Viral diarrhea is one of the leading causes of morbidity and mortality in children. This study was conducted to disclose the etiological cause and epidemiological features of viral diarrhea among children in China. From 2009 to 2021, active surveillance was performed on pediatric patients with acute diarrhea and tested for five enteric viruses. Positive detection was determined in 65.56% (3325/5072) patients and an age‐specific infection pattern was observed. A significantly higher positive rate was observed in 12–23‐month‐old children for rotavirus (47.46%) and adenovirus (7.06%), while a significantly higher positive rate was observed for norovirus (37.62%) in 6–11‐month‐old patients, and for astrovirus (11.60%) and sapovirus (10.79%) in 24–47‐month‐old patients. A higher positive rate of rotavirus in girls and norovirus in boys was observed only among 6–11 months of patients. We also observed more norovirus among patients from rural areas in the 0–5‐ and 36–47‐month groups and more rotavirus among those from rural areas in the 12–23‐month group. Diarrhea severity was greater for rotavirus in the 6–23‐month group and norovirus in the 6–11‐month group. Coinfections were observed in 29.26% (973/3325) of positive patients, and were most frequently observed between rotavirus and others (89.31%). Our findings could help the prediction, prevention, and potential therapeutic approaches to viral diarrhea in children. An estimated 1 in 10 childhood deaths results from diarrhea disease during the first five years of life.Although intensive data about the etiology and epidemiology of infectious diarrhea in children are available, the etiology differs among age groups depending on geography, climate, and economic development.22.1From July 2009 to April 2021, ongoing surveillance of acute diarrhea for pediatric patients of <5 years old was conducted at the Children's Hospital of Chongqing Medical University. The hospital is the largest children's hospital in southwestern China, with >2000 beds and an annual outpatient capacity of approximately 3 million people, serving patients with a wide geographic range across central and western China. During the study period, a standard guideline was administered for the patients recruited and laboratory tests. Briefly, acute infectious diarrhea was defined as three or more loose or watery stools per day and duration <2 weeks. Patients who had confirmed inflammatory bowel disease, celiac disease, cystic fibrosis, food intolerance, or patients who had any apparent clinical respiratory signs or symptoms were excluded. Disease outcome was defined as nonsevere (mild/moderate) or severe diarrhea based on the predefined criteria.2.2Viral DNA/RNA of six viruses (types) was tested for each of the collected samples. Briefly, stool samples were suspended in phosphate‐buffered saline, vortexed vigorously, and centrifuged at 12 000 rpm for 1 min in a microfuge. Total nucleic acids (DNA and RNA) were extracted from 140 μl of a 10% fecal supernatant using QIAamp Viral RNA Mini Kit (QIAGEN) and eluted in 20 μl DEPC water according to the manufacturer's instructions. The complementary DNA was synthesized by using the SuperScript®III First‐Strand Synthesis System for reverse transcription‐polymerase chain reaction (RT‐PCR) (Invitrogen). The real‐time RT PCR was applied to test norovirus (GI/GII) by using specific probes and primers described previously2.3p value <0.05 was considered statistically significant. All statistical analysis was performed using R version 4.1.0.Continuous variables were expressed as medians and interquartile ranges (IQR) and categorical variables were expressed as numbers (%). The viral positive rate was calculated by dividing the number of at least one positive pathogen by the number of patients tested for all five viruses. Six age groups were defined: 0–5, 6–11, 12–23, 24–35, 36–47, and 48–59 months, and the positive rate among the age groups was compared by the Cochran‐Armitage trend test. Pearson chi‐square test or Fisher exact test was performed to compare other categorical variables. To infer viral interactions between any of the two tested viruses, we applied multivariable binary logistic regression models after adjusting age, sex, the time from onset to hospital admission (delay), and the monthly background prevalence.33.1From July 2009 to April 2021, 5330 cases of younger than five years with acute diarrhea were recruited for the current research. After excluding 258 patients with incomplete data collection or inadequate sampling, the remaining 5072 patients were tested for all five viruses. Of whom 60.25% were boys, with a median age of 10 (IQR: 6‒15) months, and the largest proportion (89.41%) was <24 months. More patients were recruited from the outpatient department  than from the inpatient department. More patients resided in urban areas  than in rural areas  and 19.40% (984/5072) of the patients at the time of physical examination. Of the 5072 tested stool specimens, watery stool (67.01%) was the most commonly seen, followed by mushy stool (4.91%), mucus stool (0.87%), and bloody stool (0.20%). The median duration from onset to first hospital admission was 3 days (IQR: 1‒5). Severe disease outcome was developed in 14.39% (730/5072) of the patients  patients were positive for at least one enteric virus, and viral coinfection was determined in 973 19.18%) cases. The most prevalent virus was rotavirus , followed by norovirus , astrovirus , adenovirus , and sapovirus  . A significantly higher viral positive rate was observed in 12–23 months old children  than in other age groups, especially with a higher rate of rotavirus  and adenovirus . In contrast, a significantly higher positive rate for norovirus was observed in 6–11 months old children , while for astrovirus  and sapovirus  was observed in 24–47 months old children , gender discrepancy was observed in specific age groups. For example, for the 6–11 months group, the prevalence of rotavirus was higher in girls than in boys , while the norovirus was higher in boys . This difference was not observed for other enteric viruses   Figure .p  =  0.097, Table p = 0.023) and 36–47 months groups , while rotavirus was more frequently identified among those living in rural areas only in 12–23 months group . No such geographic difference was observed for the other enteric viruses across all age groups  and 68.84% (380 of 552), respectively, displaying no significant difference (ps Table .p < 0.001), also higher rate for rotavirus  and norovirus   Table . When th2) Table .3.3During the study period from 2009 to 2021, the overall positive rate had fluctuated across the study years, showing an upward trend from 2009, attaining the peaking level in 2012 and followed thereafter by decreased rate, to the lowest level in 2020 when the COVID‐19 epidemic was noticed Figure . A similp < 0.001, Figure An obvious seasonal pattern was observed for the overall positive rate, with a higher level of circulation observed in autumn  and winter  than in spring  and summer  , followed by the 24–35 months group (21.00%), 6–11 months (19.25%), and 36–47 months (17.27%) Figure . It's noThe viral interaction pattern was determined by logistic regressions, which revealed potential synergistic/competitive interactions among the tested viruses. Most of the interactions were negative, occurring between rotavirus‐norovirus, rotavirus‐sapovirus, norovirus‐sapovirus. Positive interaction was only seen between rotavirus‐adenovirus Figure .4In this study, by performing a systematic, continuous, laboratory‐based surveillance of acute viral diarrhea on 5072 children in Chongqing, we disclosed an age‐specific infection pattern of five dominant enteric viruses among those aged 0–59 months, with the highest prevalence of viral infection occurring at 12–23 months. The finding is consistent with previous studies indicating high susceptibility to viral infection in early childhood, especially at the age younger than five years.Consistent with previous findings in ChinaThe ranking of other viruses differed among age groups. Children aged 24–47 months were the most susceptible group to astrovirus and sapovirus infection, while adenovirus infections were most frequently determined in 12–23 months. The discrepancy among age groups was primarily related to host immunity. As shown in previous studies, the first infection of these viruses provided moderate protection against subsequent infections.Previous studies in China have indicated the unique characteristics of some specific enteric viruses associated with acute diarrhea in rural areas.In our study, viral coinfection accounted for 29.26% of the total positive detection. Rotavirus‐norovirus was the most commonly determined coinfection, followed by rotavirus‐adenovirus and rotavirus‐norovirus‐adenovirus. We also observed a significant positive interaction between rotavirus and adenovirus using the logistic regression model after adjusting age, sex, delay, and the monthly background prevalence. This finding could be supported by previous studies, albeit the reason remained obscure.Based on active surveillance performed on pediatric patients with acute diarrhea in 12 consecutive winter‐spring seasons, an age‐specific infection pattern of five dominant enteric viruses was displayed for the 0–59‐month‐old pediatric patients. This comprehensive data might assist in the planning of an integrated control program for the leading causes of acute viral diarrhea and the children that are susceptible to the predominant enteric viruses. It might also provide evidence for informing policymakers on the future vaccine and intervention development in this area. The current study also emphasizes the need for ongoing comprehensive surveillance of vulnerable children's groups. A more precise investigation in deciphering the prevalence among age, sex, and regions is warranted in the future.Wei Liu, Xiao‐Ai Zhang, and Hong‐Mei Xu: conceived and designed the study. Rui‐Qiu Zhao, Xiang Tang, Luo Ren, En‐Mei Liu, Hong‐Mei Xu, Wei Liu, and Xiao‐Ai Zhang: collected samples and data. Gang Wang, Rui‐Qiu Zhao, Yun‐Fa Zhang, Heng Ding, Yue Li, Yu‐Na Wang, Ling Yu Zhang, and Shuang Li: performed the experiments. Wei Liu, Xiao‐Ai Zhang, and Gang Wang: analyzed the data. Wei Liu, Xiao‐Ai Zhang, Hong‐Mei Xu, Gang Wang, and Rui‐Qiu Zhao: drafted the manuscript. All authors read and approved the final paper.The authors declare no conflict of interest.Supporting information.Click here for additional data file.


