However, there was a significant negative correlation between the daily TB notifications and mean air pressure (r = −0.119), precipitation (r = −0.063), relative humidity (r = −0.084), CO (r = −0.038) and SO2 (r = −0.034) (p < 0.05). (3) The random forest regression model had the best fitting effect, while the BP neural network model exhibited the best prediction. (4) The validation set of the BP neural network model, including average daily temperature, sunshine hours and PM10, showed the lowest root mean square error, mean absolute error and mean absolute percentage error, followed by support vector regression. Conclusions: The prediction trend of the BP neural network model, including average daily temperature, sunshine hours and PM10, successfully mimics the actual incidence, and the peak incidence highly coincides with the actual aggregation time, with a high accuracy and a minimum error. Taken together, these data suggest that the BP neural network model can predict the incidence trend of tuberculosis in Changde City.Background: Tuberculosis (TB) is a public health problem worldwide, and the influence of meteorological and air pollutants on the incidence of tuberculosis have been attracting interest from researchers. It is of great importance to use machine learning to build a prediction model of tuberculosis incidence influenced by meteorological and air pollutants for timely and applicable measures of both prevention and control. Methods: The data of daily TB notifications, meteorological factors and air pollutants in Changde City, Hunan Province ranging from 2010 to 2021 were collected. Spearman rank correlation analysis was conducted to analyze the correlation between the daily TB notifications and the meteorological factors or air pollutants. Based on the correlation analysis results, machine learning methods, including support vector regression, random forest regression and a BP neural network model, were utilized to construct the incidence prediction model of tuberculosis. RMSE, MAE and MAPE were performed to evaluate the constructed model for selecting the best prediction model. Results: (1) From the year 2010 to 2021, the overall incidence of tuberculosis in Changde City showed a downward trend. (2) The daily TB notifications was positively correlated with average temperature (r = 0.231), maximum temperature (r = 0.194), minimum temperature (r = 0.165), sunshine duration (r = 0.329), PM Global Tuberculosis Report 2021 published by the WHO [Tuberculosis (TB) is a chronic infectious disease caused by Mycobacterium Tuberculosis that infects many organs, the most common of which is pulmonary Tuberculosis . Tubercu the WHO , an esti2.5, PM10, O3 and CO) significantly increased the risk of drug-resistant tuberculosis [10, SO2 and NO2 significantly increased the incidence of tuberculosis [There are many factors influencing the incidence of tuberculosis. Studies have shown that meteorological factors , social rculosis , and a rrculosis . These sThe influence of meteorological factors and air pollutants on the incidence of infectious diseases and the establishment of prediction models based on them have become a research hotspot in the field of epidemiology. On the basis of traditional time series analysis, many studies have begun to consider the influence of meteorological factors in different regions, especially temperature and precipitation, on the incidence of tuberculosis, and used them as independent variables to establish the incidence prediction model of tuberculosis ,14,15. ATo sum up, considering the nonlinear relation between influencing factors and the incidence of tuberculosis, this research intends to analyze the tuberculosis notification data from the period of 2010–2021 from Changde City, Hunan province as well as the meteorological and air pollution data. It also intends to describe the occurrence characteristics of the tuberculosis and epidemic trend and explore the correlation between tuberculosis disease and meteorological factors and air pollutants. A machine learning algorithm  was used to construct the daily incidence prediction model of tuberculosis, based on meteorological factors and air pollutants. The mean absolute error (MAE), root mean square error (RMSE) and mean absolute percentage error (MAPE) were used to evaluate the prediction effect of each model; this was conducted to explore the best prediction model for tuberculosis and provide a basis for the prediction and early warning model construction of infectious diseases.Changde City , located in the north of Hunan Province, China, is not only an important node city of the Yangtze River Economic Belt, but an indispensable part of the Dongting Lake Ecological Economic Zone. With a total area of 18,200 square kilometers, the city has jurisdiction over 9 districts, counties (cities) and 5 administrative districts. According to the results of the seventh national census, the permanent population of the city is 5,279,102 people .In this study, the daily TB notifications in Changde City from 1 January 2010 to 31 December 2021 were obtained from the Disease Surveillance Information Report Management System of Changde City Center for Disease Control and Prevention. A total of 61,018 patients were collected with valid information, which were presented in the form of individual cases, including gender, age, occupation type, date of diagnosis, whether they were severe patients and diagnosis results, etc. The diagnosis of tuberculosis was based on the WS 288-2017 versions of the Diagnostic Criteria for Tuberculosis released by the Chinese Health and Family Planning Commission [http://data.cma.cn/ (accessed on 20 May 2022)). Meteorological variables included daily average temperature (°C), maximum temperature (°C), minimum temperature (°C), relative humidity (%), air pressure (kpa), precipitation (mm), average wind speed (m/s) and sunshine hours (h).Meteorological data from 1 January 2010 to 31 December 2021 were downloaded from the National Climate Data Sharing Center (http://sthjt.hunan.gov.cn/ (accessed on 20 May 2022)). The air quality factors involved included particulate matter with an aerodynamic diameter of less than 2.5 μm , particulate matter with an aerodynamic diameter of less than 10 μm , ozone , sulfur dioxide , nitrogen dioxide  and carbon monoxide .Air pollutants were downloaded from the Department of Ecology and Environment of Hunan Province  original data are represented by grades; (2) data do not obey bivariate normal distribution, so it is not suitable for product difference correlation analysis; (3) the overall distribution is unknown. After pre-analysis, this study found that tuberculosis incidence data did not conform to normal distribution, so non-parametric Spearman rank correlation analysis was used to detect the relationship between various meteorological factors, air pollutants and TB notifications.Support vector regression is an application of a support vector machine in regression. Based on elegant mathematical theories, it aims to find an optimal plane in a multi-dimensional space that can divide all sample units into two categories . This plRandom forest is a machine learning algorithm proposed by American scientist Leo Breiman  in 2001.The Back propagation neural network, also known as the BP neural network, is one of the most widely used artificial neural networks. It was formally proposed by a group of scientists led by Rumelhart and McCelland in 1985 . The BP The evaluation indexes of the prediction model in this study include root mean square error (RMSE), mean absolute percentage error (MAPE) and mean absolute error (MAE):iY is the actual value, Descriptive analysis and correlation analysis were conducted with IBM SPSS 20.0 . The prediction model was built by R4.1.3 software , in which the packages of “e1071”, “randomForest” and “neuralnet” were used to build the support vector regression model, the randomForest regression model, and the BP neural network model, respectively. Statistical test level was α = 0.05.From 2010 to 2021, there were 61,018 newly diagnosed tuberculosis patients in Changde City, including 43,720 males and 17,298 females, with an annual incidence rate of 89.18/100,000. The age of onset was mainly 16–59 years old, followed by over 60 years old. Farmers accounted for the largest proportion of patients, followed by household workers and unemployed groups . OverallA total of eight meteorological factors and six ambient air pollutants were selected in this study, and their basic descriptions are shown in 2.5 (r = 0.097), PM10 (r = 0.215) and O3 (r = 0.084) (p < 0.05), and were negatively correlated with mean air pressure (r = −0.119), precipitation (r = −0.063), relative humidity (r = −0.084), CO (r = −0.038) and SO2 (r = −0.034) (p < 0.05). There was no significant correlation between the daily TB notifications and the mean wind speed and NO2 (p > 0.05). According to the correlation coefficients, there are strong correlations between mean temperature, maximum temperature, minimum temperature, mean air pressure and PM2.5, PM10  (The daily TB notifications in Changde City from 2010 to 2021 were positively correlated with average temperature (r = 0.231), maximum temperature (r = 0.194), minimum temperature (r = 0.165), sunshine hours (r = 0.329), PM < 0.05) .10, SO2, CO and O3, which were correlated with the number of daily incidences as independent variables . Model 2 (SVR2) excluded variables with correlation coefficients less than 0.09, and only included average daily temperature, sunshine hours and PM10 with correlation coefficients greater than 0.1  included daily average temperature, relative humidity, precipitation, sunshine hours, PMrelation ). MeanwhXnorm is the normalized value): In machine learning models, the support vector machine and the neural network, which are solved by the gradient descent method, usually need to normalize the data first, which aims to bring the data of different dimensions to within the same range so that they can more quickly find the optimal solution through gradient descent and can eliminate the influence of characteristics between the dimensional data. The normalization formula is as follows  at each node in the random forest is generally 2~M, randomly selected from the total characteristic variable (M). In this study, model establishment and independent variable selection are the same as support vector regression. Therefore, the Mtry of RFR1 can be 2 to 10, and the Mtry of RFR2 can be 2 to 5. When selecting the optimal parameters, the combination of Mtry and Ntree finally selects the following parameters according to the principle of minimum mean square error (MSE) through continuous attempts :When the Mtry of RFR1 is 3 and Ntree is 1000, the minimum MSE of the model validation set is 27.67. When Mtry = 2 and Ntree = 1000 for RFR2, the minimum MSE of the model validation set is 24.01. The optimal parameters were selected to construct the final model and predict the daily incidence of pulmonary tuberculosis in Changde City in 2021. The results are shown in The BP neural network model mainly contains a multi-layer feed-forward network with an input layer, hidden layer and output layer, and each characteristic variable included in the model is taken as a node of the input layer. In this study, two BP neural network regression models were established according to the relationship between the daily incidence of tuberculosis, meteorological factors and air pollutants in the same period (model establishment and independent variable selection were the same as support vector regression). We used an empirical formula to preliminarily determine the number of neurons in the hidden layer:  1 to 10 . TherefoWhen the network structure is 10-3-1, the number of neurons in the hidden layer is 3, the threshold is set to 0.01, and the minimum MSE of the BP1 test set is 25.40. When the network structure is 5-5-1, the number of neurons in the hidden layer is 5, the threshold is set to 0.05, and the minimum MSE of the BP2 test set is 22.85. The model structure of the BP neural