidase and endoglucanase activity [A. niger monoculture [T. reesei with different Aspergillus strains [One of the main challenges in sustainable conversion of plant materials to, for example, high‐value chemicals or biofuels is posed by its recalcitrance, hindering its utilization by microorganisms. Therefore, filamentous fungi are often used for the production of enzymes for hydrolysis of lignocellulosic biomass to release easily available compounds for other organisms. These processes can be further improved economically by producing the enzymes needed on‐site using fungal consortia with complementing enzyme activities . For exaactivity . By co‐coculture . Similar strains .Trichoderma sp. T‐1, Phanerochaete chrysosporium, and A. oryzae A‐4 achieved a 26.98% higher yield of reducing sugars from wheat straw, when compared to Trichoderma sp. T‐1 alone.Since the interaction mechanisms between differing fungal strains are often poorly characterized, a statistical approach can be used to find the optimal combination for a consortium. Using a Taguchi design, Lin et al. evaluated 32 cellulolytic consortia built from combinations of six different fungal strains . The finAspergillus flavus strain with a xylanase‐secreting Aspergillus penicillioides [–1, compared to 14.8 g L–1, after 56 h incubation. The enzymatic hydrolysis step was carried out separately after the fungal co‐culture in solid‐state fermentation (SSF) on wheat bran. Despite that, the authors were able to show that the use of the co‐culture led to comparable yields as with respective monocultures with subsequent enzymatic hydrolysis using a mix of culture supernatants.Consortia can also be used to simultaneously digest cellulose and hemicellulose. For this purpose, Zhao et al. co‐cultured a cellulase‐secreting llioides , increasA. niger and T. reesei in a SSF enabling simultaneous saccharification and citric acid production from sugarcane bagasse with the productivity being comparable or even higher than with the respective monocultures while significantly reducing the labor input [T. reesei with two different production specialists, Rhizopus delemar and Rhizopus oryzae, to produce fumaric acid and lactic acid, respectively, in shake flasks [Aside from on‐site enzyme production and hydrolysis, fungal consortia can also be used in consolidated bioprocesses, where sugars released from lignocellulosic biomass by these hydrolytic enzyme systems are subsequently converted into products of value. Bastos et al. used a consortium of or input . Pursuine flasks .4.3Artificial consortia of yeast and filamentous fungi have been proposed mainly with the goal of establishing consolidated bioprocesses (CBPs), where enzyme production, hydrolysis and fermentation take place in a single process. In these consortia, the fungus’ role consists of substrate provision by enzyme secretion and hydrolysis of lignocellulosic biomass into respective monomers, which subsequently can be converted to specific products by the yeast. Additionally, the conversion of the monomers helps to prevent potential product inhibition of the fungal enzymes .Thus, CBAspergillus tubingensis and oleaginous yeast Yarrowia lipolytica to produce biodiesel from palm empty fruit bunch under non‐sterile conditions, with a maximum lipid concentration of 165 mg g–1 [Intasit et al. established a consortium of lignocellulosic and oleaginous fungus 5 mg g–1 .T. reesei with U. maydis as the itaconic acid producer [–1 with a productivity of 0.07 g L–1 h–1 during a fed‐batch cultivation. Another example is the production of fructo‐oligosaccharides (FOS) via a consortium of Aureobasidium pullulans and S. cerevisiae [–1 h–1 compared to the monoculture of A. pullulans. In this case the instant removal of released glucose avoided enzyme inhibition and increased the purity of the product.Schlembach et al. established a CBP to produce the platform chemical itaconic acid from cellulose, using cellulolytic producer . They acrevisiae . Product55.1Co‐cultures composed of bacteria and fungi or yeasts are investigated to produce a wide range of products, among them alcohols and organic acids . These cBacillus subtilis and Kluyveromyces marxianus that produces ethanol from cellulose. B. subtilis was recombinantly equipped with eight cellulose‐hydrolyzing enzymes from Clostridium thermocellum, while Kluyveromyces marxianus heterologously produced the β‐glucosidase enzyme from Neocallimastix sp. W5. The genetic modifications of the kefir yeast enabled effective saccharification and increased ethanol production 6‐fold ‐compared to a K. marxianus monoculture or a co‐culture with the kefir yeast wild‐type [Ho et al. were able to develop a bioprocess with recombinant ild‐type .S. cerevisiae and an ethanologenic E. coli strain engineered to not utilize glucose was used to convert pretreated sugar cane bagasse slurry to ethanol. With the yeast utilizing glucose and the E. coli fermenting xylose, an ethanol concentration of 24.9 g L–1, corresponding to 70% of the theoretical yield, was achieved within less than 30 h [S. cerevisiae and engineered E. coli carrying an alcohol dehydrogenase and pyruvate decarboxylase from Zymomonas mobilis achieving an ethanol yield of 0.49 g g–1 or 96.1% conversion from softwood hydrolysate [C. phytofermentans with S. cerevisiae in a 500 ml bioreactor by Zuroff et al. for ethanol production from cellulose. This mixed aerobic‐anaerobic process is enabled by controlled oxygen transfer into the reactor enabling the yeast to protect the anaerobic Clostridium from the introduced oxygen in return for soluble sugars released by the hydrolytic enzymes produced by the anaerobic bacterium. Additional cellulase led to a further increased conversion of cellulose resulting in 22 g L–1 ethanol, compared to 6 and 9 g L–1 in C. phytofermentans and S. cerevisiae monocultures, respectively [A consortium designed by Wang et al. consisting of han 30 h . Qian etrolysate . Anotherectively .Clostridium saccharoperbutylacetonicum and the white‐rot fungus Phlebia. The co‐cultivation increased saccharification, and combined with genetic inhibition of ethanol formation, final concentrations of 3.2 g L–1 butanol were achieved on a small scale (100 ml) [A study by Tri and Kamei demonstrated the production of butanol from cellulose by an anaerobic consortium of (100 ml) .T. reesei and E. coli. With a comprehensive mathematical model of the consortium to optimize key parameters, an overall concentration of 1.88 g L–1 isobutanol was achieved in shake flasks. Additionally, dynamics within the co‐culture were analyzed in detail for further stabilizing and tuning the consortium [Consolidated bioproduction of isobutanol from pretreated corn stover was demonstrated with nsortium .T. reesei fungi are responsible for the secretion of cellulolytic enzymes while the facultative anaerobic Lactobacillus pentosus was used to produce lactic acid. Concentrations of 20 g L–1 lactic acid could be achieved in a spatially structured biofilm using pretreated wood and hydrolysate as substrate in a fed‐batch process. In another co‐cultivation study using microcrystalline cellulose as substrate, they were able to produce 34.7 g L–1 lactic acid in a batch process in a 500 ml biofilm membrane reactor with a sequential inoculation scheme of T. reesei and L. pentosus [Shahab et al. used a bacteria‐fungus consortium to produce lactic acid from lignocellulosic substrates. pentosus .Pseudomonas putida and S. cerevisiae for the production of polyhydroxyalkanoates (PHA) from xylose. The substrate was converted to lactic acid by S. cerevisiae, which is a preferable substrate of P. putida. By choosing an ideal inoculation ratio of P. putida versus S. cerevisiae of 1:10, they were able to increase the PHA concentration tenfold compared to P. putida monoculture, which could only convert small amounts of xylose. In addition, sedimentation of the cells after the end of cultivation was improved, simplifying product purification [Liu et al. constructed a consortium of fication .E. coli and S. cerevisiae to produce taxanes, a precursor for anticancer drugs, from xylose. This monosaccharide was chosen as main substrate instead of glucose in order to avoid ethanol production by the yeast as it cannot utilize xylose. E. coli was genetically equipped to produce taxadienes, which were subsequently oxygenated by the S. cerevisiae cells. Acetate, a byproduct of E. coli, serves as the carbon source for the yeast, which also brings the benefit of evading acetate inhibition of the bacterial cells. An optimized inoculum ratio of S. cerevisiae to E. coli (40:1) enabled the production of taxanes. Subsequently, this strategy was adapted to the formation of other compounds like tanshinone precursors and functionalized sesquiterpenes [E. coli was modified to efficiently convert D‐xylose into L‐tyrosine and acetate, with the latter being utilized by S. cerevisiae to also form L‐tyrosine. Additionally, the yeast was able to convert this intermediate into the final product by exogenous gene expression, thus achieving a total concentration of 21.16 mg L–1 narginine in shake flask at an optimized inoculum ratio of about 70:1 (S. cerevisiae: E. coli) [Recent