Lynch syndrome (LS), also known as hereditary nonpolyposis colorectal cancer (HNPCC), is a disorder caused by an autosomal dominant heterozygous germline mutation in one of the DNA mismatch repair (MMR) genes. Individuals with LS are at an increased risk of developing colorectal and extracolonic cancers, such as endometrial, small bowel, or ovarian. In this review, the mutations involved with LS and their diagnostic methods are described and compared, as are their current uses in clinical decision making. Nowadays, LS diagnosis is based on a review of family medical history, and when necessary, microsatellite instability (MSI) or/and immunohistochemistry (IHC) analyses should be performed. In the case of a lack of MMR protein expression (dMMR) or MSI-H (MSI-High) detection in tumor tissue, molecular genetic testing can be undertaken. More and more genetic testing for LS is based mainly on next-generation sequencing (NGS) and multiplex ligation-dependent probe amplification (MLPA), which provide better and quicker information about the molecular profile of patients as well as individuals at risk. Testing based on these two methods should be the standard and commonly used. The identification of individuals with mutations provides opportunities for the detection of cancer at an early stage as well as the introduction of proper, more effective treatment, which will result in increased patient survival and reduced costs of medical care. Colorectal cancer (CRC) is currently one of the most commonly diagnosed cancers, taking third place in men and fourth in women. Only in 2018, more than 1.8 million new cases and almost 900 thousand deaths were recorded worldwide. Approximately 70–80% of them are sporadic cancers, while genetic factors are responsible for the remaining 20–30% of known cases [MLH1, MSH2, MSH6, PMS2 or with the epithelial cell adhesion molecule (EPCAM) gene [MLH1 and MSH2 are the most common ones and represent approximately 80–90% of all cases, while the other 10–20% applies to mutations in MSH6 and PMS2 genes. Mutations in EPCAM are rare and constitute about 3% of cases [LS is characterized by a predisposition to a spectrum of cancers, mainly colorectal and endometrial cancer. It is associated with autosomal heterozygous germline mutations in either one of the DNA mismatch repair system (MMR) genes-AM) gene ,5. MutatIn cells, in which a malfunction of the MMR system is observed, mutations usually occur in short tandem repeats (STRs), and the said mutations are referred to as microsatellite instability (MSI) ,7. CarriMSH2 and MLH1 genes compared with ones with MSH6 and PMS2 mutations. CRCs in LS are predominantly right-sided mucinous tumors [Colorectal cancer is the main type of cancer observed in LS patients. Individuals with LS are also at increased risk of developing synchronous (primary tumors diagnosed within six months of each other) and metachronous (primary tumors occurring >6 months apart) cancers. The risk of CRC development is significantly increased in patients with mutations in s tumors ,10,11, us tumors . Histolos tumors .MLH1/MSH2 mutations, 17–71% for patients with a mutation in MSH6 and 15% in for instances of PMS2 [MSH6 mutation, EC will more likely develop than CRC [MSH2 mutation [MSH2 gene [Individuals with LS are at an increased risk of developing not only CRC but also extracolonic cancers, like endometrial, ovarian, stomach, small intestine, urinary tract, pancreatic, brain, and that of the cutaneous sebaceous glands also known as Muir–Torre syndrome. Endometrial cancer (EC) is the most common extracolonic cancer and occurs with similar frequency to CRC in women ,12. Howe of PMS2 . Interesthan CRC . Moreovemutation ,17. For mutation , and is SH2 gene .MLH1 [The risk of developing small bowel cancer ranges from 0.4% to 12%, and the average age of onset is 46–49 vs. 50–70 in the overall population ,18. The MLH1 . The risEscherichia coli, and it requires MutS, MutL, and MutH proteins. In humans, the mismatch repair system consists of six MMR proteins, MLH1, PMS2, MSH2, MSH6, MSH3, and PMS1, which are E. coli protein homologs [The DNA mismatch repair system enhances genome stability by recognizing and repairing polymerase errors. In LS, germline variants are mutated in the genes that encode MMR proteins. Mutations in MMR proteins result in microsatellite instability, which is observed in some cancers, including those associated with LS. Originally, the MMR system was identified and characterized in homologs ,21. The The mechanism of mismatch base repair in eukaryotic cells is initiated by a MutSα (MSH2-MSH6) heterodimer, which recognizes mismatched single bases or small insertions/deletions (ID) (1–2 nucleotides long), or by the MutSβ (MSH2-MSH3) heterodimer, which recognizes larger insertions/deletions, up to 16 nucleotides. Both of the mentioned heterodimers are ATPases, and this activity is crucial for proper initiation and recognition ,21. ThroIn 3′ nick directed excision, the MLH1-PMS2, with the help of PCNA, initiates the incision of the strand in 3′ heteroduplex, resulting in a strand break usually 5′ from the mismatch, which is later used as a starting point for the EXO1 (exonuclease 1) 5′→3′ excision of the intermittent strand with the included mismatch, so in the next step, polymerase δ, after binding with PCNA, can re-synthesize the correct DNA strand, However, besides the EXO1-dependent MMR, there is also the possibility of an EXO1-independent pathway, where repeated strand breaks by MutLα might be required. That would further lead to the production of 3′ ends or the excision of a newly synthesized strand near the mismatch, then directly to polymerase δ binding and later to displacement strand resynthesis ,26. AsidMLH1, PMS2, MSH2, MSH6, are associated with LS [MLH1 promoter and not due to a mutation in the germline [Mutations in MMR genes,  with LS ,28. A lo with LS . MSI is  with LS . In the germline ,30.MSH2 and MLH1 are the most frequent due to their obligatory functions in the MMR system. The most commonly observed types of mutations in these genes are nonsense mutations, in which the substitution of a single base leads to the appearance of a stop codon and results in the reduction of a polypeptide chain . Additionally, missense mutations can also be observed [Mutations of observed . A signiobserved .MLH1 mutations constitute 40% of the variants, MSH2-30%, MSH6-20% and PMS2-10%. The type of mutations mostly observed in these genes are point mutations, and quite often-significant rearrangement, deletions or insertions, are as well. According to Knudson’s two-hit hypothesis, both copies of the MMR gene have to be inactivated for the tumor’s phenotype manifestation [According to the InSiGHT database, there are over 3000 different variants of MMR genes that predispose LS: estation . In an Lestation . MLH1 promoter in one of two alleles, which leads to silenced gene expression in most somatic tissues and the hypermethylation of MSH2 caused by EPCAM gene mutation [In LS, the most common constitutional epimutation is the hypermethylation of the mutation . The LS mutation .The epithelial cell adhesion molecule (EPCAM/CD326) is a 39–42 kDa transmembrane glycoprotein almost exclusively expressed in epithelial tissue and epithelial-derived cancers and functions not only in cellular adhesion but also signaling, migration, proliferation and differentiation . Due to EPCAM genes can cause two different, unrelated diseases such as LS or congenital tufting enteropathy (CTE), which depends on the type and nature of changes [EPCAM gene is located 15 kb upstream from the MSH2 gene and deletions of the 3′ end of the EPCAM gene, including its polyadenylation signal, first cause changes and eventually the inactivation of the promoter of MSH2, while maintaining the expression of EPCAM [MSH2, but only in the polyadenylation signal of the EPCAM gene [EPCAM at the sequence level are implicated in causing LS. Most of these deletions are in exons 8 and 9 and are mediated by a recombination between imperfectly homologous Alu repeats [EPCAM-MSH2 fusions are indicated [Mutation in  changes . The EPCof EPCAM . It shouCAM gene . It was  repeats . These mndicated .EPCAM (TACSTD1) in MSH2-associated LS cases. They indicated that 20% to 25% of cases possess deletions that were suspected of having a mutation in MSH2, but in which a germline mutation was not detected [EPCAM deletions, the observed risk of disease is comparable to that of MSH2 mutation. Contrary to this, the risk for endometrial cancer is lower compared to MSH2 mutation carriers. It should, however, be noted that this depends on the size and location of the EPCAM deletion [EPCAM mutations were indicated and they were grouped to chromosomal deletions, non-coding/splicing, frameshift/truncation and missense type. The frameshift mutation c.499dupC is the most important from a clinical point of view [MSH2, MLH1, MSH6, and EPCAM is presented in Rumilla et al. checked the frequency of deletions of detected . In the deletion . In CTE, of view . The detThe diagnostics, treatment, and care of patients with LS should differ from methods used in patients with sporadic colorectal cancer, due to genetic and clinical differences of these disease types. Efficient and cost-effective diagnostics of people with suspected LS is crucial to implement an appropriate prevention program or treatment regimen .Amsterdam criteria and the Revised Bethesda Guidelines are used in traditional testing for initial identification, Amsterdam criteria or at least one criterion of the Revised Bethesda Guidelines, then microsatellite instability testing or/and immunohistochemistry (IHC) testing should be performed [Diagnostics begin with the identification of families at high risk for cancer through family history and other distinguishing features, such as early age of onset or metachronous disease. The erformed ,51. Howeerformed ,52. In aerformed ,51.Amsterdam criteria I and II, and the Revised Bethesda Guidelines, Amsterdam criteria I involves recognition of patients at a higher risk of developing LS-associated colorectal cancer based on patients’ family history and clinical evaluation [Amsterdam criteria I was revised due to the subsequent discoveries of extracolonic cancers also being associated with LS. From now on, the Amsterdam criteria II also included the occurrence of LS-associated extracolonic cancer [Clinical diagnostics of LS are mainly based on the aluation ,13. Howec cancer .Amsterdam criteria. For this reason, new criteria for the identification of LS patients were introduced, namely the Revised Bethesda Guidelines. In patients meeting at least one of the guidelines, screening for mutation carriers in MLH1, MSH2, MSH6, or PMS2 genes is performed by way of immunohistochemistry and/or microsatellite instability testing [Amsterdam criteria and the Revised Bethesda Guidelines are not sensitive enough to detect all patients with LS. The patients’ pedigree is not always reliable or available. Furthermore, not every patient with LS fulfills all of the Amsterdam criteria [Amsterdam II criteria and the Revised Bethesda Guidelines would have missed nearly 62.5% and 50% of the LS cases in the study, respectively, and also recommend future development of a universal screening program for CRCs as well as ECs, which would increase the identification of LS [Nevertheless, several studies reveal the low sensitivity (22%) and specificity (98%) of the  testing . It is a testing . Unfortucriteria ,56. Adaron of LS .MMRpredict, MMRpro, Prediction of Mismatch Repair Gene Mutations in MLH1, MSH2, and MSH6  [PREdiction Model for gene Mutations (PREMM5), which may be considered as PREMM1,2,6 replacement [Additionally, clinical prediction models are also in use, such as 1, 2, 6) ,58 or