Rice and wheat straws were selected as the incubation substrates and sampled at 0, 4, 12, 24, 48, 72, 120, and 216 h of incubation time to measure the kinetics of dry matter (DM) and neutral detergent fiber (NDF) disappearance. Additional two bags were incubated and sampled at 4 and 48 h of incubation time to evaluate the bacterial community attached to straws. The results showed that buffalo exhibited a greater (p ≤ 0.05) fraction of rapidly soluble and washout nutrients and effective ruminal disappearance for both DM and NDF of straw than Holstein, together with a greater (p ≤ 0.05) disappearance rate of potentially degradable nutrient fraction for NDF. Principal coordinate analysis indicated that both host and incubation time altered the bacterial communities attached to straws. Buffalo exhibited greater (p ≤ 0.05) 16S rRNA gene copies of bacteria and greater (p ≤ 0.05) relative abundance of Ruminococcus attached to straw than Holstein. Prolonging incubation time increased (p ≤ 0.05) the 16S rRNA gene copies of bacteria, and the relative abundance of phyla Proteobacteria and Fibrobacters by comparing 4 vs. 48 h of incubation time. In summary, buffalo exhibits greater ruminal fiber degradation than Holstein through increasing bacterial population and enriching Ruminococcus, while prolonging incubation time facilitates fiber degradation through enriching phyla Proteobacteria and Fibrobacteres.Buffalo exhibits great efficiency in utilizing low-quality roughage, which can be due to the combined effect of host physiological feature and roughage diet fed. The present study was designed to compare the ruminal fiber degradation and the bacterial community attached to straws in buffalo and Holstein when fed with the same high-roughage diet using  Buffalo is considered to be the livestock with immersed value to be developed, providing economic value from meat, milk, leather production, and draft power for rice cultivation for thousands of years . BuffaloThe rumen is a fermentation ecosystem with strong fiber lysis, as it contains a wide microbial community of bacteria, protozoa, archaea, fungi, and bacteriophages that rapidly colonize and digest plant materials in a complex and coordinated manner . The endThe nylon bag technique has been developed in the 1930s and widely employed to quantify the ruminal degradation of feed in ruminants. The nylon bag technique exhibits good repeatability without the influence of physiological conditions of host animals and begins to attract great interest to study associations between the kinetics of feed degradation and the bacterial community attached to the rumen microbial ecosystem . The preThe experiment was conducted in Guangxi Taiminxing Animal Husbandry Co. Ltd., Nanning, China. The experimental procedure was approved by the Animal Care Committee, Institute of Subtropical Agriculture, the Chinese Academy of Sciences, Changsha, China.in situ ruminal incubation experiment. All cattle were fed two times per day at 08:00 and 16:30 with a total mixed diet containing 20% of concentrate and 80% of the wheat straw mixture  and three Holstein (280.33 ± 7.51 kg) fitted with custom rumen cannula  were randomly employed to conduct the  mixture  and had Two substrates, including rice and wheat straw, were collected and ground to pass a 4-mm screen using a Wiley mill with a standard sieve . The chemical compositions of substrates are listed in The bags were placed inside large mesh bags (40 cm × 40 cm) with three compartments to prevent them from aggregating together and incubated in each animal for 0, 4, 12, 24, 48, 72, 120, and 216 h in a staggered manner to ensure no more than three mesh bags in the rumen. Additional two bags were incubated for 4 and 48 h to evaluate the bacterial community attached to straws. When the incubation was ended, nylon bags were removed from the rumen and put into ice water to terminate microbial disappearance. The bags were then washed, dried at 105°C, weighed, and stored until measuring fiber content.2, frozen vacuum-dried, and stored at −80°C until microbial DNA extraction.Bags for bacterial community analysis were gently washed with phosphate-buffered saline (pH = 7.4) to remove the ruminal contents and loosely adhered microbes from the outer surface of the bag. Then, the liquid in the bags was gently squeezed to extract the liquid which was then discarded. The residues were removed from the bags and transferred into 15-ml tubes, flash-frozen in liquid NAll samples of substrates were dried and ground to pass through a 4-mm sieve. The DM (method 945.15), organic matter , and crude protein  were measured according to About 0.50 mL of ruminal fluid or 0.20 g of frozen-dried samples from nylon bags was used to extract microbial DNA using a modified RBB + C methodology  with sanFibrobacter succinogenes, Selenomonas ruminantium, Prevotella spp., and Ruminococcus amylophilus with primers ((−slope)-1. Final absolute amounts of target groups or species were estimated by relating the CT value to the standard curves and expressed as log10 copies/DM contents.The procedures of qPCR were followed by  primers . All samThe amplicon sequencing and analyzing were performed at the MiSeq platform through Illumina sequencing at Shanghai Biozeron Biological Technology Co. Ltd. according to our previous study . Brieflyin situ ruminal nutrient disappearance:The exponential model of p is the nutrient disappearance at time t (g/kg); a is the fraction of rapidly soluble and washout nutrient (g/kg); b is the fraction of potentially degradable nutrient (g/kg); c is disappearance rate (%/h) of fraction b. Data were fitted using the Nonlinear Regression Analysis Program .where ED, g/kg) was calculated according to the equation described by The effective ruminal degradation (k was the passage rate from the rumen (h−1) and is set to 0.02 h−1 and 0.06 h−1 in the present study.where n = 2) and straws (n = 2) as the fixed effect. When two sampling times were included, the second model included animal type (n = 2) as a fixed effect, sampling time (n = 2) as a repeated measurement, and animals as the random effect (n = 3). The interaction effect was excluded from the analytic models for the lack of significant effect (p > 0.05). Significance was considered when p ≤ 0.05, and the tendency of significance was considered when 0.05 < p ≤ 0.1.Data were analyzed using SPSS 26.0 software . The first model for analyzing the disappearance of straws was a linear mixed model, which included animal types  a, 2,ED and 6ED for both DM and NDF disappearance, greater (p ≤ 0.05) c of NDF disappearance (p ≤ 0.05), and a tendency of greater c of DM disappearance (p ≤ 0.1) of straw than Holstein. Furthermore, rice straw had greater (p ≤ 0.05) values of a + b, 2,ED and 6ED and lower (p ≤ 0.05) values of a for DM and NDF disappearance than wheat straw. Both host and incubation time altered the 16S rRNA gene copies of bacteria (p ≤ 0.05) 16S rRNA gene copies of bacteria attached to straw particles when compared with Holstein. The incubation time of 48 h had greater (p ≤ 0.01) 16S rRNA gene copies of bacteria attached to straw particles than 4 h. Wheat straw had greater (p ≤ 0.05) 16S rRNA gene copies of Fibrobacter succinogenes than rice straw.The nutrient degradation kinetics was investigated by the echnique . Buffalobacteria . Buffalop > 0.05) the observed ASV, Chao 1 value, or Shannon index, it altered (p ≤ 0.01) the bacterial community attached to the straw particles (Ruminococcus (p ≤ 0.05), Roseimarinus (p ≤ 0.05), and Lawsonibacter (p ≤ 0.05), a tendency of greater Papillibacter (p ≤ 0.1), Enterocloster (p ≤ 0.1), and Sodaliphilus (p ≤ 0.1), and a tendency of lower relative abundance of Schaedlerella (p ≤ 0.1) and Treponema (p ≤ 0.1) attached to straw particles, when compared with Holstein. Prolonging incubation time increased the Shannon index (p ≤ 0.05) and altered (p ≤ 0.01) the bacterial community attached to straw particles. Greater (p ≤ 0.05) relative abundance of phyla Proteobacteria and Fibrobacters, and Papillibacter, Monoglobus, Roseimarinus, Sodaliphilus, Stenotrophomonas, and Treponema attached to straw particles was observed at 48 h of incubation time and with lower (p ≤ 0.05) phyla Bacteroidetes, and Ruminococcus, Lawsonibacter, Paraprevotella, and Mucilaginibacter than 4 h of incubation time. Wheat straw exhibited a greater (p ≤ 0.05) relative abundance of phyla Fibrobacters and Papillibacter and a lower (p ≤ 0.05) relative abundance of Enterocloster than rice straw.The compositions of the bacteria community attached to the straw were also analyzed by 16S rRNA sequencing technique . Althougarticles . BuffaloPrevotella, Butyrivibrio, Ruminococcus, unclassified Lachnospiraceae, Ruminococcaceae, Bacteroidales, and Clostridiales, comprise the majority of all bacterial sequence in the rumen ecosystem despite host range, diets, and feeding strategies  can be found at: The animal study was reviewed and approved by Animal Care Committee, Institute of Subtropical Agriculture, the Chinese Academy of Sciences, Changsha, China.XP and MW conceived this study. MW, ZT, BL, and BT managed the project. XP and MZ conducted this experiment. XP, XZ, QL, RW, and SZ carried out the statistical analysis. XP wrote this manuscript. MW and ZT critically reviewed the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by the Strategic Priority Research Program of the Chinese Academy of Sciences (grant no. XDA26040203), the National Natural Science Foundation of China , the Hunan Province Science and Technology Plan (2020NK2066 and 2022NK2021), the Science and Technology Innovation Program of Hunan Province (2021RC2102), the China Agriculture Research System (CARS-35), and the Open Fund of Key Laboratory of Agro-ecological Processes in Subtropical Region Chinese Academy of Sciences (grant no. ISA2021203).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.https://www.frontiersin.org/articles/10.3389/fmicb.2022.1079056/full#supplementary-materialThe Supplementary material for this article can be found online at: Click here for additional data file.