network is shown in 10, has the lowest root mean square error, mean absolute error and mean absolute percentage error, followed by SVR2. The support vector regression model (SVR1) that included average daily temperature, precipitation, relative humidity, sunshine hours, PM10, O3, CO and SO2 had the highest root mean square error, mean absolute error and mean absolute percentage error. RMSE, MAE and MAPE were used to compare the SVR, RFR and BP neural network models. In this study, Spearman rank correlation analysis was used to analyze the correlation between the daily TB notifications and meteorological factors and air pollutants in Changde City, Hunan Province. Meanwhile, a machine learning algorithm was utilized to construct a tuberculosis incidence prediction model based on meteorological and air quality. MAE, RMSE, and MAPE were performed to evaluate the prediction model. This study aimed to explore an accurate prediction model of tuberculosis incidence, predict the epidemic trend of tuberculosis cases, and provide reference for epidemic prevention and control departments.From 2010 to 2021, the overall incidence of tuberculosis in Changde City, Hunan Province showed a downward trend. The number of male cases was larger than that of female cases, the age of onset mainly ranged from 16 to 59 years old, and the occupational population with the largest number of cases was farmers. It is very consistent with the epidemic characteristics of tuberculosis in other provinces of China. For example, from 2005 to 2018, 70.45% of the total cases of tuberculosis in Henan Province were male, the median age was 48 years old, and the number of farmers and herdsmen reached 81.5% . Men may2.5, PM10 and O3, and negatively correlated with the daily average pressure, precipitation, relative humidity, CO and SO2. There was no significant correlation between the daily TB notifications and the average wind speed and NO2. Higher temperatures may be associated with longer sunshine hours, and a systematic review suggests that higher temperatures lead to air currents that are generally high, providing a favorable environment for TB transmission and suggesting that pathogens replicate more easily at higher temperatures [10 level [A total of eight meteorological factors and six air pollutants were included in the correlation analysis, among which the daily TB notifications were positively correlated with the daily average temperature, maximum temperature, minimum temperature, sunshine hours, PMeratures . Long-teeratures ,37. Stud10 level . PM 2.5 10 level , inhibit10 level .10, were all lower than those of the support vector regression model and random forest regression model. We assume that the BP neural network model has better predictive performance than SVR and RFR for tuberculosis incidence. Different prediction models for infectious diseases have obvious advantages and disadvantages, so it is crucial to select an appropriate prediction model according to its applicable conditions and sample data characteristics [Using models to predict tuberculosis incidence could help identify trends and provide the basis for disease warning. This study used correlation analysis results using support vector regression, random forest regression and BP neural network model to construct six tuberculosis disease prediction models, and it compared the prediction results of the six models. It was found that the MAE, RMSE and MAPE of the BP neural network model, including average daily temperature, sunshine hours and PMeristics . SVR is eristics . SVR is eristics . Random eristics . Random eristics . Therefoeristics . Howevereristics . The BP However, some questions in this study still need more in-depth research. First, the incidence of tuberculosis may be related to the social, economic, cultural and individual conditions of the population. This study used the daily notification data of tuberculosis, so it could not obtain the social, economic and cultural data of the same period, and could not consider the individual conditions of the population. Second, studies have shown that extended exposure to air pollution has a long-term effect on lung health , and a bIn summary, using the incidence data of tuberculosis in Changde City from 2010 to 2020 as the training set and the incidence data in 2021 as the validation set for prediction, it was found that the prediction accuracy of the BP neural network model is better than that of support vector regression and the random forest regression model, which can be applied to the incidence prediction of tuberculosis in Changde City, Hunan Province. This study also provides the scientific basis and reference information for the formulation of a tuberculosis prevention and control policy for public health departments.


IntroductionAlthough rectal cancer is thought to have a higher rate of metastasis to the brain compared with colon cancer, there is limited and contradictory data on the subject. This study aims to determine the prevalence of brain metastasis for colon and rectal cancers (CRC), and to explore associations and predictors of brain metastasis (BM).MethodsThe 2010-2016 National Cancer Database (NCDB) was queried for patients with stage IV CRC. Patients with missing data on site of metastasis and primary tumor location were excluded. Chi-square test was used for categorical data and multivariate logistic regression analysis was performed to evaluate the predictors of BM.ResultsOf 108,540 stage IV CRC patients, the prevalence of BM was 1.21% from the right colon, 1.29% from the left colon, and 1.59% from the rectal adenocarcinoma (p<0.001). The presence of lung, bone, and liver metastases were the strongest predictors for BM. Bone and lung metastases increased the odds for BM by 3.87 (95% CI: 3.36-4.46) and 3.38 (95% CI: 3.01-3.80), respectively while the presence of liver metastasis decreased odds for BM by 55% . On multivariate analysis, primary tumor location was not predictive of BM.DiscussionThis study helps to characterize the prevalence and associations of BM from CRC using the NCDB. The correlation between BM and bone and lung metastases, along with negative association of liver metastasis further supports the hypothesis of systemic transmission of tumor cells. Further identification of predictors and correlations with BM may help guide surveillance among patients with advanced CRC. Although relatively rare, colorectal cancer (CRC) that metastasizes to the brain is associated with very poor prognosis -4. EarlyRisk factors that lead to the development of BM are not well described, but are commonly believed to occur in association with long survival, long-standing pulmonary metastases, and left-sided tumors -10. TherThis epidemiologic study seeks to define the relative prevalence of BM among stage IV colon and rectal cancer using a large national database, as well as to determine predictors for BM in each patient population. We hypothesized that there will be a higher prevalence of BM among patients with rectal cancer compared to colon cancer.The National Cancer Database (NCDB) is a clinical oncology database sponsored by the American College of Surgeons and the American Cancer Society. The NCDB tracks clinical and outcomes data for neoplastic diseases, representing approximately 70% of all newly diagnosed cancers in the United States. The 2010-2016 NCDB for colon and rectal cancer was queried for patients with stage IV CRC [DefinitionsFollowing inclusion and exclusion criteria, patients were divided into two cohorts, presence of BM and absence of BM. Primary tumor location, demographics, staging, and additional sites of metastasis were assessed for each cohort.Statistical analysisThe group comparison analyses were performed using Student T-tests for continuous variables and Chi-square tests for categorical variables. Statistically significant variables including primary tumor location, race, insurance status, facility type, clinical N, grade, and lung, bone, and liver metastases, were included in a multivariable logistic regression model to identify predictors for BM. Kaplan-Meier curves were generated for BM patients based upon primary tumor location. Log-rank tests were utilized to evaluate the survival distribution between these groups.All the complete case analyses were performed in SAS version 9.4 statistical software , with two-tailed p<0.05 considered statistically significant.Prevalence of brain metastasisThe prevalence of BM for all stage IV CRC patients was 13.2 per 1,000 patients . Overall, right and left colon cancer patients were less likely to have BM than rectal cancer patients. The prevalence of BM for right colon, left colon, and rectal adenocarcinoma was 12.1 (n=566), 12.9 (n=520), and 15.9 in 1,000 patients (n=342) (p<0.001), respectively , 11.5 in 1,000 patients (n=156), and 14.4 in 1,000 patients (n=86) in right colon cancer, left colon cancer, and rectal adenocarcinoma respectively . Their dThis data supports a correlation of BM with bone and lung metastases on multivariable analysis. These sites are all presumed to be associated with hematogenous spread via the systemic circulation. On the other hand, liver metastases, more indicative of hematogenous spread via the portal circulation, were significantly associated with a decreased odds of BM. These indicators of systemic versus portal spread were the strongest predictors for BM, suggesting that hematogenous spread via systemic circulation is the predominant mechanism for metastasis to the brain. These data augment the findings of prior studies, which have found that BM from CRC spread hematogenously and present with multiple lesions (commonly lung and bone) and neurological symptoms ,19. InteSome of the factors associated with BM, such as Clinical N2 staging and poorly-differentiated grade III histology, were expected. In general, high-grade tumors with increased nodal involvement are more likely to metastasize. African American ethnicity, a negative predictor of BM, requires further research. Prior studies have described an increased incidence of right colon cancer in African American populations and hypothesized that African American patients with CRC have a higher frequency of microsatellite stability ,21. The LimitationsThere are some intrinsic limitations to the NCDB, including the accuracy of data entry and missing clinicodemographic data, that affected this study’s analysis. Clinical T stage was missing for the majority of patients, likely rendering univariate and multivariate analysis of clinical T and BM invalid. The NCDB also does not include temporal information regarding metachronous or synchronous presentations of stage IV disease. As a result, this study was unable to determine the order of metastasis and whether this may predict the occurrence of brain metastases. This limited the analysis of metastatic patterns, especially when comparing hematogenous spread via the portal or systemic circulation. In addition, information such as clinical staging, genetic profiles, and date of death was missing for a significant portion of these patients, limiting the applicability of these metrics in the analysis.Future directionsFurther research and cost-benefit analysis are needed to guide additional screening for stage IV CRC patients at the time of diagnosis. While CRC patients standardly receive screening CT imaging of the chest, abdomen, and pelvis at the time of diagnosis, imaging of the head is currently not recommended due to the low incidence of BM, despite improvement in survival outcomes and treatment options with early detection of BM ,22. Our This study utilized the most comprehensive database available to determine the prevalence and risk factors for BM from CRC. This study found that rectal adenocarcinoma is not a significant predictor for BM when compared to right- or left-sided colon cancers. However, lung and bone metastases significantly increased the odds of the presence of BM, indicating that hematogenous spread via systemic circulation plays a predominant role in the occurrence of BM among patients with stage IV CRC.