PRlacement . Their flacement . Thus, tlacement ,60 or ≥2lacement . The useBefore performing costly molecular testing in individuals with suspected LS, it is recommended to undertake screening tests first, which may suggest the probability of MMR gene mutation. MSI and IHC are used to identify patients at high risk of LS for further genetic testing . The scrImmunohistochemistry can directly indicate a lack of a particular MMR protein expression, saving time and costs of testing other MMR genes. IHC uses primary monoclonal antibodies directed against specific proteins, in diagnostics for LS, against MSH2, MLH1, MSH6, and PMS2 proteins. The sensitivity and specificity of immunohistochemistry are approximately 83% and 89%, respectively ,13,61,62MSH2 and MLH1 are obligatory proteins in the MMR system and they dimerize with secondary proteins-MSH6 and PMS2, respectively. When the mandatory protein is defective, the whole heterodimer becomes unstable, and the secondary protein becomes degraded. On the other hand, when the secondary protein is altered, the heterodimer can remain stable since obligatory proteins can also form heterodimers with other secondary proteins  ,61. ShiaWhen it comes to the interpretation of IHC results, a loss of expression of the MMR protein is confirmed based on the complete absence of staining in the tumor tissue. However, in some cases, a heterogeneity of staining can be observed. This includes both areas with weak and thus uncertain staining as well as areas with both strong and no staining. Such heterogeneity can create false positive or false negative results ,64,65. TAmsterdam criteria I or II or the Revised Bethesda Guidelines, or due to the universal screening strategy-all new patients affected by CRC [Microsatellite instability testing is also a screening test performed on patients who fulfill the d by CRC ,52,66.MSI can be used for the identification of tumors caused by a defective MMR system. Microsatellites are the DNA stretches especially susceptible to acquiring errors when the MMR system is faulty. The identification process is based on analyzing the difference in the length of microsatellite repeats in tumor tissue compared to the healthy non-neoplastic tissue surrounding the tumor. Generally, panels of 10 markers  and commBefore DNA amplification, the microdissection of examined tissue must be performed. Microsatellite instability is considered to be present when, in DNA samples from tumor tissue, an additional amplicon of a different size is observed, compared to DNA samples from healthy tissue from the same patient. The additional amplicon indicates insertion/deletion in the examined microsatellite sequence and its length is changed. When ≥30% of the markers are unstable, the tumor is considered MSI-H, when less than 30% of the markers are unstable, the tumor is considered MSI-L (MSI-Low). When no additional amplicons are observed, the tumor is considered microsatellite stable (MSS). Nevertheless, it was also noted that microsatellite instability could be stated if at least one mononucleotide marker is unstable, which can reduce the number of markers in the panel and makes all diagnostic processes more cost-effective ,62,72.Alternatively, microsatellite testing can also be carried out using next-generation sequencing (NGS). No healthy tissue is needed as a benchmark in this method, which makes it possible to perform MSI testing even in individuals from whom obtaining healthy tissue is problematic or impossible. MSI-NGS can easily be included in panels already used in molecular diagnostics, which would reduce both the number of tests and overall costs .Sometimes, in tumors in patients with LS-associated cancer, all four MMR proteins are present, but nevertheless microsatellite instabilities are observed. This phenomenon can be explained by the type of mutation in the altered gene. In this case, the expression of a stable protein with a regular epitope, although unfunctional, is observed ,72.MLH1 and PMS2 are observed, tumor BRAF V600E mutation and/or MLH1 promoter hypermethylation testing is recommended to distinguish sporadic colorectal cancer from CRC caused by an MMR defective system [When MSI-H and lack of expression of both e system ,52,62,66BRAF mutation analysis is performed using immunohistochemistry and the VE1 antibody, the PCR reaction, or exon 15 sequencing. BRAF testing is widely used in LS diagnostics since the V600E mutation does not occur in LS patients but it is observed in half of the patients with sporadic CRC [BRAF mutation occurs, no further diagnostics for LS is necessary (LS excluded). If there is no BRAF mutation in a tumor, performing further genetic tests for MLH1 and PMS2 germline mutations is recommended [BRAF V600E IHC are 69 and 99%, respectively [adic CRC ,75. Whenommended . The senectively .BRAF mutation analysis, MLH1 promoter methylation also can be performed if MLH1 and PMS2 proteins are absent. If the hypermethylation and no BRAF mutation occur in the tumor tissue, it is recommended to analyze MLH1 promoter methylation results in the healthy tissue to determine epimutation. Epigenetic mutations that cause LS are rare but may be present in both tumor and healthy tissue [Besides y tissue .Microsatellite instability in tumor tissue is evidence of MMR germline mutation. However, through MSI testing, a specific altered gene cannot be determined. It is also impossible to distinguish between LS-associated and sporadic cancer. On the other hand, immunohistochemistry allows to identify the specific, mutated gene in the examined individual but does not differentiate a somatic and germline mutation. Therefore, using both methods guarantees extensive and reliable screening diagnostics for patients with LS ,78. HoweEPCAM genes. When the family mutation is known, the appropriate diagnostic method should be used, depending on the type of mutation. If a mutation is unknown, methods that enable gene scanning should be used. Gene scanning methods for unknown mutations and their mechanisms are presented in Further molecular diagnostics should be performed in patients and their families in which MSI-H and/or lack of expression of at least one MMR protein were observed. The molecular diagnostics should be complex because none of the methods can detect all types of possible mutations in MMR/Comprehensive analysis of MMR genes can be problematic due to their large size. Therefore, high throughput and massive parallel methods are required, such as next-generation sequencing (NGS) technology .With the NGS method, it is possible to sequence the whole genome , whole exome , or to perform targeted gene sequencing. The main advantage of NGS is the ability to detect single nucleotide variations (SNVs) or small insertions/deletions in several genes simultaneously ,86,87. UTargeted gene panels save time, reduce costs, and enable the exclusive analysis of areas of interest. Also, the sequencing is performed at a high depth, up to 500–1000× while in WGS the level of coverage is at 30–50×. The most commonly used type of NGS is sequencing by synthesis, the method developed by Illumina . The proEPCAM genes, are available  [In LS diagnostics, commercial targeted gene panels, including exons and exon-intron regions of MMR/Agilent) . HoweverAgilent) . Sanger Agilent) .When no point mutation is detected, it is recommended to use methods that allow for the identification of more extensive rearrangements, deletions, and insertions, such as Southern blot, Array Comparative Genomic Hybridization (aCGH microarrays) or Multiplex Ligation-dependent Probe Amplification (MLPA) ,55,62.MLPA is the most commonly used method in LS diagnostics and makes possible the detection of significant structural mutations, such as genomic deletions, duplications or rearrangements of one or more exons , which rMLH1 and MSH2 or all MMR and EPCAM genes [MLH1 and MSH2 genes. A summary of the advantages and limitations of molecular applications is presented in The results are presented as a ratio of 1.0 when both copies of the gene are noted in an examined sample, which means that each probe detected the same amount of the gene copies in both the tested and reference samples (no detected aberrations). A ratio of 0.5 indicates heterozygous deletion and 1.5 indicates heterozygous duplication. For LS, there are already designed sets of probes, which include AM genes ,92. It iAM genes . With MSEPCAM mutations as soon as possible. This allows for the commencement of observation and care programs for affected individuals and their families. Early cancer detection will result in increased treatment efficiency and patients’ survival rates [The risk of developing cancer in individuals with LS before the age of 70 is approximately 80%. Therefore, it is crucial to identify patients with MMR/al rates ,52,102. al rates ,102.MSH2 or MLH1 genes [MSH6 or PMS2, some sources advise considering the later inception of colonoscopy surveillance due to lower rates of CRC in these individuals [Individuals with LS or high risk patients are usually recommended to perform a colonoscopy every 1–2 years starting at 20–25 years old if they carry mutations in H1 genes ,52,66. HH1 genes ,104. In ividuals . In shorividuals . H. pylori testing at least [Patients at high risk of LS should also be screened for extracolonic cancers. Several approaches are proposed for EC and ovarian cancer screening, such as pelvic examinations and endometrial sampling, starting at the age of 30–35 years every year, a transvaginal ultrasound or determination of CA-125 concentration in serum. Nevertheless, there is still a need for more evidence pointing to these screening methods’ influence on the mortality or cancer rate ,52. Propat least ,52,107. at least ,52.MLH1 hypermethylation [Numerous studies suggest the role of aspirin in preventing cancer, but the evidence is not strong enough to make a recommendation for its regular use. Despite that, it might be suggested to consume 600 mg of aspirin daily for a minimum of two years to reduce LS-associated cancer risk ,52. It whylation ,109. Henhylation ,110,111.hylation . It shouhylation .With different responses of MSI-H or dMMR tumors to several treatment approaches, optimizing a personalized treatment strategy for patients with LS-associated cancer might prove to be more promising and may result in decreased mortality. This highlights the need for the detection of individuals with LS.The identification of individuals with Lynch syndrome has evolved in the past and continues to rapidly improve. The development of molecular testing allowed for the replacement of time-consuming and demanding screening methods, such as SSCP, DGGE, or DHPLC, with NGS technology. NGS makes it possible to sequence whole gene panels for many patients simultaneously, making the diagnostics process quick, accurate, and reliable. Also, MSI assay can be performed using the next-generation sequencing method and can easily be included in panels already used in molecular diagnostics, which would reduce the costs even further. Although NGS still has its limitations, there is no doubt that this method has revolutionized the whole diagnostics system. On the other hand, there is still a need for more accurate clinical criteria that would include all LS families. There are still unidentified LS families that were missed in the current approaches. Diagnostics should also be more focused on the identification of unaffected LS individuals rather than individuals with a newly developed tumor. This would lead to early detections and more frequent observations of people with MMR mutation and the introduction of a screening program, which in case of cancer development, will result in quick and more efficient treatment and thus increase the patient survival rate.


