Among all cardiac surgeries, coronary artery bypass graft is frequently performed and is expected to improve the quality of life in patients with coronary artery disease. This study aimed to look at the prevalence of the patients undergoing coronary artery bypass grafting among cardiac surgery cases at a tertiary care hospital.This was a descriptive cross-sectional study conducted at the Cardio-Thoracic and Vascular Surgery department of a tertiary care hospital among 92 patients who underwent cardiac surgery. Participants were enrolled after the ethical clearance from the Institutional Review Committee (Reference number: 574/2019). Epidemiological characters, functional New York Heart Association classification, and left ventricular function were evaluated. Data were entered in Microsoft Excel 2010 and analyzed using Statistical Package for the Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.The prevalence of coronary artery bypass graft in patients undergoing cardiac surgery was 49 (53.2%) . The mean age of 49 patients was 58.87 years. Hypertension 43 (88%), Dyslipidemia 34 (69%) and Type 2 Diabetes Mellitus 25 (51%) were major comorbidities. The mean preoperative and postoperative ejection fraction was 48.2±10.5% and 52.6±6.0% respectively. The preoperative median New York Heart Association class was 3 whereas the post-operative class was 1. Mortality was seen in one (2.04%) patient.The prevalence of coronary artery bypass graft in the patient undergoing cardiac surgery was lower than noted in other studies. Ethical approval was taken from the Institutional Review Committee (Reference number: 574/2019). These patients were enrolled from June 2019 to March 2021 after taking written informed consent. All cases were followed up for at least a 12 weeks period. The convenience sampling technique was used. The sample size was estimated as,2 × p × q / e2n = Z2 × 0.7 × (1-0.7) / (0.01)2  = (1.96)  = 81Where,n = minimum required sample sizeZ = 1.96 at 95% Confidence Interval (CI)7p = prevalence of CABG surgery in a cardiac center taken from a previous study, 70%q = 1-pe = margin of error, 10%Accounting for 10% non-response rate, the total number of participants needed for the study was 90. We included 92 participants. The variables measured were baseline clinical characteristics, comorbidities, New York Heart Association (NYHA) class, Left Ventricular Ejection Fraction (LVEF), coronary angiography findings, perioperative complications, and duration of hospital stay. LVEF was measured subjectively by visual estimation and objectively re-confirmed by M mode or modified Simpson method.Data were entered in Microsoft Excel 2010 and analyzed using IBM Statistical Package for the Social Sciences version 20. Continuous data are reported as mean and standard deviation, categorical data as frequency and percentage. Pre and post-left ventricle functions were presented with reference to NYHA and LVEF. Point estimate at 95% CI was calculated.Out of the total 92 cardiac surgeries, 49 (53.2%)  were coronary artery bypass grafting. Among 49 CABG cases, there was one (2%) in-hospital mortality whereas the remaining 48 (98%) were successfully followed up for three months. The mean and median age of the CABG patients were 58.87 and 58.0 years respectively. Forty-five (92%) of the CAD were triple vessel disease (TVD) followed by three (6%) Double Vessel Disease (DVD) and one (2%) Single Vessel Disease (SVD). Four (8%) had left main stem disease. Hypertension, dyslipidemia, diabetes, and thyroid disease were present among 43 (88%), 34 (69%), 25 (51%), and eight (16%) respectively .Perioperative inotropes and blood transfusion were used among 46 (93.8%) and 39 (79.6%) cases respectively. One (2%) patient went under IABP during the CABG procedure. The mean pump time was 88 minutes with a range of 56-192 minutes. The mean aortic cross-clamp time was 52 minutes with a range of 27-149 minutes. The mean ventilator support duration was 6 hours with a range of 4-12 hours. Median ICU stay was 2 days whereas eight (16.3%) patients had single day ICU stay and one (2%) patient had 5 days stay. The median hospital stay was 6 days whereas one (2%) patient was discharged after 3 days and two (4%) patients were admitted for 12 days before discharge. Nine (18.3%) patients had postoperative arrhythmia. Postoperative acute kidney injury (AKI) was present among seven (14.2%) cases two (4%) required hemodialysis .One (2%) patient had to consider re-surgery for sternum dehiscence. Patients with other cardiac diseases were also repaired .Preoperative mean and median EF were 48.2±10.5% and 50% respectively. Postoperatively the mean and median EF was 52.6±6% and 55% respectively. Preoperatively median NYHA class was 3 whereas the postoperative median NYHA class was 1 respectively .7 This could be due to the increased frequency of Rheumatic Heart Disease in our population and their subsequent surgeries.8 The mean and median age in our study was less than 60 years whereas in the developed country it is much higher.6 Prevalence of CAD in early ages in our setup as compared to developed countries could have been due to genetic predisposition for coronary heart disease risk factors such as possibly the metabolic syndrome in South Asia and increased exposure to risk factors. The male gender was more common to have CABG. Globally there is a tendency for female patients to receive less aggressive invasive and pharmacological treatment after ACS. However, in our study male and female ratio are almost equal (49:51). This difference in our study could have been due to the small sample size.9In this descriptive cross-sectional study, out of 92 consecutive cases of cardiac surgeries 49 patients underwent CABG. The prevalence of CABG in the patients undergoing cardiac surgery was 53.2%, which was lower than noted in other studies.10Risk factors for CAD like hypertension, dyslipidemia, and diabetes were present among more than 50% of the cases. The INTERHEART study showed that there were potentially modifiable risk factors for ACS including raised Apo B/Apo A ratio, current smoking status, psychosocial factors, diabetes, hypertension, abdominal obesity, alcohol consumption, regular physical activity, and daily consumption of fruits and vegetables.6 In CAD patients with LV dysfunction, there is marked improvement in LV functions and it may even normalize in some patients which leads to improvement in functional NYHA class shown by different studies. Preoperatively NYHA class 2, 3, and 4 symptoms were present among one (2%), 27 (55.1%), and 21 (42.8%) respectively. After 12 weeks NYHA class 1 and 2 status was among 34 (70.8%) and 14 (29.2%) patients respectively. Preoperative ejection fraction <30%, 31-45% and >45% were six (12.2%), 15 (30.6%) and 28 (57.1%) respectively. Postoperative ejection fraction 31-45% and >45% were nine (18.7%) and 39 (81.2%) respectively. This significant improvement in the outcome was comparable to the studies done by Caputti GM, et al, Islamoglu F, et al. and Mickleborough LL, et al.13 Various factors are responsible for the outcome such as preoperative LV systolic dysfunction severity, lesion pattern, case selection, surgical hands, complete revascularization, proper myocardial protection, cardiac anesthesia management, emergency cardiac facilities, and postoperative intensive care monitoring and management.15 To determine the outcome in decreased LVEF, a study was conducted by the Canadian Cardiovascular Society, which revealed a 42% improvement in Angina Class, thus concluded CABG can be performed safely for improving LVEF and quality of life.CABG has been considered as independent of the perioperative factors associated with the improvement of quality of life.16Chertow, et al. in their study show renal injury/ failure in cardiac surgery varies between 5-30% and needing hemodialysis is 1-5%, which is comparable to our study. The percentage of the patients developing postoperative complications in the form of AKI needing hemodialysis in our study was 4% which was comparable. Factors like perioperative renal ischemia or reduced renal reserve lead to postoperative renal insufficiency; increase in creatinine of more than 0.5 mg/dl or a relative increase of more than 25% from the baseline has been commonly used in different studies. The proper method of preventing this type of complication and treatment strategies are urgently needed.17 In our study, 4% of patients underwent reexploration for excessive bleeding which is a bit higher than other studies. An increased tendency of bleeding was observed in high body mass index, high European System for Cardiac Operative Risk Evaluation (EURO) score, urgent/ emergency surgeries, increased creatinine level, and low platelet counts of patients. Re-exploration leads to significant blood transfusion, adverse effects on cardiorespiratory functions, increased period of mechanical ventilation support, prolonged intensive care unit stay, hospital stay, and increase mortality.18Post cardiac surgery bleeding is well known serious complication, requiring reexploration, blood transfusion, increased in-hospital stay, and cost leading to increase morbidity and mortality.5 The differences could be due to small sample size, differences in population age group, and variation of comorbidities between two population groups. 30-day mortality risk after CABG surgery decreased from 3.1% from 1999 to 2000 to 2.4% during 2011 to 2012, while the 1-year risk remained unchanged.19Perioperative mortality in our study was 2% as compared to the Danish cohort of 51307 CABG patients 3.2%.The limitations of study was small sample size in a single tertiary center. Participants were enrolled in sequential manner rather than randomization. We used left Internal mammary artery (LIMA) and saphenous vein grafts only and did not use right internal mammary artery (RIMA) or radial grafts. We did not study the myocardial viability imaging in patients with low LV function which could have an impact on outcome.The prevalence of CABG in the patients undergoing cardiac surgery was lower than noted in other studies. This could be due to the increased frequency of rheumatic heart disease in our population and their subsequent surgeries. The baseline characteristics of the participants undergoing CABG were similar to other studies. The mortality was also comparable.