studies have shown that the modular approach, as already described for bacterial consortia, can also play an important role in fungal‐bacterial co‐cultures. Zhou et al. designed a stable co‐culture of engineered terpenes . AnotherE. coli) .Beyond the production of industrially relevant chemicals, microbial consortia could also serve as sources for new drugs. In bacterial‐fungal co‐cultures it has been demonstrated that various secondary metabolites were produced which were not detected in the respective monocultures. These substances mainly seek to subdue the growth of competitors, so they can be considered as potentially useful in pharmaceuticals given their anti‐microbial activities , 97.Komagataeibacter rheticus producing bacterial cellulose and S. cerevisiae secreting specific enzymes, which could be incorporated into the cellulose layer within the same process in order to functionalize it. This technology made it possible to develop ELMs able to perceive chemical and optical stimuli and react to them [One very special application of artificial microbial consortia lies in the production of engineered living materials (ELM). One example was reported by Gilbert et al., who designed a co‐culture of  to them .5.2Chlorella sp. and Monoraphidium sp. as well as a shift in lipid composition towards C18 saturated and monounsaturated fatty acids, which are assumed as advantageous for biodiesel properties [2 for the supply of carbon source, and the bacteria remineralizing nitrogen, sulfur, or phosphorus, as well as producing co‐factors such as vitamins for algal growth in return [Chlamydomonas reinhardtii was able to be increased 5.9‐fold in a co‐culture with Azotobacter chroococcum by using a bacteria‐algae inoculation ratio of 1:40. [Many microalgae are known to accumulate lipids and are therefore potential candidates for future biofuel production. Co‐culturing these algae with different other organisms can bring advantages as, for example, bacteria supporting lipid formation by provision of nutrients and consumption of oxygen, or filamentous organisms acting as bio‐flocculation agents . Moreoveoperties . Howeveroperties . Moreoveoperties . Bacterin return . In addin return . In a stof 1:40. .Synechococcus elongatus photosynthetically fixates CO2 and converts it into sucrose, which is secreted and serves as carbon source for heterotrophic P. putida for intracellular PHA formation. Using a 1.8 L photobioreactor and the delayed inoculation of P. putida, a maximum PHA concentration of 156 mg L–1 was able to be achieved [Beyond lipids, other products can be produced by photosynthetic bacterial co‐cultures as well. A co‐culture developed by Löwe et al. consisted of two “bio‐modules.” In the first of the latter, the cyanobacterium achieved .S. elongatus with E. coli to produce isoprene. Mutualistic interaction , and a continuous process led to an eightfold increase in isoprene production [Liu et al. established a stable co‐culture of oduction .Chlorella sp. with Aspergillus sp. for the improved production of lipids from molasses wastewater. By optimizing the inoculation ratio, a higher lipid content of Chlorella sp. and a reduced percentage of polyunsaturated fatty acids leading to potentially better properties as a biodiesel feedstock were achieved, while the fungus improved the substrate supply and decolorization of the molasses wastewater. Additionally, microalgae biomass harvesting was simplified via bioflocculation in the presence of filamentous fungi [Aspergillus fumigatus, thus offering process advantages [In addition to bacteria, other microorganisms such as fungi can also be used within algal co‐cultures. Yang et al. investigated a co‐cultivation approach of us fungi . The samvantages .2, whereas the photoautotrophic algae fixate CO2 and form oxygen and ammonium [Rhodotorula glutinis and Scenedesmus obliquous, leading to an increase in lipid content of 60%–70% [Lipomyces starkeyi and green microalgae Chloroidium saccharophilum. Using a pretreated plant biomass, a lipid content of 0.081 g g–1 and an overall productivity of 37.22 mg L–1 d–1 was achieved in shake flasks [A promising approach for consolidated bioprocesses using microalgae is the combination with oleaginous yeasts. The potential of the latter is based on mutualistic interchanging of carbon and nitrogen sources between the organisms, resulting in enhanced biomass and lipid accumulation. It is mostly the yeast that is responsible for breaking down complex substrates and supplying COammonium , 111. On 60%–70% . Zuccaroe flasks .Rhodosporidium toruloides and Chlorella pyrenoidosa in shake flasks by applying domestic and distillery wastewater as carbon and nitrogen sources. The yeast adjusted the pH of the wastewater to a level suitable for growing the microalgae, which were added 40 h after process start. In combination with the removal of inactive biomass after 72 h, a maximum lipid yield of 4.6 g L–1 was achieved under nonsterile conditions, as compared to 3.0 g L–1 and 3.4 g L–1 with algal and yeast monocultures, respectively [Rhodotorula glutinis and Chlorella vulgaris in a bubble column photobioreactor, Zhang et al. increased biomass and lipid yields by 17.3% and 70.9%, respectively, in comparison with the monocultures. Synergistic effects were observed regarding the gas balance, substance exchange, dissolved oxygen concentration, and pH level of the co‐culture [R. glutinis and C. pyrenoidosa regarding the inoculation ratio (1:3) and C/N ratio (64:1), resulting in a lipid yield of 2.48 g L–1 and a two‐fold increase in fatty acid productivity compared to the monoculture [S. elongatus and R. glutinis were investigated by Li et al. as an artificial lichen in batch and semicontinuous processes. The biomass and the total lipid yield in the batch co‐culture was 40 ‐ 60% higher than in batch monocultures of the cyanobacterium [Ling et al. established a co‐culture of ectively . Using a‐culture . Liu et oculture . Co‐cultacterium .R. glutinis and C. vulgaris was used to produce carotenoids from starch wastewater. In an illuminated 5 L bioreactor, the co‐culture produced a maximum total carotenoid concentration of 12.34 mg L–1, whereas 8.31 mg L–1 were reached in a yeast monoculture cultivation [Beyond lipids, other, more complex products can also be produced in algae‐yeast consortia by taking advantage of the same principles of gas and substrate exchange. A consortium by Zhang et al. consisting of tivation .6A vast variety of artificial microbial consortia have already been successfully developed within and across taxa. Microbial consortia show huge potential, since beneficial interactions between chosen microbial partners offer the opportunity to use cheap substrates and obtain higher product yields. However, one precondition for engineering a consortium is a knowledge of the interaction mechanisms possible. In future applications, it will be possible to investigate more microorganisms using various screening approaches for generating producing co‐cultures. Through methods like computational modeling and the use of systems biology, it is possible to create co‐cultures in which microorganisms are dependent from each other, benefit from each other, and distribute the metabolic burden of synthetic pathways imposed upon the engineered microorganisms. These methods might also enable the use of a higher number of various microorganisms within one artificial consortium. Therefore, metabolic and enzyme engineering, including methods such as directed evolution, also represent very interesting future directions for the design and improvement of microbial co‐cultures. Nevertheless, many challenges still remain before the successful industrial application of microbial consortia can become widespread across industrial bioprocesses. It should be taken into account that growing a wide variety of microorganisms in a single bioreactor requires both additional effort in expanding the microbial biomass for inoculation at a production scale and more complex control strategies in the production process. The scale‐up of these processes for commercial use also requires integrated technical and economic analyses for evaluating their feasibility. Even though these systems must still be further developed and investigated, co‐cultured bioprocesses represent a promising approach for future applications.The authors have declared no conflicts of interest.Fabian Mittermeier, Prasika Arulrajah, José de Jesús García Lima, Sebastian Hauke, Anna Stock, and Dirk Weuster‐Botz contributed to the conception and design of the review paper; Prasika Arulrajah analyzed the literature with respect to interaction mechanisms; Anna Stock, José de Jesús García Lima, and Sebastian Hauke compiled the literature data about bacterial, fungal and mixed consortia, respectively; Fabian Mittermeier coordinated literature research and evaluation; Prasika Arulrajah, Fabian Mittermeier, and Dirk Weuster‐Botz designed the figures; Fabian Mittermeier, Miriam Bäumler, Prasika Arulrajah, José de Jesús García Lima, Sebastian Hauke, Anna Stock, and Dirk Weuster‐Botz wrote the manuscript. All the authors contributed to the critical revision and final approval of the manuscript.