Lung resection surgery for non-small-cell lung cancer (NSCLC) is reportedly a risk factor for developing chronic pulmonary aspergillosis (CPA). However, limited data are available regarding the development of CPA during long-term follow-up after lung cancer surgery. This study aimed to investigate the cumulative incidence and clinical factors associated with CPA development after lung cancer surgery. We retrospectively analyzed 3423 patients with NSCLC who (1) underwent surgical resection and (2) did not have CPA at the time of surgery between January 2010 and December 2013. The diagnosis of CPA was based on clinical symptoms, serological or microbiological evidences, compatible radiological findings, and exclusion of alternative diagnoses. The cumulative incidence of CPA and overall survival (OS) were estimated using the Kaplan–Meier method, and a multivariable Cox proportional hazard analysis was performed to identify factors associated with CPA development. Patients were followed-up for a median of 5.83 years with a 72.3% 5-year OS rate. Fifty-six patients developed CPA at a median of 2.68 years after surgery, with cumulative incidences of 0.4%, 1.1%, 1.6%, and 3.5% at 1, 3, 5, and 10 years, respectively. Lower body mass index (BMI), smoking, underlying interstitial lung disease, thoracotomy, development of postoperative pulmonary complications 30 days after surgery, and treatment with both chemotherapy and radiotherapy were independently associated with CPA development. The cumulative incidence of CPA after surgery was 3.5% at 10 years and showed a steadily increasing trend during long-term follow-up. Therefore, increased awareness regarding CPA development is needed especially in patients with risk factors. Surgical resection remains the mainstay of curative treatment for non-small-cell lung cancer (NSCLC) . The impHowever, lung cancer surgery is one of the most invasive procedures in medicine and carries considerable risks for developing postoperative pulmonary complications (PPCs) such as pneumonia, empyema, and mediastinitis . While tAspergillus [Chronic pulmonary aspergillosis (CPA) is an uncommon but detrimental pulmonary disease caused by members of the genus ergillus  that usuergillus ,13,14. Aergillus .This study aimed to determine the cumulative incidence of CPA after lung cancer surgery by analyzing a large cohort of patients who complied with long-term follow-up after surgical resection for NSCLC. Furthermore, we also investigated which clinical factors were associated with the development of CPA.Patients with NSCLC who underwent surgical resection between January 2010 and December 2014 were identified retrospectively using the Lung Cancer Surgery Registry at Samsung Medical Center, a 1979-bed referral hospital in Seoul, Korea. Patients with a concurrent diagnosis of CPA at the time of surgery were excluded.The following information was then gathered using the database: patient-related factors such as age, sex, body mass index (BMI), smoking history, underlying pulmonary diseases, and other comorbidities; lung cancer-related factors such as the lobar location of the tumor and the clinical/pathological stage of the disease; and treatment-related factors such as the neoadjuvant treatment used, the extent of surgical resection, the surgical approach, PPCs, and adjuvant treatments administered. Conditions considered as underlying pulmonary disease included a previous history of pulmonary TB, chronic obstructive pulmonary disease (COPD), asthma, or interstitial lung disease (ILD). Tumor stages were determined using the seventh edition of the American Joint Committee on Cancer . Early PThis study was approved by the Institutional Review Board of Samsung Medical Center (IRB no. 2020–06-011). The requirement for informed consent was waived owing to its retrospective nature.Aspergillus infection, including positive serum Aspergillus precipitin tests  and isolation of Aspergillus spp. from respiratory specimens, or histological confirmation; (3) radiological findings compatible with evidence of disease progression; and (4) exclusion of alternative diagnoses, according to the widely accepted diagnostic criteria proposed by European Society for Clinical Microbiology and Infectious Diseases/European Respiratory Society [After surgical resection for NSCLC, most patients were followed-up for at least 5 years by a thoracic surgeon. Patients with pre-existing or newly developed pulmonary disease were jointly followed-up by a pulmonologist. Physical examinations, laboratory tests, chest radiographies, and chest CT scans were regularly performed at scheduled intervals during follow-up visits. When the development of CPA was suspected, patients were referred to a pulmonologist, and further diagnostic tests were performed. The diagnosis of CPA was established on the basis of (1) the presence of compatible clinical symptoms; (2) serological or microbiological evidence of  Society ,18.2 test or Fisher’s exact test for categorical variables and the Mann–Whitney test for continuous variables. The Kaplan–Meier method was used to estimate the cumulative incidence of CPA and overall survival (OS) after the surgery. The data of patients who were (1) alive and did not develop CPA, (2) lost to follow-up, and (3) deceased were censored at their last visit to the clinic to analyze the incidence of CPA. For the analysis of OS, the data of patients who were alive or lost to follow-up were censored at the time they were last known to be alive regardless of whether or not they developed CPA.Categorical variables are reported as number (%), while continuous variables are reported as median (interquartile range (IQR)). Patients who developed CPA were compared to those who did not develop CPA by using the Pearson χp < 0.05 for entry and p > 0.10 for removal). Tumor stages were not included in the multivariable model since they had a significant collinearity with neoadjuvant and adjuvant treatments. All tests were two-sided, and a p value < 0.05 was considered significant. Predictive Analytics Software (PASW) Statistics 25  was used for analysis.We used the Cox proportional hazard model to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the development of CPA. We entered all relevant variables into the multivariable model and eliminated variables using a stepwise backward selection method  years to assess survival, and the 5-year survival rate was 72.3% A.During the follow-up period, 56 patients developed CPA at a median of 2.68  years after their surgery. The cumulative incidences were 0.4%, 1.1%, 1.6%, and 3.5% at 1, 3, 5, and 10 years, respectively B. Most cp = 0.001), smokers , and have lower BMI  than those who did not develop the disease. The presence of pre-existing pulmonary diseases, including history of pulmonary TB, COPD, asthma, and ILD, was not statistically different for the development of CPA. Patients who developed CPA were more likely to have advanced clinical stages of NSCLC  and a histologic diagnosis of squamous cell carcinoma  (p < 0.001) and adjuvant  therapy than that of patients who did not develop the disease. Regarding surgical procedures, the rate of thoracotomies performed was markedly higher in the group that developed CPA than in the group that did not develop the disease . Both early  and late-phase  PPC were more prevalent in the group that developed CPA  . Accordioped CPA .2 increase, 0.83; 95% CI, 0.76–0.91; p < 0.001), smoking , underlying ILD , thoracotomy , late-phase PPC , and treatment with both chemotherapy and radiotherapy  were all associated with the development of CPA.To investigate which factors are independently associated with the development of CPA, both univariable and multivariable analyses were performed . Lower BIn the present study, patients with NSCLC who underwent surgical resection showed a favorable prognosis with a 5-year survival rate of 72.3%. During long-term follow-up, a small number of patients developed CPA, with a 10-year cumulative incidence of 3.5%. However, the incidence of CPA did not plateau and continued to increase many years following surgery; this suggests that CPA is an important late complication of lung surgery. We also found that factors such as lower BMI, smoking, underlying ILD, and thoracotomy, as well as PPC after 30 days and neoadjuvant/adjuvant therapy with both chemotherapy and radiotherapy, were all independently associated with CPA development.CPA often develops in patients with pre-existing structural changes of the lung. Pulmonary TB typically leaves cavitation in the lung and has been reported as the most common underlying condition in CPA development; worldwide, an estimated 1.2 million people with CPA have a history of pulmonary TB ,13. A reAnother possible explanation for the development of CPA after lung cancer surgery is the emergence of, to some degree, an impairment of the immune system. In our study, lower BMI, which is a surrogate marker of nutritional status, was an independent risk factor for CPA ,22. Howen = 2) with ILD who also developed CPA was too small, it is difficult to draw a solid conclusion. However, both patients also had idiopathic pulmonary fibrosis (IPF) and neither of them was on steroid or immunosuppressive treatment. Interestingly, both of these patients developed dense consolidations around pre-existing bullae, which corresponds to the idea that expanded air space develops in the residual lung after lobectomy [Not surprisingly, a considerable number of patients had other underlying pulmonary conditions, aside from lung cancer surgery, such as COPD, asthma, previous pulmonary TB, and ILD. Although COPD and a history of TB were common comorbidities among patients with CPA, there were no significant differences in the prevalence of these conditions between patients with and without CPA. Instead, our study showed that ILD was associated with an increased risk of developing CPA following lung cancer surgery, a finding that is consistent with a previous study . Since tobectomy ,25.n = 3), bronchiectasis (n = 1), IPF (n = 1), emphysema (n = 1), cavitary changes secondary to cancer recurrence (n = 1), and subsequent wedge resection on the contralateral lung following cancer recurrence (n = 1). Many of these patients also had other risk factors including late-phase PPC (n = 3) and use of chemotherapy or chemoradiation therapy (n = 3). The remaining four patients who did not have underlying structural abnormalities suffered repeated episodes of pneumonia involving the contralateral lung after the surgery (n = 2) or during chemotherapy (n = 2). One patient also experienced late-phase PPC. Although the lack of information on the use of neoadjuvant/adjuvant therapies in the previous study prevents further comparison, a considerable number of patients (33.3%) received these treatments in our study, which may have contributed to the development of CPA in the opposite lung.Of note, the 5- and 10-year cumulative incidences of CPA in our study, which were 1.6% and 3.5%, respectively, were lower than those of a previous study from Japan  that was conducted exclusively on lobectomy cases . Since tOur study has several limitations. First, this is a retrospective cohort study from a single referral hospital that handles the largest volume of lung cancer surgeries in the nation. While this may explain the favorable 5-year survival rate in this cohort , it may With the advent of more effective screening methods and improvements in treatment outcomes, more patients with NSCLC are surviving . Among t