Intraperitoneal paclitaxel is proved to be efficient for peritoneal metastasis of gastric cancer. It remains uncertain the efficacy and safety of the triplets regimen which combined intraperitoneal high‐dose paclitaxel with systemic SOX in gastric cancer patients with peritoneal metastasis. This study aimed to evaluate the efficacy and safety of intraperitoneal administration of high‐dose paclitaxel, intravenous oxaliplatin and S‐1 in patients with peritoneal metastatic gastric cancer.2, d1), intravenous oxaliplatin , and S‐1  of patients. The primary endpoint was 1‐year overall survival rate, and the second endpoints were progression‐free survival (PFS), overall survival (OS), overall response rate (ORR), disease control rate (DCR) and adverse events.This single‐center, prospective, single‐arm phase II study was conducted between January 2017 and May 2019 in West China Hospital, Sichuan University. Patients diagnosed with primary gastric cancer by histopathology and confirmed synchronous peritoneal metastasis were enrolled. This study aimed to evaluate efficacy and safety of intraperitoneal administration of high‐dose paclitaxel . Median PFS and OS were 6.50 months  and 16.9 months , respectively; ORR was 55.3%  and DCR was 76.6% . Thirteen patients underwent second laparoscopic detection, but only nine ultimately underwent radical gastrectomy. Subgroup analysis showed that sPCI ≤12 was a good index for a favorable prognosis. The most frequent grade 3/4 toxicities were neutropenia (40.8%), anemia (22.4%), leukopenia (18.4%), nausea (14.3%), and vomiting (12.2%). None of the patients had any intraperitoneal catheter‐related complications.Intraperitoneal high‐dose paclitaxel with systemic SOX is an effective and tolerable first‐line treatment for patients with peritoneal metastatic gastric cancer and patients with sPCI≤12 scores might be recommended crowd for this regimen as conversion therapy. Systemic SOX and intraperitoneal high‐dose paclitaxel is an effective first‐line treatment for patients with peritoneal metastatic gastric cancer and patients with sPCI≤12 scores might be recommended crowd for this regimen as conversion therapy. V325 and FLOT studies have demonstrated that the triplet regimen is superior to doublets chemotherapy in PFS and OS.At present, anticancer drugs are mainly administered intravenously; most of them cannot cross the peritoneum‐serum barrier and reach the disseminated nodule efficiently. Over the past few decades, intraperitoneal administration of anticancer drugs, such as cisplatin, paclitaxel, mitomycin, and docetaxel, has been proven to be effective for peritoneal metastasis.Hence, we developed a new intensive regimen that added intraperitoneal high‐dose paclitaxel to systemic chemotherapy SOX with a modified dosage to decrease the potential risk of severe toxicity and conducted a phase II study to evaluate the efficacy and safety of the triplets combination in GC patients with synchronous peritoneal metastasis.22.1This was a single‐center, prospective, single‐arm phase II study of intravenous oxaliplatin with oral S‐1 plus intraperitoneal paclitaxel in patients with synchronous peritoneal metastatic GC. The protocol was approved by the Ethics Committee of West China Hospital, Sichuan University, and informed consent was obtained from all patients, and the study was carried out in accordance with the Helsinki declaration and its later amendments. This trial was registered with the Chinese Clinical Trial Registry (ChiCTR1900025984).2.2Patients diagnosed with primary gastric cancer by histopathology or cytology confirmed synchronous peritoneal metastasis by biopsy of peritoneal nodules and exfoliative cytology. Other inclusion criteria were as follows: Eastern Cooperative Oncology Group (ECOG) performance status 0–2 scores, age 18 to 80, measurable or assessable lesions according to the criteria of RECIST 1.1 criteria, without other metastatic organs, and adequate organ function suitable for systemic and intraperitoneal chemotherapy. All enrolled patients underwent a multidisciplinary team (MDT) discussion. The major exclusion criteria were anaphylaxis to the drugs, massive ascites, other metastases except for peritoneal, peritoneal infection, gastrointestinal hemorrhage or obstruction, uncontrolled severe complication and underlying disease.2.3The primary endpoint was 1‐year overall survival rate, and the second endpoints were PFS, OS, ORR, DCR, and adverse events. Physical examination, abdomen and chest CT were conducted to define the stage of disease, diagnose peritoneal metastasis and evaluate the efficacy every 3 cycles. Before each course of treatment, medical history, physical examination and laboratory examinations  were performed. Complete blood cell count and liver and renal function  tests were performed weekly during the treatment. Laparoscopic exploration and gastroendoscopy were also performed when necessary. Tumor responses were assessed according to the Response Evaluation Criteria in Solid Tumor (RECIST) guidelines version 1.1, every 9 weeks. The number of malignant ascites and peritoneal cytology were also considered to evaluate the antitumor effects of the treatment on peritoneal metastasis. The incidence and severity of treatment toxicities were evaluated according to the National Cancer Institute‐Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4.0).2.42, together with another 1000 ml saline solution. Oxaliplatin was administered intravenously at a modified dose of 100 mg/m2 on day 1. S‐1 was administered orally at a dose of 80 mg/m2 for 14 days followed by a 7‐day rest. A catheter was implanted in the subcutaneous space of the lower abdomen into the pelvic cavity under ultrasound guidance. The catheter was implanted at the start of every cycle and extubated after infusion. To minimize hypersensitivity reactions to paclitaxel, patients were premedicated with dexamethasone (20 mg), ranitidine (20 mg), and diphenhydramine (20 mg) 30 min before paclitaxel administration. Intraperitoneal and combined systemic chemotherapy were generally administered on an inpatient basis for a maximum of 8 cycles followed by maintenance S‐1 therapy (40 mg/m2 twice daily) until transferred to CY0, disease progression, unacceptable toxicity, patient refusal or undergoing radical surgery. The recommended second‐line therapy in our study was doublets chemotherapy including docetaxel, cisplatin, and irinotecan with or without intraperitoneal cisplatin, which was consistent with Western and Eastern guidelines.In our study, paclitaxel was administered intraperitoneally on day 1 with an initial dose of 80 mg/m2.5The primary endpoint was 1‐year survival rate, and recent studies in advanced gastric cancer with peritoneal metastasis showed that the 1‐year survival rate was approximately 70%. The sample size was calculated based on the hypothesis that the experimental regimen's 1‐year survival rate could improve by 15%. A one‐sided, one‐sample log‐rank test calculated from a sample of 43 subjects achieved 90.5% power at a 0.025 significance level to detect a 1‐year survival rate of 85% in the experimental group and the expected number of outcome events was 14 during the study. The loss of follow‐up rate was supposed to be 10%; therefore, a total of 47 patients needed to be enrolled. Survival analysis was performed using the Kaplan–Meier method with a log‐rank test. Univariate and multivariate survival analyses were performed using the Cox proportional hazards regression model to generate a hazard ratio using SPSS . Rate calculation and 95% Confidence Interval (CI) were done by the “Hmisc” R package with the Wilson test. In all the statistical tests, P‐values ˂0.05, between each group, were deemed to show a statistically significant difference.33.1Between January 2017 and May 2019, 57 patients were recruited. 8 patients were excluded and 49 eligible patients were finally enrolled in the study . The median PFS was 6.50 months  and the median OS was 16.9 months  , anemia (22.4%), leukopenia (18.4%), nausea (14.3%), and vomiting (12.2%)  of patients whose sPCI scores were less than 12 points had the opportunity to undergo radical gastrectomy after treatment with this regimen. The median OS of the 9 patients could reach 33.4 months, which means that patients with sPCI ≤12 in synchronous peritoneal metastasis of gastric cancer might be recommended crowd for this regimen as conversion therapy. Over the past decades, cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) therapy has been developed, and its application in gastric cancer with peritoneal metastasis has also become more widespread.2, toxicity is one of the most important factors for applying the regimen. The results showed that toxicities, both hematologic and non‐hematologic, were controllable and acceptable in this study. Considering the potential toxicity of triplet regimens, the dose of intravenous oxaliplatin was decreased from 130 mg/m2 to 100 mg/m2.Since we increased the dose of paclitaxel to 80 mg/m2 of paclitaxel once a cycle with 20 mg/m2 twice a cycle directly, and patients were enrolled only from our hospital, all of whom were Chinese. The efficacy evaluation of patients was performed by researchers of this study but not an independent evaluation committee. We do not have pre‐clinical pharmacokinetic research on high‐dose paclitaxel administered by intraperitoneal infusion, which is crucial for further clinical administration.There are some limitations to our study. First, it was a single‐arm phase II study, which made it impossible to compare 80 mg/mIn conclusion, the combination of intraperitoneal high‐dose paclitaxel and modified SOX is a safe therapy for advanced GC with peritoneal metastasis. Patients with sPCI ≤12 in synchronous peritoneal metastasis of GC should be recommended as conversion chemotherapy for this regimen. Compared with previous studies, it is more convenient and possibly more effective in some patients, but further clinical trials are necessary for a larger group of patients.Study concept and design: Meng Qiu, Jiankun Hu. Data acquisition: Li Tu, Ni Lu. Quality control of data: Wei‐Han Zhang. Data analysis and interpretation: Li Tu, Meng Qiu. Statistical analysis: Li Tu, Zi‐Han Xu, Kun Yang. Manuscript preparation: Li Tu, Wei‐Han Zhang. Manuscript editing: Meng Qiu. Manuscript review: Meng Qiu, Jiankun Hu. Administrative, technical, or material support: Hong‐Feng Gou, Qing Zhu, Ming Liu, Yu Yang.This work was supported by the National Key Development Plan for Precision Medicine Research (2017YFC0910004).No authors report any conflict of interest.All procedures followed were in accordance with the Declaration of Helsinki and the study was approved by the Institutional Review Board of our center. All patients provided written informed consent before enrollment.


This study aimed to develop a method for evaluating pelvic floor function using M‐mode ultrasound imaging and quantify the effectiveness of urinary incontinence rehabilitation.Eight participants aged 66–76 years, with urinary incontinence following radical prostatectomy, underwent pelvic floor muscle training. Using M‐mode ultrasound, we compared bladder base elevation time, length, and speed during pelvic floor muscle contraction. The results showed that four patients recovered urinary continence. Four patients displayed a 38.4%–80.1% reduction in urinary incontinence volume. Bladder elevation time was significantly reduced in all patients. Moreover, elevation speed increased significantly. Bladder base elevation time was 0.1 s in all patients in the acquired urinary continence group.Reducing bladder base elevation time to <0.2 s might be essential to achieve urinary continence. An elevation time of ≥0.3 s indicated significant pelvic floor muscle dysfunction. BBEBladder base elevationHoLEPHolmium laser enucleation of the prostatePTPhysical therapistPFMPelvic floor musclesPFMTPelvic floor muscle trainingRPRadical prostatectomyUCUrinary continenceUCAUrinary continence acquiredUIUrinary incontinenceUIIUrinary incontinence improvedUsing M‐mode ultrasonography enabled an easy evaluation of the bladder base in terms of elevation time, length, and speed during PFM contraction. Reducing the bladder base elevation time to <0.2 s was essential to recover UC. An elevation time ≥0.3 s indicated significant PFM dysfunction.Generally, RP is highly effective in prostate cancer, with 97% of the patients surviving for at least 5 years following surgery.A multidisciplinary treatment approach determined by urologists, physiotherapists, and other healthcare professionals is the therapy standard for post‐RP UI. In men, PFMT is recognized as the physiotherapeutic modality for post‐RP UI. Moreover, the European Association of Urology recommends this procedure in patients with post‐RP UI.From September 2020 to March 2021, PT initiated PFMT in eight patients with post‐RP UI, aged 66–76 years . The Ethical Committee of the Yawatahama City General Hospital approved this study (IRB number: 20210325–002). All patients provided written informed consent prior to enrollment. Out of these eight patients, four were recruited immediately post‐surgery and four were 3 months to 6 years post‐surgery. Moreover, RP was performed through laparotomy in four patients, robotic surgery in two, and laparoscopic surgery in two. In all cases, no nerve‐sparing technique was used.Following PFMT with guidance by a PT, the bladder base was visualized by transabdominal ultrasound tomography, with scans obtained in the sagittal imaging plane. In addition, we evaluated BBE time, length, and speed during PFM contraction using the M‐mode system.The parameters obtained upon the diagnosis of UC (Pad‐free) were compared with values before intervention. In patients without UC, the current (end of May 2021) parameters were compared to those before intervention.Furthermore, PFMT involved a method to train the PFM, trunk, and hip joints in a coordinated process Fig. . InstrucUltrasound evaluation was performed using Aplio 300 TUS‐A 300 . Moreover, we used a 3.5 MHz convex‐type probe, with the patient placed in the supine position and the hip and knee joints slightly flexed. To detect the bladder base, urine was stored in the bladder for at least 60 min. The bladder base was visualized in the mid‐sagittal imaging plane in B‐mode, and the M‐mode cursor was set at the part with the largest range of motion during PFM contraction. We recorded the waveform (movement) of the bladder base during PFM contraction Fig.  and analp‐value <0.05 was considered statistically significant.All analyses were performed using IBM SPSS 26.0 software . The values are expressed as mean ± standard deviation. We performed the Wilcoxon signed rank test to compare the variables before and after PFMT. A P = 0.012)  . Improved UI was observed in all cases, and four of the eight patients (Pad‐free) restored UC  Fig. , the ele12) Fig. . The len12) Fig. . HoweverUC Table . MoreoveUC Table . In healIn the UCA group, all cases were within the 0.1 s range in elevation time. In contrast, three patients in the UII group had elevation time ≥0.2 s.The BBE speed ≥20 mm/s was recorded in two of the eight patients before PFMT and in all patients following it.In the UCA group, BBE time was substantially reduced, and all cases were within the 0.1 s range. Moreover, BBE time in all healthy men and in patients with post‐HoLEP UCA was also within this 0.1 s range. Therefore, BBE time <0.2 s was considered an index for restoring UC, by continuing PFMT, in patients with UI. In addition, BBE time did not record an average ≥0.3 s following the appropriate continuation of PFMT in all participants. Therefore, an average ≥0.3 s was considered an indicator of significant PFM dysfunction.In all participants, BBE length did not significantly improve following PFMT. Miller et al. reported that the median vesical neck position in older women with UI was significantly dorsocaudal relative to its usual position among younger women.The BBE speed <20 mm/s was recorded in six of the eight patients before PFMT. Therefore, a BBE speed <20 mm/s might be associated with a high risk of UI.Pelvic floor function could be easily assessed by M‐mode ultrasonography. In addition, BBE time and speed were indicative of pelvic floor function and related to UI. Regardless of the duration of postoperative UI and age, improvement in UI or acquired UC could be expected. A BBE speed <20 mm/s might be associated with a high risk of UI. Reducing BBE time to <0.2 s was important to recover UC and ≥0.3 s was considered an indicator of significant PFM dysfunction.Yukimasa Ide: Conceptualization; data curation; investigation; methodology; project administration; writing – original draft. Nobuki Kikuchi: Validation; writing – review and editing. Tetsuya Fukumoto: Methodology; project administration; writing – review and editing. Hajime Takeda: Conceptualization; formal analysis; methodology; project administration; supervision; validation; writing – review and editing. Takafumi Okura: Formal analysis; project administration; resources; supervision; visualization; writing – review and editing.The authors declare no conflict of interest.The protocol for this research project has been approved by a suitably constituted Ethics Committee of the institution and it conforms to the provisions of the Declaration of Helsinki. The Committee of the Yawatahama City General Hospital, Approval number: 20210325–002.All informed consent was obtained from the participants.N/A.