The PGP traits of the isolated strains are positively correlated with the PSBs abundance and the sample characteristics (soil and climate). The morphological and biochemical characteristics of the strain allowed us to identify around nine different bacterial genera, including Bacillus, Pseudomonas, and Rhizobium. The findings showed that bacterial communities, density, and potency are closely correlated to various edapho-climatic conditions such as temperature, precipitation, soil nutrient status, and soil texture. These findings could be used to improve an effective plant-PSBs system and increase agricultural output by taking into account their specific ecological traits and plant growth mechanisms.Phosphate solubilizing bacteria (PSB) is an advantageous way to supply phosphate (P) to plants. The Mediterranean climate of Morocco, especially the low-lying areas, is semi-arid with nutrient-depleted soils in which small-scale, low-income farmers dominate without access to expensive inorganic fertilizers. However, there is not a wide range of PSBs suitable for various agroecological situations. Furthermore, our understanding of the soil and climatic variables that influence their development is limited. This study aims to examine the impacts of specific environmental factors, such as climate and soil, on the abundance, potential, and diversity of PSBs in four agricultural regions of Morocco. To assess the possible impact of these factors on the P solubilization capacity of PSBs and plant growth-promoting (PGP) traits, we analyzed the soil and climate of each sample studied. Similarly, we tested the P solubilization efficiency of the isolates. The bacteria were isolated in a National Botanical Research Institute’s phosphate (NBRIP) agar medium. A total of 51 PSBs were studied in this work. The P-solubilization average of Rock P (RP) and Tricalcium P (TCP) of all strains that were isolated from each of the four regions ranged from 18.69 mg.L Bacillus, Pseudomonas, Rhizobium, Enterobacter, and Burkholderia which can reduce the use of chemical P fertilizers [Phosphorus (P) is the second most essential nutrient after nitrogen, required by plants for growth and development. The low availability of P in the soil is mainly due to the complexes it forms with other elements when applied, thus becoming unavailable to the plant without the help of microbes . In acidtilizers –7 by thetilizers  while prSoils contain diverse communities of microorganisms that interact with plants and respond to their specific physical and chemical characteristics. These microbial communities contribute to essential soil ecosystem services, including organic matter decomposition, nutrient cycling, disease control, and plant nutrition . Climate4+ content, and this had an impact on the structure of the bacterial community above and below the soil (rhizosphere and root). Among the different abiotic stresses, low temperature is a major limitation to the growth, reproductive stage, and plant grain yield [The occurrence, abundance, diversity, and bioactivity of PSB vary in different soils. The variation is attributed to the different soil properties including the nutritional conditions and physiochemical properties. However, PSBs are influenced by biotic or abiotic factors such as interactions with other microorganisms, agronomic activities, ecological conditions, and soil types . Researcin yield . In addiin yield  show thain yield .Since PSBs can play a key role in enhancing the host plant’s ability to withstand stressful conditions. We hypothesized that the environmental conditions observed at the sampling sites might be correlated with the soil types, the expression levels of the different P-solubilising traits of the isolated bacteria, and, conversely, their potential to promote plant growth. Therefore, we addressed the question: are the performance and plant growth promotion mechanisms of rhizobacteria associated with the environmental conditions of their soil source? Considering the above facts, the present study focused on the several effects of climate and soil conditions on the abundance, potential, and diversity of PSBs in the rhizosphere of legumes in four dissimilar bioclimatic stations of Fez—Meknes regions, Morocco. In addition, to assess the potential impact of these factors on the capacity of PSBs, we tested the P solubilization efficiency of isolates, evaluate their plant’s growth trait potential, and assessed the impact of environmental conditions at each study site on the PSB strains. A better understanding of microbial consortium patterns is essential and becomes a prerequisite for the sustainable use of these biofertilizers in agriculture. The study results could provide an effective approach for the agronomic improvement of microbial inoculants to enhance soil P mobilization for plant growth either in intensive production or in agroecological applications in Morocco.Soil samples were collected from cultivated and spontaneous plants from different rhizosphere sites of four dissimilar bioclimatic stations distributed in the sub-mountainous and central areas of the Fez—Meknes regions from December to January 2020 . As this-1 TCP. After nine days of incubation at 28 ± 2°C, the colonies’ diameter and the visible halos were measured to calculate the P solubilization index (PSI) by the following formula  agar plates , 19. To  formula :PSI=CDCD: Colony Diameter. HD: Halo zone Diameter.Samples collected from the crop field correspond to four sites named Ayt Saleh, Ayt Yaakoub, Tafrant, and Dayt Amira. Sites samples description and bacteria analyses are described in The current study has focused on the Emberger rainfall quotient to determine the climate type that governed each studied area. It is the ratio between precipitation amount and the average of thermal extremes (warmest—coldest months), all corrected by the extreme thermal amplitude (M—m). Emberger noted that thermal amplitude is a significant factor in plant species distribution, which leads to microbial species diversity , 21. ThiTo investigate the effects of climatic and edaphic parameters on PSBs population density in the environmental samples, we analyzed the relationships between these parameters and PSBs population density using univariate linear regressions. In addition, the rainfall and temperature of each site were studied using an umbrothermal diagram to give more details on how PSBs abundance and diversity can be affected.-1 RP alone and 5 g.L-1 TCP alone was used. The amount of assimilable P content was carried out by the ascorbic acid colourimetric method [2PO4 (concentration from 0 to 1 mg.L-1) was used to calculate P content. To identify PSB genera, we extended the morphological and biochemical tests conducted by Janati et al. (2022) [To measure the solubilization capacity of isolates a liquid NBRIP medium supplemented with 5 g.Lc method  after se. (2022) . In this3 and 587.4 mL of 98% H2SO4, solution) and kept in the dark at room temperature for 30 min. The development of a pink-red colouration indicates the production of auxins. The absorbance of each sample was measured with a spectrophotometer at 530 nm, and auxin concentrations were determined based on a standard range prepared with standard solutions ranging from 0 to 50 μg.mL-1 auxins.Auxin production of PSBs was determined according to the method of  with som3.6H2O solution. Then, 72.9 mg HDTMA (hexadecyltrimethylammonium bromide) dissolved in 40 Ml of deionized water was added to CAS to a final volume of 100 mL [The culture on agar medium containing chromium azurol S (CAS) allows the detection of the secretion of siderophores by the microorganisms. The principle is that the culture medium initially has a blue colour due to the Iron/CAS/HDTMA complex which turns orange-red following the displacement of iron by the siderophores produced by the microorganism. All the test strains were inoculated into TSA liquid medium and were shaken at a 180 rpm incubator for 2 days at 28 ± 2°C. The fermentation broth was centrifuged at 6800 × g for 10 min. A solution consisting of 60.5 mg CAS in 50 mL of deionized water was amended with 10 mL FeClf 100 mL , 27. FouAr=absorbance of reference (CAS reagent) and As = absorbance of the sample.2 0.1 g, MgSO4 0.5 g, KH2PO4 1 g, K2HPO4 1 g, yeast extract 4 g, agar 15 g in 1 L, and pH was maintained at 7.2). Different sources of insoluble zinc salts like zinc oxide (1.244 g/L = 15.23 mM), zinc phosphate (1.9882 g.L-1 = 5.0 mM), zinc carbonate (1.728 g.L-1 5.2 mM), and zinc sulfide (1.124 g.L-1 11.54 mM) at a final concentration of 0.1% were added in the medium individually and autoclaved at 121°C for 30 minutes [The zinc-solubilizing ability of these strains was evaluated in mineral salt medium , the preliminary screening for PSB isolates was performed to investigate species affiliation of each potential isolate based on growth in a different medium; King A and King B medium to identify pseudomonas , Yeast eThe region map was prepared using the SIG software. Data were analyzed using SPSS software, and results were expressed as the means ± standard deviation of three replicates. Data were examined by ANOVA I analysis, and mean comparison was performed by Duncan’s multiple range test at p ≤ 0.05. Principal Component Analysis (PCA) was performed to give a summarising view of obtained results, how soil and environmental characteristics influenced isolates biological attributes, and to determine which inter-related parameters most influenced isolates P solubilizing potential of the genera diversity indices were calculated using PAST free software version 3.4 (Cells.Kg-1 of soil). The value of air-filled porosity present in the studied soils indicates adequate pore distribution and continuity; Dayt Al Amira and Ait Saleh present the highest value of 15%. The result confirms that Ait Saleh has the maximum organic matter (5.64%) and permeability (29 mm/hr). On the other hand, the Dayt Al Amira site showed the highest amount of P2O5, K2O, and MgO , however, Tafrant site has the highest value of CaO with 9450 mg.Kg-1. There was a positive correlation between total N and mineral N in the studied regions, Ait Yaakoub and Dayt Al Amira have the highest mineral N value (8.9 and 8.2 mg.Kg-1), respectively, against 0.3% of total N, followed by Ait Saleh and Tafrant. In terms of soil pH, it was close to neutral or slightly basic (pH = 8.23 on average), and the soil was moderately calcareous. Cation exchange capacity ranged between 31.6 and 41 cmol.kg-1. Maximum electrical conductivity, reflecting soil salinity, was recorded in the Ait Yaakoub sample at 300.33 (ds.m-1).One hundred sixty-four PSBs strains were obtained from the rhizosphere of legumes, cereals, and spontaneous plants based on morphologically different colonies and remarkable halo solubilization formed in the NBRIP-TCP medium. Fifty-one strains showed different capacities for P-solubilization and soluble P concentration in NBRIP-TCP and NBRIP-RP mediums and were named as PSBs. Ait Saleh region showed the highest PSBs load of 3.16x10The average percentage of nutrient parameters in the soil showed important mean values. Agricultural legume soils analyzed for physicochemical characteristics revealed that Dayt Al Amira has the highest mineral content region with remarkable values of Al, Ca, Mg, and P . We note2) for the different regions using three methods show that all formulas give approximately the same results. The value of Q2 using Stewart’s formula differs only slightly from the Q2 developed by Emberger and Mokhtari (2 obtained and the minimum temperatures of the coldest month (m) (limiting factor). The Q2 values plotted on the Emberger diagram illustrate the shift in The regions studied are characterized by different thermal and water profiles. Rainfall-thermal quotients (QMokhtari . Emberge2 (126 approximately). However, the Tafrant site has the most significant value and the Ait Yaakoub site has the minimum value. These results give an idea of the PSBs distribution in these regions given that the Ait Saleh and Dayt Al Amira sites have the most important PSBs load respectively.We noted that Dayt Al Amira and Ait Saleh sites have close values of Q2 being approximately 172.57. On the other hand, the Ait Yaakoub site is placed at the limit of sub-humid and semi-arid climate with warm winter and Q2 close to 101.23, whereas the two other sites Dayt Al Amira and Ait Saleh are in sub-humid climate in soft winter, with Q2 close to 126.89 and 126.04, respectively.The climatogram analysis reveals that the Tafrant site is the only site subjected to the humid bioclimatic stage in warm winter with QFurthermore, the umbrothermal diagram shows that the Tafrant site has the most precipitation but is countered by high temperatures, such as the Ait Yaakoub site, which exceeds 17.8 degrees Celsius