Computer navigation technology is gradually applied to the placement of pedicle screws, but its security and effectiveness still lack of high-quality evidence-based medical evidence. In this study, we will perform a systematic review of previously published randomized controlled trials to investigate the accuracy and effectiveness of computer navigation vsersus fluoroscopy guidance for pedicle screw placement.All study protocols adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed (MEDLINE), The excerpta medica database, Web of Science , The Cochrane Library , Cochrane Methodology Register), China National Knowledge Infrastructure, Chinese Science and Technology Periodical Database, WanFang, Chinese Biomedical Literature Database will be searched for relevant articles up to 18 April, 2020. We will include randomized controlled trials of computer navigation and fluoroscopy guidance for pedicle screw placement. The Cochrane Handbook (v6) will be used for assessment of study bias and reliability, and a meta-analysis will be performed using STATA 16.0. The main outcome will be the proportion of accurate implanted screws. Additional outcomes including: overall complication rate, radiation dosage, length of surgery, length of stay, estimated blood loss.The quality of the assessments will be assessed through Grading of Recommendations Assessment, Development, and Evaluation. Data will be disseminated through publications in peer-reviewed journals.We will evaluate the accuracy and other perioperative parameters between computer navigation and fluoroscopy guidance for pedicle screw placement.PROSPERO 2020 CRD42020172087. After Harrington, Roy Camille and other improvements, it is widely used in spine corrective, fixation and fusion operations, and is now 1 of the most frequently performed spinal surgery procedures. PSs have good biomechanical properties, which can bring favorable results in the treatment of various spinal diseases.In 1959, Boucher There is a high rate of misalignment, even for experienced spine surgeons. It was previously shown that 2.39% to 10% of patients required revision surgery when percutaneous PSs implantation.–8 In the open surgery, 10% to 40% cases were reported dislocated, and the rate of revision was as high as 7.6%.,10 In addition, more and more attention has been paid to the risk of radiation exposure of doctors and patients caused by intraoperative fluoroscopy. From the biomechanical point of view, PSs should be ideally placed along the pedicle axis to ensure the appropriate screw diameter and length, and the ideal position also ensures the best protection of adjacent structures. PS dislocation can lead to serious complications, such as involve potential nerves, vital blood vessels, and Viscera damage to structures neighboring the spine. If the screw position is found to be undesirable through fluoroscopy during the operation, it can be adjusted in time, but repeatedly regulate the screw track will affect the holding force and lead to failure of internal fixation, which will affect the stability and fusion of the spine. What's worse is that only after the operation, the dislocation of screw position is found with complications, and it needs to be renovated, which will seriously affect clinical efficacy, patient satisfaction, and medical expenses. Therefore, the initial accuracy of PS is very critical.Conventionally, PS implantations are mainly assisted by anatomic landmarks and intraoperative C-arm fluoroscopy.–14 A series of different navigation systems have been used in PS insertion since 1995, and even more  are under development or just beginning to be adopted–23.In order to improve the safety and accuracy, navigation and robot technology are applied to the PS implantation, especially in the percutaneous PS technology.At present, there are few randomized controlled studies on robots. In this study, we will systematically review published randomized controlled trials (RCTs) and perform a meta-analysis comparing computer navigation vs. fluoroscopy guidance to evaluate the accuracy of screw placement and other related perioperative indicators, such as overall complication rate, radiation dosage, length of surgery, length of stay, and estimated blood loss. Which could provide relevant data support for the development of digital orthopedics, evaluate the advantages and disadvantages of current navigation technology, and provide relevant support for the improvement or research and development of new navigation system and robot system.22.1,25 and has been registered in PROSPERO 2020 (CRD42020172087). All data analysis will adhere to the PRISMA statement.,27All methods will conform to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols guidance 2.22.2.1Prospective RCTs that compare the accuracy and other perioperative parameters between computer navigation and fluoroscopy guidance for PS placement.2.2.2Adults (≥18 years) that underwent posterior PS fixation of the spine2.2.3Computer navigated surgery.2.2.4Fluoroscopy guidance .2.2.52.2.5.1(1)Proportion of accurately implanted screws according to 0 mm grading criteria(2)Proportion of accurately implanted screws according to 2 mm grading criteria2.2.5.2(1)Overall complication rate(2)Radiation dosage(3)Length of surgery(4)Length of stay(5)Estimated blood loss2.2.6Republished literature, unable to obtain full text or data, the type of study could not be confirmed and fundamental research will be excluded.2.3All the major electronic databases will be searched from inceptions to the April 18, 2020. The basic search strategy is outlined in Table 2.4We will use EndNote X9 to manage retrieved literature and eliminate duplicate data. Two investigators  will independently review the study titles and abstracts. Studies that fail to meet the required criteria will be excluded. Full texts will be evaluated and disagreements regarding study selection will be solved by discussion with a third reviewer (FXH). The reasons for exclusion will be documented. All selection procedures will conform to PRISMA guidance as outlined in Fig. .2.5 The standardized form including: Administrative information ; Details of study ; Details of participants and procedural details: ; all outcome indicators, and adverse events. If required, authors will be contacted for further information. Data extraction procedures will be assessed by a third reviewer (CRG).Data will be extracted by LQC and CBT using the standardized data extraction form based on the Cochrane Handbook.2.6 This scale includes 7 risk of bias items, and each will be described as low, unclear, or high risk. Data will be presented in the risk of bias graph. Discrepancies will be resolved or as required, by a third reviewer (YY).LQC and CBT will perform quality assessments and review the risk of bias using the Cochrane Collaboration's risk-of-bias assessment method (v6).2.7Q and I2 statistic will be used for the assessment of statistical heterogeneity. Homogenous data will be compared using the Fixed-effects model (Q test with P >.1 and I2 <50%). Heterogeneous data will be compared using the random-effects (Q test with P < .1 or I2 statistic >50%). Standardized mean differences and 95% confidence intervals for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence intervals will be used for the assessment of overall effect sizes. Qualitative and quantitative studies will be analysed separately and conclusions drawn. If quantitative synthesis is not appropriate, A systematic narrative synthesis will be generated in the form of text and tables.Data analysis and processing will be performed using STATA 16.0  by LQC and CBT. The Cochran 2.82.8.1These will be conducted based on minimally invasive versus open surgery, deformity surgery  versus no deformity surgery, lumbar versus thoracic Surgery.2.8.2Studies with a high risk of bias will be excluded to permit the evaluation of the robustness and reliability of the analysis.2.8.3Funnel plots will be constructed and Egger regression tests will be performed for the assessment of bias for studies containing ≥10 RCTs. If publication bias is encountered, the fill and trim method will be used for subsequent analysis.2.9 Study limitations, inaccuracies, inconsistencies, indirect evidence, and publication bias will be used to rate evidence quality using 4 levels, namely:Grading of Recommendations Assessment, Development, and Evaluation will be used for the assessment of the quality of the evidence presented.(1)high;(2)moderate;(3)low; and(4)very low.2.10All data will be disseminated through publications in peer reviewed scientific journals. The study includes no primary patient data or patient identifiers meaning local ethical approval is not required.3Minimally invasive and digitization are the inevitable trend of spine surgery development. For improvements in the safety and accuracy of the procedures and to concomitantly reduce radiation exposure, navigation and robot technology are applied to the PS implantation, and continuously evolving. Navigation assisted PS implantation has a history of more than 20 years, and has been reported by many authors. But there is still no meta-analysis based on RCT about it. Therefore, our research will provide surgeons with evidence-based results on whether the navigation technology can achieve the purpose of safety, accuracy and reducing radiation exposure; meanwhile, we will evaluate the advantages and disadvantages of current navigation technology, and provide relevant support for the improvement or research and development of new navigation system and robot system.Conceptualization: Qianchun Li, Botao Chen, Xiaohong FanFormal analysis: Qianchun Li, Botao Chen, Xiaohong FanFunding acquisition: Xiaohong FanInvestigation: Qianchun Li, Botao Chen, Yang YuMethodology: Qianchun Li, Leiming Jiang, Xiaohong FanSupervision: Yang Yu, Rigao Chen, Xiaohong FanValidation: Yang Yu, Rigao Chen, Xiaohong FanVisualization: QianChun Li, Botao ChenWriting – original draft: Qianchun Li, Botao Chen, Rigao Chen, Yang Yu, Leiming Jiang, Xiaohong FanWriting – review & editing: Qianchun Li, Botao Chen, Rigao Chen, Yang Yu, Leiming Jiang, Xiaohong Fan


Childhood onset systemic lupus erythematosus is a rare disease that is more common amongst Southeast Asian children compared to the West. It is typified by a peripubertal onset and a female preponderance, which increases with advancing age. Organs commonly involved at diagnosis include haematological, renal, and mucocutaneous. Fever, malar rash, and cutaneous vasculitis are common. Lupus nephritis is typically proliferative especially Class IV and contributes to both disease activity and damage. Antinuclear antibody and anti-dsDNA positivity are both prevalent in this region. Disease activity is higher than Western cohorts at onset but responds to therapy reducing to low disease activity by six months. However, organ damage occurs early and continues to accumulate over the time, a consequence of both active disease  and steroid-related complications especially in the eye (cataract and glaucoma) and musculoskeletal systems (avascular necrosis). Infections remain the leading cause of death and mortality in this region is highly variable contributed by the heterogeneity in social economic status, healthcare access, and availability of paediatric rheumatology expertise in the region. Systemic lupus erythematosus (SLE) is a prototypic chronic multisystem autoimmune disease that is highly heterogenous in its clinical manifestations and severity. Although SLE predominantly affects young women, children and adolescents contribute to 15–20% of this population ,4,5. WheIn addition to these differences between adult and childhood-onset SLE, genetics and ethnicity have also been reported to influence SLE disease expression contributing to clinical heterogeneity. Both Asian children and adults with SLE are prone to more serious clinical manifestations and have a poorer outcome when compared to white populations ,12,13,14Southeast Asia (SEA) comprises of 11 countries of diverse history, religion, and culture but bounded by geographical location. They include Brunei, Cambodia, Timor-Leste, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam. Of these, only Brunei