In July 2021, the MDS transformed in acute myeloid leukemia (AML) with 21% medullar blast cells and the same cytogenetic abnormalities. A treatment based on venetoclax and azacytidine was then initiated. The patient was still alive in September 2021.In 2012, a 77‐year‐old woman was diagnosed with low‐risk myelodysplastic syndrome (MDS). In 2017, 5 years after diagnosis, her blood count showed anemia (96 g/l) and a medullar examination showed multi‐lineage dysplasia with 8% blast cells. Cytogenetic analysis on bone marrow cells showed an isolated 5q deletion. An erythropoietin treatment was started with initially a major response. In 2019, 7 years after diagnosis, in front of the anemia aggravation, lenalidomide was initiated and stopped 1 year later because of pulmonary hypertension. A growth‐factor‐based‐treatment was initiated, without effect. In June 2021, the bone marrow examination showed 16% blast cells and the medullar karyotype  mostly seen in AML and MDS, traditionally associated with an aggressive clinical course, poor response to chemotherapy and extremely short survival. The distinctive characteristic of our case lies in the presence of all variable cytogenetic manifestations known in amplification such as hsr, ring chromosomes and double minute chromosomes (the latter was only seen with FISH, Figure hsr is present on different chromosomes as a jumping translocation, another rare cytogenetics event.c event <% mostly


ImportaDespite improvements in treatment over the past two decades, many patients still have poor outcomes. Patients with human immunodeficiency virus (HIV) PCNSL have been shown to have particularly poor outcomes, although the reason for this is not well understood . Most clIn our study, we aimed to report the real‐world survival of PCNSL at three large academic US centers, including those who received high‐dose methotrexate (HD‐MTX) versus those who did not. We also compared the survival of HIV PCNSL relative to non‐HIV PCNSL and evaluated factors that may account for differences in clinical outcomes among various subgroups.22) with or without other chemotherapeutic agents, imaging to determine progression, and survival data. Data were analyzed for the entire cohort and separately for HIV and non‐HIV groups. Demographic variables were summarized using appropriate statistics  and compared between HIV and non‐HIV patients using Fisher's exact tests or Wilcoxon rank‐sum tests. Progression‐free survival (PFS) and overall survival (OS) rates were compared between HIV and non‐HIV patients using log‐rank tests. We also conducted multivariate analyses on PFS and OS using Cox proportional hazard regression model. This study was approved by the Institutional Review Board of each participating site and is in accordance with the Declaration of Helsinki.The medical records were queried for patients ≥ 18 years of age newly diagnosed with PCNSL at 3 academic US medical centers . The dates of diagnosis occurred between January 2004 and July 2020. Inclusion criteria included only the diffuse large B‐cell lymphoma (DLBCL) histology. Cases were excluded if there was any disease outside of the central nervous system (CNS) or if they previously had systemic DLBCL. Demographic information was collected from the medical record, as well as disease‐related information, HIV status, HD‐MTX treatment (defined as ≥ 3 g/m33.1We identified 158 cases of PCNSL (Table p = 0.0014) and OS  compared to those who did not receive HD‐MTX.One hundred fifty‐seven of 158 cases were evaluable for survival. The median PFS for the entire cohort was 1.18 years and the median OS was 3.24 years. Patients who received HD‐MTX had a significant improvement in PFS  and had a worse performance status . Notably, patients with HIV were less likely to receive HD‐MTX compared to patients without HIV . Patients who received HD‐MTX were also older  and had an improved PS . The frequency of receiving frontline whole‐brain radiation therapy (WBRT) trended towards significance in favor of the HIV PCNSL group. Other factors such as gender, deep structure involvement, elevated CSF protein, and elevated LDH were not significantly different between the groups.Twenty‐six of the 157 cases were HIV positive (Table p = 0.32), but there was a statistically significant difference in OS   or OS  , and treatment with HD‐MTX resulted in a decreased risk of progression . PS and HIV status did not have a significant impact on PFS. In terms of OS, each of the following factors had a statistically significant impact: increasing age , treatment with HD‐MTX , and HIV status . PS did not have a significant impact on OS.In a multivariate analysis (MVA), we evaluated the impact of each of the following variables on PFS and OS: PS, age, HIV status, and treatment with HD‐MTX. Increasing age correlated with a higher risk of progression , 63.2% of patients had a CD4 count <50 at diagnosis of PCNSL. Additionally, 42% had newly diagnosed HIV at the time of PCNSL presentation, while only 36.8% had been on ART for ≥3 months prior to PCNSL diagnosis. These variables were also compared according to HD‐MTX status. Those who received HD‐MTX (N = 10) did not have a statistically significant difference in any HIV‐related factors compared to those who did not receive HD‐MTX (N = 9).In a subset of HIV PCNSL patients at the University of North Carolina (4In one of the largest real‐world analyses of PCNSL to date, we found a median PFS of 1.18 years and a median OS of 3.24 years in patients with previously untreated PCNSL, including HIV PCNSL. As expected with real‐world data, survival rates were lower compared to a prospective trial evaluating a HD‐MTX induction regimen followed by WBRT consolidation, which had a median PFS of 3.3 years and median OS of 6.6 years , 6. In eTo evaluate this further, we compared patients who were able to receive treatment with HD‐MTX with those who were not. As expected, those who received HD‐MTX had significantly improved PFS and OS. This was further supported by the MVA, which showed that treatment with HD‐MTX was associated with improved PFS and OS independent of age, PS or HIV status. This lends further support to HD‐MTX‐based regimens as the standard frontline treatment for PCNSL, and most patients should be offered HD‐MTX‐based induction. However, there is likely selection bias in this non‐randomized study that could contribute to these findings. Not all patients are candidates for HD‐MTX due to severe renal failure or other comorbid conditions, and they may have worse survival due to these factors. Further research is needed to identify alternatives for these patients.HIV PCNSL has been evaluated in several retrospective, and few prospective, studies , 7–10. IIn order to further evaluate the reasons for the discrepancy between HIV and non‐HIV PCNSL survival, we compared only those patients who received frontline HD‐MTX. This revealed that in those receiving HD‐MTX, the discrepancy in OS between HIV and non‐HIV PCNSL was no longer statistically significant. This was likely driven by the improvement in OS from 0.3 years to 3.6 years in the HIV PCNSL patients who received HD‐MTX. Therefore, it seems that at least part of the difference in survival is being driven by the lower use of HD‐MTX in certain HIV PCNSL patients. When we compared patient and disease factors between HIV and non‐HIV PCNSL patients, we found that a PS ≥ 2 was significantly more common in the HIV PCNSL group. This could account for some of the reason why these patients did not receive HD‐MTX. The HIV PCNSL cohort was significantly younger than the non‐HIV PCNSL group, so older age was not a factor in this discrepancy. Despite the potential impact of these contributing factors, the MVA revealed that HIV status is associated with worse OS independent of HD‐MTX, age, or PS. Age and HD‐MTX were also independently associated with worse OS. The fact that HIV PCNSL patients had worse PS and received HD‐MTX at lower rates likely compounded the abysmal survival in this group.5In this large retrospective analysis of PCNSL, we have shown that real‐world survival is poor compared to clinical trial results. Additionally, HIV PCNSL has worse OS than non‐HIV PCNSL. This difference was not seen when evaluating only patients who have received HD‐MTX. HIV PCNSL patients received HD‐MTX at lower rates, likely due to worse baseline PS. The MVA showed that HIV status, age, and receiving HD‐MTX all independently contributed to survival outcomes, with HIV status having the largest magnitude effect. Every patient with PCNSL should be considered for treatment with HD‐MTX regardless of HIV status, and new treatment approaches for relapsed HIV PCNSL need to be evaluated.Christopher Dittus: Seagen, BeiGene and Genmab. Natalie Grover: Genentech, ADC Therapeutics, Kite, Novartis, Tessa Therapeutics. Jonathon B. Cohen: BMS, Genentech, LOXO, BioInvent, Novartis, Takeda, Astra Zeneca, Loxo, Beigene, Kite, Pharmacyclics, Abbvie. Steven I. Park: BMS, Seagen, Morphosys, Epizyme. Tarsheen Sethi, Alfredo Voloschin, JR, Xianming Tan, and Anne Beaven: No conflict of interest to disclose.This study is in accordance with the Declaration of Helsinki for the ethical treatment of human research participants.The authors received no specific funding for this work.