To compare the reader performance of artificial intelligence computer-aided detection synthesized mammograms (AI CAD SM) with that of digital mammograms (DM) when used alone or in combination with digital breast tomosynthesis (DBT) images.n = 4) study compared the reader performances in 388 cases . The overall accuracy of the breast-based assessment was determined by four radiologists using two sequential reading modes: DM followed by DM + DBT; and AI CAD SM followed by AI CAD SM + DBT. Each breast was rated by each reader using five-category ratings, where 3 or higher was considered positive. The area under the receiver-operating characteristic curve (AUC) and reading time were evaluated.This retrospective multireader (P < 0.0001) than that of DM. The mean AUC of AI CAD SM + DBT was higher than that of DM + DBT (P = 0.094). A significant reduction in the reading time was observed after using AI CAD SM + DBT when compared with that after using DM + DBT (P < 0.001).The mean AUC values for DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT were 0.863, 0.895, 0.886, and 0.902, respectively. The mean AUC of AI CAD SM was significantly higher (AI CAD SM + DBT might prove more effective than DM + DBT in a screening setting because of its lower radiation dose, noninferiority, and shorter reading time compared to DM + DBT. Digital breast tomosynthesis (DBT) images have been successfully used for population-based breast cancer screening. There is evidence of improved overall performance with digital mammograms (DM) when used along with DBT compared to that when used alone . HoweverIn the recent years, deep learning-based artificial intelligence (AI) systems have been quickly evolving in the field of breast imaging and surpassing the performance and clinical value of traditional computer-aided detection (CAD) for mammography . In addiThis retrospective, fully crossed, completely randomized, multireader, multicase study was approved by the Institutional Review Board of our hospital. Written informed consent to was obtained from all the recruited patients enrolled in this study. FUJIFILM , which invented the new SM for the reading, provided the equipment and support for this study. The data and materials submitted for publication were always under the control of the researchers who were not FUJIFILM personnel. According to the joint research and development agreement, 500 DM + DBT examinations with a bilateral two view  image were performed at ? Hospital between January 2020 and August 2020. All DM + DBT examinations were performed with a narrow-angle DBT system with 15-degree tube motion from 15 projection images ). DM and DBT were performed during a single breast compression per view. We decided that the comparison of the reader performance was performed at the per-breast level using only mediolateral oblique (MLO) view images taking the reading time and readers’ attention span during the reading study into consideration.We excluded patients with past surgical history from a case set and developed the case set of 388 breast images from 198 DM/AI CAD SM + DBT examinations in sequence based on the diagnostic work-up patients, which comprises 84 breast cancers, 83 biopsy-proven benign lesions, and 221 normal or benign cases (BI-RADS score of 1 or 2)  with negWe utilized the latest version (under development) of FUJIFILUM image processing approach to generate the AI CAD SM used in this study. The AI algorithm uses a fast and efficient convolutional neural network, ESPNet . They haFour Japanese radiologists who were ranked as having an “A” certification from the Japan Central Organization on Quality Assurance of Breast Cancer Screening  performed the image evaluations. The radiologists were blinded to the case selection. The readers had between 5 and 30 years of experience in mammography  and their experience with DBT ranged from 2 to 8 years . None of the radiologists had prior experience with the new SM reading.The evaluations of the images by the readers were conducted in two stages. The examinations were read twice as follows: (a) DM followed by DM + DBT, and (b) AI CAD SM followed by AI CAD SM + DBT. At least 4 week intervals were allowed as wash-out periods. In each reading mode, the radiologists were prompted to rate each breast using the two-dimensional (2D) image alone followed by the rating of the DBT using the five-point forced BI-RADS  scores . The mosThe reading times were automatically recorded per examination using the workstation software from the moment the examination was displayed until the reader document the image findings including the locations and radiological characterizations of the cancers and benign lesions were documented. The readers did not use a timer and were blinded to the reading time.To acquaint themselves with the workstation and interpretation procedure, all radiologists were trained to review sets of 100 DM + DBT and sets of 200 breast images from 100 DM/AI CAD SM + DBT examinations (not included in the study) before participating in this study.The radiologists used a reading dual-monitor workstation with an electronic reporting system  and a 5MP DB/DBT-certified diagnostic color display  calibrated to the DICOM Grayscale Standard Display Function, for the image interpretation.An unblinded review of every case per breast was performed by one radiologist , who was not involved in the observer study, to determine　the standard pathologic reference and reference mammographic findings. The radiologist also confirmed that there were no discrepancies between the pathologic diagnoses and mammographic findings of 84 breast cancers and 83 biopsy-proven benign lesions. The number of true and false interpretations by the readers was assessed for each image, including the location and radiological characterization of the cancers and benign lesions and the confirmed normal status. This study was modeled in a screening setting: hence, the final assessments of the images were categorized as follows: positive  and negative .P values were computed based on the 100,000 bootstrap samples (1000 resamples of cases by 100 resamples of readers). A linear mixed model with the subject and reader as variable factors was used for inter-method comparisons of the reading time. Statistical inferences for all analyses were performed at a significance level of 0.05. The statistical analyses were performed using the R package for Windows .The mean area under the receiver-operating characteristic (ROC) curve (AUC) was used to assess the accuracy of the reported forced BI-RADS ratings. The reader-averaged AUC was analyzed using the random-reader, random-case model to account for the