Low Dietary Diversity (DD) result in severe problem among the vulnerable group in low-income countries (LICs), whose diets are predominantly starchy staples. Lactating Women (LW) from LICs are considered a nutritionally vulnerable group. It results in many consequences on the health and well-being of children, households, communities, and the nation. However, there is little empirical evidence on factors contributing to low DD among LW in Ethiopia and the proposed study site. Therefore, this study aimed at assessing the DD and associated factors among LW in Pawie district, Northwest Ethiopia.A Community-based cross-sectional study was conducted among 806 LW from March to May 2019 G.C. DD assessed using 24 h dietary recall methods with structured questionnaires.A mean dietary diversity score (DDS) was computed for ten food groups. Food insecurity measured using a 9-item Household Food Insecurity Access Scale (HFIAS). The multivariable logistic regression model was used to see the relevant associations. The variables which have a significant association with DD were identified based on AOR, P-value ≤ 0.05, and 95% Cl.A total of 806 LW aged 15–49 years were interviewed with a response rate of 100%. About two-third of LW had low DD (<5 food groups). Fathers occupation being daily laborer , birth interval less than 24 months , family size greater than six members  and food insecurity  were more likely associated with the low DD among LW compared to their counterpart.The DD among LW was low. Low Dietary Diversity was statistically associated with low birth intervals, large family sizes, and food insecurity. Hence, attention should be paid to the identified factors of low DD of LW to improve their health, and that of their children as well as their family. Lactating women, Dietary diversity, Household Food Insecurity Access Scale, Pawie, Ethiopia. Hence, lactating Women(LW) are vulnerable to malnutrition due to the physiological vulnerability that comes with childbearing is the first reason, and maternal nutrient needs increase during lactation .Low Dietary Diversity results in severe problems among LW in LICs, whose diets are predominantly starchy staples. Similarly, the consumption of animal products, seasonal fruits, and vegetables are generally absent or minimal. The DD in LW is critical because they require additional energy and nutritious foods , 3. LW'sIn Northern Ghana, 52% of LW dietary diversity scores were less than five different food groups. The five most widely consumed food groups were cereals and grains, fish and seafood, dark green leafy vegetables, species, condiments and beverages, and other vegetables apart from vitamin A rich vegetables such as tomatoes, onion, and egg-plant .In Southwestern Bangladesh: a lower educational achievement, the husband is a daily wage earner, and higher household size (3 or high family members) may likely be associated with low mean DDS of LW . In NortTo prevent and correct a nutritional vulnerability in LW, one of the best interventions is DD and might be a means of achieving the sustainable development goals (SDGs) in an integrated manner , 10. Des22.1The study was conducted in the Pawie district. It is tracking down in Benishangul-Gumuz Regional State, Northwest Ethiopia. The study area has an estimated 5, 244 square kilometers, which is located at 623 and 447 KMs away from the capital city of Ethiopia (Addis Ababa), and the regional capital city Assossa respectively. According to the 2016 Metekel zone finance and economic development projection, a total of 51,895 population are living in the district . Administratively Pawe district has 20  kebeles . According to the 2016 bi-annual report of the Pawie district health office, there were 2,425 LW in the district. Currently, Pawe district has one general hospital, four public health centers, and 20 health posts .Grains, potato, sorghum, pea and beans, and vegetables  are the primary agricultural products.2.2A community-based cross-sectional study was conducted from March to May 2019 to assess dietary diversity and associated factors among lactating women in Pawie district Benishangul Gumuz Regional State, Northwest Ethiopia.2.3All lactating women who lived in the Pawie district for at least six months were eligible for the study, LW who was permanently residing in the selected kebeles were considered the study units.2.4In this study, the sample size was determined, by using the single population proportion formula. Taking the prevalence of good DDS as 47.8% for lactating women  to obtai2.5Multistage sampling technique was employed to select kebeles, households, and lactating women. From a total of 20 rural kebeles of Pawie district, five kebeles were selected by simple random sampling (lottery method) technique. LW was allocated to each selected kebeles by proportionate allocation. From each selected kebele, LW were designated by a simple random sampling method.2.6The data was collected with a face-to-face interview by the data collectors using a structured and pre-tested questionnaire. The questionnaires was adapted from English published articles and Food and Agriculture Organization (FAO) guidelines for measuring individual DD, 2011 and Household Food Insecurity Access Scale (HFIAS) to measure household food insecurity . WrittenA total of 16 food groups  considered. These food groups further regrouped into ten food groups , nuts and seeds, all dairy, flesh foods (including organ meat), eggs, vitamin A-rich dark green leafy vegetables, other vitamin A-rich vegetables and fruits, other vegetables, and other fruits) during analysis , 4.The Minimum Dietary Diversity Score (DDS) was calculated for each LW during the previous 24 h to classify the mother's dietary diversity as good DD (≥5 food groups) or poor DD (<5 food groups) from ten food groups. Then, the outcome variable coded as a good DD ≥ 5 food groups as “1” and poor DD < 5 food groups as “0” for logistic regression analysis , 15.The score of the respondents has taken, and respondents were classified as having good DD and poor DD by taking their responses if they consume greater or equal to five food groups and less than five food groups respectively , 16. The2.7For administering the structured questionnaire, 2 Public Health Nutrition and 8 health extension workers were employed as supervisors and data collectors sequentially. The training was given for two days for both supervisors and data collectors on the objective, the relevance, confidentiality of information, respondent's right, time of data collection, and reorganization of the collected data from respective sub-cities, and submission on due time.In addition, a pre-test was conducted on 5% of the actual sample size out of sampled kebele. The principal investigator and the supervisors checked the collected data for completeness, and corrective measures were taken accordingly. The collected data were cleaned, coded, and explored before analysis.2.8The data were entered, coded, and cleaned using the Epi data and exported to SPSS software version 21 for analysis. Frequencies and cross-tabulations used to summarize descriptive statistics of the data. Bivariate logistic regression was employed to see the association of each variable with dependent variables. Finally, independent variables with p-values < 0.2 in the bivariate logistic regression were entered into multivariate logistic regressions to control the effect of confounding. All variables with P–values less than 5% considered to have a significant relationship with the outcome variable.2.9Ethical clearance was obtained from the institutional review board of the school of nursing, College of Medicine and Health Sciences, Bahir Dar University. The letter was submitted to Pawie district health office. An official permission letter from the office was obtained for the next steps.The written permission letter from the district health office was submitted to each kebeles administrative office, which is the actual data collection conducted. All lactating mothers were informed about the objective of the study. Then after the objectives of the study was explained, all mothers' age was >18, and informed verbal consent from every LW was obtained. The right to participate or withdraw from the study at any time without any requirement was disclosed to the participant clearly. Furthermore, the confidentiality of the information obtained from participants was guaranteed by all data collectors and investigators by using code numbers and keeping the questionnaires locked.33.1A total of 806 LW aged 15–49 years interviewed, with a response rate of 100%. Of the total LW, 50% were in the age group 20–29, 586 (72.7 %) were Amhara. Of the entire study participants, 474 (58.8%) were Orthodox. Nearly two-thirds, 493 (61.2%) LW were unable to read and write, and 570 (70.7%) participants were housewives. 521 (64.6%) of the study participants had a family member of 4–6 members, whereas 639 (79.3%) birth intervals were greater than 24 months .Table 1S3.2A 532 LW were getting the water from the piped source. Almost all participants had a functional toilet. 757 (95.9%) of LW had at least one Antenatal care (ANC)” follow-up, and from these greater than two-third of LW had more than three times follow-ups in the last pregnancy, but only 128 (15.9%) of LW have had Postnatal care (PNC) follow-up to the previous delivery.Almost all LW didn't suffer from any chronic disease illness during their breastfeeding period, but only 29 (3.6%) of LW had a history of illness in the last two weeks. 676 (83.8%) of LW gave birth at a health facility, and all LW practice exclusive breastfeeding .Table 2H3.3A 71.6% of the LW consumed cereals, white roots, and tubers in the previous 24 h, whereas 54.1% consumed vitamin A-rich vegetables and tubers in the previous 24 h. Similarly, 50.2% consumed other fruits and vegetables in the previous 24 h. 68.1% consumed fats and oils in the previous 24 h, and two-third were organ meat and fish meat in the previous 24 h during their lactation period. Based on the categories, 297 (36.8%) of the LW had a good DDS (consumed ≥ five food groups), and 63.2% were with low DDS (consumed < five food group) .Table 3D3.4th of the LW were unable to eat preferred foods. 168(20.8%) of the LW was eating a limited variety of food, and only15% of LW consumed the food that they did not go to eat really, and over 1/4th of LW were skipping their meals in the last 24 h. The overall prevalence of food insecurity, 334 (41.4%) of the LW was food insecure  and existing research, good DD during lactation for all LW is critical for maternal health, the health of their children, family, and nation . The maiIn this finding, 36.8 % of the LW had good DD, and 63.2 % did not receive minimum DD. This is higher than the study done in Pakistan , Kenya , EthiopiThis finding is almost consistent with the study done in Bale zone , NortheaOn the other hand, the finding of this study is lower as compared with another study which is done in Nepal , Debre TIn the current study, Father's occupational status being a daily laboring father, two times more likely to have low LD. Similarly, finding in Debre Tabor, Ethiopia , JakartaMothers with families seize >6 family members were 1.5 times higher risk for poor dietary diversity as compared to mothers who have less than six family sizes in this study. This is supported by the studies conducted in Wolega, Guto Gido woreda, and Nekemte referral hospital family size (AOR = 4.604, 95%CI = 1.903–11.140 have significant relation with mothers’ DD in the study area , 35. WheIn this study, Mothers whose birth interval <24 months 3 times more likely to have a risk for poor DD as compared to their counterpart. Because, the mothers have no time to care for themselves rather they caring and worry for their little child and the next child, that may challenge their economy as well as they may have less the chances of meeting nutrient requirements for the family by improving nutritional status.Mothers who had food insecurity were two times more likely to have poor DD as compared to the mothers who were food secured in the current study. Similarly, in a study in Mali and Debub Bench zone, women from extremely food insecure households were less likely to have good DD , 36. WheThe husband's educational status, age, marital status, monthly income, owns agricultural land, and employment status were not associated with the DD of mothers during their lactation periods in the current study. It was disproved by a cross-sectional survey conducted in southwestern Bangladesh , in nort5Nearly two-thirds of the LW doesn't achieve the minimum DDS, and father's occupation, low birth intervals, family size being large family, and being a food-insecurity household were the significant predictors of minimum DDS in this study. Federal Ministry of Health, regional health bureaus, and agricultural government: prioritizing, planning, designing, and initiating DD intervention programs to improve maternal nutrition through appropriate food-based approaches strengthen nutrition education programs on proper maternal MDD practices and DD intake during lactation periods focused on the main predictors. In general, it is not the only task of the government; it requires multi-sectorial involvements, so every sector works cooperatively to improve the nutrition outcomes of LW. The health personals work on family planning, ANC and PNC should counsel the Women to increase the awareness of LW on how to improve the DD.6The strength of this study was we used a large sample, a community-based, and required statistical analysis. However, the limitations of the study were that the data was collected by interview of the mothers about the previous 24 h of recall dietary diversity assessment, so there might be recall biases about what they consumed within the last previous 24 h , 39.Sileshi Mulatu, Chalachew Yenew: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.Habtamu Dinku: Conceived and designed the experiments; Wrote the paper.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.