Cerebral phaeohyphomycosis is a fungal brain infection with a high fatality rate. It is caused by dematiaceous fungi and is increasingly recognized as a cause of serious illness in both immunocompetent and immunocompromised patients. We report cerebral phaeohyphomycosis in a liver transplant recipient. He was treated with multiple surgeries and antifungals and made a complete recovery. This report highlights that early and aggressive surgical intervention and extended antifungal coverage can have a positive outcome even in immunocompromised patients. The fungal infection in immunocompromised patients should be considered and treated aggressively. Cerebral phaeohyphomycosis is a fungal brain infection with a high fatality rate. Early and aggressive surgical intervention and extended antifungal coverage can have a positive outcome even in immunocompromised patients. The fungal infection in immunocompromised patients should be considered and treated aggressively. Common pathogens associated with this infection belong to dematiaceous fungi. Dematiaceous fungi are a heterogeneous group of ubiquitous fungi that form dark colonies and have pigmented hyphae.Rhinocladiella mackenziei in an immunocompromised liver transplant recipient. After aggressive surgeries and antifungals, the patient made a complete neurological recovery.We present a case of cerebral phaeohyphomycosis secondary to 2A 57‐year‐old gentleman, previously fit and well, a farmer by profession, underwent a living donor liver transplantation for decompensated chronic liver disease secondary to hepatitis B and D co‐infection. Post‐operatively, immunosuppressive therapy was started with oral prednisolone 20 mg once daily (tapered till the end of the third month), along with oral tacrolimus (with an adjusted dose for achieving a level of 5–8 ng/mL). He also received oral trimethoprim‐sulphamethoxazole and oral fluconazole 200 mg once daily for 3 months as prophylaxis for opportunistic infections as per local institutional protocol. His post‐transplant hospital course was uneventful.At four‐month post‐transplantation, he presented with acute onset of non‐remitting painless blurred vision in both eyes for 2 weeks. This was accompanied by a one‐week history of continuous high‐grade fever, which was relieved temporarily with antipyretics. He also complained of a continuous, diffuse, and moderate dull headache for 1 week which did not relieve with oral analgesia. He also reported a week of non‐projectile, non‐bilious vomiting four to five times a day. He had no history of unconsciousness, seizures, vertigo, diplopia, and weakness.On physical examination, his pulse was 78/minute, blood pressure was 124/82 mm of Hg, respiratory rate was 18/minute, and body temperature was 101 F. His Glasgow coma scale was 15/15. Nuchal rigidity, jolt accentuation, Kernig's sign, and Brudzinski's sign were absent. Cranial nerve examination and fundal examination were unremarkable. The patient had normal bulk, tone, reflexes, and power bilaterally in the upper and lower limbs. The sensory and cerebellar examination was unremarkable.9/L, 85.3% neutrophils) and a raised C‐reactive protein (12.1 mg/L). Electrolytes, liver, and renal function tests were normal. Contrast‐enhanced T2‐weighted magnetic resonance imaging (MRI) brain showed a hyperintense single ring‐enhancing parieto‐occipital lesion 3.4 cm × 2.5 cm × 3.9 cm with peripheral vasogenic edema suggestive of a brain abscess.  voriconazole (200 mg) twice daily on the recommendation of the infectious disease(ID) team after getting the culture report.Specimens were inoculated on Saboraud's dextrose agar , sheep blood agar , and potato dextrose agar . The plates were incubated at 25 and 37°C and were observed daily. After 3 weeks of inoculation, the growth of greenish colonies with raised peripheral edges was seen. Then, slide culture was prepared on malt extract agar  and mature sporulating colonies of However, the patient's symptoms, including headache and fever, did not subside 2 weeks after the surgery. On fifteen post‐operative day, MRI brain was repeated which showed residual brain abscess. So re‐evacuation was planned for source control. The residual brain abscess was drained, and the pus was re‐cultured. Repeated cultures grew the same organism.One week after the 2nd surgery, the patient's fever resolved completely. He was discharged after 1 month of total hospital stay. The headache also resolved after 1 month. The patient recovered completely without developing any focal neurological deficit. At discharge, he was advised voriconazole 200 mg once daily orally for 1 year by the ID team. Long‐term voriconazole therapy was discussed with the patient. Patient compliance was good and he completed therapy for 1 year.During this illness, the patient was continued on low‐dose tacrolimus (0.5 mg twice daily) due to ongoing sepsis. However, 1 month after his recovery, the tacrolimus dose was adjusted to achieve blood tacrolimus levels of 5–8 ng/mL. His liver function test remained stable throughout the illness despite being on a lower immunosuppression dose. The patient is doing well until the last follow‐up (one‐year post‐surgery).3Rhinocladiella mackenziei is being reported increasingly with cerebral phaeohyphomycosis.Rhinocladiella mackenziei can cause respiratory infections, deadly brain abscesses, and widespread sepsis.The hallmark of cerebral phaeohyphomycosis is the presence of a brain abscess. Immunodeficiency like solid organ transplantation, chronic liver disease, connective tissue disorders, and chronic steroid use can predispose to cerebral phaeohyphomycosis.Literature review reported a single brain abscess in 51.6% of patients while multiple brain abscesses in 48.4% of the patients.The most recent joint European Confederation of Medical Mycology (ECMM) and European Society of Clinical Microbiology and Infectious Diseases (ESCMID) clinical guidelines for cerebral phaeohyphomycosis treatment recommend complete control of the source of infection along with antifungal coverage.Rhinocladiella mackenziei.Despite treatment, cerebral phaeohyphomycosis has a high mortality. The average survival is up to 4.7 months.4Rhinocladiella mackenziei is a life‐threatening brain infection with high morbidity and mortality. Early and extensive surgical intervention with extended antifungal coverage can have a favorable outcome. Cerebral phaeohyphomycosis should be considered in immunocompromised patients with central nervous system symptoms.Cerebral phaeohyphomycosis caused by Kaleem Ullah: Formal analysis; investigation; writing – original draft. Muhammad Asif Baig: Investigation; methodology; writing – review and editing. Abdul Wahab Dogar: Investigation; methodology; writing – review and editing. Shams Uddin: Investigation; methodology; writing – review and editing. Chaudhary Abdul Fatir: Investigation; methodology; writing – review and editing. Ali Asad: Investigation; methodology; writing – review and editing. Muhammad Junaid Tahir: Investigation; methodology; writing – review and editing. Ka Yiu Lee: Investigation; methodology; writing – review and editing. Khabab Abbasher Mohamed Ahmed: Investigation; methodology; writing – review and editing. Zohaib Yousaf: Investigation; methodology; writing – review and editing.None.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Type 2 diabetes mellitus (T2DM) patients may have cardiac remodeling and dysfunction from the early stage of disease. This study aimed to determine the association between cystatin C (CysC) and early cardiac functional or structural impairment in T2DM patients without renal dysfunction.A total of 1135 T2DM patients without renal dysfunction and known heart diseases were included in our study. Cardiac function and structure were evaluated by echocardiography. Patients were diagnosed as left ventricular hypertrophy (LVH), impaired left ventricular (LV) diastolic function, and categorized into four different LV geometry patterns including normal, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy.E/e' ratio, and negatively associated with Tissue Doppler e', E/A ratio (p < .05). As a continuous variable, increasing CysC levels were associated with prevalence of LVH , impaired LV diastolic function , concentric hypertrophy  and eccentric hypertrophy  according to multivariate logistic regression analyses. While as a categorical variable, the highest CysC quartile (CysC > 1.04 mg/L) was associated with LVH , impaired LV diastolic function , and concentric hypertrophy .In multivariate linear regression analyses, CysC was positively associated with interventricular septum, LV mass index, left atrial volume index, CysC was significantly associated with early LV remodeling and cardiac functional impairment in T2DM patients with normal renal function. It could be a reliable and convenient biomarker detecting early impairment of cardiac function and structure in T2DM patients. Cardiovascular diseases (CVDs) and diabetes nephropathy (DN) are the major complications of T2DM with high morbidity and lead to high mortality. Coronary artery disease (CAD) and myocardial infarction are the most severe cardiovascular complications of T2DM resulting in adverse prognostic consequences.Cystatin C (CysC), a potent cysteine protease inhibitor that plays pleiotropic roles in human vascular pathophysiology,Although CysC has already been shown to be a risk factor of CVD morbidity and mortality regardless of patients with nephropathy or not,22.12 which was defined as renal dysfunctionThis cross‐sectional observational study consecutively enrolled type 2 diabetic patients who admitted in the Third Affiliated Hospital of Sun Yat‐sen University for glycemic control and finished echocardiography examination from April 2019 to May 2020. T2DM was diagnosed according to the 1999 criteria of the World Health Organization (WHO).2.2–1.154) × (age–0.203) × 0.742 . HbA1c levels were evaluated by high‐pressure liquid chromatography . The concentration of serum CysC was measured by particle‐enhanced turbidimetric immunoassay .Demographic and clinical data, including gender, age, height, weight, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), lifestyles , comorbidity, duration of diabetes and medications in the past 2 weeks were obtained for all patients by a well‐trained researcher. Blood pressure and HR were measured in the right upper arm using oscillometric methods after 10 min of rest. Body mass index (BMI) was calculated as body weight divided by the square of height. Hypertension was diagnosed as SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg or current use of antihypertensive medication.2.32 in men or 95 g/m2 in women.E) and late (A) diastolic velocities and E/A ratio