possible correlations during the evaluation of the breasts in the same patient. Additionally, the correlations between repeated assessments of the same cases by different radiologists using different modalities, and between-reader variabilities were assessed. Bootstrap percentile confidence intervals (CI) and the corresponding estimated The mean (± standard deviation) compressed breast thickness during DM + DBT was 38.8 mm ± 14.5. The mean glandular dose for a single mammographic view was 1.12 mGy ± 0.32 (standard deviation) for DM and 1.62 mGy ± 0.49 for DBT. These dose levels constitute an average dose reduction of 41% (1.12 mGy/2.74 mGy) for AI CAD SM + DBT as compared with DM + DBT.P < 0.0001; Fig. P = 0.094), and three readers performed somewhat better with AI CAD SM + DBT than with DM + DBT. In addition, the mean AUC of AI CAD SM alone and DM + DBT did not differ significantly (P = 0.312); and three readers performed somewhat better with AI CAD SM alone than with DM + DBT. Except for a single reader, who performed slightly worse  with DM + DBT when compared with DM alone, improvements in the performances of the remaining three readers were observed when DBT was made available to them after a review of either the DM or AI CAD SM alone.The mean AUC values for DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT were 0.863, 0.895, 0.886, and 0.902, respectively. The AUC of AI CAD SM alone was significantly higher than that of DM alone , whereas a significant difference was noted between DM alone and DM + DBT (P = 0.034). In the dense breast cases (n = 32), the sensitivities of the 2D images alone were improved in the corresponding sequential reading modes when DBT were made available to them .The cancer detection sensitivities for DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT were 84.2, 87.5, 87.2, and 88.4%, respectively (Table n = 14), the sensitivities for DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT were 96.4, 92.9, 96.4, and 92.9%, respectively (Table P = 0.286) and DM + DBT and AI CAD SM + DBT (P = 0.286).For the malignant calcification lesions (n = 83), the sensitivities for DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT were 53.6, 47.3, 55.7, and 48.8%, respectively (Table P = 0.012), DM + DBT and AI CAD SM + DBT (P = 0.002), and AI CAD SM alone and DM + DBT (P = 0.001). These findings indicated that the benign recall rates of AI CAD SM were lower than those of DM. The sensitivity of AI CAD SM alone was significantly lower than that of DM + DBT in the dense breast cases.Similarly, for the verified benign cases n = 8, the senn = 39) were 44.9, 31.4, 44.2, and 30.8%, respectively (Table P = 0.001). Similarly, the sensitivity of AI CAD SM + DBT was significantly lower than that of DM + DBT (P < 0.0001), and that of AI CAD SM alone was significantly lower than that of DM + DBT (P = 0.002).The sensitivities for DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT in the benign calcification lesions n = 9 were 44P < 0.001) than that of DM + DBT .The mean reading time per examination for AI CAD SM + DBT  was significantly shorter (P = 0.056). To the best of our knowledge, this is the first study to show that the detection accuracy of the AI CAD SM alone was equivalent to that of DM + DBT. Moreover, the benign recall rates of the AI CAD SM including calcification lesions were lower than those obtained with DM or DM + DBT. One explanation is that mass margins and calcification morphologies are accurately highlighted on AI CAD SM, and this may improve the perception of benign lesions. These results indicated that AI CAD SM maintained the performance benefits of the DBT examinations and could be used as standalone 2D mammograms with higher performance compared to DM alone. Thus, the latest version of the image processing algorithm for generating the AI CAD SM might meet the demand of radiologists.The latest version of image processing technology was used to generate a novel SM in this study. The new things about it are as follows. First, the use of this new SM (AI CAD SM) alone increased the reader performance for breast cancer detection in terms of the overall accuracy when compared to DM alone. Second, the reading time was significantly decreased, and the accuracy was improved after using AI CAD SM + DBT when compared to that observed after using DM + DBT. Furthermore, the cancer detection sensitivity was markedly improved after using AI CAD SM alone when compared to that observed after using DM alone . This might be because the readers might not have been able to reach the plateau in their learning curves with regard to the AI CAD SM, despite the training provided before the study. Nonetheless, AI CAD SM alone or in combination with DBT demonstrated a higher performance than DM .Evaluation of the performance of the readers based on the breast density is important for screening mammography. In the case of dense breasts, the cancer detection sensitivity of AI CAD SM or AI CAD SM + DBT was better than that of DM or DM + DBT, statistical significance notwithstanding. This finding is in line with those reported previously –17. The Evaluation of the performance of the readers based on the calcification lesions is important, particularly when using the AI CAD SM.The sensitivities of DM, AI CAD SM, DM + DBT, and AI CAD SM + DBT were similar for malignant calcification lesions. In the benign calcification lesions, the sensitivities of AI CAD SM alone or AI CAD SM + DBT were significantly lower than those of DM alone or DM + DBT. In addition, the sensitivity of AI CAD SM alone was significantly lower than that of DM + DBT. These findings indicated that AI CAD SM was significantly superior to DM in terms of the specificity and sensitivity for the detection of calcification lesions in a screening setting. Previous studies have reported that the detection and interpretation of calcifications, especially amorphous calcifications, using SM was challenging , 18–22. This study has several limitations. First, this study used so an enriched data with malignant cases; hence, the results may not be generalized to a real-world screening program. Second, this study used only the MLO view; access to the CC view could slightly increase the sensitivity and specificity of the results . Thus, fIn conclusion, the use of the AI CAD SM + DBT could allow for a more effective screening program with higher performance, especially in terms of an increase in the detection accuracy and a reduction of in the reading time as well as radiation dose, when compared to the DM + DBT. The AI CAD SM might be considered as standalone 2D mammograms with higher performance compared to the DM.