CNNM2  pathogenic variants have been reported to cause hypomagnesemia, epilepsy, and intellectual disability/developmental delay (ID/DD). We identified two new cases with CNNM2 novel de novo pathogenic variants, c.814T>C and c.976G>C. They both presented with infantile-onset epilepsy with DD and hypomagnesemia refractory to magnesium supplementation. To date, 21 cases with CNNM2-related disorders have been reported. We combined all 23 cases to analyze the features of CNNM2-related disorders. The phenotypes can be classified into three types: type 1, autosomal dominant (AD) inherited simple hypomagnesemia; type 2, AD inherited hypomagnesemia with epilepsy and ID/DD; and type 3, autosomal recessive (AR) inherited hypomagnesemia with epilepsy and ID/DD. All five type 1 cases had no epilepsy or ID/DD; they all had hypomagnesemia, and three of them presented with symptoms secondary to hypomagnesemia. Fifteen type 2 patients could have ID/DD and seizures, which can be controlled with antiseizure medications (ASMs); their variations clustered in the DUF21 domain of CNNM2. All three type 3 patients had seizures from 1 to 6 days after birth; the seizures were refractory, and 1/3 had status epilepticus; ID/DD in these AR-inherited cases was more severe than that of AD-inherited cases; they all had abnormalities of brain magnetic resonance imaging (MRI). Except for one patient whose serum magnesium was the lower limit of normal, others had definite hypomagnesemia. Hypomagnesemia could be improved after magnesium supplement but could not return to the normal level. Variations in the CBS2 domain may be related to lower serum magnesium. However, there was no significant difference in the level of serum magnesium among the patients with three different types of CNNM2-related disorders. The severity of different phenotypes was therefore not explained by decreased serum magnesium. We expanded the spectrum of CNNM2 variants and classified the phenotypes of CNNM2-related disorders into three types. We found that DUF21 domain variations were most associated with CNNM2-related central nervous system phenotypes, whereas hypomagnesemia was more pronounced in patients with CBS2 domain variations, and AR-inherited CNNM2-related disorders had the most severe phenotype. These results provide important clues for further functional studies of CNNM2 and provide basic foundations for more accurate genetic counseling. MMGT1, MAGT1, NIPAL1, NIPAL4, MRS2, CNNM2, and CNNM4. CNNM2, previously known as ACDP2 (Ancient Conserved Domain Protein 2), has been demonstrated to be related to magnesium homeostasis in humans , brain MRI, serum electrolytes, gene variants information, and mode of inheritance.Two Chinese cases with infantile-onset epilepsy and global DD had been identified to have novel Written informed consent was obtained from the parents of both patients. This study was approved by the institutional review boards of Peking University First Hospital. We collected 5 ml of peripheral venous blood from patients and their parents. Genomic DNA was extracted for trio-whole exome sequencing (WES). The pathogenicity of the variants was predicted by SIFT, PolyPhen-2, CADD, and MutationTaster. Variants were evaluated against the overall population in 1000 Genomes, gnomAD, and ExAC databases. The pathogenicity was classified according to variant classification standards based on the American College of Medical Genetics and Genomics (ACMG) guidelines, 2015.de novo missense heterozygous variant c.814T>C [p.Phe272Leu]. He still could not raise his head steadily at 6 months of age. His seizures started at 10 months after birth, mainly characterized by eyes gazing to the left side and perioral cyanosis, sometimes accompanied by jaw tremor, right lower limb raising, and hand tremor. EEG showed focal frontal epileptic discharge. Although ictal EEG of this patient was not available, the electrical-clinical features indicate that his seizures were focal seizures. The seizures were clustered, up to eight attacks per day, only 2–3 days per month. He had been seizure-free from 12 months of age by levetiracetam monotherapy. He had DD. When he was 1 year old, he could sit and crawl without others' help. He could walk without support from 1 year 3 months of age, but he still could not walk steadily now. He began to vocalize at 1 year old, but he could not make the sound of “babamama” till now. He had no apparent malformations. Brain MRI was normal. His initial serum magnesium was 0.56 mmol/L. After his seizures were completely controlled, he was diagnosed with causative gene and began to receive magnesium supplement at 1 year old. But diarrhea occurred after oral administration of magnesium, which was improved after suspension of magnesium supplementation. It was considered that diarrhea was related to gastrointestinal side effects of oral magnesium, so the treatment with magnesium supplementation was interrupted, and his parents did not monitor serum magnesium level for him regularly. During magnesium supplementation treatment, his highest serum magnesium was 0.62 mmol/L and he had no seizures, but no improvement in psychomotor development was observed.Case 1 was a 2-year-old boy who carried a novel identified de novo missense heterozygous variant c.976G>C [p.Val326Leu]. Her seizures started at 8 months after birth and always occurred during sleep. Seizures involved eye opening and fearful expression, eye and head turning left, and then tonic and clonic jerks of the four limbs. Seizures were accompanied by perioral cyanosis. Ictal EEG showed the seizure onset from the right hemisphere . Finally, according to the ACMG guidelines, both variants were clarified as likely pathogenic (LP) (Both cases were identified nic (LP) . Other pCNNM2 variant (15/23). Most of the cases are with seizures at onset. In type 2 cases, 86.7% (13/15) had epileptic seizures, and 93.3% (14/15) had ID/DD in the course of the disease. Based on limited available details, the age at seizure onset was 4 months to 1 year in most cases, but 16 years of age in one case. Their seizures showed good response to antiseizure medications (ASMs); multiple kinds of ASMs had been reported to be effective, including phenobarbital, valproic acid, clobazam, levetiracetam, and lacosamide. All type 2 patients had ID/DD, characterized by language expression dysfunction. Physical development was normal in type 2 cases. Physical examination revealed no apparent malformations. Brain MRI was normal except for corona radiata and centrum semiovale white matter T2 slightly hyperintense in one case. Of the cases, 93.3% had definite hypomagnesemia; their initial serum magnesium was 0.44–0.66 mmol/L. However, borderline hypomagnesemia was found in one case whose initial serum magnesium was 0.72 mmol/L. Hypomagnesemia could be improved after magnesium supplement but could not return to the normal level. Type 3, AR-inherited hypomagnesemia with epilepsy and ID/DD, was relatively rare. Only three cases had been reported. But this is the most severe type of CNNM2-related disorders. Their seizures onset from 1 to 6 days after birth, much earlier than that of type 2. They could have myoclonic seizures, generalized tonic–clonic seizures, and status epilepticus. In type 3 cases, multiple ASMs were used, but seizures were refractory; valproic acid, levetiracetam, lamotrigine, and topiramate may decrease the frequency of seizures. All type 3 cases had severe ID/DD, and language development was most severely delayed. They all had brain MRI abnormalities, including dysmyelination and progressive cerebral cortical atrophy. The patient who carried c.1642G>A homozygous variant had more severe clinical manifestations, including swallowing difficulties, recurrent aspiration pneumonias, bilateral optic disc pallor, bone metabolism disorder, and facial abnormalities, which were not seen in the two patients who carried c.364G>A homozygous variants. In contrast, hypomagnesemia was no more severe in this severe type than in the other two types. Initial serum magnesium was 0.38–0.5 mmol/L. Serum magnesium could be increased to 0.49–0.66 mmol/L after magnesium supplement but could not be corrected normal. CNNM2-related disorders. We used one-way ANOVA to compare the initial serum magnesium in patients with three types of CNNM2-related disorders, and no significant difference was found  domain . Of the variant site, 75% is located in or immediately adjacent to the DUF21 domain. All variants that caused CNNM2-related disorders type 3 were missense variants. One variant was located on the extracellular segment near the N-terminal, and another was located on the second CBS domain, whereas the latter variants cause a more severe phenotype. It was noteworthy that all variants located in DUF21 domain caused type 2 of CNNM2-related disorders. Among all 23 cases, patients with variants on CBS domain had lower serum magnesium, but the difference was not significant (1 domain . Variantnificant .2+) have an inhibitory effect on the excitability of nerve cells in the central nervous system, skeletal muscle, and myocardium. Normal serum magnesium is 0.7–1.1 mmol/L. Neuromuscular irritability, tremor, hypokalemia, and hypocalcemia present when serum magnesium is less than 0.7 mmol/L. If serum magnesium is less than 0.4 mmol/L, hypomagnesemia can cause more severe clinical symptoms, including tetany, nystagmus, seizures, mental disorders, and arrhythmias . Some pathogenic missense variants have been proved as LOF variants  compared with wild type. Therefore, it is thought that CNNM2 protein is involved in the reverse transport of magnesium and sodium ions in the distal convoluted tubule of the kidney, transporting magnesium ions from within renal tubular epithelial cells to capillaries  contains a frameshift variant located near the N-terminal (p.Ile40SerfsX15), a missense variant in the CBS domain (p.Thr568Ile), and a stop-gain variant located in the CNBH domain, where p.Ile40SerfsX15 and p.Ser795* can cause changes in mRNA and protein length, and the structurally abnormal mRNA and proteins may be degraded, causing a decrease in intracellular CNNM2 expression, which affects the transmembrane transport of magnesium. p.Thr568Ile is located in the CBS2 domain in the core region of the CNNM2, which is highly conserved, and the