were obtained afterward. Peak early diastolic mitral annular velocity (e') was measured at the junction of the interventricular septum with the mitral annulus in the apical four‐chamber view by pulsed‐wave Tissue Doppler imaging, and the septal E/e' ratio was calculated. Peak tricuspid regurgitation (TR) systolic jet velocity was assessed with continuous wave Doppler across the tricuspid valve. According to the 2016 ASE/EACI recommendation,E/e' ratio > 14; (2) septal e' < 7 cm/s; (3) TR velocity > 2.8 m/s; (4) LAVi > 34 ml/m2.Transthoracic echocardiography (IE33 echocardiography system) was performed on all participants according to the recommendations of the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACI)2.4χ2 test for categorical variables. We used linear regression analyses to assess the association between CysC levels and cardiac structure and function. Univariate linear regression setting CysC as independent variable and echocardiographic parameters as dependent variables (Model 1) was performed first. Afterward, two multivariate linear regression models were performed to adjust the confounding factors. The first model was adjusted for age, gender, and BMI (Model 2). The second model was additionally adjusted for HR, duration of T2DM, hypertension, smoker, drinker, medications, eGFR, UA, HGB, LDL‐C, HDL‐C, TG, HbA1c (Model 3). In Model 3, we also conducted sensitivity analysis replacing eGFR with Cr in the covariates to compare the different effect of eGFR and Cr. Afterward, univariate and multivariate logistic regression analyses were used to investigate the association between CysC and prevalence of LVH, impaired LV diastolic function, and different LV geometric patterns. Similarly, univariate (Model 1) and two multivariate logistic regression models (Model 2 and Model 3) were performed with the same covariates in linear regression analyses mentioned above. Furthermore, we conducted subgroup analysis stratified by HbA1c levels, presence of hypertension, BMI, gender, age, eGFR, smoking status, alcohol consumption, and tested for potential interactions of these covariates with CysC levels separately. For all tests, a two‐tailed p < .05 was considered to indicate statistical significance.All statistical analysis was performed by using SPSS 26.0 for Windows (SPSS Inc). Continuous variables were expressed as mean ± SD and categorical variables were presented as frequencies with percentage. Patients were grouped into quartiles according to serum CysC levels . Baseline characteristics and echocardiographic parameters were compared among groups using one‐way analysis of variance for continuous variables or Pearson 33.1From May 2019 to September 2020, 2038 T2DM patients finished echocardiography examination consecutively enrolled in the study. After exclusion of individuals with known heart diseases, impaired renal function, or missing CysC data, a total of 1135 patients  were eligible for analysis . There were no associations between CysC and LVEF, LVDd (p > .05). After adjusting for age, gender, and BMI (Model 2), these associations were similar (p < .05). Further adjusting for HR, duration of T2DM, hypertension, smoker, drinker, medications, eGFR, UA, HGB, LDL‐C, HDL‐C, TG, HbA1c (Model 3), CysC levels remained associated with IVS, LVMI, LAVi, A velocity, E/A ratio, Tissue Doppler e', E/e' ratio, and TR velocity (p < .05).Univariate and multivariate linear regression analyses were performed afterward to investigate the association between CysC levels and echocardiographic parameters Table . UnivariFor comparison, we also investigated the associations between other renal function indices (eGFR and CR) and echocardiographic parameters  and 348 (30.7%) cases, respectively. LV geometry classified as normal, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy were correspondingly observed in 392 (34.5%), 424 (37.4%), 229 (20.2%), and 90 (7.9%) cases.p < .001). Results were similar when we categorized individuals by CysC quartiles: the highest CysC quartile (CysC > 1.04 mg/L) was significantly associated with LVH and impaired LV diastolic function in both unadjusted and adjusted models (p < .001) (Table 2), but not in older patients and those with BMI ≥ 28 kg/m2 (p for interaction <.10). Moreover, the association between CysC and impaired LV diastolic function was existent in the patients with BMI < 28 kg/m2 but not in those with BMI ≥ 28 kg/m2 (p for interaction < .10)  Table . Subgrou1) Table , but notp < .05). As a categorical variable, highest CysC quartile (CysC > 1.04 mg/L) was significantly associated with both concentric and eccentric hypertrophy (p < .05), while it was only correlated to concentric hypertrophy after adjusting for all covariates (p < .05)  Table .4A velocity, E/e' ratio and TR velocity, and lower E/A ratio and Tissue Doppler e'. But CysC was uncorrelated to LVDd and LVEF. Moreover, increased CysC was significantly associated with LVH, impaired LV diastolic function, and LV concentric hypertrophy. These associations were independently of Cr and Cr‐based eGFR, while such relationships were not existent between Cr or eGFR and echocardiography parameters mentioned above.Our study found the association between CysC and early cardiac structural and functional impairment in T2DM patients with normal renal function and without organic heart diseases. In the echocardiography parameters, elevated serum CysC levels were independently associated with greater IVS, LVMI and LAVi, higher It has been already established that T2DM resulted in various target organ damage such as DN, diabetic retinopathy, atherosclerosis CVD and diabetic cardiomyopathy. Even in patients with prediabetes, the risk of CVD and heart failure were significantly increased.2 to avoid the confounding of moderate to severe renal impairment. Eventually, the associations between CysC and cardiac structural and functional abnormality were still existent in patients with normal renal function. In addition, this is the first study to demonstrate these associations in T2DM patients without heart failure and structural heart disease. As T2DM is the most important risk factor of preclinical cardiac dysfunction progression,Prospective epidemiological studies have already demonstrated that CysC was an independent risk factor of future CVD occurrence and progression.Although CysC has been proven to be an independent risk factor of CVD, the mechanisms still remained controversial. Van der Laan SW et al performed a Mendelian randomization studyFirst, as mentioned above, CysC has been proved to be a reliable biomarker of renal function and was more sensitive than Cr in the early stage of renal dysfunction. Similarly, previous studies also suggested that CysC could be a preferable marker in early recognition of diabetic nephropathy. Although we have excluded the patients with decreased eGFR and elevated Cr, a subset of the patients included in our study still might have early diabetic kidney damage. Our study has already excluded the patients with heart failure and structural heart diseases, thus the impairment of cardiac structure and function could be mainly attributed to diabetes itself which was considered to be the early stage of diabetic cardiomyopathy. As microvascular complications of T2DM, there were many common pathophysiological mechanisms of diabetic nephropathy and diabetic cardiomyopathy.Second, microvessels and myocardia impaired by diabetes might secrete more CysC into the circulation. Previous studies have already suggested that tissue CysC levels were reduced in atherosclerotic plaques while cells outside of the vascular walls secrete more CysC into the circulation.In addition, although Mendelian randomization study did not find a causal role of CysC in the etiology of CVD, basic research still showed the direct effect of CysC in cardiovascular pathophysiological changes. As an endogenous inhibitor of cysteine protease, the imbalance between cysteine proteases and CysC was considered to be implicated in the pathogenesis of cardiac remodeling.There were some limitations in our study. First, as a cross‐sectional study in single center, the sample size was relatively small. Second, considering the economic feasibility and clinical applicability, we evaluated cardiac structure and function using transthoracic echocardiography rather than cardiac MRI. Although we have already included indices reflecting cardiac function as comprehensive as possible, we did not have the cardiac mechanics indices such as global longitudinal strain, which could help to evaluate cardiac function more precisely. Third, our study excluded the patients with known organic heart diseases. Except CAD, other structural heart diseases could be diagnosed by echocardiography. However, definite diagnosis of CAD required coronary computed tomography angiography or coronary angiography. Most patients in our study finished these examinations, but there were still a small number of patients diagnosed CAD through clinical symptoms, electrocardiogram, and echocardiography. Finally, this is a cross‐sectional study without follow‐up for the future changes of cardiac structure and function. Although our results have provided evidence that CysC could be a marker detecting the early impairment of cardiac structure and function in T2DM patients, the causality relationship between CysC and LV remodeling and diastolic dysfunction cannot be determined. Thus prospectively cohort study was expected to investigate the effects of CysC in the future cardiac structural and functional changes.5In summary, our study demonstrated that elevated serum CysC was significantly associated with early LV remodeling and cardiac functional impairment in T2DM patients with normal renal function, mostly reflecting in LVH, impaired LV diastolic function, and LV concentric hypertrophy. These associations indicated that CysC could be a reliable and convenient biomarker detecting early impairment of cardiac function and structure in T2DM patients.Xinxue Liao and Xiaodong Zhuang designed the study and were in charge of the overall direction and planning. Zhuoshan Huang analyzed the data and wrote Abstract, Introduction, Results, and Discussion parts of the manuscript with input from all the authors. Junlin Zhong was responsible for echocardiography examination and wrote Methods part of the manuscript. Shaozhao Zhang and Zhenyu Xiong performed the statistical analyses. Yiquan Huang and Menghui Liu prepared figures and tables. Zhuoshan Huang, Junlin Zhong, and Xiaomin Ye collected the data needed for our study. Yifen Lin and Xiangbin Zhong were responsible for the modification of manuscript.The author declares no conflict of interest.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.