Anastomotic leakage (AL) is one of the most serious postoperative complications after colorectal anastomosis. This study aims to evaluate the feasibility and diagnostic accuracy of magnetic resonance imaging (MRI) in the early detection of AL in patients with clinically suspected AL after rectal anterior resection.This was a prospective study including patients who underwent anterior resection and postoperative MRI examination. AL was diagnosed by comprehensive indictors, which were mainly confirmed by clinical signs, symptoms, and retrograde contrast enema (RCE) radiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of diagnosing AL with MRI were calculated.In total, 347 patients received anterior resection for rectal cancer, and 28 patients were suspected to have AL. Finally, 23 patients were included and received MRI examination. The median time interval from surgery to MRI was 10 days (3–21 days). The median distance from anastomosis to anal verge was 4.0 cm (2.0–10 cm), and 11 patients underwent diverted ileostomy. Eighteen patients had an anastomotic leak, including one patient who had a pelvic abscess and five patients who had no evidence of AL in the MRI examination. The overall sensitivity and specificity were 94.4% (95% CI 70.6% to 99.7%) and 80% (95% CI 29.8% to 98.9%), respectively. The PPV was 0.94 (95% CI 0.71 to 0.99) and the NPV was 0.80 (95% CI 0.29 to 0.99). For patients who had anastomosis less than 5 cm, the diagnostic accuracy of MRI was 93.7% (15/16). T2-weighted imaging with fat suppression can effectively reveal the leak track.The accuracy of plain MRI examination in diagnosing AL was favorable for patients with a suspected AL. T2-weighted imaging with fat suppression was the best imaging modality to diagnose AL. A multicenter prospective study with more samples is needed to further determine the safety and feasibility of MRI in the diagnosis of AL. ANastomotic leakage (AL) is one of the most serious postoperative complications after rectal resection. The frequency of AL is 1.5% to 15% according to the previous literature . Most ofIt is imperative to identify AL as early as possible given the severity of the complications associated with AL. Actually, clinical symptoms and signs of AL are not typical, and AL may be confused with other less life-threatening postoperative complications , 8. TherWater-soluble contrast enema (WSE) and computed tomography (CT) imaging are the most prominent methods used to detect AL; however, some studies have shown that WSE has a high false-negative rate, even up to 46%, in patients with AL , 10. CT Magnetic resonance imaging (MRI) has an undisputed role in the evaluation of anal fistula based on a sensitivity of up to 100% and a specificity of 86% for visualization of the fistula track , 15. WheThis was a prospective study that was conducted at the Fujian Medical University Union Hospital (FMUUH) from November 2020 to June 2021. In total, 347 patients received anterior resection for rectal cancer during this period, and 28 patients were suspected to have AL. Finally, 23 patients were included and received MRI examination after the remaining 5 patients refused to undergo MRI. Three patients received hand-sewn anastomoses because they had rectal cancer that was too low to receive intersphincteric resection (ISR). The pelvic drain was placed routinely in patients who received rectal anterior resection in our institution. Generally, the drain tube was removed 5–7 days after surgery.Anastomotic leakage after anterior resection of the rectum was defined as an interaction between the intra- and extraluminal compartments due to a defect in the integrity of the intestinal wall at the anastomosis between the colon and rectum or the colon and anus according to the consensus of the International Study Group of Rectal Cancer (ISREC) , and a pAll patients received MRI examination at an appropriate time after AL was suspected. The baseline clinicopathological characteristics and the clinical data after surgery, such as laboratory findings, surgery reports, radiology reports, symptoms, and signs, were recorded. This retrospective study was approved by the institutional research ethics committee of FMUUH (2021KY136).MRI examinations were achieved using a whole-body 3T MRI system  using an 18-channel body matrix coil combined with a 32-channel spine matrix coil. The scan protocol comprised 2D sagittal T2WI FS and 3-dimensional (3D) axial T2WI FS with coronal and sagittal reformations. The MR parameters used in 2D sagittal T2WI FS were as follows: FOV of 20 × 20 mm, slice thickness of 2 mm, TR/TE of 7680/84 ms. In addition, 3D axial T2WI FS was acquired with the following parameters: FOV of 23 × 23 mm, TR/TE of 1700/100 ms, and slice thickness of 1 mm without spacing. All patients received MR examination without enhancement scan and contrast enema.All MRI results for patients with suspected AL were independently evaluated by two experienced abdominal radiologists (GC & HW). The following features indicated AL: 1) presence of peri-anastomotic air and/or fluid; (2) disintegration of the anastomotic staple line; and (3) leakage of the tract from the anastomosis to the pelvic and/or adjacent organ  and negative predictive value (NPV) were calculated. All analyses were performed with SPSS 23.0 for MAC .Twenty-three patients who underwent rectal resection with colorectal end-to-end anastomosis and were clinically suspected to have AL were included in the final analysis. Among them, there were 5 females and 18 males, and the median age was 58.1 (41–84) years old. The median distance from the inferior edge of the tumor to the anal verge was 8 cm (4–15 cm), and 13 patients received neoadjuvant therapy before surgery. The median distance from anastomosis to anal verge was 4.0 cm 2.0–10 cm), and 11 patients underwent diverted ileostomy. Anastomosis was performed by hand sewing in 3 patients and by stapling in 20 patients. Seventeen patients also received contrast enema (CE) radiography before or after MR examination at one- to two-day intervals. The clinical characteristics are shown in Tables .0–10 cm,All 23 patients signed the consent form and underwent MR examination after surgery. The median time interval from surgery to MR was 10 days (3–21 days). No adverse events caused by MRI were found during the study period. Eighteen patients were found to have an anastomotic leak, including one patient who had a pelvic abscess and five patients who had no evidence of AL on MRI examination. Among patients whose MRI indicated AL, three patients had no signs or symptoms of AL, but the bacterial culture of drainage fluid was positive, indicating a grade A leak. One patient whose anastomosis was located 10 cm from the anal verge had a negative MR result, but CE indicated an AL  and 80% (95% CI 29.8% to 98.9%), respectively. The PPV was 0.94 (95% CI 0.71 to 0.99) and the NPV was 0.80 (95% CI 0.29 to 0.99). In total, 16 patients had an anastomosis smaller than 5 cm, and the diagnostic accuracy of MRI for these patients was 93.7% (15/16). For patients who received CE, eight patients had positive results, and nine patients had negative results. The sensitivity and specificity values were 37.5% (95% CI 16.3% to 64.1%) and 100% (95% CI 5.5% to 100%), respectively. The PPV was 1 (95% CI 0.52 to 1.00), and the NPV 0.09 (95% CI 0 to 0.43).All patients were cured by conservative treatment, including pelvic drainage, antibiotics, and anal tube drainage.AL following anterior resection is a severe complication that can increase morbidity and mortality. If AL is detected as early as possible, adverse events could potentially be reduced. Alves et al. found that the mortality rate increased from 0 to 18% if the diagnosis of a leak was made after the fifth postoperative day . HoweverThe best imaging method to detect AL has been debated in previous studies in past decades , 20, 21.CT is also an important imaging tool for assessing AL because it provides a more precise image of the anastomosis and peri-anastomotic structures compared with conventional radiology. A pelvic abscess close to the anastomosis is also considered AL according to the definition provided by ISREC, which indicates the diagnostic advantage of MRI and CT compared with CE. However, the sensitivity of CT scanning is unfavorable in some studies with values ranging from 14.8% to 68% , 23. TheMRI has been widely recognized as the gold standard imaging modality for the assessment of anal fistula due to its high accuracy in discriminating the fistula and surrounding structure , 24. AltGuy et al. compared MRI-enema with fluoroscopic water-soluble contrast enema in the assessment of pelvic intestinal anastomotic integrity and found that MRI-enema offers a more detailed assessment of anastomotic leakage, providing additional pelvic information and an equivalent patient experience . AlthougFurthermore, CT involves radiation, so the procedure cannot be performed again in a short period of time to evaluate the anastomosis after therapy. However, CT is quick and readily available. On the other hand, according to the results of our study, T2WI with fat suppression was considered to have the best diagnostic value. This finding indicated that patients with suspected AL could receive T2WI with fat suppression imaging to reduce the scan time. However, when considering the cost-effectiveness of health economics, the feasibility of MRI in the assessment of AL required further study.Limitations of our study include the small sample size, which might influence the true diagnostic accuracy of MR. Second, this is a single-center prospective observational study with a short study period. Finally, the diagnosis of AL was confirmed by consensus between surgeons and radiologists based on clinical, laboratory, and radiological data in some patients with atypical signs and symptoms of AL due to the lack of a gold standard to diagnose AL.In conclusion, the accuracy of plain MRI examination without CE in the diagnosis of AL was favorable for patients with suspected AL. A multicenter prospective study with more samples is needed to further estimate the safety and feasibility of MRI in diagnosing AL.


EGFR positive NSCLC patients in Canada is limited. Administrative databases in Alberta, Canada were used to evaluate EGFR testing and mutation prevalence in de novo metastatic NSCLC, as well as the characteristics, treatment patterns, and outcomes of individuals with Exon 19, L858R and Exon20ins mutations. Between 2013–2019, 2974 individuals underwent EGFR testing, of which 451 (15.2%) were EGFR positive. Among EGFR positive individuals, 221 (49.0%) had an Exon 19 mutation, 159 (35.3%) had an L858R mutation, and 18 (4%) had an Exon20ins mutation. The proportion of individuals who initiated 1L systemic therapy was 89.1% for Exon19, 85.5% for L858R, and 72.2% for Exon20ins carriers. The primary front-line systemic therapy was gefitinib or afatinib monotherapy for individuals with Exon 19 (93.4%) and L858R (94.1%) mutations versus platinum combination therapy for individuals with Exon20ins mutations (61.5%). The Exon20ins cohort had worse median overall survival from initiation of 1L systemic therapy (10.5 months [95% CI: 8.0-not estimable]) than the Exon19 (20.6 months [95% CI: 18.4–24.9]), and L858R cohorts (19.1 months [95% CI: 14.5–23.1]). These findings highlight that Exon20ins mutations represent a rare subset of NSCLC in which treatment options are limited and survival outcomes are worse relative to individuals with more common types of EGFR mutations.Real-world evidence surrounding  EGFR, and in Canada, EGFR mutations are identified in approximately 15% of all lung cancer cases ) versus those with Exon19 (20.8 months [95% CI: 18.2–24.4]) or L858R (15.7 months [95% CI: 14.1–21.9]) (1–21.9]) . These f1–21.9]) .Median PFS for individuals with Exon20ins was 7.0 months since diagnosis (95% CI: 3.3–15.1), 4.4 months since initiation of 1L (95% CI: 1.5-not estimable), and 3.3 months since initiation of 2L (95% CI: 2.2-not estimable).To assist with dissemination of the study findings and synthesis of the results we have included a plain language summary and graphical abstract in the EGFR mutation types, with higher rates of utilization in the first year of diagnosis and declining rates in subsequent years . Future qualitative research is needed to help identify potential barriers to and reasons for a lack of EGFR testing.Herein, we present real-world evidence pertaining to EGFR mutations was 15.2%, with Exon20ins representing less than 1% of NSCLC patients. The prevalence of EGFR mutations was in line with previous estimates for Canada [EGFR prevalence in the total population [EGFR mutations (6.9%) in their cohort, but the cohort was primarily composed of early stage cases [EGFR prevalence in advanced or metastatic NSCLC.Among those who underwent testing, the overall prevalence of r Canada  but is lr Canada  which hage cases . To our EGFR mutation, with a focus on Exon20ins mutations [EGFR positive