variation may cause a loss in CNNM2 function. Variation of AD-inherited hypomagnesemia with epilepsy and ID/DD (type 2) included missense variants, stop-gain variants, deletion variant, and two heterozygous deletion CNVs. Most of them  clustered in the DUF21 domain, the transmembrane structure of CNNM2 with unknown function. And five of the nine variant sites are located in the intramembrane structure. These patients had manifestations of central nervous system involvement independent of hypomagnesemia, including ID/DD and epilepsy, suggesting that functional abnormalities in DUF21 domain may be more closely related to neurological function. The pathogenic mechanism may be abnormal transmembrane structure caused by mutations, rather than a decreased expression of CNNM2, causing abnormal neuron excitability. This suggests that in addition to affecting magnesium reabsorption in the kidney, the function of CNNM2 may also include participating in the regulation of neural cell excitability in the central nervous system, and the important core of regulatory function may be the transmembrane region DUF21. p.Leu48Pro is located near the N-terminal, and this site was located in a region that crosses the endoplasmic reticulum (ER) membrane during protein transport  was related to type 1 CNNM2-related disorders. This may suggest that the region near Ser795 has a relatively important effect on the function of the CNBH domain. But the pathogenic mechanisms of these three variants could not yet be well-explained. Variations of AR-inherited hypomagnesemia with epilepsy and ID/DD (type 3) are missense variants, including p.Glu122Lys located between the N-terminal and DUF21 domain and p.Val548Met located in CBS domain. p.Glu122Lys is adjacent to the DUF21 domain, and this variant causes a change in the charge of the amino acid residue, suggesting that some regions of the N-terminal of CNNM2 may form some interaction with the DUF21 domain electrostatically, which, like the variants of type 2, alters the membrane structure of DUF21 domain, causing changes in neuron membrane excitability, resulting in similar central nervous system manifestations. p.Val548Met is located in the CBS domain of CNNM2, and this variant causes the most significant decrease in serum magnesium and the most severe neurological phenotype, suggesting that this variant site may be the core position of the CBS domain, and the amino acid changes caused by this variant significantly affect the function of the CNNM2. The patient carried p.Val548Met had initial serum magnesium of 0.38 mmol/L; however, considering that p.Thr568Ile carriers had equally severe hypomagnesemia but did not develop any central nervous system phenotype, this indicated that the remarkable hypomagnesemia per se cannot explain the severe phenotype of the central nervous system in this patient. Therefore, the mechanism by which p.Val548Met leads to severe CNS phenotypes may be at least partially related to the DUF21 domain, as in type 2 cases.Different phenotypes of in p.Thr58Ile, andCNNM2-related disorders had hypomagnesemia, the serum magnesium was different in each case, which may be related to the protein domain where the variant was located. Among the 23 reported cases, those with variants in the CBS domain had lower serum magnesium levels, and the lowest two had variants both located in the CBS2 domain . This suggests an important role for the CBS domain in the Mg2+ transport function of CNNM2.Although all patients with de novo heterozygous variants in CNNM2 . We summarized and classified the phenotypes of CNNM2-related disorders into three types. We found that CNNM2 related central nervous system phenotypes were most associated with DUF21 domain variations, whereas hypomagnesemia was more pronounced in patients with CBS2 domain variations, and AR-inherited CNNM2-related disorders had the most severe phenotype. The limitation of our study is the relatively small sample size. The features summarized from 23 patients might not be the real characteristics for such a complicated disease. More cases and further biological functional studies are needed to confirm, modify, and interpret our findings. However, our findings provide important clues for mechanism studies of CNNM2-related disorder and provide the possibility for accurate genetic counseling.In summary, we reported two cases first in the Chinese population with hypomagnesemia, epilepsy, and DD caused by novel The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Written informed consent was obtained from the minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.YJ: study design and revision of the manuscript. YW and YJ: collection of clinical and WES data. HZ: follow up the patients' information and analyses and draft preparation. All authors contributed to the article and approved the submitted version.This work was supported by the National Key Research and Development Program of China , by the National Natural Science Foundation of China , by Beijing Natural Science Foundation (grant number: 7212109), by the Beijing Key Laboratory of Molecular Diagnosis and Study on Pediatric Genetic Diseases (grant number: BZ0317), and by the Fundamental Research Funds for the Central Universities . The authors declare no competing financial interests. The funding agencies had no role in the study design, the experiments, analysis, or interpretation of data, the writing of the report, or the decision to submit the article for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


PAH, SLC22A5, and ACADS are the leading causes of IMDs in this area. This study demonstrates the importance of utilizing MS/MS in IMD screening for early diagnosis and treatment. This strategy may be used for prenatal genetic counseling to avoid irreversible growth and intellectual development disorders in children.Neonatal inherited metabolic disorders (IMDs) are closely associated with early neonatal death and abnormal growth and development. Increasing attention has been paid to IMDs because of their high incidence and diversity. However, there are no reports about the incidence of IMDs in Changsha, China. Therefore, we retrospectively analyzed the screening results of neonates to evaluate the characteristics of IMDs in the area. From January 2016 to December 2020, 300,849 neonates were enrolled for expanded newborn screening by tandem mass spectrometry in the Neonatal Disease Screening Center of the Changsha Hospital for Maternal & Child Health Care. Newborns with mild initial results were recalled for repeated tests; if the second test was still positive, the patient was referred for confirmatory tests. A total of 71 confirmed cases were identified in our study, with an incidence rate of 1:4,237. There were 28 cases of amino acid metabolic disorders, representing 39.44% of the IMDs diagnosed, with an incidence rate of 1:10,745. Twelve newborns were diagnosed with organic acid metabolic disorders, accounting for 16.66% of IMDs, with an incidence rate of 1:25,071. There were 31 cases of fatty acid oxidation disorders, representing 43.05% of IMDs, with an incidence rate of 1:9,705. Overall, 14 types of IMDs were found in Changsha. The most common disorders in the region were primary carnitine deficiency, hyperphenylalaninemia and short-chain acyl-CoA dehydrogenase deficiency. Their incidence rate is respectively 1:13,675, 1:16,714 and 1:42,978. The mutations in  Inherited metabolic disorders (IMDs), also called inborn errors of metabolism, are a type of disease associated with abnormal accumulation of metabolites and deficiency of essential substances caused by metabolic pathway defects . To dateThis study included 300,849 newborns born in six districts and two counties in Changsha from January 2016 to December 2020. Informed consent was obtained from the parents for the sample collection and testing.After 72 h from birth, all newborns were fully breast-fed, and four drops of heel blood were collected by acupuncture and transferred to special blood collection cards (Schleicher and Schuell 903 filter paper) issued by our center. There were at least four blood spots on the filter paper, and the diameter was not less than 8 mm. The blood drops were allowed to penetrate naturally, and dry blood spots on the front and back sides of the filter paper were verified to be consistent and free from contamination. After the blood spots were naturally dried, they were placed in a sealed bag and stored in a refrigerator at 2–8°C. The samples were collected by logistics personnel within five weekdays and delivered to our central laboratory for testing.After extraction with an organic solvent containing an internal amino acid standard and acylcarnitine, samples were analyzed using a Waters TQD MS/MS screening system. The detection reagent was a NeoBase™ non-derivatized MS/MS Kit , that has internal quality controls. After passing the internal quality control, data analysis and report distribution were carried out. There were 74 screening indicators , includi41 kinds of IMDs were included in our screening panel. Each IMD had one or more screening indicators including metabolites and ratios, and their cut-off values. When the results met the positive rules of IMDs, they were considered as positive. All the positive rules of IMDs were indicated in Urine samples were collected from infants or prepared in urine filter paper. After urea removal, protein precipitation, oximation, and derivatization, the samples were analyzed by Agilent gas chromatography-mass spectrometry (6890-5977B) and quantified by the internal standard method.2. And then it was analysed by using Shimadzu high performance liquid chromatography (LC-20ADXR).Neonatal urine is collected in a light proof container, ascorbic acid (10 mg/ml) should be added immediately. After mixing, it should be kept away from light at −20°C or transferred to 5 × 5 cm special filter paper. The urinary filter paper with 4.7 mm in diameter were punched and added with 1 ml purified water, filtrating with chromatography column. The supernatant was centrifugated after adding MnOTwo drops of heel blood were collected from the suspected positive neonate by acupuncture and transferred to special blood collection cards (Schleicher and Schuell 903 filter paper). 