Contemporary therapies improve breast cancer (BC) outcomes. Yet, many of these therapies have been increasingly linked with serious cardiotoxicity, including reports of profound hypertension. Yet, the incidence, predictors, and impacts of these events are largely unknown.Leveraging two large U.S.‐based registries, the National Inpatient Sample (NIS) and the Food and Drug Administration Adverse Event Reporting System (FAERS) databases, we assessed the incidence, factors, and outcomes of hypertensive events among BC patients from 2007 to 2015. Differences in baseline characteristics, hypertension‐related discharges, and complications were examined over time. Further, we performed a disproportionality analysis using reporting‐odds‐ratios (ROR) to determine the association between individual BC drugs and hypertensive events. Utilizing an ROR cutoff of >1.0, we quantified associations by drug‐class, and individual drugs with the likelihood of excess hypertension.p < 0.001). Moreover, in FAERS, those with hypertension versus other BC‐treatment side‐effects were more frequently hospitalized , and were most commonly associated with chemotherapy (45.9%). Outside of Eribulin , no specific drug was associated with a higher reporting of hypertension; however, collectively BC drugs were associated with a higher odds of hypertension .Overall, there were 5,464,401 BC‐admissions, of which 46,989 (0.8%) presented with hypertension. Hypertensive BC patients were older, and saw initially increased in‐hospital mortality, which equilibrated over time. The mean incidence of hypertension‐related admissions was 732 per 100,000 among BC patients, versus 96 per 100,000 among non‐cancer patients  and the Food and Drug Administration Adverse Event Reporting System (FAERS) databases, we assessed the incidence, factors, and outcomes of hypertensive events among breast cancer patients from 2007‐2015. We found that breast cancer therapies associate with a substantial increase in limiting hypertension. We also sought to explore whether breast cancer was associated with a higher prevalence of hypertension‐related hospitalizations, and the potential factors underlying the development of these potentially limiting events.22.1The National Inpatient Sample (NIS) is a large administrative database of all‐payer health care utilization produced by the Agency for Healthcare Research and Quality (AHRQ) and is the largest publicly available all‐payer inpatient database in the U.S. Developed under the AHRQ Healthcare Cost and Utilization Project (HCUP), NIS includes administrative and demographic data from a 20% sample of discharges among all U.S. HCUP hospitals—excluding rehabilitation and long‐term acute care hospitals—equating approximately 8 million hospital stays from over 1000 hospitals. This study queried NIS hospital discharge datasets from January 2007 through December 2015.http://www.fda.gov/).The U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) is a publicly available, spontaneous reporting system that contains data on adverse drug events and medication errors submitted to the Food and Drug Administration (FDA). The FAERS contains data generated by reports from healthcare professionals and patients, as well as drug manufacturers for serious adverse reactions. The information is provided as free text and adverse drug events are coded with the Medical Dictionary for Regulatory Activities (MedDRA). All reports available in the FAERS database from Quarter 1, 2007 to Quarter 4, 2015 were accessed and downloaded from the FDA website (2.2DX1) for hypertension (174.x − 175.x) and at least 1 additional diagnosis code for breast cancer (401.x–405.x); near 99% were female. Hypertension typically reflected values deemed high enough by the treating provider to impact care and/or require hospitalization. Patients were considered non‐cancer  patients if they did not have a cancer Diagnosis Clinical Classification System (DXCCS) code or a cancer comorbidity code. We selected female controls, as the vast majority breast cancer is seen women.We identified all hospitalized adults (≥18 years) among the NIS cohort based on the International Classification of Diseases, Ninth Revision (ICD‐9), who had a primary diagnosis code  among FAERS cohort extraction of drug‐hypertension event pairs among patients presenting with breast cancer indication. We implemented natural language processing (NLP) techniques to pre‐process drug information captured in the unstructured text of the database. NLP strategies included text mining with entity recognition, relation detection, word sense disambiguation, and temporal inference.2.4Within NIS, our primary outcome was the report of clinical hypertension events , by breast cancer status. NIS provided data on specific outcomes including length of stay and discharge disposition. The inpatient hospital charges were converted to estimated costs using the HCUP‐provided cost to charge ratios and wage index for a given year. The wage index corrects for geographic variations in costs among hospitals. Estimates were inflation adjusted to 2015 U.S. dollars using annual hospital consumer‐price indices data from the U.S. Bureau of Labor Statistics.2.5t‐tests, and χ2 tests. Categorical variables are presented as N (%) and continuous variables are presented as mean ± standard deviation (SD). We determined the association between each of the aforementioned categorical demographic and patient factors with each of the aforementioned complications and hypertension‐related discharge using χ2 tests. Odds ratios (ORs) with 95% confidence intervals (CI) and their associated p values are presented for each of these analyses.Differences in baseline characteristics, hypertension‐related discharges, and complications were examined in each cohort over time with parametric and non‐parametric approaches, including both paired and unpaired N = 196 H‐HTN, N = 10,889 NH‐HTN), diabetes , stroke , and myocardial infarction . In instances of age and comorbidity, our conclusions remained the same (Table S2).For NIS, we used survey analysis techniques to account for data clustering and stratification. This leveraged established bias‐corrected weighted estimate equations for complex data, to model hypertension outcomes a function of covariates.For FAERS, spontaneous adverse events (AEs) of hypertension associated with breast cancer drugs were analyzed using the reporting odds ratio (ROR), a measure to highlight disproportionally reported signals of spontaneous adverse drug reaction reports in FAERS from Quarter 1, 2007 to Quarter 4, 2015. To calculate ROR, a 2 × 2 contingency table was drawn for each association between hypertension and a drug of interest (Table S1).p value of ≤0.01 was considered significant. All statistical analyses were performed with R software, version 3.5.1 ; packages utilized included cluster, odds ratio, sensitivity, survey, survival, and tidyverse. This study was deemed institutional review board exempt: Existing data from a large database such as NIS was collected in such a manner that subjects could not be identified directly or through identifiers linked to the subjects and FAERS data are publicly available.We plotted summary statistics for clinical outcomes and associated drug classes over the selected 9‐year period. A 33.1p < 0.001). Breast cancer patients were older , more commonly men, and reported a median Elixhauser comorbidity score of 18 (SD = 15.1) . In comparison to white women, black and Hispanic breast cancer patients saw higher rates of hypertension‐related admissions   presented with hypertension. The overall weighted average prevalence of hypertension‐related admissions was 732 per 100,000 admissions, compared to 96 among non‐cancer patients  compared to those without hypertension noted. The total number of adverse events in FAERS from all breast cancer drugs was 44,798 . Overall, the HER2 Targeted drug trastuzumab had the most frequent hypertension‐related adverse events from 2007 through 2015, followed by the monoclonal antibody bevacizumab (Table S3). Although trastuzumab had an elevated ROR of 1.28, regarding overall adverse events it was more likely to be associated with hypertension‐related adverse side effects compared to all other adverse side effects . Additionally, the combined ROR for the top 20 most commonly reported breast cancer drugs was 1.66 , indicating greater odds of being reported for a hypertension‐related adverse event compared to all other adverse events. This relationship may be driven in majority by eribulin, which had one of the highest hypertension‐related adverse event ROR irrespective of drug class . Moreover, over time hypertension‐related events associated with overall breast cancer therapies increased in number from 2007 through 2015 (p < 0.001), and this was largely driven by the chemotherapy arm ; but was unchanged over the 2007 to 2015 period. However, despite breast cancer patients seeing higher initial mortality, the overall risk of in‐hospital mortality remained similar among those with hypertension and underlying breast cancer over time versus those without cancer  compared to hypertension‐related admissions among non‐cancer patients at the index visit. However, nearly 82.6% of hypertension‐related hospitalizations in breast cancer patients compared with 56.9% in the non‐cancer patients, were billed to Medicare/Medicaid (p < 0.001). These trends were consistent over the period considered.Within NIS, overall unadjusted in‐hospital mortality rates followed a decreasing trend among all groups over an extended period of time from 2003 to 2015  is large enough to compensate for those errors. The dataset also does not allow for precise staging of cancer, beyond the presence of advanced or metastatic disease, nor is there provision for ongoing anticancer therapy, timing, or type of anticancer therapy , or code status. Use of more than one drug at a time could not be delineated. Spontaneous reporting system databases like FAERS are also distinguished by some important limitations, most notably no definitive proof of the causal relationship between exposure to the drug and the reported adverse event.5In the era of contemporary cancer therapies, limiting hypertension is an increasingly common limitation of effective anticancer therapy. Among breast cancer patients, common anticancer strategies associated with a significantly increased risk of profound hypertension, even leading to a greater than sevenfold increased need for hospitalizations. The occurrence of these events is associated with increased morbidity. These effects were most evident in older and minority populations. Given the expected continued rise in the number of breast cancer therapies, enhanced evaluation, and vigilance for the detection of hypertension, and effective blood pressure controlling strategies, are needed.Concept and design: RC, RS, AG, DA.Acquisition, analysis, or interpretation of data: RC, AC, RS, AG, AD, LK, DA.Drafting of the manuscript: RC, AC, RS, AG, AD, DA.Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: RC, AC, AG, PO, OON, DA.Supervision: DA.Dr. Addison was supported by NIH grant number K12‐CA133250, K23‐HL155890, and by a Robert Wood Johnson Foundation (Harold Amos)—American Heart Association Faculty Development Program grant. Dr. Carter was supported by the Mary H. and J. Churchill Hodges Clinical Prevention Program Fund at the Ohio State University Wexner Medical Center.All other authors declare no conflicts of interests in relation to the work presented in this manuscript.The data that support the findings of this study are available from the corresponding author upon reasonable request.Figure S1Click here for additional data file.Table S1‐S4Click here for additional data file.