The mechanisms of age-dependent reproductive decline in men are largely overlooked. An age-dependent reduction in nicotinamide adenine dinucleotide (NAD+) levels has been reported in multiple somatic and female reproductive tissues, including oocytes and ovarian tissue. However, the relationship between NAD + levels and male reproduction has not yet been studied. In the current study, the association between sperm NAD + level and paternal age was investigated. In addition, we also investigated whether sperm NAD + levels were related to semen quality.In this pilot observational cohort study, semen samples from 51 male subjects who visited a university-affiliated reproductive medical center for preconception consultation  were recruited. Their anthropometric characteristics were recorded, and semen analysis was performed. Their sperm NAD + levels were evaluated spectrophotometrically.6 sperm, 30–40 years: 125.60 ± 16.28 nmol/106 sperm, > 40 years: 115.59 ± 16.55 nmol/106 sperm). Additionally, linear regression also revealed no correlation between sperm NAD + concentration and the age of the participants . Noticeably, a negative correlation was found between the sperm NAD + concentrations and the sperm quality parameters, including sperm concentration , sperm count , mobile sperm number , and DFI . The semen volume and mobility rate were not related to the sperm NAD + concentration.There were significant differences among the three age groups in the major parameters of semen quality. The sperm NAD + level was, however, similar among the three groups (< 30 years: 91.61 ± 15.59 nmol/10Unlike the age-related decrease of NAD + levels in oocytes and ovarian tissue, the sperm NAD + concentration is not age dependent. Sperm NAD + levels are negatively correlated with sperm quality, suggesting a unique role of NAD + in spermatogenesis, which warrants further study and opens opportunities for pharmaceutical interventions for oligozoospermia. In recent years, the trend in parenthood at an older age has become more noticeable, especially in modern societies. Couples intentionally delay their marriage and children bearing to obtain additional education or to build a career. For instance, the average age of first-time fathers rose from 27.4 years in 1972 to 30.9 years in 2017 in the U.S., with 9% of fathers over 40 years old. Such sociodemographic changes have had a profound influence on contemporary fertility.It is well acknowledged that age-dependent ovarian reserve decrease is a significant factor causing infertility in modern society, as female gamete quality declines more quickly. People have only gradually turned their focus toward the contribution of male aging to infertility. In addition to decreased sexual functioning and coital frequency, it is well established that parental age profoundly impacts male fertility . It is cA considerable body of evidence has suggested that semen parameters, including motility, morphology, and volume, are negatively influenced by increased parental age . NotablyWhile most scientific endeavors have focused on female reproductive aging, the mechanisms of age-dependent reproductive impairment in men are largely overlooked. Recent studies have revealed a new marker of female reproductive aging, an age-dependent decline in nicotinamide adenine dinucleotide (NAD+) in oocytes and ovarian tissue 5]. Impo. Impo5].NAD+, the precursor of the pyridine nucleotide family, basically has two functions, a critical electron-transfer intermediate that fuels redox reactions and a substrate for various oxidoreductase enzymes . NAD + hThis study was approved by the Ethics Committee of Beijing Chao-Yang Hospital . All of the participants in the current study were enrolled from the reproductive medical center of Beijing Chao-Yang Hospital from July to September 2021. They were husbands of secondary infertile couples who had a previous birth but failed to conceive after one year of unprotected intercourse. Informed consent was obtained from each participant. Their semen samples were collected for semen analysis as a routine fertility examination. The final 61 participants aged 22–60 years old were all in good mental and physical states. Patients with known conditions that may cause dysspermia were excluded, including chronic diseases, urogenital infections, varicocele, oligozoospermia, and azoospermia. Their general information, including body mass index (BMI), education levels, smoking status, and abstinence period, was collected through a questionnaire.The semen specimens were collected by masturbation after 2–7 days of sexual abstinence. Semen samples were masturbated into a sterile plastic container and then transferred to our andrology laboratory. Incubation at 37 °C for 30 min was performed to allow liquefaction. After liquefaction, the semen volume was evaluated by weighing. A computer-aided sperm analysis (CASA) system  was used to measure the semen parameters (sperm count and motility) . A macroSperm chromatin integrity was assessed by a flow cytometric-based sperm degree of DNA fragmentation chromatin structure assay . The assays were performed according to the manufacturer’s instructions. Finally, the DNA fragmentation index (DFI) was used to express the sperm chromatin integrity.Prior to measurement of the sperm intracellular NAD + levels, the semen samples were washed to avoid contamination with seminal fluid. Briefly, a 300 µl semen sample was diluted 1:2 with human tubal fluid (HTF) and centrifuged at 500 × g for 10 min. After carefully aspirating the supernatant, the sperm pellet was resuspended in 1 ml HTF and then centrifuged again at 500 × g for 5 min. The supernatant was carefully removed and discarded. The sperm pellet was used for the measurement of sperm intracellular NAD + levels using an NAD/NADH Cell-Based Assay Kit  according to the manufacturer’s instructions. The sperm pellet was resuspended in 120 µl of the assay buffer provided by the kit and then transferred to a 96-well plate. The following steps of the intracellular NAD + concentration assays were performed strictly according to the manufacturer’s protocol. The NAD + levels were measured and calculated using a plate reader  at a wavelength of 450 nm.Categorical parameters are summarized with counts and percentages. Continuous variables are described with means and standard deviations. First, a one-sample Kolmogorov–Smirnov test was used to determine whether the analyzed variables followed a normal distribution. If the parameter was consistent with a skewed distribution , these variables were log-transformed before further statistical analyses. Second, the chi-square test or Fisher’s test was used to analyze the nominal variables, while Student’s t-test was employed to analyze the quantitative variables. Linear regression was used to explore the correlation between NAD + levels and sperm quality parameters. All data analyses were conducted using SPSS 11.0 software . A P value < 0.05 was considered statistically significant.A total of 61 participants were recruited from October 2020 to January 2021. Ten out of the 61 participants were excluded for conditions including azoospermia (n = 1), oligozoospermia (n = 8), and urogenital infections (n = 1). The mean BMI of the group older than 40 years old was slightly lower than that of the other two groups, but the difference did not reach statistical significance. Approximately 72% of participants had received undergraduate or higher education, and the distribution of education status was similar among the three age groups. Regarding smoking status, approximately 35% of the subjects were smokers, and the percentage of smokers was similar among the age categories. The mean abstinence period was not significantly different among the three age categories ) increased the NAD + concentration in testes and significantly impaired sperm count and motility . This phThis is the first report focusing on the relationship between the sperm NAD + concentration and reproductive aging in normozoospermic men. The next goal will be to determine whether high levels of sperm NAD + have an adverse influence on the clinical outcomes of ART. The role of NAD + in spermatogenesis also warrants further study, which may lead us to develop novel therapeutic approaches to dysspermia.