and Singapore are developed countries with high income, whilst the remainder are middle- or low- income countries, with significant variation in access to healthcare.In this paper, we aim to review and summarize the epidemiology and demographics, clinical manifestations, laboratory features, and outcomes of childhood-onset systemic lupus erythematosus in Southeast Asia. Published papers regarding the aforementioned information on childhood-onset systemic lupus erythematosus from SEA were obtained, analyzed, and then compared to the corresponding information reported elsewhere.SLE is a rare childhood disorder with an estimated incidence of 0.3–0.9 per 100,000 children-years and a prevalence of 3.3–8.8 per 100,000 children . ArkachaThe onset of cSLE is reported to peak during the peri-pubertal years with a median age of onset between 11–12 years and the disease is rare under the age of 5 years . In SEA,On the other hand, Gulay and Dans reported a higher age of diagnosis in the Philippines (mean 14.7 ± 2.7 years), but this could be due to a skewed population as their youngest patient was 8 years of age and the peak for the predominantly female cohort was 17 years . AnotherThe female preponderance observed in cSLE with a typical female to male ratio of 5:1 is similarly seen in this region ,17,27,28Tan et al. also found that the Malay ethnicity was disproportionately over-represented in the multi-ethnic Singapore population, suggesting possible genetic influence and a racial predilection, but this was not similarly seen in Malaysia, a predominantly Malay population ,29.The most common organ systems involved at diagnosis in SEA are the hematological, renal, and mucocutaneous systems . The invHematological abnormalities are very common in SEA with almost all (98.4%) patients in Singapore being affected . Tan et Arthritis was present in high numbers in Singapore (56.3%) and Vietnam 58%), which is comparable to Western pediatric studies (61–65%) but still less than in adult studies %, which ,26,29. TMalar rash is the predominant cutaneous manifestation in this region with a high prevalence affecting 1/2 to 2/3 of the cohorts, which is comparable to studies from the West ,32,34. SRenal disease is a main contributor to long-term morbidity and mortality in lupus and is more common in children when compared to adults . It is aThe predominant histopathology of lupus nephritis (LN) in Asian children was Class IV lupus nephritis (39.4–54%), which is similarly reflected in other Western countries like USA (38%) and Canada (46%) ,17. ClasAt diagnosis, neurological diseases were generally uncommon in this region, ranging from 14.1–20%, which is similar to Western literature ,22,29,31Serositis is comparable to other reports in the world, except for a higher occurrence in Philippines (26.9%) and Vietnam (36%) ,24. The Constitutional symptoms, especially fever, malar rash, and cutaneous vasculitis, are known to be more common in children as evident in our regional SEA cohorts ,29,32,39Antinuclear antibody (ANA) positivity was generally high in this region with low incidence of ANA negative lupus (<4%). Dung et al. reported a low ANA positivity of 67% in Vietnam but interestingly had the highest anti-dsDNA antibodies in the region and high prevalence of renal disease ,28,31. HChildren with SLE have significantly more active disease at presentation as measured by SLE Disease Activity Index (SLEDAI) scores when compared to adults ,11,28,40SLEDAI scores at diagnosis in SEA  indicateAlong with higher disease activity, children with SLE also exhibit more damage when compared to adults . DiseaseThere is paucity of renal survival data in SEA with end stage renal failure rates reported between 3.14% in Malaysia and 6.6% in Thailand, which are high compared to 0.5% in the United Kingdom cohort ,22,23,28Although the survival of children with SLE has improved over the years to more than 90% since the 1980s, the mortality rates in children are still higher when compared to adults ,34,44. IWith the improved survival of children with SLE in this region, majority will today live until adulthood. The concept of planned transition from pediatric to adult rheumatology care thus becomes more important. There are currently no published papers on transitional care in SEA and only two countries  have formal transitional care programs ,51. ThisSLE in Southeast Asian children share many similar features with other cSLE cohorts around the world. Unique characteristics include a higher disease activity at presentation and the predominance of proliferative renal disease. Disease damage occurs early from both active disease and steroid-related complications. Mortality is variable in the region affected by heterogeneity of healthcare access and socio-economic status of the region. Knowledge gaps on cSLE still abound in SEA and calls for more collaborative research to improve the wellbeing and outcomes of Southeast Asian children with lupus.


This study examined the psychological distress caused by non-coercive lockdown (mild lockdown) in Japan. An online survey was conducted with 11,333 people  during the mild lockdown in the seven prefectures most affected by COVID-19 infection. Over one-third (36.6%) of participants experienced mild-to-moderate psychological distress , while 11.5% reported serious psychological distress (K6 score ≥ 13). The estimated prevalence of depression  was 17.9%. Regarding the distribution of K6 scores, the proportion of those with psychological distress in this study was significantly higher when compared with the previous national survey data from 2010, 2013, 2016, and 2019. Healthcare workers, those with a history of treatment for mental illness, and younger participants (aged 18–19 or 20–39 years) showed particularly high levels of psychological distress. Psychological distress severity was influenced by specific interactional structures of risk factors: high loneliness, poor interpersonal relationships, COVID-19-related sleeplessness and anxiety, deterioration of household economy, and work and academic difficulties. Even when non-coercive lockdowns are implemented, people’s mental health should be considered, and policies to prevent mental health deterioration are needed. Cross-disciplinary public–private sector efforts tailored to each individual’s problem structure are important to address the mental health issues arising from lockdown. Given the spread of the coronavirus disease 2019 (COVID-19) infection, as of June 2020, the number of infected people worldwide is still increasing ,4,5,6 anUnder these circumstances, it may be useful to examine the impact of a ‘mildly enforceable lockdown’ in Japan. A total of 4111 infections and 97 deaths were confirmed in Japan by 6 April 2020 [There is a high prevalence of psychological symptoms such as depression and anxiety among people who experienced lockdown during the COVID-19 pandemic ,3,4,5,6,The timing of data collection is important in examining the effects of mild lockdown, which change daily. We selected the data collection as the period from the start of mild lockdown—based on the declaration of a state of emergency—until mild lockdown phasing out began . After our data collection was completed, the mild lockdown was phased out on 14 May 2020, and it was fully lifted on 25 May 2020. Therefore, our data collection period was in the middle of the mild lockdown—a period of great distress and less susceptible to recall bias. We examined the impact of mild lockdown on the population by identifying the distribution of psychological distress severity during these periods and comparing it with data previously collected by the government.There is also an urgent need to identify the impact on those considered vulnerable  to determine appropriate responses to the difficulties faced by vulnerable populations during these pandemics ,9. WhileIn sum, given that there are currently no research findings specifically addressing the impact of mild lockdown, this study is useful in that it clarifies the impact of mild lockdown on various populations and provides basic data that will be useful in formulating optimal strategies during future periods of infection spread and pandemics.A total of 11,333 participants  were included for analysis. Participants’ socio-demographic characteristics are described in n = 2783, 24.6%), Kanagawa , Osaka , Saitama , Chiba , Hyogo , and Fukuoka . The exclusion criteria for participants were: aged < 18 years, high school students, and living outside the seven prefectures. The online survey was completed on the second day after link distribution. All participants voluntarily responded to the anonymous survey and provided informed consent online. The survey procedure was clearly explained, and participants could interrupt or terminate participation at any time without explanation. This study was approved by the Research Ethics Committee at the Graduate School of Social and Industrial Science and Technology, Tokushima University (no.212), and was performed according to the ethical standards of the 1964 Declaration of Helsinki and its amendments.The number of people collected in each prefecture was determined according to the ratio of the number of people living in each province to the total population of the seven prefectures /46,548,456 (the population of the seven prefectures) ≒ 24.6%): Tokyo   to examiPsychological distress was measured by the Japanese version of the K6 , a six-iWe adopted a threshold of five points commonly used to screen for mild-to-moderate mood/anxiety disorders . K6 scorWe also used the Japanese version of the Patient Health Questionnaire-9 (PHQ-9)  to colleLoneliness and social networks are key factors associated with mental health ,26,27 anThe UCLA-LS3 consists of 10 items, each rated from 1 (never) to 4  . The scoSocio-demographic information collected included age, sex, occupation, marital status, and income. To compare the impact on groups assumed vulnerable to the effects of lockdown in previous studies ,8,9,11, It is important to consider psychosocial variables, such as stressors and stress management strategies specific to lockdown, in identifying factors that influence the impact of mild lockdown. Given that such variables have not previously been adequately considered ,5,6, we Based on previous literature regarding the COVID-19 pandemic ,6,8,11, Data records are available in XLSX format from the Open Science Framework (OSF) platform together with files of the questionnaires . The dat2 tests for categorical variables and analyses of variance (ANOVAs) for continuous variables. Hochberg’s GT2 method was used for multiple comparisons of ANOVAs to account for differences in numbers between groups. We also used Pearson’s χ2 tests against published CSLC data and data from this study to compare the change in the proportion of those with mental illness (K6 ≥ 5) before and during the mild lockdown .To determine the socio-demographic and psychological characteristics of groups classified by psychological distress severity (NPD (K6 score ≤ 4), MMPD (K6 score 5–12), and SPD (K6 score ≥ 13)), we compared these characteristics using Pearson’s χTo elaborate on psychological distress severity in the group assumed to be vulnerable, we conducted ANOVAs with K6 scores as the dependent variable for each of the following categories: healthcare worker , psychiatric illness , physical illness , and age in years . Hochberg’s GT2 method was used for multiple comparisons to account for differences in numbers between groups.Multinomial logistic regression analyses were conducted to examine the effects on psychological distress of socio-demographic characteristics  that previous studies suggest increased vulnerability, and psychosocial variables related to mild lockdown, including loneliness and social networks. Based on Field , the modAdditionally, we assumed that various