on an annual basis. This is not the case for the Ait Saleh and Dayt Al Amira sites, which have significant rainfall and moderate to low temperatures respectively.The lowest average rainfall in all regions makes July the driest month of the year, with only 2 mm in Tafrant, 4 mm in Ait Yaakoub, 13 mm in Ait Saleh, and 25 mm in Dayt Al Amira. While an average of 136 mm makes December the month with the highest rainfall in Tafrant. Although, Ait Yaakoub record’s rainfall is recorded in November with an average of 70 mm. However, in Ait Saleh and Dayt Al Amira, April has the highest rainfall of the year with an average of 79 mm and 80 mm, respectively . This fith day of incubation. Isolate WJEF8 shows a maximum solubilization index with PSI = 3.84 [-1 and 94.54 mg.L-1 accompanied by significant variations between the different isolates (p ≤ 0.05). Maximum TCP solubilization was observed for the WJEF61 strain. On the other hand, the concentration of soluble P in the RP-NBRIP medium in each site varied between 18.69 mg.L-1 and 40.43 mg.L-1 accompanied by significant variations between the different isolates (p ≤ 0.05). The maximum solubilization of RP was observed for the WJEF51 strain. These isolates were found to solubilize TCP more than RP and the most occurred ones were in the Ait Saleh site. The results of the experiments indicated that P solubilization varied according to the microbial isolates and the type of insoluble phosphate (TCP or RP). The solubilization of TCP and RP in the NBRIP liquid medium by the tested strains was accompanied by a significant decrease in pH.Results revealed that all isolated strains from studied regions were able to produce halo-forming colonies on the NBRIP-TCP amended solid medium. Although, there was a significant difference in all tested strains. The solubilization halo zone ranged from 1.1 cm to 4.2 cm, and the appearance of the halo zone in all strains was noticed after the 4I = 3.84  (Table 5The pH of the medium inoculated with the selected strains decreased significantly from 4.88 to 4.47 (TCP) and 4.67 to 4.50 (RP), respectively, after nine days of incubation. Based on the one-way analysis of variance (ANOVA), we noted a significant difference between the solubilization of RP and TCP within the four sites. It is interesting to mention that the Ait Saleh site has the highest solubilization potential, taking into account that this location has the maximum PSBs load.-1 to 8.426 μg.mL-1. We emphasize that the Ait Saleh site is the source of 70.59% of the bacteria that produce auxins, in which WJEF59 has the highest auxins concentration of 101.87 μg.mL-1.The data obtained on auxins production showed that from 51 isolates approximately 33.34% can produce auxins . It was Based on the data collected on siderophores production, out of 51 isolates, approximately 25.49% can produce siderophores . These iFrom the 51 PSB isolates, five  were assessed to be ACC deaminase producers in which values ranged from 0.27 to 0.58 nmol α-ketobutyrate mg/protein/h) . The higThe results on Zn-solubilization revealed that approximately 23.53% of 51 isolates can solubilize four sources of Zn: zinc oxide, zinc phosphate, zinc carbonate, and zinc sulfide. When compared to other compounds, the isolates were found to be more efficient to solubilize zinc from zinc phosphate. Bacteria from the Ait Saleh region dominate this study, accounting for 75% of all zinc-solubilizing bacteria. The halo zone of solubilization ranged from 14 mm to 31 mm, whereas ZSI ranged from 2.22 to 4, . We note2S belong to the Ait Saleh site In this study, nine bacterial genera were identified based on different tests performed in specific media for the phenotypic characteristics, namely Pseudomonas, Rhizobium, Clostridium, Serratia, Proteus, Burkholderia, Staphylococcus, Streptococcus, and Bacillus )  to identH’s diversity and Dominance D, the variation among the four studied sites was somewhat important and close. Tafrant had the highest diversity evenness, while Ait Yaakoub had the lowest.The correlation between the ability of isolates to solubilize phosphate on NBRIP medium and selected environmental conditions prevailing at the locations from which soils were sourced was investigated. Based on morphological diversity, Ait Saleh had the highest number of individuals , while Tafrant had the lowest  . AccordiA hierarchical heat map of the bacterial distribution at the different studied sites, classified by genus, is presented in Soil microbial communities are affected by several factors including soil conditions and environmental changes. These extreme events have serious repercussions on the structure of microbial communities, including the increase in the relative abundance of rare species and the emergence of pathogens capable of infecting plants. The present study focused on the effect of climate and soil conditions on the abundance, potential, and diversity of PSBs from the legumes rhizosphere located at different bioclimatic stages in four regions of Morocco. In addition, to assess the potential impact of these factors on the capacity of PSBs, we tested the P solubilization efficiency of isolates, evaluated their plant’s growth trait potential, and assessed the impact of environmental conditions at each study site on the PSB strains. The selection of an efficient PSB is crucial, as it practically increases P in the plant rhizosphere . Phospha-1)), pH, and total and available P of all samples. As result, all sites differed in both climatic and soil conditions. Soils in the investigated sites can be described as fertile and biologically active, with optimal properties for legume cultivation. Mineralogical compositions of different sites analyzed indicate that Al, Ca, Fe, K, Mg, Na, and P are the most important minerals in the distribution of the various sites. In addition, physicochemical characteristics revealed that the Dayt Al Amira site has the most significant values of the most minerals content with remarkable values of Al, Ca, Mg, Mn, and P. Maximum electrical conductivity, reflecting soil salinity, was recorded in the Ait Yaakoub soil sample of 300.33 (ds.m-1) followed with Dayt Al Amira 241.2 (ds.m-1), in addition, Dayt Al Amira registers the maximum cation exchange 37.2 (cmol+.kg-1). We focused on these geographic, climatic, and environmental parameters, as they are potentially important factors influencing the population density of PSBs in the environment [4 (Cells.Kg-1 of soil), likely resulting from primary soil properties related to their different pedogenesis such as texture and nutrient abundance. However, research by Hoeber et al. (2020) [3-N, and dissolved organic carbon in the soil suggest functional couplings between soil PSBs and microbes responsible for soil nitrification and organic matter degradation. In terms of soil pH, it was close to neutral or slightly basic (pH = 8.23 on average), and the soil was moderately calcareous, which probably does not favour the bioavailability of P. Phosphate-solubilizing activities of PSBs are negatively affected by many factors such as temperature, pH, salinity, and dissolved oxygen [To date, only a few studies have focused on the population density of PSBs in different habitats and the factors that influence this. For this reason, we collected information on a place name, geographic location (latitude and longitude), mean annual precipitation (MAP) and mean annual temperature (MAT) of the study sites, soil physicochemical analysis, and the population density of the PSBs   showed td oxygen . Changesd oxygen . Soil pHd oxygen .2 being approximately 172.57. On the other hand, the Ait Yaakoub region is placed at the limit of Sub-humid and Semi-arid climate with also warm winter and Q2 close to 101.23, whereas the two other stations Dayt Al Amira and Ait Saleh classified as Sub-humid climate in soft winter, with Q2 close to 126.89 and 126.04, respectively. This explains why the latter two regions have a high abundance of PSBs. Instead, Kałużewicz et al. (2018) [2 enrichment fertilization in the open air can stimulate daily C uptake, plant growth, above-ground biomass production, microbial communities, and soil C, by reducing evapotranspiration for stomatal closure. Similarly, reductions in evapotranspiration cause impairment in the plant’s capacity to uptake nutrients, and indirectly to a lack of sufficient microbial population resources, which explains the high PSBs load in the Ait Saleh site, given the favourable conditions. These results provide further evidence of the functional coupling between PSBs and their geographical location, whereby edaphic and climatic conditions significantly affect their occurrence.Besides soil properties, several abiotic factors can affect microbial communities . Abiotic. (2018)  noted th. (2018) . Rising . (2018) , and thi. (2018)  and micr. (2018)  showed t-1 and 40.43 mg.L-1, while the medium containing TCP was between 71.71 mg.L-1 and 94.54 mg.L-1. We noted that strains from the Ait Saleh site contain the highest value of solubilization either with TCP or RP. These results are in agreement with other studies done by Elhaissoufi et al. (2020) [Bacillus and Pseudomonas, various species and strains differ in their capacity to mobilize P due to differences in the secretion of organic acids, phosphatases, and phytase or other P-solubilizing mechanisms [Bacillus [Pseudomonas [Pseudomonas is the dominant genus of PSBs in the group of isolated strains, followed by the Bacillus genus. Less frequent isolates were of the Streptococcus and Burkholderia genera. In contrast, the most efficient P-solubilizing strain was the Rhizobium genus. This effect might be based on the varying site-specific environmental conditions and their interactions with the genotypes. Zhang et al. (2019) [The solubility index on TCP-NBRIP medium was in agreement with previous studies conducted on different plants’ rhizosphere, where the PSBs solubility index ranges from 2 to 3.84 –57. The . (2020) , who rep. (2020)  who indi. (2020) . Many re. (2020)  reveal t. (2020)  found ma. (2020)  indicatechanisms . SeveralBacillus  and Pseuudomonas  species . (2019)  mentione. (2019)  pointed Azospirillum brasilense SM in vitro. Zinc solubilization results show a wide variation by isolates recovered from rhizosphere soil samples collected from different agricultural and soil management practices on nutrient agar medium. The isolates exhibited a significant variation in zinc solubilization. Maximum zinc solubilization was observed for zinc phosphate followed by zinc oxide. These findings are in accordance with Ramesh et al. (2014) [2 from respiration, the importance of all these processes is variable and dependent on the organisms and growth conditions [Among the PGP traits, auxins are powerful growth hormones produced naturally by plants. They are found at the tips of shoots and roots and support cell division as well as stem and root growth. They can also influence plant orientation by directing cell division to one side of the plant in response to sunlight and gravity . Indole-. (2014)  who repo. (2014)  who foun. (2014) . Organic. (2014) . Althougnditions . The abinditions . Bacterinditions . In addinditions . Among tnditions , which enditions . Thus, aThis research work provides valuable insights into the PSB’s density in different habitats. The main objective of this study was to evaluate the effect of climate and soil conditions on the abundance and diversity of PSBs in four varied regions in Morocco. In addition, we tested the P solubilization efficiency and the PGP traits of isolates to assess the potential impact of the cited factors on the competencies of PSBs. The density of the PSBs population was significantly different between the four sites due to varied environmental conditions: temperature, humidity, and precipitation of the selected sites. The abundance of PSBs and PGP traits were positively correlated as the Ait Saleh site, the most PSBs load, show 70% and 69% of auxins and siderophores production, respectively. Based on the mentioned results, the climate appears to exert the most selective pressure on PSBs phenotypes such as P solubilizing competence. Also, we noted that climate influences the structure of PSBs communities in the studied sites. In general, this study makes a significant contribution to the sustainable agriculture field by conducting a thorough investigation of PSBs’ performance associated with the environmental conditions of their soil source. We suggest extending the field of work and investigating different regions that are more likely to contain efficient PSBs with traits and ecological mechanisms that can improve agricultural production as well as directing research toward appropriate pathways.S1 TableValues for both RP and TCP liquid NBRIP medium.(PDF)Click here for additional data file.