To analyze the obstetric high-risk factors and serological characteristics of early-onset neonatal bacterial infections (EONBI).119 neonates with early-onset bacterial infection who were admitted to the neonatal ward of our hospital from October 2020 to December 2021 were recorded as the study group, and 100 neonates without bacterial infection who were admitted during the same period were used as the reference group. Comparative analysis of obstetric high-risk factors and serological characteristics of EONBI.P > 0.05). The gestational age and birth weight of newborns in the study group were lower than those in the reference group (P < 0.001). Comparing the maternal factors of EONBI between the two groups, there was no statistical difference in age, number of obstetric inspections, whether to use antibiotics, and mode of delivery (P > 0.05). Univariate analysis showed that preterm birth, unexplained asphyxia, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h were significantly associated with EONBI (P < 0.05); while there was no significant difference between the two groups in the comparison between diabetic mother and child and maternal fever at delivery (P > 0.05). Multifactorial analysis showed that preterm birth, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h had a good multivariate dependence on EONBI (P < 0.05), while there was no significant association with unexplained asphyxia, diabetic mother and child, and maternal fever at delivery (P > 0.05). The incidence of neonatal temperature >37.9°C was higher in the study group than in the reference group (P < 0.05), and there were no statistical differences in the comparison of other clinical manifestations (P > 0.05). The CRP level of neonates in the study group (47.33 ± 4.14) mg/L was higher than that of the reference group (4.84 ± 1.03) mg/L (P < 0.001). The WBC level of neonates in the study group (5.64 ± 1.18) 109/L was higher than that of the reference group (0.28 ± 0.04) 109/L (P < 0.001). The PCT level of neonates in the study group (5.41 ± 0.85) µg/L was higher than that of the reference group (0.24 ± 0.07) µg/L (P < 0.001).There was no statistical difference between the two groups in terms of gender and age at admission (EONBI is closely associated with several obstetric high-risk factors, including preterm birth, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h; EONBI has no specific symptoms and signs, but serum CRP, WBC, and PCT levels are significantly higher than those of newborns without co-infection with bacteria. Newborn infants are immunocompromised and have low resistance, so bacteria can easily invade the body from the skin mucosa, umbilical cord stump, respiratory and digestive tracts causing bacterial infections in newborns, which are common types of inflammatory infections in the first 72 h of life , 2. GeneCurrently, no global assessment data on the incidence of bacterial infections in newborns are available for each country. According to incomplete statistics at home and abroad, the incidence of early-onset neonatal bacterial infections (EONBI) can range from 1% to 10% throughout live births, and once a neonate develops a systemic infection, the chance of causing its death can be 20% to 40%, and even if the child survives, 10% to 30% of the children can still be left with varying degrees of sequelae later in life , 7. AlerAccording to previous reports, in the early stages of bacterial infection, children often present with some signs, symptoms or changes in laboratory tests of inflammatory response, and these children are often accompanied by the presence of high-risk factors predisposing the newborn to bacterial infection . HoweverThe subjects of this experiment were neonates with ≥1 of the following obstetric high-risk factors who were admitted to the neonatal ward of our hospital from October 2020 to December 2021: preterm birth, unexplained asphyxia, diabetic mother and child, fecal contamination of amniotic fluid, maternal fever at delivery (≥38°C), maternal infection during pregnancy , premature rupture of membranes ≥18 h. All children were admitted to the hospital at an age of ≤3 days and had no other obstetric high-risk factors or complications outside the scope of the above study, and no congenital anomalies.n = 119) with co-infection and the reference group (n = 100) without co-infection according to whether they were co-infected with bacteria or not. Inclusion criteria for the study group: ① With ≥1 obstetric high-risk factor; ② At least one of the following main conditions was met: blood culture or sputum culture or peripheral secretion culture (+); one or more clinical signs of infection ; ③ If the above primary condition was (−), then at least one of the following secondary conditions was satisfied: elevated C-reactive protein (CRP) >8 mg/L; increased white blood cell (WBC) >25 × 109/L or decreased <5 × 109/L; decreased platelets <100 × 109/L. Exclusion criteria for the study group: Excluding sepsis, pneumonia, necrotizing small bowel colitis, urinary tract infection, meningitis, enteritis and impetigo and other diseases with clear etiology and site of infection, excluding infection by other pathogenic microorganisms such as viruses, mycobacteria and protozoa. Inclusion criteria for the reference group: children with obstetric high-risk factors but no clinical manifestations of infection, negative laboratory indicators, and clinical exclusion of infection.The children were divided into the study group  levels prior to antibiotic administration in both groups to assess their serological characteristics. The assay was performed by collecting 5 mL of fasting elbow vein blood, centrifuging it at 2,000 r/min for 10 min, and finally storing the separated plasma in a refrigerator at −20°C. 7,600 Hitachi automatic biochemical analyzer  and immunoturbidimetry were used to detect CRP and PCT levels, AU5800 automatic blood analyzer  and supporting reagents were used to detect WBC levels.The neonates in both groups were monitored continuously for 72 h, and they were given antibiotics of the third generation or more of cephalosporin immediately after infection for 1–3 weeks. Those who ruled out infection were given lower antibiotics or no antibiotics, paying attention to intensive care of local infection.χ2 test was performed. In order to exclude the influence of confounding factors on the results of the study, with EONBI as the dependent variable, the relationship between EONBI and 7 obstetric high-risk factors was analyzed by multivariate Logistic regression. P < 0.05 was considered statistically significant.SPSS 22.0 software was applied for statistical analysis, and the measurement data were expressed as mean ± standard deviation, and paired t-test and ANOVA were performed. The statistical data were expressed as ratios, and the P > 0.05). The gestational age and birth weight of newborns in the study group were lower than those in the reference group (P < 0.001)  .P > 0.05)  .P < 0.05); while there was no significant difference between the two groups in the comparison between diabetic mother and child and maternal fever at delivery (P > 0.05)  .P < 0.05), while there was no significant association with unexplained asphyxia, diabetic mother and child, and maternal fever at delivery (P > 0.05)  .P < 0.05), and there were no statistical differences in the comparison of other clinical manifestations (P > 0.05)  .P < 0.001). The WBC level of neonates in the study group (5.64 ± 1.18) 109/L was higher than that of the reference group (0.28 ± 0.04) 109/L (P < 0.001). The PCT level of neonates in the study group (5.41 ± 0.85) µg/L was higher than that of the reference group (0.24 ± 0.07) µg/L (P < 0.001) (The CRP level of neonates in the study group (47.33 ± 4.14) mg/L was higher than that of the reference group (4.84 ± 1.03) mg/L (< 0.001) .The clinical symptoms of early neonatal bacterial infections are atypical. At present, the diagnostic criteria for neonatal bacterial infection at home and abroad are mostly based on the clinical manifestations of severe infection or even sepsis. There is a lack of scientificity and consistency in the early judgment of infection, and there are often two drawbacks: One is the failure to detect bacterial infections in newborns in a timely manner, leading to the spread of infection; the other is the use of antibiotic treatment for all newborns with obstetric high-risk factors, leading to the misuse of antibiotics . As seenThe results of this paper showed that preterm birth, unexplained asphyxia, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h were significantly associated with EONBI. Preterm delivery has been reported as a high risk factor significantly associated with EONBI and 64% of fecal contamination of amniotic fluid is associated with chorioamnionitis . The preThe multifactorial analysis in this paper shows that preterm birth, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h had a good multivariate dependence on EONBI, and the most significant risk factor for EONBI is maternal infection during pregnancy. This further confirms that genital tract infection during maternal pregnancy is an important factor in triggering intrauterine infection . During In recent years, there has been a significant increase in the prevalence of gestational diabetes, which has been reported to be as high as 5.8% to 25.1% . As the Previously, the clinical diagnosis of neonatal infectious diseases was based on the detection of peripheral blood WBC counts, and the results of WBC detection were affected by various factors, and some neonates had poor WBC count bases, and the detected WBC levels were still in the normal range even though bacterial infections had occurred in the body, so WBC could only be used as a routine reference index for the diagnosis of infectious diseases , 22. CRPEONBI is closely associated with several obstetric high-risk factors, including preterm birth, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h; EONBI has no specific symptoms and signs, but serum CRP, WBC, and PCT levels are significantly higher than those of newborns without co-infection with bacteria.


