N = 44,941, 89.6%). Tests were maximal or symptom-limited. Common clinical symptoms included dizziness , chest pain or distress , and musculoskeletal limitations . Out of 50,142 tests, three adverse events occurred, including one sustained ventricular tachycardia, one sinus arrest with junctional escape rhythm at a rate of 28 bpm, and one syncopal event with fecal and urinary incontinence. The rate of adverse events was 0.8 events per 10,000 tests  in men, 0.4 per 10,000 tests (0.7–2.2) in women, and 0.6 per 10,000 tests (0.21.8) total. This study represents the largest dataset analysis of exercise testing in the clinical Chinese population. Our results demonstrate that clinical exercise testing is safe, and the low rate of adverse events related to exercise testing might be due to the overall changes in clinical practice over time.This 18-year cross-sectional study was conducted to provide data on the safety of exercise testing in the clinical Chinese population. We retrospectively identified exercise tests completed at Xiangya Hospital of Central South University from January 1, 2002 to December 31, 2019. From 43,130 unique individuals , a total of consecutive 50,142 tests  were retrieved. Demographics, patients' medical history, exercise testing characteristics, and exercise testing-related adverse events were described. Safety data is expressed as the number of adverse events per 10,000 tests, with 95% confidence interval. The average patients' age was 51 ± 13 years. The majority of patients were diagnosed with at least one disease ( Exercise testing, including standard exercise testing (SET) and cardiopulmonary exercise testing (CPX), is commonly used to aid in the diagnosis and prognosis of coronary artery disease (CAD), the assessment of the integrated physiologic function of the cardiovascular, pulmonary, and musculoskeletal systems, and the evaluation of perioperative risk –3.via large-scale surveys that included results from multiple types of patients from varying facilities with diverse testing protocols  from 43,130 unique patients were included. The study and application for waiver of written informed consent were reviewed and approved by the Ethics Committee of Xiangya Hospital of Central South University . Written informed consent for participation was not provided by either the participants or the participants' legal guardians/next of kin; written informed consent was waived because of the retrospective nature of the study and in accordance with national and institutional requirements. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in Patients' demographics , medical and medication history, adverse events related to exercise testing, and exercise test data were retrieved from an electronic medical record system. All patients were codified and anonymized to protect the confidentiality of individual patients.Exercise Standards for Testing and Training (Both SET and CPX procedures followed the exercise testing guidelines of the American Heart Association (AHA) scientific statement: Training , 24. Expvia cycle ergometry. The workload for the CPXs was gradually increased each minute by a workload calculated as the value of the predicted maximal work rate divided by 8–12 according to the individual's health condition and activity habit so that the duration of CPX was within 8–12 min . The patients were asked about symptoms and to score their rating of perceived exertion  accordingly at the end of each stage. The patients were encouraged to continue exercising until they presented at least one of the following termination criteria: (1) achievement of ≥85% predicted maximal heart rate , (2) plateau in heart rate with increasing workload, (3) plateau in oxygen consumption with increasing workload, (4) respiratory exchange ratio (RER) of ≥1.10, (5) RPE ≥17 , (6) angina increasing to three on a scale of four, (7) severe fatigue or dyspnea, (8) a decrease in systolic blood pressure with increasing work rate, (9) severe supraventricular or ventricular arrhythmias, (10) signs of poor peripheral perfusion, or (11) the patient requested to stop  were reported and further classified as low (<5.0 METs), moderate (5–6.9 METs), high (7–10 METs), and very good (>10 METs) as previously described , 27.Adverse events related to exercise testing were defined as any of the following unexpected events that occurred during or within 24 h after a SET or CPX: (1) death, (2) external defibrillation or implantable cardioverter–defibrillator discharge, (3) sustained supraventricular and ventricular tachycardia (wide complex tachycardia lasting longer than 30 s), (4) myocardial infarction, (5) unstable angina, (6) administration of advanced cardiac life support medications, (7) worsening heart failure, (8) syncope, (9) stroke, (10) transient ischemic attack, (11) referral for direct hospital admission, and (12) direct referral to an emergency department.via person-to-person communication with all five faculties who work in the exercise testing laboratory of the Division of Cardiac Rehabilitation, Xiangya Hospital Central South University. Two of them  are the laboratory initiators (May 2001) and are still working in the laboratory. The rest of them  have been working in the laboratory for more than 10 years.All adverse events were identified by reviewing electronic medical records and documented adverse event reports that were routinely created when an adverse event occurred and were stored in the Division of Cardiac Rehabilitation, Xiangya Hospital Central South University. An adverse event report includes a printed completed medical record, physical examination reports, exercise testing report, details of the adverse event, and outcome. To avoid missing data, we re-verified the number of adverse events The Power Analysis & Sample Size software, version 15.0  was used to calculate power based on our sample. Group sample sizes of