Protein S‐palmitoylation  is a reversible lipid posttranslational modification catalyzed by the zinc finger DHHC‐type containing (ZDHHC) protein family. The reverse reaction, depalmitoylation, is catalyzed by palmitoyl‐protein thioesterases (PPTs), including acyl‐protein thioesterases (APT1/2), palmitoyl protein thioesterases (PPT1/2), or alpha/beta hydrolase domain‐containing protein 17A/B/C (ABHD17A/B/C). Proteins encoded by several oncogenes and tumor suppressors are modified by palmitoylation, which enhances the hydrophobicity of specific protein subdomains, and can confer changes in protein stability, membrane localization, protein–protein interaction, and signal transduction. The importance for protein palmitoylation in tumorigenesis has just started to be elucidated in the past decade; palmitoylation appears to affect key aspects of cancer, including cancer cell proliferation and survival, cell invasion and metastasis, and antitumor immunity. Here we review the current literature on protein palmitoylation in the various cancer types, and discuss the potential of targeting of palmitoylation enzymes or palmitoylated proteins for tumor treatment. Several oncogenes and tumor suppressors are modified by protein palmitoylation, a process that is dynamically controlled by the ZDHHC and PPT enzyme families, which add and remove palmitate, respectively. Palmitoylation affects protein stability, protein–protein interactions, membrane localization, and signaling transduction, thereby regulating tumor survival and tumor progression. Palmitoylation enzymes or palmitoylated proteins are potential targets for tumor treatment. These features are accompanied by genome instability and mutation, cellular metabolism, replicative immortality, sustained inflammation, evasion of growth suppressors, and immune suppression . The aboProtein palmitoylation is a reversible lipid modification, through which palmitate, a 16‐carbon palmitic acid, is added to a cysteine (Cys) residue via a thioester bond . PalmitaPalmitoylation is catalyzed by the zinc finger DHHC‐type containing (ZDHHC) protein family , while depalmitoylation, the reverse reaction, is catalyzed by Acyl‐protein thioesterases (APT1/2), palmitoyl protein thioesterases (PPT1/2), or alpha/beta hydrolase domain‐containing protein 17A/B/C (ABHD17A/B/C) , 7.Biochemically, palmitoylation can significantly enhance the hydrophobicity of the modified protein in specific subdomain or subdomains, considering that a few proteins are mono‐palmitoylated and many other proteins are potentially multi‐palmitoylated. The increased level of hydrophobicity may affect varied aspects of protein features and functions; for example, it might modulate the associated affinity with membrane structure  and thus determine the protein localization Fig. , throughversus protein palmitoylation functions that are shared across cancers, and discuss how palmitoylation can be specifically targeted for cancer treatment in a case‐by‐case scenario.Numerous proteins, including key oncogenes and tumor suppressors, are palmitoylated, and their palmitoylation seems to be closely associated with tumorigenesis and tumor progression Fig.  13, 15,,15, 17. 22.1in vitro and in vivo [Palmitoylation could have a direct impact on substrate activity and regulate tumor growth. It has been presented that palmitoylation of phosphatidylinositol 4‐kinase IIα (PI4KIIα) simply accelerates tumor growth in mice by regulating its catalytic activity and subcellular localization , 22 Fig, and imp in vivo  ; more evidence from xenografts or in vivo tumor models will strengthen these claims.Palmitoylation is also suggested to be involved in controlling metastasis in breast cancer, either promoting or inhibiting. For instance, palmitoylation of CD44 at Cys286 and Cys295 inhibited cell migration by promoting the lipid raft affiliation, and abrogating palmitoylation by mutating the palmitoylation site reduced CD44 raft localization, increased CD44‐ezrin interaction, and improved invasive MDA‐MB‐231 cell migration . On the oylation . As angioylation ; it is soylation . This inoylation  , which binds to programmed cell death protein 1 (PD‐1) on T‐cells and transmits immunosuppressive signals . Interes2.4de novo synthesized fatty acids, including palmitate, benefit tumor cells [de novo palmitate synthesis in prostate and breast cancer cell lines . Increased palmitate levels then result in mtEGFR palmitoylation at Cys797 and subsequent mtEGFR activation to decrease the sensitivity of pC3 cells to tyrosine kinase inhibitors (TKI) [Recent studies have shown that or cells . Signalirs (TKI) .33.1Many reported palmitoylated proteins related to prostate cancer are involved in regulating cell proliferation or survival. Src family kinases Src, Fyn, or Lyn act as major convergence points for numerous receptors and cell‐autonomous signaling pathways, resulting in enhanced cell proliferation, and metastatic potential during cancer progression , 34. Pal3.2A study published in 2004 showed that the cancer metastasis suppressor KAI1/CD82 was palmitoylated at multiple sites  to inhibit migration and invasion of prostate cancer cells; and palmitoylation deficiency by mutating palmitoylation sites resulted in the loss of this inhibitory effect . This st3.2.1In immortalized prostate epithelial cells, overexpression of FASN activated β‐catenin via Wnt1 palmitoylation, and subsequently activated ligand‐independent AR . Further44.1Palmitoylation was shown to be closely related to the progression of colorectal cancer (CRC) , 46. StiWnt signaling has a key role in tumorigenesis, including CRC progression . Of note4.2The palmitoylation of SFK family member YES plays an important role in regulating the activation of the RAS/MAPK signaling pathway. Mechanistically, the palmitoylation of YES at the SH4 domain regulates its localization in the cholesterol‐rich membrane microdomain, which augmented the phosphorylation of EGFR, SHC, and SHP2, the upstream regulators of RAS/MAPK signaling, thereby inhibiting colon carcinoma cell adhesion and promoting invasion . Akin to4.3PD‐L1 is specifically palmitoylated at Cys272 by ZDHHC3 in human colorectal cancer cell lines; inhibiting such palmitoylation promotes ubiquitin‐mediated protein degradation of PD‐L1, thereby activating antitumor immunity and significantly suppressing tumor growth . Accordi5Hematological cancers are commonly known as blood cancers, which usually form in the bone marrow or cells of the immune system. Although called blood cancer, hematological cancers include cancers such as a wide range of myelomas, lymphomas, and leukemias.5.1Scutellaria baicalensis Georgi with antileukemic properties—reported that Wogonoside inactivates the NRAS/RAF1 signaling pathway by blocking NRAS palmitoylation in acute myeloid leukemia (AML) cells [The RAS family members HRAS, NRAS, and KRAS were the first oncogenes identified in human cancers . A 2018 L) cells . Of noteL) cells . A seconL) cells . KRAS4A L) cells . InteresL) cells   cells .Moreover, another study showed that the alkyl phospholipid 10‐(octyloxy) decyl‐2‐(trimethylammonium) ethyl phosphate (ODPC), which specifically induces apoptosis in leukemia cells by targeting the high cholesterol domain in cell membranes , lowered5.2As shown above, KAI1/CD82 palmitoylation prevents tumor metastasis in both breast and prostate cancers; however, the palmitoylation of KAI1/CD82 on the membrane of AML cells promotes the development of aggressive leukemia through recruiting and stabilizing protein kinase C alpha (PKCα) in membrane clusters, and subsequently sustaining ERK signaling . Convers5.3It has been suggested that immune suppression is closely related to leukemogenesis, yet possibly mediated by diversified molecular machineries. Extended evidence suggests that the uptake by monocytes of AML‐derived extracellular vesicles with abundant palmitoylated proteins on their surface promotes the differentiation of myeloid‐derived suppressor cells, thereby enhancing immune escape  Fig. 2,.66.1The melanocortin‐1 receptor (MC1R) is a member of the GPCR family that is expressed on melanocytes and enhances ultraviolet (UV) tolerance when activated , which r6.2NRAS activating mutations [et al. [It was suggested that ZDHHC20 mutants in melanoma cells reduce palmitoylation of melanoma cell adhesion molecule (MCAM) and impair the MCAM ability to inhibit cell invasion, whereas Wnt5a promotes depalmitoylation of MCAM at Cys590 via phosphorylated APT1 ; APT1 inutations , 73  accounts for nearly 85% of all lung cancer cases that are clinically diagnosed . The lin99.1ZDHHC19‐mediated SMAD family member 3 (Smad3) palmitoylation at Cys421 enhances activation of the transforming growth factor (TGF) signaling pathway, and Smad3 interaction with E1A binding protein P300 (EP300) promotes mesenchymal‐like transition in the mesenchymal subtype of glioblastoma (GBM) . Importa9.2In advanced GBM, the membrane expression and palmitoylated form of solute carrier family 1 member 3  were dramatically downregulated, resulting in impaired glutamate uptake   at Cys103, Cys106, Cys181, Cys182, and Cys184 to enhance ovarian cancer progression and, reversely, defective CLDN3 palmitoylation inhibits membrane localization and protein stability of CLDN3, with a negative impact on ovarian cancer cell growth . In addier cells . On the er cells   is the most frequent primary liver cancer and a serious medical problem , there aMoreover, protein palmitoylation has been implicated in the development of renal clear cell carcinoma (RCC), bladder cancer, gastric adenocarcinoma, and osteosarcoma. The expression patterns of ZDHHC have been correlated with RCC prognosis, as well as with the immune profiles, molecular features, and signaling pathways of RCC . In bladReduced ZDHHC2 expression has been linked to lymph node metastasis and is an independent predictor of poor prognosis in gastric adenocarcinoma  Table 11. In pit12By summarizing palmitoylated proteins in different types of cancer Fig. , it was 13Since its discovery more than 40 years ago, scientists have gained a more detailed understanding of the biological role and regulation of protein palmitoylation. Abnormal palmitoylation status has been reported in several disease states, such as in neurodegenerative diseases , 105, in13.1For targeting ZDHHCs or PPTs, shRNA or enzyme activity inhibitors were commonly used to either downregulate the protein expression or inhibit the enzymes functioning. For example, inhibiting PPT1 with DC661 also dramatically suppresses the development of a variety of tumors . For tar13.2ZDHHC5 regulated Flotillin2 palmitoylation is important for Flotillin2 localization in lipid rafts , which s13.3ZDHHC3‐mediated palmitoylation plays a key role in regulating the expression, stability, and function of integrin α6β4, and knockdown of ZDHHC3 with shRNA affects integrin‐dependent cable formation and signaling in prostate tumor cells . Moreove13.4in vivo [Cancer stem cells (CSCs) are types of tumor cells with self‐renewal and multi‐differentiation capabilities, which play a key role in tumor progression. One study illustrated that a small‐molecule inhibitor, RU‐SKI 43, targets SHH‐palmitoylating Hedgehog acyltransferase (HHAT), and effectively reduces colon CSCs survival at low dosages by blocking all signaling downstream of SHH . Surprisin vivo . Last, bin vivo   with gilteritinib (FLT3 inhibitor) also significantly suppressed FLT3‐ITD‐mediated signaling and leukemia progression [It was revealed that the universal palmitoylation inhibitor 2‐Bromopalmitate (2‐BP) and all‐trans retinoic acid have a synergistic differentiation‐inducing effect in acute promyelocytic leukemia. Mechanically, it was suggested that 2‐BP covalently binds to retinoic acid receptor alpha (RARα) and prevents RARα degradation, resulting in the promoted transcription of RARα‐target genes . This sugression , indicatgression . Howevergression . Therefogression . Additiogression  (Table 113.6280‐288/45‐59) or the mouse model antigen ovalbumin (OVA257‐264/323‐339) conjugated to palmitolate anhydride (C16:0) was developed that is efficiently internalized by DCs and subsequently cross‐presented to CD8+ T‐cells, ultimately inhibiting melanoma progression [It was reported that inhibition of PPT1 with specific PPT1 inhibitors hydroxychloroquine (HCQ) or dimeric CQ DC661 induced interferon‐β secretion in macrophages and enhanced the antitumor efficacy of the anti‐PD‐1 antibody in melanoma . In addigression   significantly suppressed GBM cell survival by inhibiting the cell cycle and promoting apoptosis  Table 11. Intere13.10in vitro and in vivo, possibly by disrupting tubulin palmitoylation, expression and microtubule organization [Two selective and potent FASN inhibitors, TVB‐3166 and TVB‐3664, were discovered and used in ovarian, lung, prostate and pancreatic cancer mouse models, which presented that inhibiting FASN in combination with taxane therapy inhibited tumor cell growth both nization . Mechaninization   signaling pathway. Moreover, GNS561 and sorafenib (a multikinase inhibitor) were found to have a synergistic impact on preventing tumor development and cell proliferation in a mouse tumor model , 143 , palmitoylation‐targeting strategies should be carefully designed according to each specific situation.Initially, several studies reported that 2‐BP was used to inhibit tumorigenesis at a cellular level ; howeverin vitro and in vivo.No specific and potent inhibitors have so far been developed to target ZDHHCs. However, considering that ZDHHCs might have multiple and even cross‐substrates for palmitoylation , potentiin vitro studies in cell lines. Therefore, introducing a palmitoylation antibody and novel tools as specific agonist or antagonist of palmitoylation will greatly advance the research fields.Third, it is difficult to establish a direct mechanistic connection between palmitoylation of specific proteins and their function in cancer. This stems from the lack of specific palmitoyl transferase inhibitors, of palmitoyl‐mimetic mutations, or of consensus palmitoylation sequences that make gain of function studies challenging. Moreover, there are no antibodies to palmitoylated epitopes, and therefore correlation between palmitoylation levels of a protein and tumor grade in patient samples are extremely difficult. It should be noted that most of the examples summarized here are Together, it can be visualized that the functional studies of palmitoylation in tumorigenesis are mostly focused on breast cancer, prostate cancer, colorectal cancer, leukemia, melanoma, pancreatic cancer, and NSCLC, but are less explored in other types of cancer, including RCC, osteosarcoma, GBM, ovarian cancer, HCC, bladder carcinoma, gastric adenocarcinoma, and pituitary tumors. More pathogenic mechanisms related to protein palmitoylation are expected to be discovered in all these human cancer types, which will give a solid theoretical basis for therapeutic development in the future.The authors declare no conflicts of interest.BZ, QH, and EK conceived and designed the project, BZ and EK wrote the article, and BZ, YL, and EK revised the article.