risk and protective factors are intricately related and that people may have diverse backgrounds of psychological distress in lockdown situations. It is important to understand the background of psychological distress to consider approaches tailored to individuals’ difficulties. However, no previous studies have elaborated on this. Therefore, non-parametric Bayesian co-clustering  was usedFor all tests, significance was set at α = 0.05 (two-tailed). Analyses and figures were drawn using SPSS version 22.0 , MATLAB R2017a , and RStudio version 1.1.442 .The socio-demographic characteristics by severity of psychological distress, as measured by the K6, are shown in p < 0.001), females (p < 0.001), employed (p = 0.045), homemakers (p = 0.020), healthcare workers (p < 0.001), unmarried (p = 0.001), currently being treated for psychological problems (p = 0.001), and had received treatment for psychological problems in the past (p < 0.001), as compared to their counterparts.In the MMPD group, significantly more participants were aged 20–39 years (p < 0.001).In the SPD group, the following characteristics were observed to be significantly more prevalent: aged 18–19 years or 20–39 years, females, students, unmarried, income of less than 2 million yen, currently being treated for psychological problems, and having been treated for psychological problems in the past . In contrast, psychosocial variables that were significantly less prevalent in the MMPD group than in the NPD group were social network size (LSNS-6 score), exercise, healthy eating habits, healthy sleep habits, activity, offline interaction with family or friends, altruistically motivated preventive behaviors, and optimism . Similar results were observed in the SPD group, with the difference being that there was less online interaction with family or friends (p = 0.004), and altruistically motivated preventive behaviors were not different from those in the NPD group.The psychometric characteristics by psychological distress severity are shown in 2(8) = 41.9, p < 0.001, V = 0.205; p = 0.006; p = 0.002, respectively) and the percentage of psychological distress group was significantly higher (p < 0.001). Additionally, in 2010, the percentage of unknown groups was significantly higher (p < 0.001).There was a significant difference in the proportion of those with psychological distress (K6 score ≥ 5) in 2010, 2013, 2016, 2019, and 2020  = 3.50, p = 0.015, η2p = 0.001) and those who were healthcare workers had significantly more psychological distress than those who were not healthcare workers  in each group is shown in F = 359.32, p < 0.001, η2p = 0.087). Significantly more psychological distress was reported by those who were currently being treated for psychological problems, had ever been treated for psychological problems, or both, than by those who had not been treated for psychological problems  = 159.22, p < 0.001, η2p = 0.040): psychological distress was higher for those aged 18–19, 20–39, and 40–64 years than those aged ≥ 65  = 1.51, p = 0.210, η2p = 0.000; There was also a significant difference among age group  > 1.30) that predicted MMPD included being aged 20–39, a healthcare worker, and treatment for psychological problems either currently or in the past. Protective factors were optimism  = 0.86–0.92, p < 0.001) and healthy sleep habits .First, the prominent risk factors  that predicted SPD were indicated as follows: aged 18–19, 20–39, or 40–64, female, current and past being treated for psychological problems, past treatment for physical diseases, loneliness, frustration, COVID-19-related anxiety, or COVID-19-sleepless. Protective factors were optimism  and healthy sleep habits .Next, the prominent risk factors  showed particularly severe deterioration of relationships with familiar people and COVID-19-related sleeplessness , showed particularly high levels of loneliness and frustration, and a lack of online interaction with family or friends and optimism , showed highly pronounced difficulties in work or schoolwork and deterioration of household economy  had high levels of difficulties in work or schoolwork, while they were also highly optimistic, engaged in extensive online interactions, and maintained healthy sleep habits , COVID-19-related anxiety and deterioration of household economy were indicated, while high levels of optimism and social networks were characteristic of the cluster , there was a pronounced deterioration of relationships with familiar people and a high level of loneliness, while the cluster was characterized by low difficulties in work or schoolwork and low COVID-19-related anxiety , and to elucidate the risk and protective factors for psychological distress associated with mild lockdown. The study was conducted before the mild lockdown was phased out, and the seven major cities where the mild lockdown was initially implemented were included in the data collection.Based on K6 and PHQ-9 scores, ~50% of participants were distressed and ~20% were depressed. Regarding the distribution of K6 scores, the proportion of those with psychological distress was significantly higher when compared to previous national survey (CSLC) data from 2010, 2013, 2016, and 2019. This suggests that the one-month mild lockdown adversely affected the mental health of the population, consistent with previous studies reporting increases in depression, anxiety, and stress during the lockdown [The groups most likely to be significantly affected by mild lockdown were healthcare workers, those who were currently or previously treated for psychological problems, and younger participants (aged 18–19 and 20–39 years). In these groups, there was a significantly larger proportion of those with MMPD or SPD and a significantly higher level of psychological distress.Healthcare workers experienced increased psychological distress, especially MMPD, consistent with previous studies reporting a higher risk to healthcare workers ,44. It iHistory of treatment for psychological problems was the most significant risk for psychological distress severity. In China and Italy, exacerbations of psychological distress, such as stress and depressive symptoms, have also been reported in patients with psychiatric disorders during lockdown ,48, suggComparing age groups, younger adults were at particularly high risk, consistent with studies from China  and SpaiIn contrast, those aged > 65 years had the lowest psychological distress of all age groups. This can be attributed to the fact that the elderly maintained the best lifestyle habits, such as exercise, healthy eating, and sleep, and had the lowest levels of frustration and anxiety about COVID-19 compared to other age groups . Since JBased on the distribution of psychological distress, other populations that require consideration are women, unmarried, and low-income individuals. Consistent with this study, previous research has shown that being a woman ,4,12 andPsychological risk factors for psychological distress included COVID-19-related sleeplessness, COVID-19-related anxiety, and frustration. In contrast, this study revealed that healthy sleep habits and high levels of optimism were protective factors against psychological distress. Sleep problems are widely known to affect mental health , and thiFurthermore, because COVID-19-related sleeplessness is also closely linked to COVID-19-related anxiety , an apprInterestingly, previous studies have not focused on the usefulness of optimism as a protective factor. As an approach to increasing optimism as a protective factor, it is important for governments and social media to first communicate the prospects, based on scientific and objective information . AdditioA comprehensive mapping of psychological distress severity and the structure of interactions between psychosocial variables revealed that there are various dynamics of difficulties behind psychological distress. In particular, factors such as high levels of loneliness, deterioration of relationships with familiar people, COVID-19-related sleeplessness, increased COVID-19-related anxiety, deterioration of household economy, and work and academic difficulties characterized the main SPD clusters. Although these risk factors were present, the absence of overlapping risk factors and the presence of protective factors were characteristic of the main NPD clusters. The results suggest the importance of an approach that reduces the variety of psychosocial risk factors faced by each individual and also fosters protective factors.Given the diverse backgrounds of psychological distress caused by mild lockdown, a collaborative and cross-disciplinary approach by a variety of agencies is crucial to provide optimal support for individuals’ difficulties. In other words, it is essential for federal and local government agencies and institutions in the fields of industry, medicine, welfare, and education to work together in a flexible manner to focus on the difficulties of the individual. For instance, for people with significant loneliness and deterioration of household finances, it is necessary to establish a support system that can alleviate these concerns; for example, strengthening social support in communities , workplaThis study had some limitations. Given that we employed a cross-sectional design, it is difficult to examine the long-term impact of mild lockdown and the causal effect of risk and preventive factors. Longer-term follow-up is needed to clarify the evolution of prevalence and causal relationships, such as what variables mitigate or exacerbate the effects of mild lockdown. Additionally, while the results indicate demographic characteristics that may be risk factors for psychological distress, the analysis remains at an exploratory level, because this study provides a preliminary report of the effects of mild lockdown. Considering that different psychological burdens among healthcare workers depend on their job duties , furtherDespite these limitations, this study provided ample data from seven major cities where the highest numbers of cases were reported during the implementation of mild lockdown following the declaration of a state of emergency. Given that retrospective studies suffer from the effects of recall bias, the current data—collected during the implementation of the mild lockdown and examined ~1 month from implementation to just before the lockdown was lifted—may prove useful in clarifying the impact of the mild lockdown. The findings could be used during future periods of infection spread to inform how to help vulnerable populations. Specifically, this study sheds light on how to protect individuals’ mental health during lockdowns and on the effective implementation of various evidence-based policies and approaches.In conclusion, ~50% of people in major cities in Japan reported mild or greater psychological distress during their one-month mild lockdown experience. This percentage was larger than that observed in previous national surveys. The effects were particularly pronounced among healthcare workers, those with a history of treatment for psychiatric disorders, and younger adults. It was also indicated that support should be considered for women, students, unmarried, and low-income individuals. Among the psychological variables, COVID-19-related sleeplessness, COVID-19-related anxiety, and frustration were risk factors for increased psychological distress, while healthy sleep habits and optimism were protective factors. Mapping the structure of the interaction of psychosocial variables revealed that there were various backgrounds of psychological distress, indicating the need for specific intervention strategies tailored to each individual’s problem structure. The results suggest that cross-disciplinary public–private sector efforts are important to address individuals’ mental health issues arising from lockdown.