test, which is comparable to our estimate of 4.0% [EGFR mutations [We found that individuals with Exon20ins tended to have worse survival and complete fewer lines of therapy compared to those with the more common Exon 19 and L858R mutations, which may be attributable to the lack of targeted therapies available to Exon20ins carriers. A recent study from the United States using the Flatiron Database quantified the prevalence, treatment patterns, and survival of advanced NSCLC patients with an utations . The pre of 4.0% . Similarutations .EGFR mutations [Other studies have also investigated various aspects of Exon20ins patient groups. A recent systematic review found the prevalence of the Exon20ins mutation ranged from 0.1–4% of all NSCLC cases, and 1–12% of all utations . Treatmeutations ,22,23,24utations . Median utations . The PFSutations ,22,23,24EGFR positive NSCLC cases. A recent systematic review, completed in 2021, aimed to search for studies on HCRU and did not identify any [EGFR mutation types, with higher rates of utilization in the first year of diagnosis and declining rates in subsequent years for all EGFR mutation types.To our knowledge, this investigation is among the first to quantify healthcare resource utilization differences among tify any . We searEGFR mutations in this cohort. However, this methodology may have missed certain types of mutations. Specifically, single-gene PCR testing is known to be inferior to other methods, such as multi-plex NGS, for identifying subtypes of EGFR mutations [An important limitation of this analysis includes the lack of precision for some estimates due to small sample sizes, particularly for the Exon20ins cohort considering the rarity of this mutation. It is also possible that some Exon20ins mutation patients were missed due to the type of testing used. PCR testing was primarily used to identify utations ,25. DataEGFR testing patterns as well as the characteristics, treatment patterns, and outcomes of individuals who were EGFR positive. The leveraging of these data was particularly helpful with respect to the identification of individuals with Exon20ins given the rarity of this mutation and associated challenges of recruiting such individuals into a prospective study. To our knowledge, this is the largest and most current Canadian study on this topic. Lastly, our reliance on administrative data allowed us to objectively examine overall survival with an adequate follow-up duration and little risk of attrition bias.The primary strength of this investigation was our ability to leverage a large, representative, population-based dataset to gather real-world evidence on EGFR mutations in metastatic NSCLC are comparable to those published in other regions at 15.2%. These findings confirm the rarity of Exon20ins mutations, with a prevalence of less than 1% among NSCLC patients who undergo EGFR testing. Rates of EGFR testing have increased over time, and were particularly high among those who were referred to a medical oncologist and who had non-squamous disease. Individuals with Exon20ins tended to have worse survival and complete fewer lines of therapy compared to those with the more common Exon 19 and L858R mutations. These findings highlight that Exon20ins mutations are exceedingly rare in NSCLC and are associated with worse overall survival and fewer treatment options compared to the more common Exon 19 and L858R EGFR mutations.Within the Canadian setting, the rate of


Protein, starch, amylose and total soluble sugars are basic metabolites of seed that influence the eating, cooking and nutritional qualities of rice. Chlorophyll is responsible for the absorption and utilization of the light energy influencing photosynthetic efficiency in rice plant. Mapping of these traits are very important for detection of more number of robust markers for improvement of these traits through molecular breeding approaches.qProt1, qPC6.2, and qPC8.2 for protein content; qTSS8.1 for total soluble sugar; qAC1.2 for amylose content; qCH2 and qSLCHH for chlorophyll a (Chl. a) while qChl5D for chlorophyll b (Chl. b) were validated in this population. The QTL controlling total protein content qPC1.2; qTSS7.1, qTSS8.2 and qTSS12.1 for total soluble sugars; qSC2.1, qSC2.2, qSC6.1 and qSC11.1 for starch content; qAC11.1, qAC11.2 and qAC11.3 for amylose content; qChla8.1 for Chl. a content and qChlb7.1 and qChlb8.1 for Chl. b identified by both Generalized Linear Model and Mixed Linear Model were detected as novel QTL. The chromosomal regions on chromosome 8 at 234 cM for grain protein content and total soluble sugars and at 363 cM for Chl. a and Chl. b along with the position at 48 cM on chromosome 11 for starch and amylose content are genetic hot spots for these traits.A representative panel population was developed by including 120 germplasm lines from the initial shortlisted 274 lines for mapping of the six biochemical traits using 136 microsatellite markers through association mapping. A wide genetic variation was detected for the traits, total protein, starch, amylose, total soluble sugars, chlorophyll a, and chlorophyll b content in the population. Specific allele frequency, gene diversity, informative markers and other diversity parameters obtained from the population indicated the effectiveness of utilization of the population and markers for mapping of these traits. The fixation indices values estimated from the population indicated the existence of linkage disequilibrium for the six traits. The population genetic structure at K = 3 showed correspondence with majority of the members in each group for the six traits. The reported QTL, The validated, co-localized and the novel QTL detected in this study will be useful for improvement of protein, starch, amylose, total soluble sugars and chlorophyll content in rice.The online version contains supplementary material available at 10.1186/s12870-022-04015-8. Rice is life and principal staple food crop for the large global population. But, the protein content in rice grain is low. Protein is highly required for plant growth and development. It takes part in numerous biochemical reactions in the body and acts as hormone, antibody, performs transport and storage of nutrients and many more functions. Protein content also affects the eating and cooking quality of rice . EnhanceHigher chlorophyll content in rice varieties produce more dry matter and grain yield than low chlorophyll containing genotypes. Chlorophyll content (CC) is used in rice breeding programs as an effective index for high photosynthetic efficiency . The ChlAssociation mapping is an effective approach to detect genes/QTL for complex traits with a wide genetic pool through marker-trait association analysis. Naturally occurring variations can be exploited to detect QTL that regulate such traits in rice through association mapping. The study of genetic diversity and structure is helpful to recognize the population behaviour. Population structure (Q) with relative kinship (K) analyses were used to check the panel population composition for linkage disequilibrium (LD) mapping. The marker-trait association based on both the generalized linear model (GLM) and mixed linear model (MLM) were estimated and have been shown to perform better than other model analysis. For easy improvement of eating, cooking, nutritional qualities and chlorophyll content, we need robust molecular markers and also validation the reported QTL for improvement of these traits through marker-assisted breeding. Therefore, this mapping study will provide novel QTL and validation of these reported target QTL including use in marker-assisted breeding. In this study, the main target was to detect the candidate genes/QTL for total protein, total soluble sugars, starch, amylose and chlorophyll content in rice by genotyping with 136 simple sequence repeat (SSR) markers covering all the chromosomes.A set of 274 diverse rice germplasm lines were collected from Gene Bank of ICAR-NRRI, Cuttack were used in the study , observed heterozygosity (H), major allele frequency (A), expected heterozygosity (He), and polymorphic information content (PIC) were estimated by using Power marker V3.25 . A similr2and p-values. The false discovery rate (FDR) and adjusted p- values  were also calculated. The false discovery rate (FDR) in the association study were computed following the previous publications [TASSEL 5 software was used to know the marker-trait association of the six biochemical traits. Two statistical models namely, General linear model and Mixed linear model were used in the TASSEL 5.0 software. The genetic association between phenotypic trait of the rice accessions and SSR makers were determined using the software . Markersications , 41.A total of 274 rice germplasm lines were phenotyped for protein, total soluble sugars, starch, amylose and chlorophyll content  and 33 (starch content ranging from medium to low and amylose content ranging from medium to high) genotypes. The sub-cluster II with 51 genotypes were sub-grouped into two: one with TKM10 and Jira, both with high mean values for amylose and starch content and very low values for TP; and other having 49 genotypes showing similarity for starch and amylose content ranging from low to high mean values.The sub group with 49 genotypes was again grouped into two, as per similarities of starch, amylose and TP. This gave rise to two groups, one including Manavari and Pandya and other with the rest 47 genotypes. Manavari and Pandya were similar, both having very high- starch and medium values for amylose and TP content. The mass with 47 genotypes ranged high to very high for starch, low to medium for amylose and low – very high for TP values. This group was divided into sub-groups with 22 and 25 genotypes. The cluster with 22 genotypes was similar at a point having similarities for mean values: Chl. b medium to very low, starch- high, amylose- medium and TP- medium to very high. The other one with 25 genotypes were found to have mean values ranging from high to very high for starch and low to medium for amylose.Diversity of the panel population was assessed using the estimated diversity parameters by genotyping the population using 136 SSR markers. A total of 506 markers alleles were detected from the population which indicated that the population is diverse  obtained at K = 2 and the whole population was divided into two subpopulations  of sub-population 1 and sub-population 2 was 0.1704; sub-population 1 and sub-population 3 estimated to be 0.1186 while between 2 and 3 sub-populations was estimated to be 0.2302. The average distance (expected heterozygosity) among the members in sub-population 1 was 0.4264; within the individuals in sub-population 2 was 0.3901 while 0.3783 was computed for sub-population 3. The population structure analysis classified the population into sub-populations based on thepeak value of ∆K at K = 3 Fig. . MajoritThe cluster analysis grouped the genotypes on the basis of genotyping results using 136 SSR markers data and placed the germplasm lines into different clusters which showed correspondence with the studied biochemical traits in the germplasm lines. The UPGMA tree differentiated the genotypes into traits in the 4 different clusters  was performed in a population to know the genetic variations present within and between the sub-populations Table . The genr2 value in a population versus the markers physical distance in million base pair to know the trend of linkage disequilibrium decay in the population  in the two dimensional plot was constructed based on the marker data of genotyping results using 136 SSR markers that grouped the 120 panel germplasm lines on their genetic relatedness among the members Fig. A. The inThe un-rooted tree is reared using phylogenetic tree. The tree indicates no common ancestor or node in the tree. The germplasm lines containing high to very high estimates of biochemical traits are grouped together forming the sub-population 3. This group is depicted in green color in the un-rooted tree Fig. B. The va, total protein content, total soluble sugars, starch, amylose, chlorophyll a and chlorophyll b content were detected to be above the threshold level and found to be associated with the SSR markers using the GLM and MLM approaches  at p < 0.01, low p value, high r2 value (Table Significant marker-trait associations for total soluble sugar were detected to be associated by the markers RM247, RM337, RM248 and RM566 through analyzing by both GLM and MLM approaches. In a mapping study by Yang et al. , reporteg et al.  is validue Table B. These qAC1.1 for amylose content on chromosome 1 but at 40 cM position. Zheng et al. [qAC1.2 at 102.5 cM in the marker interval of C904-R2632. In the study of Swamy et al. [qac1.1 for amylose content at position 60-90 cM in marker interval of RM243-RM582 on chromosome 1. Also, Swamy et al. [qac1.2 and gel-2 QTL for amylose content and gel consistency in marker interval of RM580–RM81 at the position 90-100 cM