5 mm diameter blood spot was punched and put into the centrifugal tube. Afrer adding potassium chloride, shaking and centrifugating, then determinating by Shimadzu ultraviolet spectrophotometer (UV2600).PAH, PTS , ACADS , SLC22A5  and other genes related to IMDs were customized by Agilent, and the target region sequences were enriched by multiple probe hybridization  or intelligence quotient (IQ) was evaluated every one to 3 years after birth, and the following methods of intelligence measurement were used for each age: the Gesell Developmental Scale for children < three years old, the Wechsler Preschool Scale of Intelligence (WPPSI) for four to six years old, and the Wechsler Intelligence Scale for School-Age Children (WISC-R) for > six years old. DQ or IQ > 70 was considered normal. Individuals were closely monitored during treatment for adverse drug reactions and adaptation to feeding practices.All data were analyzed by SPSS 21.0 statistical software. The positive rate was calculated using the percentage method.A total of 300,849 newborns  were screened; 4,923 newborns were suspected to be positive in the first screening, 4,315 newborns were successfully recalled for retesting (87.65%), and 71 newborns were confirmed to have IMDs, where 14 types of IMDs were found. .Among the 300,849 newborns, 71 were diagnosed with neonatal metabolic diseases , with an overall incidence rate of 1:4,237 . There wl-carnitine. During the treatment, the blood was reexamined every 1–3 months to observe the levels of free carnitine and other acylcarnitine in order to adjust the treatment dosage. No clinical symptoms were observed during follow-up. Twelve children with HPA were treated with a special diet and drugs under the guidance of newborn screening specialist doctors. Their growth and intelligence were similar to those of normal children of the same age. Seven newborns with SCADD were given dietary guidance to avoid starvation, supplemented with carnitine, and examined regularly. One patient with VLCADD was also given dietary guidance to avoid fasting, and was prescribed a high carbohydrate, low fat diet, especially to limit the intake of long-chain fatty acids. One case of PA, one case of GA-Ⅰ, and two cases of isovaleric acidemia  were recommended a low-protein diet, special formulas, and oral l-carnitine for treatment. They were ordered for reexamination once every 3 months. Three cases of 2-methylbutyryl-CoA dehydrogenase deficiency  and three cases of 3-methylcrotonyl-CoA carboxylase deficiency  were not given special treatment, and their condition was normal during the follow-up. If the carnitine level was very low, l-carnitine was supplemented, and it was suggested to limit isoleucine and low protein in the long-term diet and to avoid long-term starvation. One patient with MADD was in a normal condition after birth. He was required to regularly follow up and monitor the indicators. When clinical symptoms appear, he should actively receive symptomatic support treatment and l-carnitine and vitamin B supplements. One patient with TYR-III was given a low phenylalanine and low tyrosine diet. Two patients with citrullinemia type I  had a long-term restriction on protein intake, used special milk powder, and regularly monitored blood ammonia values to avoid infection and prevent the occurrence of high blood ammonia. Two patients with hypermethioninemia  did not show any clinical symptoms at birth. They were ordered to regularly monitor the concentration of methionine and to control the diet. Among the 71 confirmed cases, one patient died prematurely, 63 patients had normal physical and mental development, and there were no cases of acute metabolic disorder. The follow-up of seven children diagnosed and treated in another hospital showed a stable condition with no abnormality.The follow-up situations of 71 confirmed cases were demonstrated in The incidence rate of IMDs in Changsha varies greatly across countries. The incidence rate of IMDs in California, United States, is 1:3,367 , 1:2,960PAH , which accounting for 12.5% of mutations in HPA  , which encodes Citrin, causing impaired urea cycling and NADH transport and associated metabolic disturbances, The urea cycle and associated pathways were shown in SLC25A13  gene and MCCC2 (OMIM* 609014) gene, respectively. To date, at least 66 MCCC1 and 83 MCCC2 mutations have been reported , which encodes the carnitine transporter protein, the biochemical metabolic pathway was shown in SLC22A5, with the mutation frequencies of 24.32, 21.62, and 16.22%  gene is the most common mutation, accounting for 23.08% in all mutations associated with SCAD found in Changsha. The newborn screening programs in Australia (In Australia, Germany, and the United States, the overall incidence rate of FAODs is nearly 1:9,300; however, they are uncommon in Asia . It was d 16.22% , respectd 16.22% . 15 kindd 16.22% , that ard 16.22% . SCADD iustralia  and Massustralia  have folustralia . It is iIn summary, we report the incidence, disease spectrum, and genetic characteristics of neonatal IMDs for the first time in Changsha. FAODs had the highest incidence rate of IMDs in Changsha, which is contrary to previous reports. This may be due to variation in the different regions and populations. The most common IMDs were PCD, HPA and SCADD. Finally, the screening of neonatal IMDs by MS/MS in Changsha is conducive to early diagnosis and intervention. And our findings show newborn screening by MS/MS may miss part of the IMDs, the performance of our newborn screen program needs to be improved, and the combination of MS/MS with gene screening is necessary in future.


Knee osteoarthritis (KOA) is a chronic and degenerative bone and joint disease, with KOA, cartilage degeneration, destruction and subchondral bone remodeling as the main pathological features. Its clinical symptoms are knee pain, swelling, limited activity, and long course of disease can cause joint deformities. At present, the early treatment of Western medicine is mainly the use of nonsteroidal drugs for anti-inflammation and removing pain, but because the efficacy of these drugs is unstable, the disease is easy to repeat after treatment, and the clinical effect is not good. Although Biqi capsule has advantages in the treatment of KOA, there is a lack of standard clinical studies to verify it, so the purpose of this randomized controlled study is to evaluate the efficacy and safety of Biqi capsule in the treatment of KOA.This is a prospective randomized controlled trial to study the efficacy and safety of Biqi capsule in the treatment of KOA. The patients were randomly divided into a treatment group and a control group according to 1:1. Among them, treatment group: Biqi capsule combined with diclofenac sodium sustained release tablets; Control group: Diclofenac sodium sustained-release tablets alone. Both groups were treated with standard treatment for 2 weeks and were followed up for 30 days to pay attention to the efficacy and safety indexes. Observation indicators included: the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Hospital for Special Surgery Knee Score (HSS), liver and kidney function, adverse reactions, and so on. SPSS 25.0 software is used for data analysis.This study will evaluate the efficacy and safety of Biqi capsule in the treatment of KOA, and the results of this experiment will provide a clinical basis for Biqi capsule in the treatment of KOA.OSF Registration number: DOI 10.17605/OSF.IO/6HB9D Statistics show that, more than 50% of people over the age of 60 have radiographic signs of osteoarthritis, and more than 35% have corresponding symptoms. The incidence of KOA is high, the cost of surgical treatment is high, the long-term effect is not significant, and the recurrence rate is high, which seriously affects the work and life of patients.Knee osteoarthritis (KOA) is a common clinical chronic arthritis. Its pathological features are mainly destruction of articular cartilage and hyperplasia of bone, and its clinical manifestations are recurrent joint pain and progressive limitation of joint motion. which is widely used in the treatment of KOA, diclofenac sodium is a common nonsteroidal anti-inflammatory drug preparation in the treatment of KOA. By inhibiting the activity of cyclooxygenase, it reduces the production of prostaglandin, inhibits the activation and differentiation of lymphocytes, and inhibits the production of white blood cells and bradykinin, showing good anti-inflammatory and analgesic effects. However, the efficacy of these drugs is unstable, and the disease is prone to recurrent attacks, which makes it difficult to effectively control the progress of the disease.Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in the treatment of inflammatory pain,,13 Traditional Chinese medicine believes that the basic pathogenesis of KOA is based on deficient root and excessive superficial, deficiency of liver and kidney qi and blood is the essence, wind, cold and dampness, blood stasis and phlegm, stagnation and accumulation of qi, resulting in obstruction of blood and qi, blood does not nourish the tendon and vessel, joint pain and limited movement. Therefore, the treatment of this disease focuses on tonifying liver and kidney, dispelling wind and eliminating dampness, dredging the meridians and relieving pain. The main ingredients of Biqi capsule include Semen Strychni (Ma Qianzi), Pheretima (Di Long), Radix Changii (Dang Shen), Rhizoma Chuanxiong (Chuan Xiong), Radix Salviae Miltiorrhiae (Dan Shen), Radix Notoginseng (San Qi), Radix Cyathulae (Niu Xi) etc. It has the functions of nourishing qi and blood, dispelling wind and dehumidifying, promoting blood circulation, and relieving pain. Modern pharmacological research has found that, Biqi capsule can promote the production of tissue inhibitor of metalloproteinase-1, reduce the expression of interleukin 1 and matrix metalloproteinase-3, so as to protect articular cartilage and improve inflammation, it can also effectively regulate the ability of physical coordination and immune function, and has less adverse reactions.