Data were collected and analyzed before and after 8 weeks of intervention. Our results showed a significant interaction between the group and time, with both AEW and walking independently and synergistically ameliorating AGEs, AOPPs, MDA, NLR and WBCs levels. Moreover, the AEW group had a higher physical and total QoL score. The walking group and the combined group had higher scores in physical, mental and total QoL compared to the control group. The synergistic effect of AEW and regular walking are an advisable treatment for patients with T2DM.Alkaline electrolyzed water (AEW) and walking are strongly recommended for ameliorating oxidative stress and inflammation. Nevertheless, there is a lack of information on the combination of both on alleviating inflammation, oxidative stress, and improving the quality of life (QoL). We investigated the synergistic effects of drinking AEW and walking on advanced glycation end products (AGEs), advanced oxidation protein products (AOPPs), malondialdehyde (MDA), white blood cells (WBCs), neutrophil-lymphocyte ratio (NLR) and QoL. In total, 81 eligible patients with type 2 diabetes (T2DM) were randomly allocated via single blind to four groups: consumed 2 L/day of AEW ( Type 2 diabetes (T2DM) is characterized by insulin resistance, wherein there is an overproduction and secretion of insulin in the early stage which lead to reduced insulin secretion and pancreatic beta cell death at late states. It has been reported that oxidative stress and inflammation are the risk factors for developing T2DM, and major causes of the complications and mortality among patients with T2DM ,2,3. TheOxidative stress biomarkers, such as advanced glycation end products (AGEs), advanced oxidation protein products (AOPPs) and malondialdehyde (MDA), are crucial parameters that facilitate more-individualized treatments of T2DM. Furthermore, higher levels of these markers are powerful predictors for developing vascular complications , and higIt was found that regular aerobic exercise effectively reduces fasting blood glucose (FBG) and AOPPs and maintains a stable blood pressure . RegularAlkaline electrolyzed water (AEW) is produced near the cathode during water electrolysis. AEW is a common health-beneficial drink that acts as a medical device that exhibits the alkaline power of hydrogen pH 8~10), and has negative oxidation-reduction potential (ORP), which has the ability to scavenge reactive oxygen species (ROS) and reduce inflammation, and can protect deoxyribonucleic acid from oxidative damage . AEW is , and hasTherefore, we conducted a randomized control trial study to investigate the effects of regular walking, the consumption of AEW, and their combined synergistic effect on reducing levels of AGEs, AOPPs, MDA, the NLR and WBCs, and on increasing the QoL of patients with T2DM. The objectives of this study were to assess the effects of regular walking, drinking AEW, and their combined synergistic effect on ameliorating oxidative stress  and inflammatory markers (the NLR and WBCs), FBG, and on promoting the QoL among Indonesians with T2DM, over a period of 8 weeks.Declaration of Helsinki. Written informed consent was obtained from each participant after they had received both verbal and written information about the research. Moreover, the trial study was registered with the Thai Clinical Trials Registry (Identifier: TCTR20200403002). The data was extracted electronically in a comma-separated variable format for a statistical software package. Databases were maintained on a secured server within the password-protected computer system and data were anonymized. Only members of this research study team will have access to the data. The electronic data will be deleted within five years following publication. Sample size calculation in this study used G-Power statistical software based on prior research [F-test, an a priori type of power analysis, with an effect size of 0.25, a power (1–β) of 0.8, and an α level of 0.05, for four groups . This method produced a total estimated sample size of 76. In this study, the sample size of each group was 19 subjects. We estimated a 5% dropout rate and decided to increase the sample size to 20 subjects in each group.The study protocol was reviewed and approved by the Clinical Research Ethics Committee of Siti Khotidjah Muhammadiyah Sepanjang Hospital  and Institutional Review Board Ethics Committee of Institute Health Science Strada Indonesia  and conformed to the provisions of the A randomized control trial with a four parallel intervention group design was conducted to evaluate the effects of regular walking, AEW supplementation, and the two combined on ameliorating oxidative stress and inflammatory markers, and improving the QoL among Indonesians with T2DM, with 8 weeks intervention. Individuals with T2DM were recruited from two community clinics between 1 July and 30 November, 2018 in East Java, Indonesia. In this study, there were 154 patients with T2DM identified from medical records at recruitment; 81 met the study inclusion and exclusion criteria. The inclusion criteria were (1) Indonesian nationals aged 17~80 years, (2) those who agreed to participate in the study, (3) patients who were diagnosed with T2DM at least six months before, (4) no previous myocardial infarction, stroke or diagnosed coronary artery disease, (5) those who visited the community clinic outpatient department and completed the questionnaires, (6) those who were diagnosed with T2DM as confirmed by a physician with 2 h blood glucose test results of >200 mg/dL or FBG of >126 mg/dL , and (7)www.randomizer.org) with a ratio of 1:1, and the sequence was performed by research assistants who were not involved in data collection. Once a patient agreed to participate in the study, this information was passed by the research assistant to a clinical nurse who then allocated the patients to the groups based on an opaque and sealed envelope with the identifiers that were given to all participants according to their sequence of entering the trial. It was impossible to blind the participants due to the nature of the interventions.The group assignment sequence was generated by a computer (−), copper , iron , nitrate , nitride , calcium carbonate , aluminum  and sulfate , produced in a private laboratory (ISO 14001: 2015 and 9001:2015 certified), and was approved as a water consumable. Research assistants controlled the information report 3 days per week and encouraged participant adherence to the intervention protocol for safety management. Data were collected at the baseline before alkaline electrolyzed water intervention (T0) and post-intervention at 8 weeks (T1) to investigate the effects of the alkaline electrolyzed water interventions.As recommended by other studies ,24,27, pParticipants in the regular walking group were instructed to walk around the house, park or roads for a duration at least 30 min, five times/week  for 8 weeks, without measuring the distance or speed . Self-reParticipants in the combined alkaline electrolyzed water and regular walking group were instructed to consume 2 L/day of supplemented alkaline electrolyzed water at pH 9.5 and to walk for at least 30 min five times/week or 150 min/week for 8 weeks. Research assistants controlled the frequency and duration of regular walking and alkaline electrolyzed water consumption reports 3 days/week and encouraged participants to adhere to the intervention protocol for safety management. Data were collected at the baseline before combined alkaline electrolyzed water and regular walking intervention (T0) and post-intervention at 8 weeks (T1) to investigate the effects of the combined alkaline electrolyzed water and regular walking interventions.Control group participants were advised to continue their habitual diet and activity. They were recommended to not do any additional physical activity or to consume alkaline electrolyzed water supplementation, and research assistants controlled the control group participants’ daily activity and diet consumption 3 days/week and encouraged them to continue their habitual diet and activities for safety management. Data were collected at the baseline (T0) and post-intervention at 8 weeks (T1) to investigate the effects of habitual diet and activity.Research assistants collected data using a questionnaire containing questions concerning participants’ demographic characteristics collected at the baseline, and included participant’s age, diabetes duration, gender, marital status, income, educational level and smoking status. Furthermore, factors including dietary habits, depression, anxiety and stress, that may influence oxidative stress, inflammatory markers and QoL, were also collected. This study measured the relevant biochemical features of T2DM, including AGEs, AOPPs, MDA, NLR, WBC and FBG.TM Microplate Absorbance Reader 1,681,130  at 450 nm at the Institute of Tropical Diseases, an International Research Center at the University of Airlangga (ISO 17025:2008 certified). According to the manufacturer’s instructions, the detection ranges of AGEs, AOPPs and MDA were 10~4000 ng/L, 0.1~40 ng/ml and 0.2~70 nmol/ml, respectively. The inter-assay and intra-assay coefficients of variation were <8% and <10%, respectively. The NLR and WBCs were measured using a fasting blood sample (3 mL) that was withdrawn from the antecubital vein. NLR was determined by dividing the absolute blood neutrophil count by the absolute lymphocyte count. The blood was mixed with dipotassium ethylenediaminetetraacetic acid (1.5~2.2 mg/mL). FBG, NLR and WBCs were analyzed using an automated XP-100 hematology cell counter  in a private laboratory (ISO 14001: 2015 and 9001:2015 certified).Participants were invited to participate in each clinical measurement session after 12 h of fasting. All venipuncture was performed by trained phlebotomists. All biochemical analysts and trained phlebotomists were blinded to the treatment group. Concentrations of AGEs , AOPPs  and MDA r = 0.626–1 and had good internal consistency, with a Cronbach’s alpha of 0.789 [The 36-Item Short Form Survey (SF-36) is one of the most widely used instruments to measure self-reported QoL . In addiof 0.789 .To determine the behavioral dietary intake, 25 items of a self-reported food frequency questionnaire (FFQ) were used. Subjects were asked to report their average frequency intake of each food group, which has four options of more than once per day, one to six times per week, one to three times per month, and never. Moreover, we used the rank-determined dietary score . The FFQ was established to have good performance validity with a content validity index of 0.75 , and wasWe measured levels of depression, anxiety and stress using Depression, Anxiety and Stress Scale-21 (DASS-21) items . CronbacThe safety of the method of four parallel intervention groups was assessed by the incidence of adverse events during the trial study period. The potential adverse events included fatigue and increased urine production. These were self-recorded by participants and monitored by physicians once a week, as well as being well-documented by clinical nurses. In the event of a side-effect, the physician and investigators should immediately discontinue the intervention and intervene.Study fidelity was established through meetings between investigators, clinical nurses, research assistants, research fellows and physicians to review the procedures, confirm competency measurement and equalize perceptions in the conducting of the research.p value of <0.05 considered statistically significant. Continuous and categorical data were reported using descriptive statistics of the mean (standard deviation (SD)) and n (%), respectively. Chi-squared and one-way analysis of variance (ANOVA) tests were respectively used to compare sociodemographic and baseline outcomes among the four groups. Generalized estimating equation models (GEE) with appropriate link functions and distribution assumptions were used to compare differential changes in outcomes across time and between groups. The models were adjusted for potential covariates including stress, anxiety and depression levels, and carbohydrate, protein, fat, fast food and fiber consumption scores. Missing data due to loss to follow-up (n = 1) were assumed to be missing at random, and data were analyzed following the intention-to-treat basis.Statistical analyses were performed using SPSS 25.0 , with a n = 20), regular walking intervention (n = 20), combined AEW and regular walking intervention (n = 20), and control group intervention (n = 21). The overall compliance of patients to the AEW and regular walking intervention was optimal. However, one control arm participant (1.24%) was lost to follow-up (contact lost) at 8 weeks, and no harms or unintended effects were measured in each group available for the intention-to-treat analysis. No statistically significant differences were noted in sociodemographic or clinical characteristics, including age, diabetes duration, gender, marital status, income, education, smoking status, physical activity, stress level, anxiety level, depression level or consumption of carbohydrates, protein, fat, fast food and fiber among the four groups , were detected, as follows: physical component score = 15.656 (12.966~18.346); mental component score = 13.869 (10.397~17.341); total QoL = 14.763 (12.364~17.163). The physical component and total QoL scores significantly increased in the AEW group (11.938 (9.687~14.118) and 6.315 (5.108~7.523) respectively), but no changes occurred in the mental component score (0.694 (−0.090~1.447)). Moreover after 8 weeks of the intervention, the combined AEW water and regular walking group saw significant increases in the physical component, mental component and total QoL scores of 22.750 (20.242~25.258), 27.113 (24.089~30.163), and 24.933 (23.090~26.776), respectively. In contrast, the control group showed no changes in the physical component, mental component or total QoL scores .The intervention effects on biomarkers and QoL after the 8-week intervention are shown in To our knowledge, this is the first community-based randomized control trial study to explore the effects of regular walking and consumption of AEW on oxidative stress, inflammatory markers and QoL among patients with T2DM. Community-based health programs are practical and relatively low-resource, often requiring lifestyle-changing educational programs. Previous studies suggested that community-based RCT can diagnose as well as monitor how well diabetes is controlled and improve community health habits, which ultimately reinforces the high priority given to the translation of research into new practices .These results extend our understanding that T2DM participants who regularly walked for a duration of 30 min at least 5 times/week, or spent 150 min/week regularly walking for 8 weeks, exhibited significantly reduced WBCs, NLR, FBG, MDA, AGEs and AOPPs. Our study was consistent with a prospective cohort study, which indicated that low/moderate-intensity physical activity such as walking was inversely associated with WBC counts, especially for patients with moderate to vigorous physical activity . AdditioIn the present study, we found that the AEW group had lower oxidative stress and inflammatory markers after an 8-week intervention compared to the control group. The antioxidant, anti-obesity and antidiabetic effects of AEW were reported in previous studies . The proAdditionally, our study demonstrated that participants in the combined regular walking and AEW intervention groups exhibited synergistic amelioration of FBG, AOPPs, AGEs, MDA, NLR and WBCs compared to a control group after an 8-week intervention. The possible mechanism for this synergistic effect might be the effects on antioxidants. Those findings are similar to the results of this study, which determined that antioxidative stress rose in those who consumed AEW. Importantly, Weidman et al.  stated tOur study had some limitations that must be considered. First, although it is essential to determine the immediate effects after an 8-week intervention, evaluation of the long-term follow-up is also necessary. Second, walking speed was not recorded, and this could have induced an underestimation of the effect of the regular walking intervention on outcomes. Third, we did not measure the pharmacokinetics of AEW in the gastrointestinal region of the subjects. Therefore, future research should investigate the molecular mechanisms of hydrogen at the physiological level, such as the gastrointestinal region. Fourth, the present study was not able to measure HbA1c due to the higher cost and longer time required to detect (>3 months), and did not include dietary management intervention, which may influence our findings. Lastly, all enrolled participants were of the Javanese ethnicity; consequently, the generalizability of our result may be limited.In conclusion, our findings revealed that regular walking and the drinking of AEW, both independently and synergistically, reduced FBG, AGEs, AOPPs, MDA, WBCs and the NLR, as well as promoting the QoL of patients with T2DM over 8 weeks, so it is a feasible treatment in advanced T2DM.