on chromosome 1. Thus, these reports validated for the QTL qAC1.2 for amylose content on chromosome 1. The QTL, qAC11.1 has been detected on chromosome 11 for amylose content at 27 cM with RM6091 showing r2 value 0.1099. This QTL is reported in earlier findings of Lee et al. [qAC11.1, qAC11.2 and qAC11.3 (Fig. .In our investigation, the amylose content is detected to be significantly associated with the marker, RM315 on chromosome 1 at 92 cM position. Li et al.  reportedg et al.  reportedy et al.  reportedy et al. , reportee et al.  which isr2 value of 0.06383 on chromosome 2 at 249 cM. Panahabadi et al. [qSTh2.1 for starch content on the same chromosome but at a position of 4.04 cM. This confirms qSC2.1at 247 cM and qSC2.2 at 249 cM as novel QTL for seed starch content. Two QTL detected on chromosome 6 and 11 at 212 and 48 cM position were detected for starch content by analyzing in both the models (Table qSC6.1 and qSC11.1. Yang et al. [ALK gene as starch synthesis gene at 12.9 cM on chromosome 6 with marker RM8200.In this investigation, marker RM6374 was associated with the trait, seed starch content showing i et al.  reportedg et al.  reportedqCH2 for Chlorophyll a on chromosome 2 was reported earlier by Kun et al. [qCH2 is validated in this mapping study and will be useful in chlorophyll improvement program in rice. However, no QTL for chlorophyll content was reported on chromosome 8 at 363 cM position. This detected QTL may be a new QTL and designated as qChla8.1. The QTL detected on chromosome 5 was located at 109 cM position. Ye et al. [qSLCHH reported by Ye et al. [qChlb 5D controlling chlorophyll on chromosome 5 at 68.2 cM position. The QTL detected by us at 67 cM may be the same QTL and hence qChlb 5D is validated in this mapping population. The other two QTL detected for this trait were not reported earlier at these locations and designated as qChlb7.1 and qChlb8.1 (Table Chlorophyll a content is significantly associated with the SSR markers RM1347, RM405 and RM3231 located on chromosome 2, 5 and 8 at 82, 109 and 363 cM positions, respectively. The QTL, n et al.  within me et al.  reportede et al. . The trae et al.  reportedqChla8.1 and qChlb8.1 for Chl. a and Chl. b on chromosome 8 at 363 cM position were co-localized and located very closely. Another two QTL, qPC8.2 and qTSS8.2 on chromosome 8 at position 234 cM controlling protein and total soluble sugars content were found to be co-localized. Similarly, the QTL, qSC11.1 and qAmy11.1 starch and amylose content are significantly associated with marker, RM3701 and detected to be closely located at 48 cM position on the chromosome 11 (Table The QTL, qProt1, qPC6.2, and qPC8.2 for protein content; qTSS8.1 for total soluble sugar; qAC1.2 for amylose content; qCH2 and qSLCHH for chlorophyll a while qChl5D for chlorophyll b were validated in this study. A total of 13 QTL controlling total protein content qPC1.2; qTSS7.1, qTSS8.2 and qTSS12.1 for total soluble sugars; qSC2.1, qSC2.2, qSC6.1 and qSC11.1 for starch content; qAC11.1, qAC11.2 and qAC11.3 for amylose content; qChla8.1 for chlorophyll a content and qChlb7.1 and qChlb8.1 chlorophyll b detected by both Generalized Linear Model and Mixed Linear Model were detected as novel QTL. Co-localization of QTL, qChla8.1 with qChlb8.1 for Chl. a and Chl. b; qPC8.2 and qTSS8.2 for protein content and total soluble sugars while qSC11.1 and qAmy11.1 for starch and amylose content were observed in the study. The validated, co-localized and the novel QTL detected in this study will be useful for improvement of protein, starch, amylose, total soluble sugars and chlorophyll content in rice.A wide genetic variation for protein, starch, amylose and total soluble sugars and chlorophyll content were observed in the germplasm lines used for association study. The prospectus donor lines carrying higher content of these biochemical traits were identified. The STRUCTURE software classified the representative population into 3 genetic structure groups. Specific allele frequency, gene diversity, informative markers and other diversity parameters estimated from the population in the panel population using 136 SSR markers. Various groups and sub-groups obtained from the population showed relationship within the members for their biochemical traits. Linkage disequilibrium was detected in the studied population for the six biochemical traits. Previously reported QTL, Additional file 1: Supplementary Fig. 1.Additional file 2: Supplementary Fig. 2.Additional file 3: Supplementary Table 1. Mean estimates of chlorophyll a, chlorophyll b, starch, amylose, total protein andtotal soluble sugars content in the initial shortlisted population containing of 274 germplasm lines.Additional file 4: Supplementary Table 2. Markers information of the selected 136 SSR markers used in the genotyping of 120 rice landraces.Additional file 5: Supplementary Table 3. Assessment of genetic diversity parameters of the panel population containing 120 rice landraces using 136 SSR markers loci.Additional file 6: Supplementary Table 4. Genetic structure ancestry value at K = 3 and classification of the panel population containing 120 landraces based on the biochemical traits.Additional file 7: Supplementary Table 5. Significant marker-trait associations detected for chlorophyll a, chlorophyll b, starch, amylose, total protein and total soluble sugars by GLM approach at p < 0.01.Additional file 8: Supplementary Table 6. Significant marker-trait associations detected for chlorophyll a, chlorophyll b, starch, amylose, total protein and total soluble sugars by MLM approach at p < 0.01.


There was no difference in the SPK score, best corrected distance visual acuity, tear meniscus height, contrast sensitivity, DEQS and Schirmer test at all time points. Spherical aberration was statistically lower in the diquafosol group at 1 week. The protective effects of diquafosol on the BUT was more pronounced in patients with a pre-operative BUT of less than 5 s compared with those with a BUT longer than 6 s. Conclusions: Diquafosol eyedrops prevented the shortening of the BUT following FLACS, even in patients with short pre-operative BUT values.Purpose: To analyze the protective effects of diquafosol eyedrops on the ocular surface following femtosecond laser-assisted cataract surgery (FLACS). Design: A prospective, randomized contralateral study. Methods: Bilateral FLACS with a trifocal IOL (PanOptix) implantation was performed in 40 eyes in 20 patients . Patients received 3% diquafosol eyedrops six times daily in one randomly chosen eye (diquafosol group), and physiological saline six times a day in the other eye (control group). Other medication included 1.5% levofloxacin, 0.1% dexamethasone and 0.1% diclofenac three times daily in both eyes. The pre and post-operative tear break-up time (BUT), superficial punctate keratopathy (SPK) scores and visual function were compared between both eyes, and all patients answered the dry-eye-related quality of life score (DEQS) questionnaire. Results: The BUT between groups was similar pre-operatively and on the first day post-op; however, the BUT was statistically longer in the diquafosol group compared to saline at 1 week (5.5/3.7 s) and 2 weeks (4.8/3.0 s) ( Diquafosol is reported to promote tear fluid and mucin secretion through purinergic P2Y2 receptor agonist action [2 receptor, which is expressed in goblet cells and meibomian glands in the ocular surface [2 receptor agonists stimulate mucin secretion from goblet cells in vitro. Mucin stimulants are a new target for the treatment of dry eye since mucin increases the tear film stability and protects against the desiccation of the ocular surface [2 receptor [− transport across the rabbit conjunctival epithelium in the serosal to mucosal direction. Both tear fluid and active Cl− secretion from isolated rabbit conjunctiva were stimulated by diquafosol in a concentration-dependent manner [Dry eye is caused by multiple factors and results in symptoms of visual disturbance and discomfort . Diquafot action . Diquafo surface . P2Y2 re surface . Diquaforeceptor ,6. Diquat manner .A randomized, double-blind, multicenter clinical trial revealed that the diquafosol solution significantly decreases fluorescein corneal and rose bengal scores compared with artificial tears . Diquafop < 0.001) [A diquafosol ophthalmic solution of 3% demonstrated efficacy in dry eye due to various causes, including dry eye following cataract surgery. ,14,15 Th< 0.001) . The BUT< 0.001) .Cataract surgery has been reported to increase the incidence of dry eye post-operatively by up to 8.4% ,19. In tSurgery-induced dry eye leads to patient dissatisfaction following multifocal intraocular lens (IOL) surgery, and one study reported that the use of cyclosporine 0.05% therapy reduced dry eye signs and improved visual quality after surgery. However, cyclosporin is not approved in Japan for dry eye. In fact, up to 35% of complaints following multifocal IOL surgery was attributed to dry eye, and the most common interventions pursued were treatment for dry eye (24%) . There aCompared to manual cataract surgery, femtosecond laser-assisted cataract surgery results in a higher frequency and severity of dry eye . Both suThis was a prospective, randomized, contralateral study involving patients with cataracts who underwent bilateral phacoemulsification with FLACS and diffractive trifocal IOLs implantation in February 2020. The study was approved by the Ethics Committee at Omiya Nanasato Eye Institute . The study was registered in a clinical trial registry . Patients who were 50 years or older and had cataracts in both eyes were eligible for the study. All patients signed a written consent form prior to enrollment. Patients were excluded from the study if they had previously used diquafosol or topical steroids. Patients who did not have an indication for multifocal IOLs, and patients with co-morbidities such as glaucoma age-related macular degeneration (AMD) or diabetic retinopathy, were also excluded from the study. Visual acuity, SPK scores and BUT were similar between the diquafosol and control eyes .All patients were scheduled to undergo FLACS cataract surgery in one eye, and then the other eye 1 week later. Patients were randomized to receive 6 daily doses of topical 3% diquafosol in 1 eye, and physiological saline solution in the other eye starting on the first day after cataract surgery for a period of 2 weeks. Both the choice of eye to be treated with diquafosol and the eye to first undergo surgery was randomly chosen. Eye drop bottles were masked so that the patient was not aware of which medication was used. Other post-operative treatment included 1.5% levofloxacin, 0.1% dexamethasone and 0.1% diclofenac eye drops in both eyes, 3 times daily for up to 2 weeks. Levofloxacin and 0.1% diclofenac were also applied 3 times on the day of surgery, and 0.5% tropicamide was used for mydriasis.®, with implantation of the diffractive trifocal IOL TFNT00 for eyes with less than −1.0 D astigmatism, and TFNT30, 40, 50 or 60 depending upon the degree of astigmatism greater than −1.0 D. Both eyes were examined at 1 month pre-op and 1 day, 1 week and 2 weeks post-op. Uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) at 5 m, uncorrected near visual acuity (UNVA) and corrected near visual acuity (CNVA) at 40 cm, uncorrected intermediate visual acuity (UIVA) and corrected intermediate visual acuity (CIVA) at 70 cm, BUT, SPK scores, Schirmer test values and spherical aberration using the CASIA 2 (Tomey) were recorded at each time point. Visual acuity was expressed in logMAR. Contrast sensitivity was measured pre-op and 2 weeks post-op. Using the CASIA 2, tear meniscus height, area, length and circumference was measured at 1 day, 1 week and 2 weeks after surgery.FLACS and phacoemulsification and aspiration (PEA) were carried out by the same surgeon (KY) in the same institution. FLACS was carried out using the LenSx system to perform 2 corneal incisions, capsulotomy and lens fragmentation. Corneal wound sizes were 2.3 mm for the primary incision and 1.2 mm for the secondary incision. FLACS and PEA were performed in the same operating room. Additional topical anesthesia (4% lidocaine) and disinfection with 0.5% povidone iodine were conducted between FLACS and PEA. PEA was performed using the CenturionBUT was measured by slit lamp with a blue filter using a standard fluorescein paper strip and balanced saline solution. The Schirmer test was conducted using topical anesthesia. SPK was scored using the National Eye Institute (NEI) staining grade. In brief, the cornea was divided into five sections, each assigned a value from 0 (no staining) to 3 (severe staining) based on the amount, size and confluence of the punctate staining. Contrast sensitivity was measured with the CSV-1000 (Vector Vision), and the dry-eye-related quality of life score (DEQS) questionnaire was performed at the end of the 2 week study period. Both the BUT and SPK scores were recorded by 