Immune checkpoint inhibitors (ICIs) have considerably improved patient outcomes in various cancer types, but their efficacy remains poorly predictable among patients. The intestinal microbiome, whose balance and composition can be significantly altered by antibiotic use, has recently emerged as a factor that may modulate ICI efficacy. The objective of this systematic review and meta-analysis is to investigate the impact of antibiotics on the clinical outcomes of cancer patients treated with ICIs.PubMed and major oncology conference proceedings were systematically searched to identify all studies reporting associations between antibiotic use and at least one of the following endpoints: Overall Survival (OS), Progression-Free Survival (PFS), Objective Response Rate (ORR) and Progressive Disease (PD) Rate. Pooled Hazard Ratios (HRs) for OS and PFS, and pooled Odds Ratios (ORs) for ORR and PD were calculated. Subgroup analyses on survival outcomes were also performed to investigate the potential differential effect of antibiotics according to cancer types and antibiotic exposure time windows.107 articles reporting data for 123 independent cohorts were included, representing a total of 41,663 patients among whom 11,785 (28%) received antibiotics around ICI initiation. The pooled HRs for OS and PFS were respectively of 1.61 [95% Confidence Interval (CI) 1.48-1.76] and 1.45 [95% CI 1.32-1.60], confirming that antibiotic use was significantly associated with shorter survival. This negative association was observed consistently across all cancer types for OS and depending on the cancer type for PFS. The loss of survival was particularly strong when antibiotics were received shortly before or after ICI initiation. The pooled ORs for ORR and PD were respectively of 0.59 [95% CI 0.47-0.76] and 1.86 [95% CI 1.41-2.46], suggesting that antibiotic use was significantly associated with worse treatment-related outcomes.versus control, prospective observational studies and interventional trials involving microbiome modifiers are crucially needed to uncover the role of microbiome and improve patient outcomes. Such studies will reduce the existing publication bias by allowing analyses on more homogeneous populations, especially in terms of treatments received, which is not possible at this stage given the current state of the field. In the meantime, antibiotic prescription should be cautiously considered in cancer patients receiving ICIs.As it is not ethically feasible to conduct interventional, randomized, controlled trials in which antibiotics would be administered to cancer patients treated with ICIs to demonstrate their deleterious impact https://www.crd.york.ac.uk/prospero/, identifier CRD42019145675. CurrentThis significant and steadily increasing use of ICIs and the variation of response between patients warrant attention to the factors that mitigate their efficacy. Only between 15 and 60% of patients, depending on cancer types, do respond to ICI treatment , which lIn recent years, the gut microbiome has been increasingly discussed as playing a crucial role in the education and development of major components of the host’s immune system, and therefore in a certain number of health conditions and diseases . The rolCancer patients are particularly vulnerable to bacterial infections and antibiotics (ABX) are often used in the clinical practice. ABX are known to induce profound changes to the gut microbiome and to disrupt the balance between the various bacterial groups, genera and species normally found in each healthy individual. Microbiome disruption, called dysbiosis, can last for several weeks or even months after ABX intake , 10, andBy including in the present meta-analysis a total of 107 articles reporting clinical data based on ABX exposure on 123 independent cohorts, for a total of 41,663 patients, we aimed to exhaustively cover the literature of the field and to provide novel analyses that were not performed in previously published meta-analyses. In particular, the impact of ABX use on treatment-related outcomes such as Objective Response Rate (ORR) and Progressive Disease (PD) rate has been poorly investigated to date, with few articles included in the meta-analyses having performed such analyses. Also, the potential differential effect of ABX use depending on the cancer type has not been investigated in as many cancer types as possible, and, for instance, the impact of ABX use in urothelial carcinoma (UC), in which ICIs are increasingly used, has never been conclusively examined. Hopefully, our findings will help improve the understanding of the links between ABX use and ICI efficacy, optimize individualized clinical care during cancer immunotherapy and benefit patient prognosis.This meta-analysis aims to answer the following questions: is the use of ABX before and/or during an anti-PD-L(1)-based treatment associated with a modification of the response to treatment and survival in cancer patients? Are there elements related to the cancer, the ABX therapy itself and/or the time window of ABX exposure relative to ICI initiation that could modulate this impact and help physicians issue best practice recommendations?22.1https://www.crd.york.ac.uk/prospero/ and the research work was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  and a comprehensive query Figure 12.3Studies were included in the present meta-analysis if they fulfilled the following criteria: 1) study subjects were patients diagnosed with any type of cancer and treated with anti-PD-(L)1 agents, either as monotherapy or in combination with other anticancer treatments, 2) ABX-exposed patients received ABX before and/or after the initiation of and/or during immunotherapy, regardless of ABX class, route of administration and duration of use, 3) ABX-unexposed patients (the control group) did not receive ABX within the defined timeframes, and 4) studies provided data, suitably formatted for inclusion, on the associations between ABX use and at least one outcome retained for this meta-analysis, namely Overall Survival (OS), Progression-Free Survival (PFS), ORR and PD.i.e. they reported data on overlapping patient populations, which was identified by looking at patient recruitment centers and study periods), the most recent study was selected for inclusion in the meta-analysis.If several studies were redundant ), immunotherapy characteristics , ABX treatment characteristics , indication, class, route of administration and duration of use) and outcomes of interest based on ABX exposure. Authors were contacted when crucial data, such as the number of ABX users, were missing in a study.Using a standardized data extraction spreadsheet, the following data were collected from each of the included study, when available: first author’s name, publication year, publication type , country, patient and cancer characteristics  and their 95% Confidence Intervals (CI) were included in the meta-analysis when reported as such in the studies and estimated from Kaplan-Meier curves with the Tierney et al. approach  when notRegardless of the outcome, results yielded by multivariate analyses were preferred over results yielded by univariate analyses, when available, for inclusion in the meta-analysis. When results were available on multiple ABX exposure time windows in a given study, pre-defined criteria of selection were applied to include the largest number of qualitative results and to make the most relevant analyses possible , a star-based system that rates non-randomized studies based on the three following domains: selection of the study groups, comparability of the study groups and ascertainment of the outcomes.2.62.6.1OS and PFS are respectively defined as time from immunotherapy initiation until death by any cause or loss to follow up (for OS) or until radiological evidence of progressive disease or loss to follow-up (for PFS). One of the aims of the meta-analysis was to evaluate the impact of ABX use on the survival and survival without cancer progression of cancer patients treated with ICIs by calculating pooled HRs for OS and PFS along with their 95% CI across all cohorts.ORR and PD are treatment-related outcomes, with ORR representing the number of patients experiencing a complete or partial response, and PD equated, for the purpose of the meta-analysis, with the number of patients experiencing cancer progression. One of the aims of the meta-analysis was to assess the association between ABX use and response to treatment by calculating pooled Odds Ratios (ORs) for ORR and PD along with their 95% CI across all cohorts.2.6.2In order to minimize between-study heterogeneity and to determine factors influencing the impact of ABX use on survival and treatment-related outcomes, several subgroup analyses were conducted, subject to an acceptable number of cohorts per group. As the number of studies reporting data on treatment-related outcomes was relatively small, the subgroup analyses were restricted to survival outcomes.2.6.2.1A cancer type formed a separate category if at least four cohorts of patients with that cancer type were available with data on both OS and PFS according to ABX exposure. An “Other” category was created to group cancers for which less than four cohorts of patients with that type of cancer reported data on survival outcomes, while an “Aggregated” category was defined to group cohorts having pooled patients suffering from various types of cancer.2.6.2.2i.e. the day of the first administration of immunotherapy. Of note, a patient included in the TW  may have taken ABX only in an unspecified short period included in this TW .Five ABX exposure TWs relative to ICI initiation were selected, based on the TWs defined in the included studies and with the assumption of a stronger impact of ABX when taken around ICI initiation: , , ,  and “undefined” , Day 0 being the day of initiation of the treatment with ICIs, 2.6.3Lung cancers are responsible for the largest number of cancer-related deaths worldwide2.7I2. For survival outcomes, a value of HR > 1 indicated that ABX use was negatively associated with the considered outcome, while a 95% CI > 1 indicated that the association was statistically significant. For treatment-related outcomes, a value of OR for ORR < 1 indicated that ABX use was negatively associated with treatment response, and the association was statistically significant if the 95% CI was inferior to 1. On the contrary, a value of OR for PD > 1 indicated that ABX was associated with an increased odd of cancer progression, while a 95% CI > 1 indicated that the association was statistically significant. For all analyses, a p-value ≤ 0.05 was considered to be statistically significant.All calculations of HRs and ORs were performed using the inverse variance-weighted average method according to a random-effect model, to best accommodate the high heterogeneity expected from the included studies and measured using the Higgins and Thompson statistic 2.8via a trim-and-fill approach. A sensitivity analysis was also conducted to assess the risk of one individual study biasing the results using the leave-one-out approach.One weakness of a meta-analysis is that it relies on the available published literature and can be affected by publication bias, which occurs when the results of a study have an impact on the decision to publish the study. For example, it is known that researchers are less likely to publish their study when their working hypothesis is not met . Publication bias was assessed for pooled HRs for OS and PFS and pooled ORs for ORR and PD through the generation of funnel plots that were analyzed for asymmetry using Begg and Egger tests. If a publication bias was detected, its impact on the meta-analysis results was assessed All analyses were performed using R version 3.6.1 and the meta package , 34.33.1The literature search conducted on PubMed initially retrieved 2,036 hits, of which 1,950 were excluded based on their title or abstract, leaving a total of 86 candidate studies for full-text reading. 