Long non-coding RNA (lncRNA) can predict the prognosis of patients with coronary heart disease (CHD) after obtaining percutaneous coronary intervention (PCI), while this conclusion still needs to be further confirmed. Therefore, this study attempted to explore the relationship between lncRNA and prognosis in CHD patients after PCI.The database was retrieved from China National Knowledge Infrastructure (CNKI), Chinese Biomedical literature Database (CBM), Chinese Scientific and Journal Database (VIP), Wan Fang database, PubMed, and EMBASE. Hazard ratios (HRs) and its 95% confidence interval (CIs) were applied to assess the prognostic effects of lncRNA on overall survival (OS). RevMan 5.3 and STATA 16.0 software were used to perform meta-analysis.The results of this meta-analysis would be submitted to peer-reviewed journals for publication.This review provided a comprehensive overview of the relationship between lncRNA and prognosis in CHD patients after PCI, and offered recommendations for clinical practices or guidelines. Clinical manifestations of CHD include arrhythmia, angina pectoris, myocardial infarction, heart failure, and sudden death. Vascular smooth muscle cell changes phenotype after injury, migrates to intima and attracts extracellular matrix polymerization, thus playing an important role in the development of atherosclerosis. Hyperlipidemia, hypertension, and smoking belong to the risk factors of CHD.–7 The prognosis of CHD patients is regulated by many factors such as angina pectoris, myocardial infarction, ischemic heart failure, and sudden death.Mainly caused by atherosclerosis, With the emergence of PCI, its rapid development and the continuous emergence of new anticoagulant and antiplatelet drugs have constantly broken through the limited field of PCI therapy. However, no effective biological index can be adopted to judge the prognosis of CHD after PCI.Revascularization is the most effective method for the treatment of coronary heart disease. Although it cannot completely cure coronary heart disease, it can greatly improve CHD patients’ clinical symptoms, thus increasing their life quality and survival rate. At present, coronary artery reconstruction mainly involves coronary artery bypass grafting and percutaneous coronary intervention (PCI).With the production and rapid development of the second generation sequencing, especially the application of RNA sequencing, long non-coding RNA (lncRNA) has gradually become a hot spot in the field of life science. The expression level of lncRNA in blood samples may be regarded as a prognostic and diagnostic biomarker. In order to analyze the effect of LncRNA on the prognosis of CHD after PCI more accurately, this study reviewed the literature on the relationship between lncRNA and prognosis in CHD patients after PCI, and applied meta-analysis to evaluate the relationship between lncRNA and prognosis in patients CHD after PCI.22.1This meta-analysis protocol is based on the Preferred Reporting Items for Systematic Reviews and meta-analysis Protocols (PRISMA-P) statement guidelines. The protocol of the systematic review was registered on Open Science Framework, and the registration number is DOI 10.17605/OSF.IO/RAZ6J.2.2We searched China National Knowledge Infrastructure (CNKI), Chinese Biomedical literature Database (CBM), Chinese Scientific and Journal Database (VIP), Wan Fang database, PubMed, EMBASE, and all these electronic databases, without language restrictions. The PubMed search strategy was illustrated in details in Table 2.3(1)CHD was diagnosed based the coronary artery score of the American College of Cardiology.(2)LncRNA was expressed in serum or plasma.(3)Reported LncRNA survival-related data.(4)Patients were divided into LncRNA positive and LncRNA negative.(5)Published as full-text articles.Papers without sufficient data, literature reviews, case series, conference summaries, animal studies, and other unrelated studies were excluded from the analysis.2.42.4.1First of all, 2 researchers read and checked out the titles and abstracts of relevant literatures independently. After excluding the literatures that obviously do not meet the inclusion criteria, and downloading the remaining literatures for further full-text reading, the literatures that really meet the inclusion criteria were enrolled. The 2 researchers cross-checked the results. A self-made data extraction form was made to extract the required information from the included literatures. If there are differences, a third party would involve the discussion or consultation in this study. The flowchart of the study selection Fig.  could pr2.4.2http://digitizer.sourceforge.net/).The extracted information includes the title of the paper, name of the first author, journal, year of publication, country, race, age, sex, sample size, LncRNA detection method, LncRNA type, overall survival (OS), hazard ratio (HRs), and 95% confidence interval (CIs). If we can’t access survival data directly, we would obtain HRs and 95% CIs from the Kaplan–Meier survival curves by referring to Engauge Digitizer version 4.1  was adopted to evaluate the quality of the included studies.2.6OS was taken as prognostic outcomes, and the results were expressed as HRs with 95% CIs.2.7If there exists insufficient or missing data in the literature, we would only analyze the currently available data and discuss its potential value.2.8I2 test were used to test the heterogeneity of the included study (test level α = 0.1). I2 ≤ 25% indicated that the heterogeneity was small, 25% < I2 ≤ 50% marked moderate heterogeneity, and I2 > 50% revealed that there was a high degree of heterogeneity among the research results. When there is no heterogeneity among the research results, the fixed effect model is adopted for meta-analysis. When there exists heterogeneity among the research results, the stability of the conclusion is verified, and the random effect model is decided for meta-analysis.Statistical analysis was performed with STATA 14.0  and RevMan 5.3 . The 95% CIs and HRs were utilized to evaluate the relationship among LncRNA expression and OS. First of all, chi-squared test and 2.92.9.1According to the detection methods of LncRNA, ethnicity, the source of survival data, and type of LncRNA, we analyzed the subgroup.2.9.2Sensitivity analysis was conducted to assess the impact of individual studies on the overall merger value.2.9.3,15 Besides, Egger and Begg test were adopted for the evaluation of potential publication bias.If the number of studies included in a certain outcome index was no <10, funnel chart could be used to evaluate publication bias.2.10Our research data were derived from published literatures, because there was no patient recruitment and personal information collection. Therefore, ethical approval was not required.3 Therefore, it is necessary to detect CHD in the early stage, especially before the occurrence of left ventricular dysfunction. It is very helpful to use circulatory or imaging biomarkers to identify the high risk of adverse cardiovascular events in CHD patients. However, the lack of available CHD biomarkers limits the risk prediction.Cardiovascular disease, especially CHD, is still the leading cause of death worldwide, resulting in a significant social and economic burden. Although drug therapy, PCI, and other treatments can improve the prognosis of CHD, the mortality rate is still very high.In the past 10 years, the research on lncRNA in terms of the occurrence and development of CHD and other heart diseases has become more and more in-depth. LncRNA not only regulates cell proliferation, apoptosis, injury, autophagy, and differentiation, but also participates in the occurrence and development of a variety of cardiovascular diseases through different molecular mechanism. Therefore, it can be regarded as a new regulatory factor for diagnosis and treatment.–22 Pezawas et al proposed that the expression of LncRNA UCA1 in plasma of patients with acute myocardial infarction decreasing significantly in the early stage, and gradually rising after the third day, so it was regarded as a marker of acute myocardial infarction. Hu and Hu put forward that ANRIL has good diagnostic value for CHD, and its high expression is correlated with the increased degree of stenosis, increased inflammation and poor OS in CHD patients. LncRNA is stable in plasma and other body fluids, so it can be applied as a biomarker for some diseases. We hope to conduct a meta-analysis in accordance with PRASMA statement to provide more evidence for LncRNA as a prognostic marker of CHD after PCI. However, this study also has some limitations. Our search does not include learning languages other than Chinese and English, so it may lead to some selective bias. Most importantly, there may be some heterogeneity due to the application of different treatments in various studies.Some plasma LncRNA, such as ANRIL, LincRNA-p21, and myocardial infarction-related transcription factor-1, significantly increases in atherosclerosis and may play an important role in the pathogenesis of atherosclerosis.Conceptualization: Ling Ma, Fei Wang.Data curation: Xiaoqing Cai, Peng Zhang.Resources: Piqi Jiao.Software: Yan Liu, Bin Yuan, Hongbin Liu.Writing – original draft: Ling Ma, Fei Wang.Writing – review & editing: Ling Ma, Fei Wang.