–19 Therefore, we intend to evaluate the efficacy and safety of Biqi capsule in the treatment of KOA by this randomized controlled trial.In recent years, the application of traditional Chinese medicine in KOA has been widely recognized.22.1This is a prospective randomized controlled trial to study the efficacy and safety of Biqi capsule in the treatment of KOA. This trial will follow the comprehensive trial reporting criteria. The flow chart is shown in Figure 2.2This research scheme is in line with the Helsinki Declaration and approved by the Clinical Research Ethics Committee of our hospital. This experiment has been registered he open science framework (OSF) (registration number: DOI 10.17605/OSF.IO/6HB9D). Before being randomly divided into groups, all patients are required to sign a written informed consent form and they are completely free to choose whether or not to continue the trial at any time. The flow chart of the study is shown in Figure 2.3:Diagnostic criteria: according to the diagnostic criteria of KOA established by the Chinese Medical Association in 20101.The knee joint has frequent pain 1 month before seeing a doctor.;2.X-ray film showed osteophyte formation;3.Morning stiffness time ≤30minutes;4.Accompanied by bone friction;5.The examination of synovial fluid is consistent with KOA;6.Age ≥40 years old. KOA can be diagnosed in a combination of 1, 2, or 1, 3, 4, 5, or 1, 3, 4, 6.Inclusion criteria:1.Meet the diagnostic criteria of KOA;2.Age ≥40 years old;3.;X-ray shows Kellgren-Lawrence grade I ∼ II4.All patients have signed the agreement, and the data used in the study are complete.Exclusion criteria:1.Combined with another organ dysfunction;2.Suffer from other serious diseases such as malignant tumors;3.Concomitant with serious mental illness;4.Patients who are allergic to or have contraindications to the medication in this study;5.Unable to understand the study protocol or unwilling participants after explanation.Exit criteria:1.Those who have serious adverse events and serious complications should not be further tested;2.Those who are poor in compliance and have an impact on the judgment of effectiveness and safety;3.Poor compliance, affecting effectiveness and safety judgment;4.Subject requests to withdraw from the study for any reason.2.4α=1.96, 1-β=0.9, μβ=1.28. Sample size estimation formula for δ=π1-π2 comparison of 2 sample rates:This study was a pilot clinical trial. According to the analysis and calculation of the relevant literature published in the past 10 years, the therapeutic efficiency of western medicine is 73.81%. The effective rate of traditional Chinese medicine combined with Western medicine is 90.7%. The sample size of multiple sample rates was used to estimate the formula, if the significance test level is α=0.05, then μThe sample size of each group was calculated to be 102 cases. Taking factors such as shedding into account, the expansion is about 20%, and 256 patients were calculated to be included. The included patients were randomly divided into control group and observation group by random number generator according to the serial number of treatments. Each group had 128 cases.2.5In this study, patients who meet the criteria will be selected through prehospital recruitment, and the patients and their families will approve the study plan and sign the informed consent form. The patients were randomly assigned to the treatment group and the control group. Among them, the treatment group will receive Biqi capsule.  approval number Z10910026; Tianjin Darentang Jing Wanhong Pharmaceutical Co. Ltd; 0.3g × 48 tablets) Oral administration is 1.2 g (4 tablets)/time, 3 times/d Combined with diclofenac sodium sustained-release tablets Oral 75 mg (1 tablet), once a day for 2 weeks; The control group was given diclofenac sodium sustained release tablets.  Oral 75 mg (1 tablet), once a day for 2 weeks. Patients in both groups will receive the same routine nursing, avoid tobacco, alcohol, and irritating food during medication, pay attention to rest, avoid weight-bearing on affected limbs, monitor liver and kidney function, patients with more joint effusion will be given suction treatment. If necessary, the attending physician may adjust the protocol according to the patient's condition, and all interventions will be recorded in detail for final result analysis. We will set up special drug administrators, and nurses will be responsible for the preparation of drugs and solutions. Therefore, this study is not blind to nurses, but to researchers, patients, and statisticians. The health status of each patient was evaluated before and after treatment, including efficacy and safety indicators, and all patients were followed up by telephone for 30 days. The contents of the follow-up include cardiovascular events and rehospitalization.2.61.Observation index:a. a total of 24 items were used to evaluate the overall joint from 3 aspects: pain, stiffness, and joint function. Each item was recorded by using a visual analogue scale (VAS). The higher the score, the more serious the condition.;The Western Ontario and McMaster Universities osteoarthritis index (WOMAC),b. the total score of HSS is 0 to 100, and the higher the score, the better the knee joint function of patients.Evaluation of knee joint function by Hospital for special surgery knee score (HSS),c.Adverse reaction: Including abnormal liver and kidney function and any uncomfortable symptoms  during treatment.d.The clinical curative effect refers to the evaluation criteria of osteoarthritis in Chinese traditional medicine new drug clinical research guiding principle.e.Significant effect: The pain symptoms disappeared or basically disappeared, joint function was basically normal, able to live and work normally, WOMAC score decreased ≥70%;f.Effective: The pain basically disappeared, the joint movement was slightly limited, living, and working ability was improved, and 30% ≤ WOMAC score decreased <70%;g.Invalid: The pain and joint function were not significantly improved compared with those before treatment, and the WOMAC score decreased by <30%.2.7The data were collected according to the evaluation criteria before the beginning of treatment, 1 week after treatment and 2 weeks after the end of treatment. After 30 days of treatment, each patient was followed up by outpatient or telephone. Record in detail the reasons for the loss of follow-up for those who are unable to collect follow-up information. All data will be collected by 1 or 2 assistants in collaboration. Personal information about potential participants and registered participants will be collected, shared, and stored in a separate kept in a separate repository to protect pre -, during and post-trial confidentiality. Access to the database is limited to the researchers in this research group.2.82.8.1Full Analysis Set: Including all the subjects who were randomly assigned to the group, took the drug at least once and visited at least once, and used the full analysis data for intent-to-treat (ITT) analysis.Per-protocol set: Including all subjects who comply with the protocol, have no missing baseline variables, and whose primary variables are measurable.Safety Set: They included random enrolment, at least one medication, and at least one postmedication safety interview.2.8.2t test is used between groups, and paired sample t test is used within group. The results are expressed by  and Radix Salviae Miltiorrhiae (Dan Shen) are used as sovereign drug in the prescription, replenishes qi and nourishes blood, Radix Salviae Miltiorrhiae (Dan Shen) promotes blood circulation and nourishes blood; Radix Notoginseng (San Qi) promotes blood circulation and relieves pain, removes blood stasis and stops bleeding; Rhizoma Chuanxiong (Chuan Xiong) dispels wind and relieving pain, qi and blood circulation; Radix Cyathulae (Niu Xi) tonifies liver and kidney and promotes blood circulation and menstruation; Semen Strychni (Ma Qianzi) collaterals and disperses knots, reduces swelling and relieves pain; all kinds of medicines are used together to play the functions of replenishing qi and nourishing blood, dispelling wind and dehumidification, promoting blood circulation and relieving pain. At the same time, Radix Changii (Dang Shen) in Biqi capsule has anti-oxidation, anti-inflammatory, anti-cancer and many other effects–37; Semen Strychni (Ma Qianzi) can enhance the total antioxidant capacity of organisms and improve the recovery of sensory function and motor function.Traditional Chinese medicine believes that “the knee is the house of tendons”, KOA belongs to the category of “Knee arthralgia (xibi)” and “arthralgia aggravated by cold (tongbi)” in traditional Chinese medicine. The cause of the disease is that the patient is feeble and old, deficiency of liver and kidney, loss of muscles and veins or living in wetlands for a long time, wind, cold and dampness soaking in the joints, obstruction of meridians, and collaterals leads to pain. The main disease pathogenesis is essential empty and out solid, the root cause is deficiency of liver and kidney qi and blood, the wind-cold-dampness and gas stagnation, blood stasis, phlegm coagulation is manifestation. The treatment should be replenishing qi and nourishing blood, tonifying and replenishing liver and kidney, dispelling wind and eliminating dampness and promoting blood circulation to arrest pain. Biqi capsule is widely used in the clinical treatment of rheumatoid arthritis, cervical spondylosis, scapulohumeral periarthritis, and other diseases.The purpose of this randomized controlled trial is to verify that Biqi capsule can improve the clinical symptoms and joint function in patients with KOA. Since there are no standard clinical studies to evaluate the efficacy of Biqi capsule in patients with KOA, we intend to evaluate its efficacy and safety through prospective randomized controlled trials.This study also has some limitations. Because of the short time of planned follow-up, we are unable to understand the impact of long-term results. Therefore, we may extend the follow-up time if necessary. At the same time, due to the influence of treatment, this study could not be strictly double-blind, which may affect the results to a certain extent.Data curation: YaZhou Zhou, WenGang Wang.Formal analysis: YaZhou Zhou, WenGang Wang.Funding acquisition: YaZhou Zhou.Resources: WenGang Wang, Ke Tian.Software: Hui Huang, Mengrui Jia.Study design: YaZhou Zhou, WenGang WangSupervision: Ke Tian, Hui Huang.Writing – original draft: YaZhou Zhou, WenGang Wang.Writing – review & editing: YaZhou Zhou.