2 independent examiners (RK and YS) who were not told to which group the eye belonged.p < 0.05. Normality and chi-square tests were also performed in this study. For the normality test, the mean (standard deviation) was used.A statistical power analysis was performed to estimate the number of cases required to observe a difference of 20%, confidence level at 95% and a standard deviation of 20. The calculations revealed that the minimum number of cases required to show a significant difference between the two groups was 16. The two-tailed paired or unpaired Student’s t-test was used to compare the mean values between two groups. Relations among variables were investigated by calculating the two-tailed Pearson correlation coefficients and partial correlation coefficients. Data were expressed as mean (standard deviation) or percentages. Statistical analyses were performed with SAS System software version 9.1 , and significance was accepted at This study included 40 eyes of 20 patients . The average age of the patients was 68.8 ± 6.3 years old (range 60 to 82 years old). None of the patients had moderate to severe dry eye prior to surgery. Patients with a short BUT had mild superficial punctate keratitis (SPK). The pre-operative best corrected visual acuity was 0.42 ± 0.12 logMAR in the diquafosol (DQS) group and 0.41 ± 0.11 in the control group.The average laser irradiation time was 33.4 ± 4.0 s, and the average phacoemulsification time was 10.6 ± 3.5 min. The cumulative dispersed energy (CDE) of the Centurion device was 3.3 ± 1.9. The Emery–Little classification grade of cataracts ranged between G2 and G4, and there was no difference in cataract grade between the DQS group and control. There were no incidences of posterior capsule rupture, IOL decentration or endophthalmitis during the study. Regarding the comparison of the post-operative best corrected visual acuity between the DQS group and control at 5 m, 70 cm and 40 cm, there was no statistical difference at all time points measured post-operatively A–C.p < 0.05) in the DQS group at 1 week and 2 weeks post-op  and the control (4.6 ± 4.1 mm) B.2 one day post-op, 0.035 ± 0.038/0.032 ± 0.013 mm2 1 week post op and 0.066 ± 0.011/0.005 ± 0.065 mm2 2 weeks post-op in the DQS and control group, respectively. There was also no difference in tear meniscus height and circumference . A higher score implies more discomfort. There were no side effects observed in any of the eyes enrolled in the study.The DEQS questionnaire did not reveal a statistical difference in any of the questions; however, there was a marginal difference in the question “Felt down due to eye symptoms”, which was higher in the control group (0.6 ± 1.3) compared to the DQS group (0.3 ± 0.7)  . They alThe short follow-up period of 2 weeks may be a limitation of this study. However, the objective of this study was to observe the effects of diquafosol on short-term dry eye symptoms due to surgery, which may affect patient satisfaction. A recent article showed that pre-operative treatment for dry eye significantly improved the corneal surface condition and accuracy of the predicted postoperative refraction in dry eyes . The numIn conclusion, we found that the use of diquafosol is effective in preventing post-operative dry eye following FLACS. Diquafosol seems to work by compensating for mucin production by goblet cells that may have been damaged by the suction ring used during surgery. Of all of the dry eye parameters studied, the BUT time was significantly improved by diquafosol, which may be related to the decrease in HOAs.


The objective of this study was to evaluate the quality of anticoagulation by the time in therapeutic range (TTR) for patients with 12-week INR follow-up interval.From January 2018 to December 2020, a selective group of patients who underwent mechanical valve replacement and followed up at our anticoagulation clinic for adjustment of warfarin dose were enrolled. The incidences of complications of anticoagulation therapy were reported by linearized rates. TTR was calculated by the Rosendaal linear interpolation method.p = 0.001), atrial fibrillation (p < 0.001), NYHA ≥ III (p < 0.001), and lower preoperative left ventricular ejection fraction . In multivariate analysis, female gender (p = 0.023) and atrial fibrillation (p = 0.011) were associated with TTR < 60%. The incidence of major bleeding and thromboembolic events was 2.7% and 1.1% patient-years, respectively. There was one death which resulted from cerebral hemorrhage. The incidence of death was 0.5% patient-years. The difference in anticoagulation-related complications between the TTR < 60% group and the TTR ≥ 60% group was not statistically significant.Two hundred and seventy-four patients were eligible for this study. The mean age of these patients was 52.8 ± 12.7 years, and 65.7% (180 cases) of them were females. The mean duration of warfarin therapy was 16.7 ± 28.1 months. A total of 1309 INR values were collected, representing 66789 patient days. In this study, the mean TTR was 63.7% ± 18.6%, weekly doses of warfarin were 20.6 ± 6.0 mg/weekly, and the mean monitoring interval for the patient was 53.6 ± 27.1 days. There were 153 cases in good TTR group (TTR ≥ 60%) and 121 cases in poor TTR group (TTR < 60%). The calculated mean TTR in both groups was 42.6% ± 22.1% and 74.8% ± 10.4%, respectively. Compared with the TTR ≥ 60% group, the TTR < 60% group exhibited a more prevalence of female gender (For patients with stable international normalized ratio monitoring results who are follow-up at anticoagulation clinics, a 12-week monitoring interval has an acceptable quality of anticoagulation. The female gender and atrial fibrillation were associated with TTR < 60%. Patients with mechanical heart valve prostheses need to receive oral anticoagulant therapy for life long, or they may accompany with valve thrombosis and subsequent systemic embolism . WarfariThe interval between INR monitoring and stable doses of oral anticoagulants continues to be controversial . The AmeTime in the therapeutic range (TTR), which estimates the percentage of time a patient’s INR is within the therapeutic treatment range or goal, is commonly used in the assessment of anticoagulant quality , 10–14. The retrospective research was conducted in Henan Province People’s Hospital. From January 2018 to December 2020, a selective group of patients who received warfarin treatment and followed up at our anticoagulation clinic were enrolled. All of them had undergone mechanical valve replacement. Patients were seen as qualified to participate in the research if they meet the following criteria: (1) aged at 18 years old or above, (2) accepted warfarin treatment for at least 12 months, and (3) had a stable dose for the previous 12 weeks. Patients were excluded from this study under the following conditions: (1) monitoring interval > 13 weeks; (2) ethnic minorities of China.Referring to our anticoagulation clinic’s anticoagulant criteria, the target range for INR in our hospital is 1.5 to 2.5. INR < 1.5 is defined as subtherapeutic range while INR > 2.5 as supratherapeutic range. We adjust the dose and monitoring intervals according to the protocol in Time in therapeutic range (TTR) is defined as the number of person-day within a pre-determined therapeutic range divided by the total number of person-days on warfarin , 17. TTRThe approach to follow-up is to review the electronic record system and conduct a telephone interview. The clinical data of patients include the type of mechanical valve, age, gender, INR values, intervals of INR monitoring, duration of anticoagulant management, warfarin dose, and anticoagulation-related complications.Anticoagulation-related complications included major bleeding events, thromboembolic events, and death. Major bleeding events were defined as bleeding that should receive hospital treatment, such as cerebral hemorrhage, gastrointestinal hemorrhage, and hematuria. Other bleeding events, including epistaxis, gingival bleeding, and ecchymosis, were classified as minor bleeding events. Thromboembolic events include cerebral vascular embolism, systemic embolism, and atrial thrombosis. Death was evaluated by the medical record or a death certificate for relationship with bleeding or thromboembolism.This retrospective study followed the tenets of Declaration of Helsinki and was approved by the ethics review board of Henan Province People’s Hospital. A waiver of consent was received from them at the same time.t-test. Categorical data were reported as rates and were analyzed with the chi-squared test. Independent predictors for TTR < 60% were evaluated with the logistic regression model. Variables with p < 0.20 in univariate analysis were incorporated into multivariate analysis. A two-sided p < 0.05 was regarded as statistically significant. The incidences of valve-related complications were reported by linearized rates. All data were analyzed with Statistical Package for Social Sciences .Continuous variables were described in the form of means ± standard deviation (SD) and were analyzed with Student’s Two hundred and seventy-four patients were eligible for this study. As shown in A total of 1309 INR values were collected, representing 66789 patient days, each patient with a mean of 4.8 ± 1.6 INR values. In this study, the mean TTR was 63.7% ± 18.6%, weekly doses of warfarin were 20.6 ± 6.0 mg/weekly, and the mean monitoring interval for the patient was 53.6 ± 27.1 days. There were 153 cases in good TTR group (TTR ≥ 60%) and 121 cases in poor TTR group (TTR < 60%). The calculated mean TTRs for both group were 42.6% ± 22.1% and 74.8% ± 10.4%.p = 0.001), atrial fibrillation (p < 0.001), NYHA ≥ III (p < 0.001), and lower preoperative left ventricular ejection fraction . The mean age in the TTR ≥ 60% group was 51.9 ± 13.8, and the mean age in the TTR < 60% group was 53.3 ± 11.2; there was no statistical significance (p = 0.2227). Although the prevalence rates of diabetes mellitus (p = 0.143), hypertension (p = 0.760), and smoking (p = 0.127) in the TTR < 60% group were even higher, it was not statistically significant. In multivariate analysis, female gender (p = 0.023) and atrial fibrillation (p = 0.011) were associated with TTR < 60%. Multivariate analysis of predictors of TTR < 60% is shown in Univariate analyses of preoperative variables associated with TTR < 60% are shown in p = 0.090, In this study, the average duration was 16.7 ± 28.1 months. There were three major bleeding events during follow-up: two cases of gastrointestinal bleeding and one case of cerebral hemorrhage. The occurrence rate of major bleeding events was 1.6% patient-years. There were two thromboembolic events: one case of cerebral embolism and one case of atrial thrombosis. The occurrence rate of thromboembolic events was 1.1% patient-years. There was one case of death which resulted from cerebral hemorrhage. The incidence of death was 0.5% patient-years. The difference in anticoagulation-related complications between the TTR < 60% group and the TTR ≥ 60% group was not statistically significant  of INR monitoring after discharging from the hospital is a significant challenge due to geographical restriction, limited economic resource, and less medical knowledge . To reduIn our study, the average TTR for patients with a 12-week INR follow-up interval has reached to 63.7%. A majority of the previous studies have reported that it ranges between 40 and 78% , 21, eveThis study has demonstrated that female gender and atrial fibrillation are associated with TTR < 60%. Avarello and colleagues  found a Although the occurrence rate of major bleeding and thromboembolic events was lower , 3, we dThere are some limitations in this study. First, it is a retrospective research and is a single-center study. Second, the result of TTR in this study is sampled from not a large number of patients. Third, the result of TTR is based on patients who had at least two INR values, and not all patients were included in the whole observation period. This point may also influence the results of TTR .The study used TTR to evaluate the quality of anticoagulation management. There reached an acceptable result of TTR for patients with 12-week INR follow-up interval in stable PT monitoring results. We also found that female gender and atrial fibrillation were associated with TTR < 60%. However, future well-designed prospective studies with a large sample size and detailed analyses of anticoagulation-related complications are still warranted to confirm our findings.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Henan Province People’s Hospital. The patients/participants provided their written informed consent to participate in this study.XZ and XX conceived and designed the experiments. XZ and SW performed the experiments. XZ and XC analyzed the data. XZ, GL, and XL contributed reagents, materials, and analysis tools. XZ wrote the manuscript. All authors contributed to the article and approved the submitted version.