20 studies were consequently discarded due to different reasons, including redundancy and/or overlapping cohorts, and the reporting of outcomes other than the ones retained for this meta-analysis. An additional 30 relevant studies were extracted from the screening of major oncology conference proceedings, and 11 were further identified by reviewing the references of relevant articles in the field. 67 articles published in peer-reviewed journals, 25 posters and 15 abstracts were ultimately included in the meta-analysis, representing a total of 107 articles , 35–137,As shown in 3.2Baseline characteristics of studies and patients included are displayed in Overall, a total of 41,663 patients diagnosed with cancer and treated with an anti-PD-(L)1-based treatment were included in the meta-analysis, among whom 11,785 (28%) were administered ABX in varying timeframes around ICI initiation.The United States of America (USA) and Europe were the continents providing most cohorts and patients , followed by Asia . Within Europe, France and Spain produced most cohorts and included most patients .The very large majority of patients included in the meta-analysis had a locally advanced or metastatic cancer. The number of patients enrolled in the studies ranged from 31 to 3,634, with the largest cohorts including NSCLC patients. In terms of number of patients (and of cohorts), NSCLC was by far the most represented cancer, with 40% of the 41,663 patients suffering from this cancer (and 41% of the cohorts including NSCLC patients), followed by UC , melanoma , renal cell carcinoma (RCC)  and hepatocellular carcinoma (HCC) . The remaining cohorts included patients suffering from cancer types less represented in this immuno-oncology literature, namely head and neck cancer, esophagogastric/gastric cancer, gynecologic cancers, cutaneous squamous cell carcinoma, Hodgkin lymphoma, colorectal cancer and sarcoma . Finally, 18 cohorts  grouped patients suffering from various cancer types, of which NSCLC was once again the most represented cancer type (37%), followed by melanoma (29%).via oral route. More detailed information on patient characteristics, anticancer treatment and antibiotic therapy is available for NSCLC patients in section 3.6.1.The studies included were largely heterogeneous in terms of reported immunotherapy and ABX treatment characteristics, but from the review of this literature, patients seemed to be predominantly treated with anti-PD-1 monotherapy, nivolumab and pembrolizumab being the most represented ICI agents. The line of treatment greatly differed between studies, but the largest cohorts included patients receiving immunotherapy as first-line treatment for locally advanced or metastatic cancers. All studies selected varying time windows of exposure to ABX, some of them being strictly defined and very narrow around ICI initiation , other 3.33.3.1112 and 80 cohorts reported data on OS and PFS based on ABX exposure, respectively, representing 40,236 patients and 12,564 ABX users (31%) for OS and 20,318 patients and 6,223 ABX users (31%) for PFS.The random-effect model yielded respective HRs for OS and PFS of 1.61 [95% CI 1.48-1.76] and 1.45 [95% CI 1.32-1.60] 4 acrossI2 of 82% for OS, I2 of 74% for PFS), due to the high variability observed between studies, notably in terms of type of cancer and ABX exposure time window.As expected, the heterogeneity factor was substantial in these global analyses  for most cancer types, which was expected given the large number of factors that can induce heterogeneity, such as the diversity of histological subtypes among each cancer type and differential cancer management, for example.As shown in the forest plots available in 3.3.3As shown in I2 > 50%) for most TWs.As shown in the forest plots available in 3.444 and 38 cohorts reported data on ORR and PD based on ABX exposure, respectively, representing 7,854 patients and 1,997 ABX users (25%) for ORR and 6,142 patients and 1,654 ABX users (27%) for PD.The random-effect model yielded ORs for ORR and PD of 0.59 [95% CI 0.47-0.76] and 1.86 [95% CI 1.41-2.46], respectively 8, suggeI2 of 57% for ORR, I2 of 74% for PD) in these analyses.As expected, the heterogeneity factor was substantial  suffering from NSCLC were included in the meta-analysis, of whom 5,022 (30%) were given ABX in the three months prior to ICI initiation and/or during immunotherapy.The reported data on NSCLC patient characteristics, anticancer treatment and antibiotic therapy were largely heterogeneous between studies.Pooling the 38 NSCLC cohorts reporting histologic data , non-squamous cell carcinoma and squamous cell carcinoma accounted for 62% and 17% of histological subtypes, respectively. According to the 32 cohorts reporting performance status scores , 87% of NSCLC patients had an ECOG PS equal to 0 or 1, with one-third of these patients having an ECOG PS of 0 and two-thirds having an ECOG PS of 1. Regarding expression of PD-L1 protein at tumor cell surface, as expressed by the Tumor Proportion Score (TPS), a TPS ≥ 50% was the most represented PD-L1 expression level among NSCLC patients, accounting for 45% of the 4,413 patients included in the 20 cohorts reporting such data, corresponding to an over-representation of this level of PD-L1 expression compared to the 30% rate usually observed , 139.Among the 38 cohorts documenting treatments in more detail , the vast majority of patients (90%) received an anti-PD-(L)1-based treatment as monotherapy. Nivolumab, pembrolizumab (both anti-PD-1 agents) and atezolizumab (anti-PD-L1) respectively accounted for 40%, 31% and 28% of the molecules received . 70% of patients were treated with anti-PD-(L)1-based treatments as first-line .β-lactams, fluoroquinolones and macrolides were the most represented classes used by NSCLC patients, accounting respectively for 52%, 27% and 14% of ABX prescriptions within the 23 cohorts documenting ABX use . This was not unexpected considering the relatively broad spectrum of antimicrobial activity of these ABX classes, which are often used for oncology patients. In the 19 cohorts reporting the indication for ABX use (917 prescriptions), more than half (51%) of the prescriptions were indicated to treat respiratory tract infections including suspected pneumonia. Finally, the oral route was the most represented route of administration and accounted for 66% of the 537 prescriptions documented in 12 cohorts, which was expected as most of these patients are treated in the community setting.3.6.2As previously mentioned, ABX use was significantly associated with impaired OS and PFS of NSCLC patients, as reported by the HRs respectively measured at 1.60 [95% CI 1.40-1.83] and 1.47 [95% CI 1.27-1.70]  for ORR and 1,803 NSCLC patients and 499 ABX users (28%) for PD. The random-effect models yielded ORs for ORR and PD of 0.65 [95% CI 0.50-0.86] and 2.09 [95% CI 1.61-2.70], respectively, confirming significantly impaired response to treatment among NSCLC patients having received ABX around ICI initiation 12.3.6.3Funnel plots for OS, PFS, ORR and PD are available in 4versus escape versus growth of the tumor). Demonstrating a deleterious impact of antibiotics on response-based endpoints could therefore be an interesting way to dispose of possible confounding factors (such as the occurrence of a severe infection requiring an antibiotic treatment), that may be associated with a poorer prognosis without being directly related to the impact of ABX use on the gut microbiome. For all these reasons, our analyses provide some novel insights that may be useful in clarifying the specific settings in which ABX should be prescribed in cancer patients treated with ICIs.With the increasing use of immune checkpoint inhibitors in cancer care, considerable efforts have been made to identify factors that may alter their effectiveness, and ABX use has recently emerged as one of them, as demonstrated by numerous retrospective and prospective studies , 35–137 etc.)  .This systematic review and meta-analysis work certainly cannot discuss causality between ABX use and impaired clinical outcomes of cancer patients treated with ICIs, nor can it elucidate the underlying mechanisms involved. It can only show an association between ABX use and reduced ICI efficacy, and growing evidence in the literature and in the clinic suggest an involvement of the intestinal microbiome and ABX-induced dysbiosis. A high gut microbiome diversity at baseline was for example significantly associated with favorable clinical outcomes in several studies on NSCLC and melanoma patients , 56, 142e.g. prior radiotherapy), patient care and other co-medications besides ABX, such as proton pomp inhibitors and steroids, may also play a role in modulating ICI efficacy, and were not necessarily captured in the included studies. A meta-analysis evaluating the impact of proton pump inhibitor use on the clinical outcomes of 15,957 cancer patients treated with ICIs effectively concluded that their usage was negatively associated with survival outcomes  on patient outcomes, thus making it impossible to refine results in this regard. Further research in the field shall investigate the differential impact of ABX classes or treatment schemes. Besides, some TWs may have been overlapping without the authors’ knowledge. For example, a patient exposed to ABX in the 30 days prior to ICI initiation could have received ABX in the 30 days following treatment start and only be included in the first category. In addition, the retrospective design made it impossible to characterize the microbiome of patients before and during ICI treatment. Second, statistical analyses demonstrated the existence of publication bias within the literature, which we attempted to mitigate by including unpublished studies such as conference proceedings abstracts and by performing analyses that confirmed that publication bias could not affect most of our results. Third, the studies have included patients whose cancer characteristics and immunotherapy treatment are no longer the most representative of the real-world setting. Indeed, studies mainly included patients treated with ICI as single agent, which no longer corresponds to standard of care, for most oncology indications, as ICIs are now mainly given in combination with chemotherapy or other treatment modalities. The impact of ABX use on patients treated with such combinations deserves to be further investigated, as only a few articles have investigated this matter , 52, 82 outcomes . A negatoutcomes .In summary, this study demonstrated that ABX use around ICI initiation was negatively associated to survival and treatment-related outcomes of cancer patients, particularly when ABX were taken shortly before or after ICI start, suggesting that ABX prescription should be cautiously considered in cancer patients receiving an anti-PD-(L)1-based treatment. Future larger, prospective observational, multicentric studies evaluating changes of the intestinal microbiome and patient outcomes during immunotherapy, and interventional, controlled, randomized trials involving microbiome modifiers such as FMT or microbiome protectors, are crucially needed to explore the hypothesis of an involvement of the microbiome, elucidate the mechanisms at stake and restore the effectiveness of immunotherapies to improve patient care. It is only through such studies, which will put an end to the current publication bias by allowing analyses on more homogeneous populations, that we will be able to definitively conclude whether or not antibiotics have a deleterious impact on the clinical outcomes of cancer patients, and take the appropriate measures to improve the treatment of these patients.The original contributions presented in the study are included in the article/AC, CL, JC, and P-AB designed the study, ran the systematic search, collected the data, and performed the analyses. AC, CL, JG, FV, GZ, JC, and P-AB discussed the results and critically reviewed the manuscript. All authors contributed to the article and approved the submitted version.