When making decisions, people tend to overweigh the impact of losses compared to gains, a phenomenon known as loss aversion (LA). A moderate amount of LA may be adaptive as it is necessary for protecting oneself from danger. However, excessive LA may leave people few opportunities and ultimately lead to suboptimal outcomes. Despite frequent reports of elevated LA in specific populations such as patients with depression, little is known about what psychological characteristics are associated with the tendency of LA. Based on the neurobiological studies of LA, we hypothesized that positive psychological wellbeing may be negatively associated with people's tendency of LA. In the present study, we set out to test this hypothesis in a sample of young adults. We evaluated LA using a decision-making task in which subjects were asked to decide whether to accept or reject a series of coin-toss gambles. Our results revealed that individuals with more advanced personal growth as assessed by the Ryff's Psychological Well-being Inventory showed reduced LA. To our knowledge, this is the first report demonstrating an association between positive psychological wellbeing and LA. These findings suggest that personal growth might be employed as interventional targets for correcting excessive LA in vulnerable populations. When making decisions, people tend to overweigh the impact of losses compared to gains  or zero gamble acceptance (n = 1) in the LA task, which hinders reliable estimation of the LA coefficient (see below). The data of the remaining 26 subjects were used for the present analysis. Notably, including six of the excluded subjects for whom we were able to obtain an estimated LA coefficient (reliability aside), the negative association between personal growth and LA coefficient identified in this study remained unchanged ; for details of this data, please see the This research was part of an ongoing larger study, the aim of which was to predict future mental health status in healthy young adults using high-level cognitive functions. The study was carried out in accordance with the latest version of the Declaration of Helsinki and approved by the Institutional Review Board of Yamaguchi University Hospital. Subjects were recruited via posters placed on campus and department homepage. Data of 33 subjects collected at the baseline of the study for the first author's thesis research were used for the analysis here. Seven subjects had to be excluded due to too many gamble acceptances  having any self-reported mental health disorders, (2) receiving medical examinations due to suspicion of any mental health disorders, (3) being suspected of mental health disorders by the research staff and subsequently diagnosed as having a mental health disorder by the Mini-International Neuropsychiatric Interview conducted by a psychiatrist, or (4) being unable to perform the laboratory tests and answer the questionnaires for this study due to severe physical conditions or other reasons. No participant was excluded owing to meeting any of the exclusion criteria.Subjects first answered questions about their demographic characteristics, including gender, age, occupation, education level, and socioeconomic status such as their personal income , whether they had made a student loan, their parents' education levels and family income.http://psychtoolbox.org/). In this task, subjects were asked to decide whether to accept or reject a series of 64 coin-toss gambles that offered equal (50%) chances of gaining or losing different amounts of money  for participating in this research and they were asked to imagine that the payment would be adjusted based on their choices : at the end of the experiment one trial would be randomly selected and subjects' actual decision in that trial would be used to adjust their payment. Specifically, if they accepted the gamble in that trial, the gamble would be executed. If the head faced up, they would receive an additional gain equal to the amount shown together with the head in that trial. However, if the tail faced up, the amount shown along with the tail in that trial would be subtracted from their original payment of 3,000 JPY. If they rejected the gamble in that trial, their payment 3,000 JPY would remain unchanged.In this study, each subject received a fixed payment of ~3,000 JPY for participating in this study. We did not actually implement the performance-adjusted payment based on a randomly selected trial but instead asked subjects to imagine vividly that kind of payment being executed. It was because our final objective was to develop useful tools for predicting mental health problems in a public health setting: it is impossible to pay people a certain amount of money based on their choices in any public health predictive tools. Meanwhile, previous research has shown that people's decision-making with hypothetic rewards highly resembles that with real rewards  in the present study, following the instruction explained to subjects, we randomly selected one trial for each subject and calculated their adjusted payment (see above). We repeated this process 100 times and used the mean adjusted payment for each subject as their performance reward.We calculated the LA coefficient (λ) for each subject using the following equation:We used the Japanese version , 2 for 50,000~100,000JPY, 3 for 100,000~150,000JPY, and 4 for 150,000~200,000JPY. Parents' education level was coded as 1 for elementary school level, 2 for junior high school level, 3 for senior high school level, 4 for vocational school level, 5 for undergraduate level, 6 for master's level, and 7 for doctorate level. Family income  was coded as 1 for ~2,000,000 JPY (upper bound not included), 2 for 2,000,000~4,000,000 JPY, 3 for 4,000,000~6,000,000 JPY, 4 for 6,000,000~8,000,000 JPY, 5 for 8,000,000~10,000,000 JPY, 6 for 10,000,000~15,000,000 JPY, 7 for 15,000,000~20,000,000 JPY, and 8 for 20,000,000~ JPY. P < 0.05 was considered statistically significant. Since we predicted a negative association between psychological wellbeing and LA, one-tailed tests were conducted. Statistical power analysis was conducted for linear regression models and single regression coefficients using G*Power version 3.1.9.7 . The mean score of each measure is shown in On average, subjects accepted 57.86 ± 23.05% of the gambles. We collapsed the 8 by 8 gain/loss combinations into a 4 by 4 matrix and calculated the probability of gamble acceptance at each cell (which thus consists of four gain/loss combinations) for each subject. The color-coded heatmaps depicting the probability of gamble acceptance averaged across all subjects are shown in r = −0.464, p = 0.008, one-tailed test), personal growth , and purpose in life , with the first two domains remaining significant after Bonferroni correction (0.05/6).As we were interested in what domain(s) of psychological wellbeing might be associated with LA, we next examined the correlation between the six domains of psychological wellbeing and λ . Specifimodel 1). The model was significant  and only personal growth  and autonomy  were significant in predicting λ. The statistical power for this linear regression (model 1) was 0.920. The statistical power for the regression coefficients of personal growth and autonomy were 0.950 and 0.646, respectively.To confirm the association, we included all six domains in a linear regression to predict λ (model 2). The model remained significant  and only personal growth was significant in predicting λ . The statistical power for this linear regression (model 2) was 0.961. Thus, across model 1 and 2, a negative association between personal growth and λ was consistently identified with a high statistical power. A scatter plot of this association is shown in To rule out the confounding of demographic factors that may affect decision-making and LA, we conducted a second linear regression analysis using personal growth and autonomy to predict λ, adding gender, age, personal income, student loan, father's education, mother's education, and family income as covariates  as covariates, model 4 adding mood measures  as covariates, and model 5 adding emotion regulation measures  as covariates. All three models remained significant  and in all three models, only personal growth significantly predicted λ . The statistical power for model 3–5 were 0.881, 0.842, and 0.844, respectively.To investigate the potential involvement of personality, mood, and emotion regulation in the association between personal growth and LA, we conducted three additional linear regression models using personal growth to predict λ, with r = −0.767, p = 0.000) such that greater LA was associated with fewer performance reward  and this correlation disappeared after partialling out λ . This indicates that the positive association between personal growth and performance reward was driven by LA.Finally, to investigate whether excessive LA is associated with poor reward outcomes, we conducted a correlation analysis between LA coefficient λ and performance reward. The correlation was significant  as well as the tendency to pursue such development, for instance, through having new experiences that challenge oneself or broaden one's horizons Ryff, . It is pWhile we observed such an association, the precise underlying mechanism remains uninvestigated. In contrast to the original LA theory that emphasizes a decision mechanism of overweighing losses over gains, several authors have recently argued that LA is driven by attention rather than decision mechanisms (e.g., Yechiam and Hochman, The recent positive psychology movement (e.g., Seligman, A limitation of the present study is that we used a small sample of young healthy participants and excluded seven subjects in our main analysis whose LA could not be reliably estimated. Although the statistical power of the association we identified was high, further investigation is required to confirm the association in samples with a bigger sample size and broader age range as well as clinical samples with known excessive LA. Another limitation is that we used just mixed gambles from an asymmetric gain/loss matrix and did not include gain-only gambles that allow us to disentangle the specific effect of LA from that of diminishing sensitivity to payoff magnitude (Yechiam and Hochman, Although it has been reported that gender (Schmidt and Traub, In summary, in a sample of healthy young adults, we found that individuals with more advanced personal growth as evaluated by the Ryff's Psychological Well-being Inventory show reduced LA. To our knowledge, this is the first report demonstrating an association between positive psychological wellbeing and LA. These findings suggest that personal growth might be employed as interventional targets for correcting excessive LA in vulnerable populations.The dataset that support the findings of this study are available from the corresponding author upon reasonable request.The studies involving human participants were reviewed and approved by Institutional Review Board of Yamaguchi University Hospital. The patients/participants provided their written informed consent to participate in this study.CC, HL, and SN: conceptualization and methodology. IK, TN, CC, TM, KH, and MH: investigation. IK and CC: formal analysis and writing—original draft preparation. IK, TN, CC, TM, HL, KH, MH, HY, and SN: writing—review and editing. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Prostate cancer is the most commonly diagnosed cancer among men around the world. Radiotherapy is a standard of care treatment option for men with localized prostate cancer. Over the years, radiation delivery modalities have contributed to increased precision of treatment, employing radiobiological insights to shorten the overall treatment time, improving the control of the disease without increasing toxicities. Stereotactic body radiation therapy (SBRT) represents an extreme form of hypofractionated radiotherapy in which treatment is usually delivered in 1–5 fractions. This review assesses the main efficacy and toxicity data of SBRT in non-metastatic prostate cancer and discusses the potential to implement this scheme in routine clinical practice. External beam radiation therapy (EBRT) is considered one of the standard treatments for organ-confined prostate cancer (PCa), with cure rates similar to those of radical prostatectomy. Hypofractionation uses a higher dose-per-fraction of radiation, which reduces the number of fractions and the total duration of treatment, allowing greater comfort for the patient and lower costs, in addition to providing a therapeutic advantage in terms of tumor control and toxicity, as the α/β of PCa is lower than that of adjacent healthy tissues . In 2018In addition, technical advances in the field of radiotherapy in recent years, such as intensity-modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT), and stereotactic radiotherapy (SBRT), have enabled the progressive implementation of extreme hypofractionation (defined by fractions of at least six Gy) in various scenarios of localized PCa treatment. The use of SBRT in PCa has provided sufficient evidence in terms of tumor control results, quality of life reported by the patient, and low toxicity ,5,6 to bThe recent publication of two randomized trials comparing the use of extreme hypofractionation versus conventional fractionation . There was a significant correlation between a positive biopsy and the risk group, and the association was stronger in high-risk and unfavorable intermediate-risk than in low-risk . Patients with a positive biopsy were at higher risk of developing a biochemical recurrence at five years (p < 0.001). In terms of quality of life, Alayed et al. carried out a comparative analysis of two prospective studies: 2START [Elsewhere, other groups, such as Zelefsky et al., have published the results of a 5-year dose-escalation trial of 136 patients with localized low-risk and intermediate-risk PCa. The initial dose was 32.5 Gy in five fractions and scaled sequentially to 35 Gy, 37.5 Gy, and 40 Gy. No patients had grade ≥ 2 late gastrointestinal toxicity, and only one patient (0.7%) had grade 3 late genitourinary toxicity. At 12 and 24 months, the IPSS score in the group that received 40 Gy was higher than the score in the group that received 32.5 Gy, but no differences were observed at 36 months between the different cohorts . The dos: 2START  and PATR: 2START , without: 2START .Furthermore, a prospective, multicenter phase II study has recently been published, evaluating toxicity after a year of SBRT treatment using three fractions in PCa of low- and favorable intermediate-risk. Fifty-nine patients were evaluated, and they were treated with 40 Gy in three fractions. Acute gastrointestinal toxicity was occasional, while 11.9% of patients experienced grade 2 acute genitourinary toxicity and 1.7% grade 3. However, no patient had persistent symptoms at 12 months post-treatment .Finally, the results of the PROSINT trial have been published : It was There are multiple published prospective trials in which thousands of patients with extreme hypofractionation have been treated, with different doses, fractions, and techniques. The most relevant have been analyzed in four reviews or meta-analysis studies.The first of these was published in 2013 , and it The most recent meta-analysis and the most extensive review to date was conducted by Jackson et al.  in 2019.In 2019, Roy and Morgan published a review of the hypofractionated and ultra-hypofractionated studies in localized prostate cancer. They concluded that SBRT is an option in treating patients with low and intermediate-risk, even though the evidence remains less solid than that supporting the use of moderate hypofractionation in these groups of risk .A review of studies conducted between 2001 and 2018 evaluating genitourinary, gastrointestinal, and sexual effects in patients treated with SBRT has recently been published , describTo date, only two randomized phase III studies have been published: HYPO-RT-PC  and PACEPending the results of biochemical control and late toxicity of PACE-B, Widmark et al. establish the bases of what could be the standard of care in patients with localized PCa, considering certain features.It was a randomized, multicenter, prospective phase III study comparing normofractionation and extreme hypofractionation in patients with intermediate- (89%) and high-risk (11%) PCa disease. One thousand, one hundred and eighty patients took part—591 were treated with 78 Gy in 39 fractions, and 589 with 42.7 Gy in seven fractions, in 2.5 weeks. Most of the patients were treated with 3D radiotherapy, something that seems obsolete in the IMRT era, without allowing the use of androgen deprivation and using 7 mm expansion to generate planning target volume (PTV). After a 5-year follow-up, the bRFS rate was 84% in both groups, with no differences in overall survival rates or acute and late gastrointestinal toxicity. In terms of genitourinary toxicity, a non-significant increase in grade ≥ 2 acute toxicity was observed in the extreme hypofractionated arm compared to the control arm (28% vs. 23%), with no differences between the two arms at the 5-year follow-up.It was a randomized, multicenter, phase III trial comparing standard fractionation and extreme hypofractionation with SBRT in localized low- and intermediate-risk PCa. Eight hundred and seventy-four patients were evaluated—441 were treated with 78 Gy in 39 fractions or 62 Gy in 20 fractions and 433 with 36.25 Gy in five fractions, on consecutive days or on alternate days. Acute toxicity data according to RTOG criteria did not show significant differences between the two arms in grade ≥ 2 gastrointestinal or genitourinary toxicity.There are no prospective studies comparing brachytherapy with SBRT. However, the results of retrospective studies in terms of biochemical control and toxicity do not show differences between the two treatment techniques, which would have to be confirmed by randomized studies ,31.SBRT treatment in localized high-risk PCa is controversial. Most SBRT studies that include patients with high-risk PCa are observational. In the prospective studies, the number of high-risk patients is low, so there is insufficient evidence to support its routine use at this time outside clinical trials.In 2018, González-Motta et al.  publisheA prospective analysis of 344 SBRT-treated patients with a median follow-up of 4.1 years has recently been published, describing a bRFS rate of 81.7% and an MFS rate of 89.1%  provide The administration of combined ERT treatments, which additionally applied a boost with SBRT, has been analyzed in a lower percentage of patients. The follow-ups in published studies have been short ,37.The PROMETHEUS study, a prospective phase II, evaluated toxicity and tumor control in 135 patients, of whom 32 (24%) were patients with high-risk PCa, after administering 46 Gy in 23 fractions and a boost of 19–20 Gy in two fractions. With a median follow-up of two years, the bRFS rate was 98.6%, without describing grade ≥ 2 acute genitourinary or gastrointestinal toxicity, and 2% grade 3 late toxicity resolved within 20 months of completion .Eade et al. published the results of a prospective phase I dose-escalation study, which compared a 46 Gy, 22 Gy, and 24 Gy boost in the prostate with 25 Gy, 27.5 Gy, and 30 Gy to the dominant lesion, respectively in two fractions, after administration of 46 Gy in 23 external radiotherapy fractions. With a median follow-up of two years, the three-year bRFS rate was 93.3%, without describing grade ≥ 2 toxicity in any of the groups analyzed .Additionally, the HYPO-PROST trial is a randomized controlled trial comparing two different prostate boost schedules (30 Gy in 15 fractions vs. 15 Gy in two fractions) administered after 46 Gy in 23 fractions to prostate, seminal vesicles, and pelvic nodes. After a median follow-up of 60.1 months, bRFS at five years was 82.9% in the normofractionated regimen versus 78.2% in the ultra-hypofractionation group. No differences were observed in terms of late gastrointestinal or genitourinary toxicity between the two treatment regimens .The use of ADT concomitant with normofractionated radiotherapy and moderate hypofractionation is now well established, and randomized clinical trials have shown an improvement in survival with the addition of ADT to normo- and hypofractionated regimens in intermediate and high-risk patients ,42,43.Despite the high level of available evidence of increased overall survival with ADT addition to normal and hypofractionated radiotherapy in high-risk patients, its appearance in SBRT studies with this subgroup of patients is very heterogeneous, with its use in some series being omitted ,33, and p < 0.001) [p-value: 0.009), although without any difference in metastasis-free survival. [Royce et al. examined the use of ADT in 7559 patients treated with SBRT, versus 133,825 treated with hypofractionation or conventional radiotherapy, using data obtained from the USA National Data Base. In the multivariate analysis, they showed that the use of ADT was significantly lower in patients who received SBRT in comparison with those who received conventional radiotherapy, or with moderate hypofractionation in all risk groups (< 0.001) . Recentlurvival. .The only phase III trial of SBRT to date with published results that included high-risk patients did not allow the use of ADT . The resAt this time, we cannot establish the true role of ADT or its optimal duration in high-risk patients treated with SBRT, given the lack of sufficient levels of evidence for this subgroup of patients. Regarding the optimal sequencing to administer treatment with ADT in combination with SBRT in localized prostate cancer, there are no data in published studies in which ADT is used that indicate the optimal period to start ADT treatment ,44, usinProphylactic nodal irradiation with normofractionated radiotherapy in patients with high-risk PCa has shown an increase in bRFS and DFS rates without showing benefits in OS . Three sAlayed et al. compared two prospective phase II trials, with and without lymph node irradiation. The fractions used in each of them were 40 Gy in five fractions to prostate plus 30 Gy in five fractions to seminal vesicles vs. 40 Gy to prostate and 25 Gy to seminal vesicles and pelvis, in five fractions. The results for OS were similar in both trials (93.2% vs. 96.7%) with a biochemical failure rate at five years without and with lymph node irradiation of 14.6% and 0%, respectively.p = 0.009), with no differences in genitourinary toxicity , (p = 0.04) with and without lymph node irradiation, respectively [No grade toxicity 3 to 4 late GU toxicity was reported in any trial. Only one patient had grade 3 late GI toxicity in lymph node irradiation group. Overall, patients receiving lymph node irradiation presented a higher rate of late gastrointestinal toxicity ,  and salvage radiotherapy in patients with a recurrence of abnormal PSA levels after surgery . To demonstrate the viability and safety of the use of SBRT in this clinical scenario, Repka et al.  conducteIn recent years, various studies have explored the possibility of administering SBRT for treating the prostate bed . SampathDetti et al. described their experience with SBRT for isolated recurrence in the PCa bed, in which 16 patients received 30 Gy in five fractions for re-irradiation or 35 Gy in five fractions for patients without prior radiotherapy treatment. With a median follow-up of 10 months, treatment tolerance was good, and only one patient experienced grade 2 acute genitourinary and gastrointestinal toxicity .In SBRT treatments of PCa, it is important to reduce the variations and the movement of the organs at risk, to obtain greater precision. By using endorectal devices, it is possible to control the movement of the prostate and rectum, either by fixing the rectum or by separating it from the prostate, decreasing the exposure of the anterior-lateral rectal wall to high radiation dosage. Currently, there are different types of endorectal devices, and the most widely used are: Endorectal balloon , hydrogep = 0.7), although it did show a 75% reduction in grade 1 rectal toxicity in the hydrogel spacer group (p < 0.03), while no grade 2 toxicity was observed in this subgroup (p < 0.015). Likewise, an improvement was seen in grade 1 genitourinary toxicity, along with patient-reported bowel and urinary quality of life, all favoring using the hydrogel spacer, although without differences in the dosimetric analysis of the urinary structures that would explain this improvement in urinary toxicity. It was notable the absence of any evaluation as to the reliability of patient masking in the study [In 2017, Hamstra et al. published the results of a single-blind, randomized phase 3 clinical trial that evaluated the use of hydrogel in patients treated with IMRT. Two hundred and twenty-two patients were randomized to either placement of a hydrogel spacer or not, administering a dose of 79.2 Gy in 44 fractions to the prostate with/without seminal vesicles. The study did not meet its primary objective, which was grade 1 or greater rectal or procedural adverse events in the first six months . Hwang et al. [p = 0.001). This dosimetric advantage contributed to a reduction of late grade 2 or higher rectal toxicity in patients with hydrogel spacer . [In 2018, the results of the dosimetric analysis of 10 patients treated with SBRT in which endorectal devices were used were published, and it enabled a reduction in the dose on the rectal wall , with thg et al.  publisheg et al. , a dosimg et al. ,67. A meg et al. , with 10= 0.05). p < 0.05), which resulted in significant improvement in rectal wall dosimetry. Rectal retractor significantly reduced rectal V16 and V14, the maximum dose, and the percentage of the posterior rectal wall that received 8.5 Gy. Nicolae et al. [Finally, the rectal retractor is a rigid device that reduces variations in the rectal filling, and rectal and prostate movements. Four studies show that the use of a rectal retractor can significantly reduce intrafractional movement and dose in the rectal wall. De Leon et al.  evaluatee et al.  analyzedWe must consider that most of the studies published to date have not shown any clear clinical benefit to support the routine use of endorectal devices in these patients, and this adds to existing doubts about the cost-effectiveness of the use of the devices  or whethOngoing clinical trials seek to address the use of SBRT in different clinical scenarios and shed light on issues, such as total treatment dose, fractionation, concomitant use of ADT, or lymph node irradiation.There are currently 3 phase III studies in the recruitment phase. One of them compares 36.25 Gy in five fractions with 70 Gy in 28 fractions in patients with stage IIA-B PCa, comparatively evaluating toxicity with both treatment regimens (NCT01766492). Another study compares SBRT with low-rate brachytherapy in terms of cost-effectiveness and cost-utility, as well as sexual dysfunction outcomes (NCT03830788). In the third ongoing phase III study (NCT01584258), patients for whom surgery is considered are randomized to laparoscopic prostatectomy or prostate SBRT delivered with 36.25 Gy in five fractions , and patients for whom surgery is not considered or who refuse surgery are randomized to either conventionally fractionated radiotherapy delivered to a dose of 78 Gy in two Gy fractions or SBRT delivered with 36.25 Gy in five fractions .Regarding phase II trials, there are at least six with active recruitment, three of them in high-risk patients , and a pExtreme hypofractionation is a therapeutic alternative to conventional fractionation in patients with low- and intermediate-risk PCa, with a similar toxicity profile and biochemical control. SBRT data in patients with localized high-risk PCa and on the prostate bed are encouraging. However, more studies are needed to shed light on using extreme hypofractionation in these scenarios. Furthermore, well-designed studies are required to evaluate using ADT concomitant with SBRT, as well as prophylactic lymph node irradiation.