In 2018, the European Working Group on Sarcopenia in Older People (EWGSOP2) updated the original definition of sarcopenia, establishing new criteria to be used globally. Early diagnosis of sarcopenia in nursing home residents and the identification of contributing factors would target interventions to reduce the incidence of malnutrition, social isolation, functional decline, hospitalization and mortality.Verify the prevalence and the degree of severity of sarcopenia according to the new EWSGOP2 criteria and to analyse its associated factors in residents living in nursing homes in Central Catalonia (Spain).A cross-sectional multicenter study was conducted in 4 nursing homes. SARC-F test was applied as the initial screening, muscle strength was measured by a dynamometer, skeletal muscle mass by bioimpedance analysis and physical performance by Gait Speed. Four categories were used: total probable sarcopenia, probable sarcopenia, confirmed sarcopenia and severe sarcopenia.p = 0.007 and OR = 0.14 (0.03 - 0.60), p = 0.008 with total and probable sarcopenia, respectively, adjusted by urinary incontinence status. For confirmed sarcopenia, obesity also represented a negative associated factor OR = 0.06 (0.01 - 0.99), p = 0.049 and the total time in sedentary behavior a positive associated factor OR = 1.10 (1.00- 1.20), p = 0.040.Among the total sample of 104 nursing home residents , 84.6% were women and 85 (81.7%)  had total probable sarcopenia, 63 (60.5%) had probable sarcopenia, 19 (18.3%) had confirmed sarcopenia and 7 (6.7%) had severe sarcopenia. In the bivariate analysis, obesity was negatively associated and total time in sedentary behavior positively associated with all sarcopenia categories. In addition, malnutrition and urinary continence were positively associated with total and probable sarcopenia. Urinary incontinence was a positive associated factor of total and probable sarcopenia. In the multivariate analysis, obesity represented a negative associated factor: OR = 0.13 (0.03 - 0.57), According the EWGSOP2 criteria, high prevalence of sarcopenia was found in institutionalized older people, ranging from 6.7 to 81.7% depending on the category. Malnutrition, urinary incontinence and total time in sedentary behavior were associated with sarcopenia, whilst obesity represented a protective factor in this population. Sarcopenia is a pathology related to the loss of strength and muscle mass in older people . This loIn 2018, the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) updated the original definition of sarcopenia to reflect new scientific and clinical evidence. The EWGSOP2’s updated recommendations aim to increase awareness of sarcopenia and its risk’s to health outcomes . PreventOlder adults who live in a NH are the frailest of our society, with high levels of functional limitations, physical dependence or cognitive impairment , 11. SarThe EWGSOP2 algorithm has already been applied to older people living in NHs  but therNCT04297904).A cross-sectional study was conducted from January to March 2020. Recruitment stopped because of the restrictions in Spain implemented due to the COVID-19 pandemic. The study follows the STROBE  standards for cross-sectional studies . The stuAll residents aged 65 years or over, permanently living in NHs were included. Subjects in a coma or palliative care (short-term prognosis) and those who refused to participate in the study were excluded. Those participants with severe cognitive impairment who could not follow the therapists’ instructions were excluded from the physical tests but included otherwise .The sample size calculation was based on the study by Rodríguez-Rejón et al. (2019)  which alEthical permission was obtained by the Ethics and Research Committee of the University of Vic - Central University of Catalonia (registration number 92/2019). Signed informed consent was gained from the resident or his/her legal guardian. All methods were performed in accordance with the relevant guidelines and regulations.Sarcopenia (main variable) was assessed according to EWGSOP2 criteria. The SARC-F questionnaire was used both to determine risk of developing sarcopenia and to assess the prevalence of sarcopenia. In order to confirm diagnosis and determine severity the following physical tests were assessed:Hand-grip muscle strength, assessed using JAMAR Plus Digital Hand dynamometer  were women. Six (3.1%) residents were smokers and 9 (4.7%) were alcohol drinkers. In total, 86 (82.7%) lived in state subsidized NHs and 18 (17.3%) in private NHs.The mean number of chronic diseases reported was 5.0 [SD = 2.4 ]: 62 (32.5%) had hypertension, 62 (32.5%) dementia, 43 (22.5%) cardiac pathology, 32 (16.8%) depression, 32 (16.8%) diabetes mellitus II, 26 (13.6%) kidney failure, 21 (11.0%) cerebral stroke, 20 (10.5%) pulmonary pathology, 20 (10.5%) mental pathology, 18 (9.6%) cancer and 14 (7.3%) Parkinson’s Disease. The mean number of medications taken per day was 6.9 [SD = 3.8 ].Fifty seven (54.3%) were at risk of malnutrition or were malnourished, 22 (21.0%) had lost weight in the previous year and only 13 (12.4%) were obese [Body Mass Index (BMI) ]. Urinary incontinence (UI) was reported in 36 (34.6%) residents and faecal incontinence in 36 (34.6%).In terms of functional capacity, according to the Barthel test, 5 (4.8%) were independent, 11 (10.6%) were slightly dependent, 40 (38.5%) moderately dependent and 48 (46.1%) totally dependent. Forty-six (44.2%) had a gait speed of less than 0.8 m/s, only 3 (2.9%) had a higher Gait Speed Test (SPPB) and 51 (52.9%) were not evaluated. Seventy-eight (75.0%) had cognitive impairment on the Pfeiffer Scale: 25 (24.0%) had moderate cognitive impairment and 53 (51.0%) had severe cognitive impairment.The residents had an average wake time of 10.7 (SD = 1.16) hours. During waking hours, residents spent a mean of 9.0 (SD = 1.64) hours in SB (sitting or reclining). Although the residents spent 84.2% (SD = 16.85) of their total waking time in SB, in these waking hours the residents also spent 1.6 (SD = 1.91) hours in an upright position (standing or stepping), walking an average of 1345 (SD = 2417.40) steps per day. They transitioned from sitting to standing an average of 18.2 (SD = 18.28) times across a 24 h period (Table Eighty-five (81.7%) residents were categorized with total probable sarcopenia: 22 (21.1%) of these residents were given this diagnosis as they had severe cognitive impairment so could not perform physical tests and 63 (60.5%) were given this diagnosis for having low muscle strength values. Of those with probable sarcopenia, 19 (18.3%) were diagnosed with confirmed sarcopenia because of low muscle mass. Finally, 7 (6.7%) individuals were diagnosed with severe sarcopenia because of the inability to walk or slow walking speed. Nineteen (18.2%) NH residents had no sarcopenia using the EWGSOP2 criteria  in NHs , 16. In We found that nutritional variables such as malnutrition and obesity, UI and % time in SB were significantly associated sarcopenia risk factors in NH residents. Furthermore, multivariate analysis showed a negative association of obesity with total probable sarcopenia, with probable sarcopenia and with confirmed sarcopenia; and a positive association of % time in SB with confirmed sarcopenia.Our results indicate that obesity acts as a protective factor for sarcopenia, with obese subjects having a lower risk of being categorized as sarcopenic. Faxén-Irving et al. , who appTwo studies report that that higher levels of SB were found to be associated with higher levels of sarcopenia , 37. PhyOur results confirm the clinical significance of interventions that include adequate nutritional support and physical exercise to improve the adverse outcomes of sarcopenia in older people living in NHs. Therefore, diagnosis of sarcopenia is very important in residential settings .The main limitation of the study lies in the relatively small sample included in the study due to the onset of the COVID-19 pandemic that prevented further data collection. However, we were able to recruit more than our sample size calculations recommended. Another important barrier was the high prevalence of people with cognitive impairment in NHs, meaning difficulties in performing the EWGSOP2 tests. For this reason, further studies are needed to verify the usefulness of the new diagnostic criteria in institutionalized older adults. However, we were able to use proxy measures for categorizing those with cognitive impairment not able to take part in the functional tests, allowing us to include all residents in this setting.The strength of this work is the involvement of all residents and the use of the most recent consensus based criteria to diagnose sarcopenia, the new EWGSOP2 algorithm, in order to verify prevalence, severity, and associated factors in NH residents. Furthermore, these associated factors were analyzed considering a wide range of variables to assess health, based on the biopsychosocial model of health. It is now important that we strive to deliver evidence-based interventions in these settings to mitigate sarcopenia and its associated health outcomes.According the EWGSOP2 criteria, a high prevalence of sarcopenia was found in this sample of institutionalized older people, ranging from 6.7 to 81.7% depending on the category of sarcopenia. Malnutrition, urinary incontinence and sedentary behaviour were associated with sarcopenia whilst obesity represented a protective factor in this population. In terms of implications for clinical practice, evidence-based interventions including physical activity and nutritional diet will be essential to decrease sarcopenia prevalence.