Breast cancer (BC) is the most commonly diagnosed cancer and the leading cause of cancer death among women. Knowledge of the clinical characteristics of BC in a population may be informative for disease prediction or diagnosis and for developing screening and diagnostic guidelines. This study aimed to evaluate the clinical characteristics of female patients with BC who were admitted to academic surgical wards in Tehran, Iran.In this cross-sectional study, demographic information and clinical characteristics of Iranian females with BC who had undergone breast surgery from 2017–2021 in four academic Breast Surgery Units were extracted from medical files and recorded via a pre-designed checklist.A total of 1476 patients with a mean age of 48.03 (± 11.46) years were enrolled. Among them, 10.4% were aged less than 35. In younger patients, Triple-negative and Her2-enriched subtypes of BC were significantly higher compared to older ones. Overall, 85.7% of tumors were invasive ductal carcinoma, 43.3% were grade 2, 41.4% were located in the UOQ, and 65.2% had presented with mass palpation. The mean pathologic tumor size was 28.94 mm, and the most common subtype was luminal B.Many characteristics of breast cancer in this study were similar to other countries and previous studies in Iran. However, a higher proportion of young BC compared with Western countries, and even with older studies in Iran, suggest a trend toward lower age for BC in recent years. These results indicate the need for preventive measures and screening in Iranian women at a younger age. According to the World Health Organization (WHO) in 2019, cancer is the first or second leading cause of death before the age of 70 in 112 of 183 countries and ranks third or fourth in a further 23 countries [In comparison to Europe and the United States, the incidence and prevalence of BC are lower in Asia. However, the mortality rate of BC in low-income countries is higher than in high-income ones –6. BasedThe nature, incidence, and prognosis of BC vary in accordance with the patient’s characteristics, such as the patient’s age, menopausal status, and family history; as well as the tumor characteristics . Recent Knowledge of the distribution and frequency of clinical characteristics of BC in a population may be informative for disease prediction or diagnosis, and assists in decision-making for treatment purposes, or developing screening and diagnostic guidelines . FurtherThis study aimed to evaluate the clinical characteristics of female patients with BC in Iran. As Tehran University of Medical Sciences is the leading academic and referral center in the country, we gathered data of all patients who had undergone breast cancer surgery during a recent 4-year period in all Breast Surgical Units of the University to report the surgical approach and evaluate their main clinical and histological features; and explore the proportion and characteristics of young BC.This multicenter cross-sectional study was approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.IKHC.REC.1400.006) and was conducted on women diagnosed with BC who had undergone breast surgery from 2017 to 2021. Informed consent had been obtained from all breast cancer patients before surgery in order to use the information for research projects. The project was run according to the ethical principles of the Declaration of Helsinki. All active Breast Surgery Units of the University, which include four academic hospitals  affiliated with Tehran University of Medical Sciences, Tehran, Iran, have participated in the present study.In this study, data of 1476 females with BC who had undergone breast surgery were extracted. The sources of this information were medical files, pathologic results as well as the electronic archive system available in some hospitals. A similar pre-designed checklist was used in all centers. The checklist contained three parts. The first part variables included demographic and reproductive characteristics, the second comprised breast cancer information, and the last part covered breast surgery data.Age, weight, height, smoking habit and alcohol consumption, age at menarche, age at first pregnancy, parity, menopausal status, age and cause of menopause, OCP use, history of abortion and family history of breast and ovarian cancer were extracted. Clinical characteristics of the disease consisted of presenting symptoms, tumor size, axillary lymph node status, core needle biopsy results, metastasis status and sites, findings of breast and axillary lymph node surgeries, tumor grade, and treatment types.Tumors had been examined histologically by board-certified pathologists dedicated to breast diseases in the four academic centers. The histologic type had been assigned according to the 5th edition of the WHO Classification of Tumors of the Breast, in 2019 ; tumor gIn this study, the tumor sites have been categorized as the upper outer quadrant (UOQ), the upper inner quadrant (UIQ), the lower outer quadrant (LOQ), the lower inner quadrant (LIQ), as well as multicentric tumors defined as tumors in different quadrants or more than 5 cm apart in one breast , 15. BC In cases with incomplete information, the patient’s records were obtained and completed through a telephone interview. Patients with incomplete medical records that could not be retrieved by phone calls were excluded from the study.p-value < 0.001). Therefore, a comparison of Ki-67% between the two groups was conducted using Mann–Whitney U-test. P values < 0.05 were considered statistically significant.Statistical analyses were conducted using SPSS software version 22 for Windows . Continuous data are presented as mean ± standard deviation (SD) and categorical data as frequency counts (percentages). Patients were categorized into two age groups: patients less than 35 years old, and those above or equal to 35 years old; with the purpose of comparing the tumor and clinical characteristics of BC in these two age populations. The Chi-square test was used to determine the differences between the qualitative variables of the two groups. The normality of Ki-67% was tested using Kolmogorov–Smirnov Test. The results showed the Ki-67% level was not normally distributed  years (range: 17 to 86 years). The baseline information of the patients is presented in Table n = 962, 65.2%) followed by nipple retraction . The mean pathologic tumor size was 28.94 (± 21.76), and the majority of patients (43.7%) were diagnosed when the pathologic size of the tumor was between 20–50 mm. The most frequent tumor grade was G2 (43.3%).Table Out of 948 tumors, in order of prevalence, 439 (46.3%) were Luminal B, 279 (29.4%) were Luminal A, 132 (14%) were triple-negative (TN) and 98 (10.3%) were Her2-enriched. Out of 1476 cases, 126 (8.7%) had at least one metastatic site. The most common sites of metastasis were bone , liver , lung , skin , and other sites .n = 760, 51.5%) had received chemotherapy, and 451 (30.5%) had undergone radiotherapy. The most frequent surgery was BCS  followed by mastectomy in 42.6% (n = 629) and the remaining had undergone mastectomy with reconstruction . Axillary lymph node dissection (ALND) had been performed for 610 (46.7%) and sentinel lymph node biopsy (SLNB) for 696 subjects (53.3%).More than half of the 1476 recorded patients . In triple-negative and Her2-enriched BC, the proportion of patients aged less than 35 was higher than those 35 years of age or above (Table Our results represented that 154 patients (10.4%) were aged less than 35, and there was a significant difference between the molecular subtype of BC considering patients’ age  in Iran, between 2017–2021 showed, the mean age of BC patients who undergone surgery is lower than 50 years old and about 10% of patients were aged less than 35. Palpation of the mass, between 20 and 50 mm, was the most common symptom in patients at the time of diagnosis. More than half of the patients had BCS surgery. The luminal subtype of BC was more prevalent in the total population. However, triple-negative and Her2-enriched BC were the most prevalent subtypes in younger patients. Since these hospitals are considered referral centers, it seems that the results of the current study have high generalizability.www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breast-cancer.html). Our study result supported a previous report which showed that BC incidence peaks among women in their forties in Iran, whereas in the United States and Europe, it peaks among women in their sixties [BC is characterized by several clinical and histological types. Large differences have been reported in the age of onset, stage at presentation, clinical manifestations, and prognosis of BC between various countries, mainly between BC patients from the Middle East or North Africa, and those from the Western populations , 17. Acc sixties . Compari sixties  revealedBased on the present study results, about one-fourth of patients reported a positive history of OCP usage. In addition, more than one-third of recruited patients had a positive familial history of BC or OC. In a nested case–control study derived from the Golestan Cohort., long-term use of OCP and a positive familial history were reported in 28.3% and 34.3% of BC patients, respectively ; these fIn consistence with our results, many studies reported that the left breast is at greater risk of developing cancer and the UOQ is the most common location of breast cancer –22. It mGlobally, IDC constitutes about 70–80 percent of all BCs . The resThe most common subtype of BC in the present study was Luminal B, followed by Luminal A, TNBC, and Her2-enriched. The frequency of molecular subtypes in our study followed the same order as those of Mighri et al. , Al TamiIn our study, 8.7% percent of patients were diagnosed with metastatic BC. Bone metastasis was reported as the most common site, followed by metastasis to the skin, liver, lung, and brain. A recent study was performed by Anwar et al. on 1,329 females with BC to investigate risk factors, patterns, and distribution of bone metastases and skeletal-related events in high-risk BC patients . Their fWorldwide, BCS is defined as the most common surgical procedure for early-stage BC . An instOne study showed that the risk of death from breast cancer has increased sharply in women younger than 35 years. Therefore, they recommended that age less than 35 years is a reasonable cut-off for defining young age-onset breast cancer . In the The current study has the advantage that it was conducted in several academic and active referral hospitals, and its results seem to be generalizable, although, this study is ongoing on a wider scale with a large sample size. However, this study had some limitations. Despite the young age of patients, data about genetic testing were scarce and therefore were not included in this study. Also, we did not have information about the ethnicity of the patients, but this could provide interesting findings.This study highlights the epidemiological and clinical characteristics of BC in Iranian women, with a special focus on factors that were not well defined in previous records in the Iranian population. In line with previous studies, invasive ductal carcinoma was the most common histologic type, grades 2 and 3 constituted the highest proportion of tumors. Luminal B was the most frequent molecular subtype, followed by Luminal A. Young women constituted a higher proportion of cases compared with older studies, suggesting a trend toward lower age for BC in recent years. These results indicate the need for more attention and preventive measures and screening in Iranian women before 50 years.