Transvaginal mesh surgery can cause mesh complications including rare rectovaginal fistula. We report a case of a rectovaginal fistula treated transvaginally without colostomy.A 57‐year‐old female was referred to us due to post‐hysterectomy prolapse and had transvaginal mesh surgery. She underwent transvaginal hysterectomy because of uterine prolapse at age 33 and had taken steroids to treat pemphigus. Two years later, she developed vaginal bleeding and discharge. Transvaginal mesh removal was planned to treat vaginal mesh exposure, but immediately before the operation digital rectal examination revealed rectovaginal fistula. Mesh removal and fistula closure were performed transvaginally without colostomy. Three years of follow‐up showed no recurrence of mesh exposure, fistula, or prolapse.Rectovaginal fistula following mesh surgery may be treated transvaginally without colostomy if infection is minimal. To evaluate mesh exposure on the posterior vaginal wall, rectal examination should be done along with vaginal examination. FDAU.S. Food and Drug AdministrationLSClaparoscopic sacrocolpopexyNTRnative tissue repairPOPpelvic organ prolapseRASCrobot‐assisted sacrocolpopexyRVFrectovaginal fistulaSUIstress urinary incontinenceTVMtransvaginal mesh surgeryRVF following TVM may be treated with a transvaginal approach without colostomy if the infection is minimal. It is important to evaluate both the mesh exposure site and the possibility of fistula meticulously.Female pelvic floor disorders including POP are highly prevalent conditions. The lifetime risk of American women for either POP or SUI is estimated to be 20.0%: 12.6% for POP and 13.6% for SUI, respectively.®‐type TVM using self‐cut polypropylene mesh. The postoperative course was uneventful.A 57‐year‐old parous female was referred to our department due to post‐hysterectomy prolapse and voiding difficulty which worsened over the past 10 years. At the age of 33, she underwent transvaginal hysterectomy and colporrhaphy due to uterine prolapse. Additionally, she had been taking oral steroids (11 mg of prednisolone per day) for over 8 years due to pemphigus. She underwent ElevateTwo years later, however, she complained of vaginal bleeding and a brownish discharge. She visited a gynecologist and a polyp near the vaginal stump was observed (biopsy: granulation tissue). She was referred to our hospital again, and a small mesh exposure (0.8 cm in diameter) at the posterior wall was diagnosed during the vaginal examination Fig. . TransvaRVF is defined as a pathological epithelialized communication between the posterior vaginal wall and the anterior rectal wall. In general, 85% of RVF are caused by obstetric trauma, and 5–7% of RVF is attributed to pelvic and rectal surgery while inflammatory bowel disease, malignancy, and radiotherapy cover most of the remaining etiologies.et al. and Hilger et al. reported a case who developed RVF 5 days and 3 months after TVM, respectively.et al. reported a series of RVF in 5 patients which occurred on average 18 months after mesh prolapse surgery .et al. reported a series of RVF in 10 patients with an average onset of 7.1 months after POP repair .et al. reported an RVF which was found due to hematochezia one month following TVM.Mesh complications are more commonly reported after TVM, but abdominal sacrocolpopexy, LSC, and RASC are also causes. Regarding TVM, vaginal mesh exposure is the most frequent complication and its reported prevalence is 2.7–17%et al. reported that experienced surgeons (TVM > 50 cases) had significantly less prevalence of vaginal mesh exposure, bladder injury and blood transfusion.Regarding mesh complications, multiple risk factors have been indicated; history of previous POP surgery, radiation, low estrogen, smoking, diabetes mellitus, steroid usage, and inflammatory bowel diseases.Various surgical approaches have been attempted to treat RVF depending on its size, location, etiology, the state of the surrounding tissue, infection, and prior repair attempts. For small (<2 cm), non‐recurrent, low‐type RVF without significant infection, transvaginal, transrectal, or transperitoneal closure is preferable due to its low invasiveness.et al. reported that a mean of 4.4 surgeries was needed, with 40% requiring a colostomy.Regarding RVF following mesh prolapse surgery, Choi To conclude, precise assessment of the site and size of mesh exposure as well as the possible presence of fistula or infection is important. We recommend not only vaginal examination but also rectal examination when mesh exposure of the posterior vaginal wall is suspected.The authors declare no conflict of interest.Aika Matsuyama: Conceptualization; data curation; formal analysis; writing – original draft. Kumiko Kato: Conceptualization; data curation; formal analysis; writing – review and editing. Hiroki Sai: Data curation. Akinobu Ishiyama: Data curation. Takashi Kato: Data curation. Satoshi Inoue: Data curation. Hiroki Hirabayashi: Supervision. Shoji Suzuki: Supervision.Not applicable.Written informed consent was obtained from the patient.Not applicable.


Systemic inflammation and handgrip weakness have been used to predict mortality in many cancers. The purpose of current study was to evaluate the association of co‐occurrence of inflammation indicators and handgrip weakness with overall survival (OS) of lung cancer (LC) patients with good performance status.The cutoff points for handgrip strength (HGS) and the four inflammation indicators were calculated using Maxstat. The time‐dependent receiver operating characteristic curve and C‐index were used to select optimal inflammation indicator for predicting OS of LC patients. The Cox proportional hazard regression model was used to calculate the hazard ratio (HR) of mortality. Kaplan–Meier curves were constructed to evaluate the association of indicators and the OS of LC patients.p < 0.001) and low advanced lung cancer inflammation index (ALI) , high systemic immune‐inflammation index (SII) , high platelet: lymphocyte ratio (PLR) , or high neutrophil: lymphocyte ratio (NLR)  were associated with increased mortality risk of LC patients. ALI had better C‐index (0.624) and time‐AUC in the prediction of OS in LC patients with good PS than other three combinations. The co‐occurrence of handgrip weakness and low ALI more than doubled the risk of death in LC with good PS .Among the 1951 patients, the mean ± standard deviation (SD) age was 60.6 ± 9.9 years, and 1300 (66.6%) patients were male. In patients with good performance status (PS), handgrip weakness (HR, 1.49; 95% confidence interval [95% CI], 1.30–1.70, In LC patients who have good PS, patients with combined handgrip weakness and low ALI have the worst prognosis.ChiCTR1800020329. HGS, ALI, SII, NLR, and PLR were independent risk factors for overall survival of lung cancer patients. Co‐occurrence of low HGS and systemic inflammation significantly elevated the risk of death. The predictive ability of handgrip weakness combined with low ALI for OS was better than the other three combinations. In‐person or telephonic questionnaires were used to follow up all participants to obtain relative data on the clinical outcomes of the participants. The inclusion criteria included: (1) ≥18 years old, (2) diagnosis of LC, and (3) length of hospital stay was longer than 48 h. The exclusion criteria included (1) organ transplantation, (2) current pregnancy, (3) HIV infection or AIDS, (4) hospitalized more than twice during the investigation period, and (5) admission to the ICU at the beginning of recruitment. A total of 1951 LC patients were included in current study. All patients enrolled signed informed consent prior to the study, within 48 h of hospital admission. The study protocol was approved by the Institutional Review Committee of Beijing Shijitan Hospital and conformed to the ethical guidelines of the 1975 Declaration of Helsinki.2.2The baseline information of the patients included age, sex, complications, smoking, the family history of tumor, complications, alcohol consumption, and nutrition support. Each patient underwent a comprehensive interview with a dietitian or clinician conducted of to obtain information of nutrition: the nutritional risk screening 2002 (NRS‐2002) score, Karnofsky Performance Score (KPS), and patient‐generated subjective global assessment (PG‐SGA) score; and anthropometric data: height, HGS, and body weight. Quality of life was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30 Version 3.0). The tumor stage for solid tumors was evaluated according to the 8th edition of the American Joint Committee on Cancer (AJCC) TNM staging system.2.3HGS (non‐dominant hand) is measured using an electronic hand grip dynamometer . When measured, the patient seated upright with his arms resting on the armrests and his elbows bent 90 degrees. All patients hold the handle with maximal force for 3 s. Three consecutive tests were