Data on health state utility in Duchenne muscular dystrophy (DMD) are few. This study estimated mean utility values by age, ambulatory status and over time, and investigated which aspects of health-related quality-of-life (HRQoL) are most strongly associated with utility in DMD.Data from placebo-treated ambulant boys with DMD with exon 51 skip amenable mutations, (NCT01254019), were included. Ambulatory function assessments were conducted at baseline and every 12 weeks for the trial duration. Family member proxies completed the Health Utility Index (HUI) at baseline, 24 and 48 weeks; and HUI3 and HUI2 utility values were summarized. Changes in HUI attribute level over time, and predictors of changes in utility, were explored.Sixty-one boys (mean [range] age of 8.0 [5–16] years) were included in the analysis. Mean baseline utilities were 0.82 (HUI3) and 0.87 (HUI2); and utilities were 0.35 (HUI3) and 0.55 (HUI2) after loss of ambulation . Over the follow-up period mean utility declined more among the older versus younger boys. Pain accounted for the highest proportion of variability (42%) in change in HUI3 utility from baseline to week 48, while for HUI2, self-care (39%) did. After LOA, change in ambulation levels explained 88% of the decline in mean HUI3 utility and change in mobility levels explained 66% of the decline in mean HUI2 utility.Utility values among this sample were higher than previously published estimates. In younger boys utility remained relatively stable, but older boys and those losing ambulation experienced important declines over follow-up.The online version contains supplementary material available at 10.1186/s12955-022-02001-0. Duchenne muscular dystrophy (DMD) is a rare progressive neuromuscular disorder caused by mutations in the gene for dystrophin, a protein required for the structural integrity of muscle cells –4. AffecThe impact of DMD on daily life results in those with DMD often being dependent on family caregivers (and sometimes other caregivers) to manage their everyday needs. Given its severity and progressive nature, DMD has a substantial impact on the health-related quality of life (HRQoL) of both patients with DMD, and their caregivers . In geneThe aspects of HRQoL that are affected by DMD and impact patient utility are not well understood . At presData derived from ambulant boys with DMD aged 5 years or older, with exon 51 skip amenable mutations, randomized to the placebo arm of the DEMAND trial , were included. The study inclusion criteria required participants be able to complete the six-minute walk distance (6MWD) of ≥ 75 m at each pre-drug visit . The stuTo measure ambulatory function, the North Star Ambulatory Assessment (NSAA), timed rising from floor (RFF), 10-m timed walk/run (10MWR), and 6MWD tests were conducted by trained assessors at baseline and every 12 weeks. The NSAA is a 17-item functional assessment scale  designed for ambulant boys with DMD, where performance on tests related to ambulatory function  are assessed on a 3 point scale  . Total sFamily members serving as proxy respondents also completed the 15-item HUI questionnaire, a preference-based utility measure, at screening, baseline, 24 weeks, and 48 weeks . The same proxy respondent was asked to complete the HUI at each assessment visit, and the recall period of the questionnaire was the past four weeks. HUI responses are used to quantify health utility  according to two complementary health-status classification systems, the HUI mark 3 (HUI3) and HUI mark 2 (HUI2) . The HUIBaseline characteristics of the sample were summarized. HUI3 and HUI2 attribute levels were calculated for each patient at baseline, 24 weeks, and 48 weeks . HUI3 and HUI2 utility values were then estimated for each patient at these same visits following the developers’ algorithm and scoring instruction . To summTo understand the scores on HUI attribute levels that fed into the HUI utility calculations, mean (SD) HUI attribute levels were computed. The proportion of patients with moderate or severe impairments in each attribute was calculated, using attribute-specific definitions provided by the developers  and pati2 measure from linear regression analyses, with a single attribute as a predictor variable. To find the percent of variation explained by a combination of attributes, all the attributes were entered into a single linear regression analysis as predictors. To understand how HUI attribute levels changed over time, the proportions of patients with worsening, no change, and improvement in level of each HUI3 and HUI2 attribute at 48 weeks vs baseline were calculated. The attributes with the largest proportion of patients with worsening and with improvement were determined.To investigate variability in changes in HUI utility from baseline to 48 weeks, the percent of variation around mean changes in HUI3 and HUI2 utility explained by changes in each attribute was estimated using the RTo understand which attributes were driving large changes in utility (i.e. change in utility of 0.2), the proportions of patients with worsening and improvement in each HUI3 and HUI2 attribute were calculated separately among patients with large declines or improvements in utility. Patients with a utility change of at least 0.2 were considered in a primary analysis, and patients with a change of at least 0.1 and 0.03   were conSome patients lost ambulation during the course of the trial and the number of patients in whom this occurred over the 48-week period was determined. Among patients with LOA, mean (SD) utility values were calculated at baseline and post-LOA. Estimates post-LOA were calculated by first finding means at the patient-level across visits, then finding the mean (SD) across patients. The mean change in utility from baseline to after LOA was also calculated and a smoothing line was fitted to utility values, with time relative to LOA on the x-axis. The percent of the decline in mean utility after LOA explained by mean change in each attribute level was determined by direct calculation via the HUI scoring algorithm.A total of 61 ambulant boys with DMD were included in this analysis. At baseline, the mean (range) age was 8.0 (5–16) years  HUI3 utility was 0.82 0.19) and HUI2 utility was 0.87 (0.13) in the overall group. Mean (SD) baseline utilities were similar between younger and older boys  HUI3 attribute levels at baseline were: vision, 1.03 (0.18); hearing, 1.00 (0.00); speech, 1.08 0.28); ambulation, 1.68 (0.91); dexterity, 1.22 (0.76); emotion, 1.12 (0.32); cognition, 1.37 (0.94); and pain, 1.77 (0.72). Of the HUI3 attributes, moderate or severe impairments at baseline were reported more frequently for attributes such as pain (in 17% of patients), ambulation (13%), and cognition (7%), compared to vision, hearing or speech for example  HUI2 attribute levels at baseline were: sensation, 1.21 (0.59); mobility, 1.62 (0.72); emotion, 1.36 (0.55); cognition, 1.22 (0.53); self-care, 1.69 (1.01); and pain, 1.45 (0.54). Of the HUI2 attributes, moderate or severe impairments at baseline were reported more frequently for attributes such as self-care (15%), mobility (13%), and sensation (8%) compared to cognition and pain for example , ambulation (32%), and cognition , the proportions of patients with worsening and improvement in levels for each HUI3 and HUI2 attribute were calculated  lost ambulation over the 48-week period; their mean (SD) utility at baseline was 0.60 (0.39) for HUI3 and 0.69 (0.14) for HUI2. Their mean (SD) utility after LOA was 0.35 (0.11) for HUI3 and 0.55 (0.07) for HUI2. The mean (SD) decline in utility after LOA was 0.25 (0.32) for HUI3 and 0.15 (0.12) for HUI2. There was a suggestion of a plateauing in utility after LOA , and across the two systems, attributes with the same name address different underlying constructs . For exaStrengths of this study include the large sample of ambulatory boys with this rare disease included, and the longitudinal design. This sample is clinically well-characterized at baseline, on a variety of functional measures with high relevance to DMD. How changes in physical function over time are related to change in utility in DMD represents an important future direction. Limitations to the study include the relatively small sample size in selected subgroups . Additionally, as all boys included in this study were skip 51 amenable, findings may not be generalizable to boys with other genotypic mutations. Further, the results are based on family members serving as proxy respondents. It is possible that utility as reported by the patients themselves might differ. Similarly rigorous longitudinal data including utility assessments that describe patients in a wider variety of health states in DMD are needed to, for example, understand the impact of varying levels of upper limb function, or respiratory status, on health state utility. Finally, the suitability and comprehensiveness of the generic preference-based measures to assess the HRQoL impact of DMD among those with DMD deserves consideration. A systematic review and other recent investigations conducted after the data collection period of the present study, highlighted the lack of evidence to support structural and content validity of the HUI and other generic instruments for assessing HRQoL impacts among those with DMD.Additionally, how well existing generic instruments cover the aspects of HRQoL most important from the patient perspective, particularly from pediatric populations,is now emerging , 27–30. Despite variability in scores, utility values among this sample of ambulatory boys with DMD were relatively high, and higher than previously published estimates. While the utility of younger boys remained relatively stable, older boys and those losing ambulation experienced important declines over follow-up. These findings are valuable in augmenting scarce data on health state utilities for ambulatory boys with DMD.Additional file 1: Appendix Table 1. Measure scoring.Additional file 2:Appendix Table 2. Number of HUI3 and HUI2 attributes affected (not level 1) at baseline.Additional file 3:Appendix Table 3. Observed changes in HUI3 utility and attribute levels from baseline to week 48, with each row representing an individual patient.Additional file 4:Appendix Table 4. Observed changes in HUI2 utility and attribute levels from baseline to week 48, with each row representing an individual patient.Additional file 5:Appendix Figure 1. Changes in HUI attribute levels from baseline to week 48 among patients with (A) a decline in HUI utility of at least 0.1, (B) an improvement in HUI utility of at least 0.1, (C) a decline in HUI utility of at least 0.03, and (D) an improvement in HUI utility of at least 0.03, between baseline and week 48.Additional file 6.Appendix Figure 2. HUI3 and HUI2 utility by time since LOA, with a black smoothing line and colors denoting individual patients (n=6).