Uterine fibroids (UF) affect up to 70%-80% of women by 50 years of age and represent a substantial economic burden on patients and society. Despite the high costs associated with UF, recent studies on the costs of UF-related surgical treatments remain limited.To describe the health care resource utilization (HCRU) and all-cause costs among women diagnosed with UF who underwent UF-related surgery.Data from the IBM MarketScan Commercial Claims and Encounters database and Medicaid Multi-State database were independently, retrospectively analyzed from January 1, 2009, to December 31, 2015. Women aged 18-64 years with ≥ 1 UF claim from January 1, 2010, to December 31, 2014, a claim for a UF-related surgery  from January 1, 2010, to November 30, 2015, and continuous enrollment for ≥ 1 year presurgery and ≥ 30 days postsurgery qualified for study inclusion. A 1-year period before the date of the first UF-related surgical claim after the first UF diagnosis was used to report baseline demographic and clinical characteristics. Surgery characteristics were reported. All-cause HCRU and costs (adjusted to 2017 U.S. dollars) were described by the 14 days pre-, peri-, and 30 days postoperative periods, and independently by the inpatient or outpatient setting.Overall, 113,091 patients were included in this study: commercial database, n = 103,814; Medicaid database, n = 9,277. Median time from the initial UF diagnosis to first UF-related surgical procedure was 33 days for the commercial population and 47 days for the Medicaid population. Hysterectomy was the most common UF-related surgery received after UF diagnosis . In both populations, 97% of patients had ≥ 1 outpatient visit from 14 days presurgery to 30 days postsurgery , and the majority of all UF-related surgeries occurred in the outpatient setting . Mean total all-cause costs for patients with UF who underwent any UF-related surgery were $15,813  in the commercial population  and $11,493  in the Medicaid population . Mean total all-cause costs for UF-related surgeries for the commercial/Medicaid populations were $17,450 /$12,273  for hysterectomy, $14,216 /$11,764  for myomectomy, $17,163 /$12,543  for UAE, $8,757 /$7,622  for ablation, and $12,281 /$5,989  for myomectomy and ablation. Mean total all-cause costs for any UF-related surgery performed in the outpatient setting in the commercial and Medicaid populations were $14,396  and $6,720 , respectively, whereas costs in the inpatient setting were $18,345  and $21,805 , respectively.This retrospective analysis indicated that surgical treatment options for UF continue to represent a substantial financial burden. This underscores the need for alternative, cost-effective treatments for the management of UF. Data between January 1, 2009, and December 31, 2015, were retrospectively analyzed. This study is exempt from institutional review board approval as the data were deidentified.International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification [ICD-9-CM] codes: 218.X; ICD-10-CM codes: D25.X) between January 1, 2010, and December 31, 2014, and a claim for a UF-related surgery between January 1, 2010, and November 30, 2015  number of days from the initial UF diagnosis to the index UF-related surgical intervention; the number and percentage of patients with UF undergoing each specific type of UF-related surgery and subsequent UF-related surgical interventions within 30 days; median (IQR) number of days from the initial UF-related surgical procedure to a secondary UF-related procedure; and the occurrence of types of UF-related surgical procedures in inpatient and outpatient settings.All-cause  HCRU among patients undergoing UF-related surgery was described for procedures occurring in the outpatient  and inpatient settings, as well as by the 14 days pre-, peri-, and 30 days postoperative periods . For outAll-cause costs (adjusted to 2017 U.S. dollars), which reflect all payments made to providers of care from both the plan and the patient, were reported. Medical costs were reported by setting of care, and all-cause total costs, defined as the sum of medical and pharmacy costs, were also reported. Patients with evidence of capitated claims anytime during the study period were excluded from cost analyses.Descriptive statistics were used to summarize direct all-cause HCRU and costs among patients receiving each type of surgery for all surgical periods. All analyses were performed using SAS version 9.3 .Of the 113,091 patients who were included in this study, 103,814 were from the commercial database and 9,277 were from the Medicaid database . MedicalThe mean (SD) ages of patients in the commercial and Medicaid groups were 44.3 (6.4) years and 41.6 (7.5) years, respectively . The majWithin the baseline year, the most common comorbidity was inflammatory disease of the pelvic organs in both the commercial and Medicaid groups , and the most commonly reported UF-related symptoms were vaginal bleeding and menstrual bleeding disorders  time from the initial UF diagnosis to first UF-related surgical procedure was 33  and 47  days, respectively. Across the surgery types, median (IQR) time to surgery ranged from 9  days for combined myomectomy and ablation to 97  days for UAE in the commercial population, and from 15  days for combined myomectomy and ablation to 139  days for UAE in the Medicaid population.The majority of patients with UF who received a UF-related surgical procedure after initial diagnosis had a hysterectomy  and Medicaid  populations, respectively. Excluding those who were never hospitalized, the mean (SD) length of hospital stay for women with UF undergoing a UF-related surgical procedure was 3.1 (1.6) days in the commercial population and 2.7 (2.8) days in the Medicaid population.The overall mean total all-cause costs (from 14 days presurgery to 30 days postsurgery) for patients with UF who underwent any UF-related surgery were $15,813  in the commercial population  and $11,493  in the Medicaid population . Overall mean total all-cause costs for UF-related surgery procedures in the commercial/Medicaid population were $17,450 /$12,273  for hysterectomy, $14,216 /$11,764  for myomectomy, $17,163 /$12,543  for UAE, $8,757 /$7,622  for ablation, and $12,281 /$5,989  for myomectomy and ablation  and 5.Mean total all-cause costs for any UF-related surgery performed in the outpatient setting were $14,396  for the commercial population and $6,720  for the Medicaid population, and mean total all-cause costs for any UF-related surgery performed in the inpatient setting were $18,345  and $21,805  in the commercial and Medicaid population, respectively. Across all surgery types, the mean total all-cause costs for UF-related surgeries performed in the outpatient setting ranged from $8,500 (ablation) to $16,872 (hysterectomy) in the commercial population and $5,491 (ablation) to $8,346 (UAE) in the Medicaid population. Mean total all-cause costs for UF-related surgeries performed in the inpatient setting ranged from $18,157 (hysterectomy) to $26,720 (UAE) in the commercial population and $4,257 (myomectomy and ablation) to $101,940 (ablation) in the Medicaid population  and 5.In both the commercial and Medicaid populations, the majority of the mean total direct all-cause costs  was attributed to the perioperative period across all surgery types and settings  and 5. M16This retrospective observational study reported direct all-cause HCRU and costs among U.S. women diagnosed with UF who underwent a UF-related surgery to provide an updated overview of the current landscape of surgical treatment options for women with UF. In both the commercial and Medicaid populations, median time to occurrence of a UF-related surgical procedure following diagnosis was < 2 months, with combined myomectomy and ablation and hysterectomy procedures having the shortest median time to surgery. These observations may reflect women’s desire to quickly alleviate symptoms, especially those women whose symptoms have considerable effect on their quality of life and daily activities.17 more than two thirds of women diagnosed with UF who had a procedure underwent a hysterectomy in both the commercial (68%) and Medicaid (75%) populations. However, when compared with the retrospective database analysis by Carls et al. (2008) in which 86% of women with UF received a hysterectomy,13 these results indicate that while hysterectomy continues to be the most common, the percentage of women in the commercial population undergoing a hysterectomy has decreased over time, consistent with published literature.17 In addition, the commercial population results further indicate that the percentage of women undergoing myomectomy, UAE, and ablation has increased over time , indicating that alternative treatment options are increasing in use. The potential reasons for this are numerous and may include concerns regarding the invasiveness of the hysterectomy procedure, costs, a preference for uterine-preserving surgical options, and a desire to retain fertility.2Consistent with reports that UF is the most common indication for hysterectomy among reproductive-aged women,13 Furthermore, while hysterectomy occurred at similar rates in the outpatient and inpatient settings, the majority of patients undergoing ablation, myomectomy, UAE, or combined myomectomy and ablation underwent surgery in the outpatient setting. These results are similar to a large study of surgical treatment of UF in the inpatient and outpatient settings across 13 states, though similar myomectomy rates were reported for the inpatient and outpatient settings.11 This finding also supports previously reported observations that rates of hysterectomy occurring in the inpatient setting are decreasing over time.17 Considering that laparoscopic hysterectomy procedures have increased dramatically, and that outpatient hospitalizations generally cost less, it is reasonable to expect this trend to continue.17Among commercially insured patients, all-cause costs incurred during the perioperative period were found to be similar to perioperative costs reported in Carls et al., once costs were adjusted to 2017 U.S. dollars.18There are several limitations of this study. Study results were derived from administrative claims data, which may include errors in claims coding and lack relevant clinical data. However, the effect of this limitation would be equally distributed across all variables and thus is unlikely to affect 1 outcome more than another. Second, this study was descriptive in nature; therefore, no statistical testing was conducted and potential confounders that may affect health care resource use and costs related to UF treatment were not considered. Further limitations include allocation to a clinical setting based on a hierarchical claims classification, which may have resulted in the misclassification of some of the services to the incorrect setting, as well as possible inclusion of claims unrelated to surgery during the preoperative and postoperative periods. Again, any potential bias caused by this would be equally distributed across all variables and, therefore, would be unlikely to artificially inflate an individual outcome. Additionally, the presence of a diagnosis code on a medical claim does not guarantee positive presence of a disease or symptom, as the diagnosis code may have been incorrectly coded or included as a rule-out criterion. Finally, as with all claims-based analyses, study results may not be generalizable to the overall population, as patients who have commercial or Medicaid health insurance may be different from those without commercial or Medicaid health insurance. However, the large size of the MarketScan claims database, which contains health care data for > 43 million covered lives, supports the generalizability of these data to a majority of the population.13To test the robustness of the study results in light of the potential limitations described above, subgroup analyses were conducted among commercial patients with and without a UF diagnosis on their index surgery claim. Results indicated that 91% of patients had a primary diagnosis of UF on their index claim, limiting the possibility that procedures were falsely attributed to UF. In addition, the 14 days presurgery through 30 days postsurgery inclusion period chosen for all-cause costs and HCRU analyses is consistent with previous literature.In addition, there are several strengths of this study. The sample sizes used to examine women with UF who underwent UF-related surgery are substantial and should provide stable estimates for the variables studied. Much of the existing information about UF among the U.S. population dates back to the early part of the last decade. Therefore, this study serves to update the literature. New surgical techniques and pharmacologic treatment options have continued to increase in number over the past several decades, although the uptake of such treatment and their effect on costs has not been evaluated. Therefore, the information presented here may be timely and valuable in describing the current landscape.These results emphasize the significant all-cause cost burden among women undergoing surgical treatment of UF. While hysterectomy is a definitive solution for UF symptoms, it is not an option for women who wish to preserve their fertility or preserve their uterus. Alternative cost-effective treatments would be highly beneficial for patients with UF. The primary objective of UF treatment should be symptom reduction and improvement in quality of life. Thus, the cost of therapy to the health care system and to women with UF must be interpreted in the context of the cost of untreated disease and of ongoing or recurrent symptoms and treatment across intervention modalities.