performed, and the maximal handgrip strength was recorded.2.42] × albumin[g/dl]/NLR), SII (platelet count [×109] × neutrophil count [×109]/lymphocyte count [×109]), PLR (platelet count [×109]/lymphocyte count [×109]), and NLR (neutrophil count [×109]/lymphocyte count [×109]).Routine blood examinations, including albumin (g/dl), lymphocyte count, neutrophil count, and platelet count, were obtained after at least 9 h of fasting within 24 h of hospitalization. The four inflammation indicators adopted in this study included the ALI , involving R packages “survival”, “survminer”, “ggplot2”, “rms”, “timeROC” and “forestplot”, and software SPSS version 21 . Depending on the variable type , variables were expressed as median , mean ± standard deviation (SD), or in absolute number and proportion. The optimal cutoff points of HGS for each sex and NLR, ALI, SII and PLR were calculated using the maximally selected rank statistics. The C‐index and time‐dependent receiver operating characteristic (ROC) curves were used to select optimal inflammatory indicator among ALI, NLR, PLR, and SII for predicting the OS of lung cancer. Spearman correlation analysis was performed to evaluate the correlation between HGS and four inflammatory indicators. In addition, we performed a logistic regression on categories of ALI (low or high), PLR (low or high), SII (low or high), and NLR (low or high) as predictors of low HGS (yes or no) to evaluate the association between four inflammatory indicators and low HGS. Cox proportional hazard models were used to assess the relationship of low HGS‐low ALI with OS during follow‐up in patients with good and impaired  PS. HRs and 95% CIs were calculated. Each combination was analyzed independently of other inflammatory markers. Analyses were adjusted for age, sex, TNM, smoking status, alcohol consumption, co‐morbidity, and family history of malignancy. The OS curves were generated using Kaplan–Meier plots, and analyzed using the two‐sided log‐rank test. Finally, stratified analyses were performed to evaluate the main associations of each variable  with survival of LC patients. Two‐sided 33.1p < 0.001) compared with patients with a poor PS  patients showed handgrip weakness at baseline. The cutoff points of ALI, SII, PLR, and NLR were 29.40, 993.78, 184.91, and 3.41, respectively  compared with patients with high ALI. There was no significant difference in the distribution of HGS and ALI in histology types (NSCLC and SCLC)  Table.3.2p = 0.130), SII , NLR , PLR , and the low HGS even after adjustment, respectively  among the four inflammation indicators   died. The median OS for the whole cohort was 25.6 months. In univariate analysis, low HGS , low ALI , high SII , high PLR , and high NLR  were associated with OS of all LC patients  had an ECOG PS of 0 or 1. The median OS was 29.6 months (95%CI: 26.2–32.9 months). A total of 880 (51.3%) patients had low HGS. In univariate analysis, low HGS , low ALI , high SII , high PLR , and high NLR  were associated with poor OS of all LC patients (Table p < 0.001) (Table The majority of the patients (3.4.3p = 0.037) (Table An ECOG PS ≥2 was observed in 239 patients (12.1%). The median OS was 8.8 months. In univariate analysis, only low ALI  was associated with poor OS of all LC patients  patients with good PS, stratified analyses were further performed. For those patients with co‐occurrence of low HGS and low ALI, increased risks of mortality were observed in all subgroups Figure .4To our knowledge, this was a novel study to assess the association between co‐occurrence of inflammatory and low HGS and OS in LC patients. Among 1951 LC patients of our study, 1715 patients had a good PS. Both low HGS and low ALI were independent strong prognostic factors for OS of LC patients. Additionally, our data demonstrated that the co‐occurrence of low HGS and low ALI had doubled mortality risk of LC patients with good PS. If prospectively validated in another large population, handgrip weakness with low ALI may be a suitable combination for identifying patients with high mortality risk, and may aid in timely clinical interventions and improving the prognosis of LC. In addition, handgrip weakness combined with high SII or high NLR could also predict poor OS of LC patients with good PS. However, ALI was a better predictor of the OS of LC patients than other three inflammation indicators. Measures of inflammatory indicators and HGS are easily obtainable in the clinical setting. The co‐occurrence of low HGS and low ALI may represent a kind of “inflammatory low HGS,” a powerful prognostic indicator in LC patients, even those with a good PS.Previous studies mainly focused on the independent effects of grip strength and inflammatory markers on LC prognosis. Our study suggested that a similar process occurs in LC patients with a good PS regardless of TNM stages at diagnosis, suggesting that handgrip weakness was not only a representation of the advanced stage of the disease. Our research found that inflammatory indicators were not associated with handgrip weakness. However, the co‐occurrence of inflammation and handgrip weakness was associated with an increased mortality risk of LC patients, which was consistent with the previous study on colorectal cancer. For example, pre‐diagnosis inflammation was associated with sarcopenia at the time of diagnosis, and co‐occurrence of sarcopenia and high NLR nearly doubled the risk of death.According to statistics, the incidence of male LC was 14.3%, which was higher than that among women (8.4%).Intriguingly, we found that LC patients with low HGS had lower ALI, or higher NLR and SII. Higher HGS was found to be associated with lower levels of inflammation, and the association between the HGS and mortality was partly explained by inflammatory indicators.2) account for approximately 4% of LC cases.2) in this study, while overweight and obese patients (BMI ≥24 kg/m2) accounted for a larger proportion (36.0%). A previous study has found a nonlinear positive association between grip strength and BMI.According to a pooled analysis of the International Lung Cancer Consortium, underweight patients (BMI <18.5 kg/mThere were several strengths in this current study. First, it may be the largest study to examine the association between systemic inflammation biomarkers and low HGS in LC. The strength of this study comes from its multi‐center, prospective nature, and large sample size; therefore, there is a good representation of the population. Second, HGS is noninvasive, fast, cost‐efficient, and easy to implement, which are very important in the oncology domain. Third, our study included all TNM stages, despite the fact that the number of patients with TNM stage I was relatively small.However, limitations in this study should also be noticed. Similar to previous studies,5In LC patients with good PS, handgrip weakness and low ALI, high NLR, high SII, and high PLR were independent prognostic indicators. We also found that the co‐occurrence of handgrip weakness and inflammation more than doubled risk of mortality in LC patients with good PS. It may represent a kind of “inflammatory low HGS.” Compared with other three inflammation indicators, ALI is a better inflammatory indicator combined with low grip strength to predict prognosis of LC. The combination of the two indicators provides effective prognostic stratification for lung cancer patients with well PS, and could provide guidance for the treatment and nursing of LC patients. However, further study needs to be performed to confirm this result.HGS, ALI, SII, NLR, and PLR were independent risk factors for overall survival of lung cancer patients.Among these four indicators, ALI was optimal inflammation indicator to predict the prognosis of lung cancer patients with well PS.Co‐occurrence of low HGS and systemic inflammation significantly associated with the elevated the mortality risk of LC patients with well PS.Hanping Shi conceptualized, supervised, and made funding acquisition; Mengmeng Song contributed to methodology, software, Writing –original draft preparation; Qi Zhang contributed to methodology and software; Chunhua Song validated, investigated, did writing –reviewing and editing; Tong Liu and Xi Zhang did writing –reviewing and Editing; Guotian Ruan validated; Xiangrui Li investigated; Yizhong Ge did methodology and investigation; Xiaowei Zhang, Kangping Zhang, Ming Yang, Qinqin Li: Investigation, Shiqi Lin, Yu Xu, Bo Li, and Xiaogang Li investigated; Kunhua Wang, Hongxia Xu, and Wei Li did investigation and data curation.All authors have completed the ICMJE uniform disclosure form. The authors have no conflicts of interest to declare.This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Committee of Beijing Shijitan Hospital.Informed consent was obtained from all individual participants included in the study.Table S1Click here for additional data file.Figure S1Click here for additional data file.