Angiogenesis inhibitors (AIs) and immune checkpoint inhibitors (ICIs) are new treatment options for advanced soft tissue sarcoma (STS) patients. This study evaluated the efficacy and safety of AIs plus ICIs in patients with advanced STS. A retrospective cohort study was performed on STS patients treated with AIs and ICIs at Shandong Cancer Hospital and Institute between August 2020 and December 2021. The primary endpoint was objective response rate (ORR); secondary endpoints included progression-free survival (PFS), disease control rate (DCR), overall survival (OS), and adverse events. Thirty-three patients were enrolled; 27 were evaluable for objective response. The ORR and DCR were 48.1% (95% CI 30.7–66.0%) and 85.2% (95% CI 67.5–94.1%). With a median follow-up of 7.6 months , the median PFS for all 33 patients was 8.90 months (95% CI 5.98–11.82). The median OS was not reached. The most common treatment-related adverse events (TRAEs) of any grade were hypertension (50.0%), ECG T-wave abnormality (30.0%), hypothyroidism (26.7%), elevated alanine aminotransferase or aspartate aminotransferase (23.3%), elevated thyroid-stimulating hormone (23.3%), and fatigue (16.7%). The most common grade 3–4 TRAE was hypertension (27.3%). Three serious TRAEs  were recorded. This study suggests that adding AIs to ICIs is beneficial in STS. Anthracycline-based chemotherapy is the standard treatment for most patients with advanced STS2. Anlotinib, an oral multi-target tyrosine kinase inhibitor that exerts significant anti-angiogenesis effects, has been approved to treat STS in China3. In a single-arm, phase 2 trial (SARC028), pembrolizumab showed activity in patients with STS, especially in patients with certain subtypes, such as undifferentiated pleomorphic sarcoma (UPS) and de-differentiated liposarcoma (DDLPS)4. In another phase 2 trial, nivolumab combined with ipilimumab demonstrated promising efficacy in certain sarcoma subtypes, including UPS, myxofibrosarcoma, and angiosarcoma5. Meanwhile, combination therapy with AIs and ICIs has been tested across various solid tumours. Increasing evidence has shown that AIs and ICIs complement each other and exhibit synergistic anti-tumour effects7. Several studies using the combination regimes of axitinib plus pembrolizumab, sunitinib plus nivolumab, and anlotinib plus TQB2450 (a novel programmed death ligand-1 inhibitor), respectively, have demonstrated the feasibility of this promising treatment strategy for STS10.For patients with STS who failed first-line treatment, angiogenesis inhibitors (AIs) and immune checkpoint inhibitors (ICIs) have emerged as new treatment optionsHowever, considering the heterogeneity of STS, it is necessary to evaluate the strategy in more subtypes further. Thus, we designed a retrospective study to evaluate the efficacy and safety of combination therapy with AIs and ICIs in a real-world setting.A total of 33 patients were included in this study Fig. . The basThe last follow-up date of this study was 1st October 2022. The median follow-up duration for the 33 patients from treatment to the date of data cut-off was 7.6 months . The median number of cycles administered was 8 . Of the 27 patients evaluable for objective response, 3 (11.1%) achieved complete response (CR), 10 (37.0%) achieved partial response (PR), and 10 (37.0%) achieved stable disease (SD); the objective response rate (ORR) and disease control rate (DCR) was 48.2% , 30.7–66.0%) and 85.2% (95% CI 67.5–94.1%), respectively. The best percentage change from the baseline of target lesions is shown in Fig. Of the seven ASPS patients evaluable for objective response, 5 (71.4%) achieved PR, and 2 (28.6%) achieved SD, so the DCR was 100%. No patient achieved CR. Of the 20 non-ASPS patients evaluable for objective response, 3 (15.0%) achieved CR, 5 (25.0%) achieved PR, and 8 (40.0%) achieved SD, so the DCR was 90%.All 30 evaluable patients experienced treatment-related adverse events -γ + and granzyme B (GzmB). The addition of an anti–PD-1 antibody further increased the percentage of CD8+ T cells via the IFN signaling pathway, which provides a scientific rationale for combination therapy of lenvatinib with PD-1 blockade to improve cancer immunotherapy11. Our study shows that AIs plus ICIs demonstrated promising clinical activity in STS, with an ORR of 48.1% (13/27) and a median PFS of 8.9 months.Accumulated pre-clinical evidence has shown that AIs enhance the efficacy of ICIs by normalizing abnormal tumour vessels and increasing the infiltration of immune effector cells into tumours4. In the Alliance A091401 study, a confirmed response was seen in 33.3% (2/6) of patients with UPS in the nivolumab plus ipilimumab cohort5. In a recently reported single-center phase 2 trial evaluating durvalumab, an anti-PD-L1 drug, and tremelimumab, an anti-CTLA-4 drug, in advanced or metastatic soft tissue and bone sarcomas, 20% (1/5) of patients with UPS showed an objective response12. However, notably, in several previous phase 2 trials reporting the efficacy of AIs plus ICIs among patients with UPS, the ORR was 0 (0 of 5) to axitinib plus pembrolizumab treatment, 0 (0 of 6) to nivolumab plus sunitinib treatment, and 0 (0 of 5) to anlotinib plus TQB2450 treatment10. Further evidence is needed to confirm the large gap and explain the underlying mechanism.The SARC028 study reported a 40% (4/10) ORR to pembrolizumab monotherapy in patients with UPS13. In a phase 2 trial of anlotinib for the treatment of advanced STS, 23.7% (9 of 38) of patients with ASPS achieved a partial response, and the median PFS was 18.23 months14. In another phase 2 trial of atezolizumab in ASPS, the ORR was 37.2% (16 of 43), and the median treatment duration was 11.3 months15. In several phase 2 trials reporting the efficacy of AIs plus ICIs among patients with ASPS, the ORR was 54.5% (6 of 11) to axitinib plus pembrolizumab treatment, 57% (4 of 7) to nivolumab plus sunitinib treatment, and 75% (9 of 12) to anlotinib plus TQB2450 treatment, which suggested superior efficacy of combination therapy over monotherapy with either AIs or ICIs10. In the present study, 71.4% (5/7) of patients with ASPS displayed a partial response, confirming the favorable efficacy of the combination therapy in this subtype.ASPS is a rare STS that is not responsive to chemotherapy. However, molecular studies have demonstrated the co-expression of VEGFR, PDGFRB, RET, and MET and high PD-L1 expression in ASPS cells, which predict the favorable treatment response of multi-target AIs and ICIs16. Pazopanib also showed a 20% (8/40) response rate, median PFS of 3 months, and median OS of 9.9 months in a retrospective study of advanced vascular sarcomas17. In the Alliance A091401 study, a confirmed response was seen in 33.3% (1/3) of patients with AS in the nivolumab plus ipilimumab cohort5. In the phase 2 trial evaluating the durvalumab plus tremelimumab in advanced or metastatic soft tissue and bone sarcomas, 20% (1/5) of patients with AS showed objective response12. In the phase 2 trial reporting the efficacy of nivolumab plus sunitinib treatment among patients with AS, the ORR was 42.9% (3/7)9. In the present study, two patients with AS showed an objective response. All the above studies confirmed the efficacy of combination therapy and monotherapy with either AIs or ICIs in this specific subtype.AS is a rare type of cancer that develops in the inner lining of blood vessels and lymph vessels. In a phase 2 study including 40 patients with AS, sorafenib yielded a 13.5% (5/37) response rate, a median PFS of 3.8 months, and a median OS of 14.9 months4. Correlative analyses of the SARC028 trial revealed an association between immune infiltrate and response to pembrolizumab in DDLPS18. In a retrospective study from China, 36.3% (4/11) of patients with DDLPS showed an objective response to AIs plus ICIs combination therapy19. In our study, only three patients with DDLPS were evaluable for ORR, and none showed an objective response. Efforts to confirm the activity of AIs plus ICIs in an expansion cohort of DDLPS patients are needed.The SARC028 study reported 20% (2/10) ORR to pembrolizumab monotherapy in patients with DDLPS21. In the subsequent randomized, placebo-controlled clinical trials of anlotinib and regorafenib, a significant increase in PFS compared with placebo  in patients with LMS was demonstrated, which confirmed the therapeutic effect of AIs in patients with LMS22. In contrast, none of the patients with LMS in the SARC028 study showed a response to pembrolizumab, which is consistent with a phase 2 evaluation of nivolumab that was stopped early for futility, suggesting that single-agent ICIs therapy may not be able to elicit a response in LMS23. However, in the Alliance A091401 study, 16% of patients with LMS in the nivolumab plus ipilimumab arm showed an objective response, which renewed hope for ICIs in patients with LMS5. In two phase 2 trials reporting the efficacy of AIs plus ICIs among patients with LMS, the ORR was 16.7% (1/6) to axitinib plus pembrolizumab treatment and 25% (1/4) to anlotinib plus TQB2450 treatment. In the present study, one of the two patients with LMS showed an objective response. In another retrospective study from China with a larger sample size, 19% (4/21) of patients with LMS showed an objective response to AIs plus ICIs combination therapy, suggesting the modest efficacy of the combination regime in patients with LMS19.AIs and ICIs have also been explored as therapeutic modalities in LMS. Although sunitinib and sorafenib showed no benefit in LMS, pazopanib demonstrated modest efficacy  in patients with uterine LMS in a retrospective analysis based on two clinical trialsThe toxicity profile of AIs plus ICIs therapy is consistent with previous studies of the drugs as monotherapy. No unexpected TRAEs occurred. The main ≥ grade 3 TRAE was hypertension, which was manageable with antihypertensive drugs. Two patients who experienced myocarditis recovered after the administration of steroids. One patient experienced rapid atrial fibrillation, which was controlled with β-blockers. All three cases with serious TRAEs stopped AIs plus ICIs therapy permanently.The present study has some drawbacks. First, this is a retrospective study with a small sample size; hence, selection bias cannot be avoided. Second, the irregular radiology examination in clinical practice may lead to bias in evaluating PFS.In conclusion, our study suggests that adding AIs to ICIs shows encouraging benefits in STS. The safety profiles of the combination strategy are manageable. Additional studies with larger sample sizes and controlled arms are needed.We reviewed all patients with STS treated at Shandong Cancer Hospital and Institute between 1st August 2020 and 17th December 2021. The main inclusion criteria were: (a) histological diagnosis of STS; (b) patients were administered with AIs plus ICIs combination therapy. We excluded patients who received prior treatment with any AI or ICI. The study profile of this study is illustrated in Fig. The AIs included anlotinib, apatinib, and sunitinib. The ICIs included sintilimab, toripalimab, camrelizumab, and pembrolizumab. The treatment regimens are listed in Supplementary Table The following data were reviewed: patients’ demographic characteristics, histological subtype, radiological imaging, laboratory test results, survival data, and adverse events (AEs) during the treatment based on the NCI Common Terminology Criteria for Adverse Events (NCI CTCAE) v5.0 criteria. The tumour response was assessed every two cycles according to the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.1. The primary endpoint was ORR; the secondary endpoints included PFS, DCR, OS, and AEs. ORR was defined as the proportion of patients who achieved complete response (CR) or partial response (PR). DCR was defined as the proportion of patients whose best response was CR, PR, or SD. PFS was defined as the time from the initiation of treatment to the time of disease progression or death due to any cause, whichever occurred first. OS was measured from the initiation of treatment to the date of death from any cause. Patients who were event-free or lost to follow-up were censored at the time of the last visit.All statistical analyses were performed with SPSS 21.0 statistical software. Continuous data were presented as mean and standard deviation if normally distributed or median and range. Categorical data were presented as numbers and percentages. PFS and OS were estimated using the Kaplan–Meier survival method.Supplementary Information.