Objective: This systematic review and meta-analysis is aimed at assessing the risks of cardiovascular adverse events in patients with rheumatoid arthritis (RA) who have been treated with fostamatinib.Methods: The electronic databases of OVID Medline, OVID EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science were searched to identify studies that reported cardiovascular events or hypertension in RA patients treated with fostamatinib. Two reviewers separately and simultaneously screened the retrieved studies based on study selection criteria, collected data and performed methodological quality assessments. The effect size of meta-analysis was estimated by the Peto odds ratio (OR) or relative risk (RR) with 95% confidence intervals (95%CI). Funnel plot was used to estimate publication bias and sensitivity analysis was performed to test the robustness of the results.Results: A total of 12 trials composed of 5,618 participants with low to moderate risk of bias were included. In comparison to the placebo, the use of fostamatinib was found to elevate the risk of hypertension  but was not associated with the risks of all-cause death , major adverse cardiovascular events , pulmonary heart disease and disease of pulmonary circulation , in addition to other forms of heart disease . Furthermore, sensitivity analysis showed no significant change in effective trends and no publication bias was found.Conclusion: Fostamatinib is associated with increased risk of hypertension; however, no increased risks of cardiovascular events were observed. Further well-planned cohort studies with large study populations and longer follow-up times are needed to elucidate the outcomes.Systematic Review Registration: [PROSPERO], identifier [CRD42020198217]. Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by persistent synovial inflammation and autoantibodies, which mainly occurs among members of the population that are over 40 years of age. Females are more prone to develop RA than males with a ratio of approxiamtely 3:1. The prevalence of RA varies on the basis of country, region, and population. For example, it is 1% for adults in developed countries and 0.2–0.34% for the Chinese . RA can The pathogenesis of RA is largely unknown. It was reported tumor necrosis factor alpha (TNFα), positioning upstream in the cytokine cascade, played a critical role in RA. Correspondingly, anti-TNFα inhibitors are thought to be potent and effective treatments. Nevertheless, nearly half of RA patients who used the anti-TNFα inhibitors failed to reach remission and needed to switch to another anti-TNFα inhibitor or another biologic . The mosSpleen tyrosine kinase (Syk) plays a critical role in the immune system by mediating inflammatory responses and malignant neoplasms, which makes Syk become a promising drug treatment target for arthritis, asthma, and malignancies like leukemia and lymphoma . Syk is Fostamatinib is a soluble pro-drug form of R406, a type of Syk inhibitor, and is the most extensively studied Syk inhibitor for RA treatment. It is effective in alleviating the severity of arthritis  as severThis systematic review and meta-analysis was performed to investigate the cardiovascular risks of fostamatinib in RA patients. The study was registered in PROSPERO (CRD42020198217) and performed on the basis of PRISMA  guidelines .A study was included if it met all the following requirements: 1): study participants were RA patients; 2); treatment was fostamatinib, regardless of the dose and usage; 3); no limitation for the control treatments, which could be placebo, anti-RA treatments, or fostamatinib with different doses; 4) outcomes were related to cardiovascular events, such as acute myocardial infarction, ischemic stroke, cardiac death, all-cause death, hypertension, or signs related to heart disease; 5); study designs were either RCTs, cohort studies, or case-control studies.A study was excluded if it was a duplicate, a commentary, a conference abstract, or if it did not have related outcomes.clinicaltrials.gov database were manually checked to identify potentially eligible studies.On July 3, 2020, electronic databases of OVID Medline, OVID EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched, using both MeSH terms and key words without language limitation. The search terms were “rheumatoid arthritis” and “fostamatinib.” The detailed search strategy can be found in the supplementary document. Reference lists of included studies and the clinicaltrials.gov database were manually checked. Two reviewers independently and simultaneously screened the studies and any disagreement was resolved via discussion or adjudication by a third reviewer if necessary.Studies were first screened by titles and abstracts, which were then followed by the reading of full texts based on study selection criteria. Microsoft Office Access 2013 was used to manage study selection. Reference lists and the via discussion or adjudication by a third reviewer if necessary.A pair of two authors independently collected data such as the trial registration number, trial duration, treatments, number of cardiovascular events and cases of hypertension, and number of participants. Any disagreement on data extraction was resolved via discussion or adjudication by a third reviewer if necessary.Risk of bias of RCTs was assessed using Cochrane Collaboration’s tool for assessing risk of bias . In doinp-value according to the recommendation by the Cochrane Handbook. I2 with values of 25, 50, and 75% indicated low, moderate, and high heterogeneity, respectively . The effect size of the meta-analysis was estimated using the relative risk (RR) or Peto Odds Ratio (OR) with 95% confidence intervals (CIs). RR values with 95%CIs were evaluated for the effect size of hypertension using the Mantel-Haenszel fixed effect model, while Peto OR values with 95%CIs were used to assess the effect size of cardiovascular events owing to the low frequency of such events. Clinical diversity across studies, by the statistical heterogeneity, was evaluated using the I-square and heterogeneity ectively . AdditioThe categorization of cardiovascular diseases was based on the 10th version of the International Classification of Diseases (ICD10),,,,,,,,,,,In total, 558 references were retrieved from the electronic databases of OVID Medline (n = 118), OVID EMBASE (n = 269), Web of Science (n = 127), and the Cochrane library (n = 44). After the removal of 159 duplicates, 399 studies underwent initial screening by titles and abstracts. Thereafter, 358 irrelevant studies were excluded, leaving 41 studies that underwent full-text reading. Finally, 12 trials . Publication bias, taking the data for hypertension as an example, was assessed by funnel plot. The results showed that the funnel plot was symmetrical, indicating no risk of publication bias .2 = 0, 1/2437 vs 3/1187)  .2 = 4, 5/2415 vs 2/1169)   . Moreove 4/1390) .2 = 0, 6/2415 vs 2/1169), and fostamatinib 100 mg administered twice daily did not have a higher risk of ischemic heart disease than fostamatinib 150 mg administered once daily   .2 = 33, 2/2415 vs 1/1169) and fostamatinib 100 mg administered twice daily did not relate to increased stroke risk than fostamatinib 150 mg administered once daily   .2 = 0, 2/2415 vs 0/1169)     , as well 3/1169) , in comp 1/1390) , as well 8/1390) .2 = 3, 408/2415 vs 51/1169)     . This invs 5/82) . Fostama 20/269) . Neverth05/1372) .Subgroup analysis revealed that longer periods of fostamatinib use were correlated with hypertension risk. When compared to the placebo, the use of fostamatinib increased hypertension risk at 12 weeks , 24 weeks , and 52 weeks  . When coTo our knowledge, this is the first systematic review and meta-analysis to assess the risk of cardiovascular adverse events in RA patients treated with fostamatinib and the results suggest that fostamatinib is associated with increased hypertension risk, when compared to the placebo, and longer periods and higher doses of use are related to higher risk. However, fostamatinib is considered safe for the cardiovascular system as fostamatinib does not increase the risks of all-cause death, MACE, ischemic heart disease, stroke, pulmonary heart disease and disease of pulmonary circulation, in addition to other forms of heart disease.The indications of fostamatinib are, in addition to RA, conditions such as acute myeloid leukemia, chronic lymphocytic leukemia, lymphoma, immune thrombocytopenia, autoimmune hemolytic anemia, and IgA nephropathy . OverallIt was reported that overexpression of the Syk gene could accelerate the development of atherosclerosis ; therefoSeveral published systematic reviews and meta-analyses also concerned the safety of fostamatinib for RA patients. Nevertheless, none of them focused on cardiovascular adverse events except for hypertension, as it had been reported that fostamatinib was associated with increased risk of hypertension . Kang etvia the telephone, was web-based, or done using sealed envelopes. Secondly, the eligible study number and sample size are small. Overall, only thousands of participants were enrolled and only one study was eligible to be a part of several subgroup analyses. Moreover, several trials did not have full-text links, which may compromise the study quality when assessing the risk of bias. Finally, only RCTs met the study selection criteria that were included, while no cohort studies or case-control studies were eligible. In total, the small study population and relatively short follow-up duration of the RCTs were not necessarily powered for detecting infrequent adverse events, such as non-hypertension cardiovascular events , nor were there sufficient follow-up durations to detect adverse events arising from hypertension. Therefore, observational studies, such as cohort studies, with long follow-up durations and large study populations are required to rule out possible cardiovascular adverse events and all-cause death of fostamatinib in RA patients.Several limitations of the systematic reviews and meta-analyses performed within this study should be considered. Firstly, several trials did not describe the method with how the random sequence generation was done nor did they detail how allocation concealment was performed. Based on Cochrane Collaboration’s tool for assessing risk of bias, the correct method of random sequence generation involves using a random number table, a computer random number generator, or by coin tossing. Almost all trials described the allocation concealment as random, but the majority of them did not give a detailed description such as whether it occurred This study suggests that the use of fostamatinib increases the risk of hypertension in a time-and dose-dependent way. Nevertheless, fostamatinib is not found to be associated with cardiovascular adverse events such as MACE, ischemic heart disease, and stroke. Well-planned observation studies, such as cohort studies, with large populations and long follow-up periods are needed to elucidate the relationship between fostamatinib and the risk of cardiovascular events owing to the limitations of the present study.