sex , exercise type , and medical history  achieve 99.2, 99.2, and 47.5% power, respectively, to detect a difference between the group adverse event rate of 0.001. The adverse event rate in the reference group is assumed to be 0.0001 according to previous studies –10. The SD) or number (percent) for continuous and categorical variables accordingly. Analyses were performed using JMP Pro Version 14 .The primary outcome of the present study is the risk of adverse events related to exercise testing in the clinical Chinese population. Safety data was expressed as the number of adverse events per 10,000 tests with a 95% confidence interval. The differences between men and women, SET and CPX, and individuals without a known disease and patients with at least one diagnosed disease in the risk of adverse events related to exercise testing were assessed by Fisher's exact test. The significance level was α = 0.05, two-sided test. Demographics and clinical characteristics of patients were displayed as mean ± standard deviation  were adults (age ≥18 years old); among them, 9,727 (19.4%) were older adults (age ≥ 60 years old). The majority of patients presented at least one comorbidity . Among them, 36,659 (73.1%) patients had CVD risk factors , 4,972 (9.9%) patients presented established CVD , and 2,747 (5.5%) patients presented malignancy . The demographic and clinical characteristics of the patients are described in A total of 50,142 exercise tests  were performed from January 1, 2002 to December 31, 2019. Of these, 20,696 (41.3%) were CPX, with the remainder being SET. The average patients' age was 51 ± 13 (mean ± standard deviation) years, and the median (interquartile range) of age was 51 (42–59) years. The vast majority of patients  are shown in The reasons for the termination of exercise testing are shown in P = 0.62), between SET  and CPX  (P = 0.57), and between individuals without a diagnosed disease  and patients with at least one diagnosed disease  (P = 0.28). The 95% confidence intervals for the rate of adverse events were 0.2–3.0 per 10,000 tests in men, 0.7–2.2 per 10,000 tests in women, and 0.2–1.8 per 10,000 tests in total. All three individuals had no known cardiovascular disease but performed pre-tests, such as an ECG and echocardiography, before conducting exercise testing. One patient who was referred for an indication of detecting CAD demonstrated sustained ventricular tachycardia with chest pain during exercise testing, one who was referred for an indication of evaluating perioperative risk experienced sinus arrest with junctional escape rhythm at a rate of 28 bpm in the 1st min of active recovery, and one who was referred for an indication of evaluating perioperative risk experienced syncope with fecal and urinary incontinence at the 10-min mark of sitting recovery. A narrative description of the three adverse events is provided in the Out of the 50,142 tests, three adverse events occurred, two men and one woman (one in SET and two in CPX). The rate of an adverse event in exercise testing was 0.6 per 10,000 tests in total, and no differences were found between men  and women   had at least one known disease at the time of testing, and the adverse event rate was 0.6 per 10,000 tests. This rate is similar to those in the generally healthy individuals   . However4 tests)  reportedThe largest surveys on the safety of exercise testing have come from North America, Germany, and Japan, respectively. Rochmis et al. reported an adverse event rate of 4.0 per 10,000 tests from 170,000 exercise tests that were performed in the combined healthy and patient populations in 73 medical centers of the US . Wendt eIn previous studies, the most common adverse event was sustained ventricular tachycardia, followed by acute myocardial infarction, across the generally healthy population , patientConcerning test safety, a key role may be played by the rate at which exercise intensity increases during the test itself. It has been suggested that the modified Bruce, modified Naughton, and Balke protocols, which use a slower rate of increase in workload, may be safer than the traditional Bruce and Naughton protocols. Currently, the available evidence supports the safety of all protocols; however, insufficient data are available to establish a hierarchy of protocol safety.Two out of three adverse events in the present study occurred during recovery, with one of these events occurring at 10 min of recovery. Our own experience is consistent with previous studies in that most adverse events occur during recovery rather than during the exercise period of the test. This data suggests that, regardless of whether a patient presents symptoms of or is with or without known CVD, the duration of active cool-down with ECG monitoring should continue for at least 10 min post-exercise or longer if the patient is symptomatic or if the blood pressure, heart rate, and/or ST segments have not returned to near-baseline values.In our clinical practice, we routinely follow the AHA guidelines , 24 regaExercise testing across a wide range of patient populations conducted at medical facilities and clinics appears to have become safer over time. A survey of 73 US testing centers in 1971 and a survey of 1,375 US testing centers in 1980 by Rochmis et al.  and StuaThis study has several limitations. The present study was conducted using single-center data, which may limit the generalizability of the findings, although the large study population with standardized protocols of exercise testing would be a strength of this study. Due to the limit of the retrospective design and only three adverse events that occurred, we are unable to explore the effects of physical activity, exercise capacity, category or severity of diseases, and potential pre-test screening methods on the risk of adverse events and to investigate the temporal changes in adverse event rates. To address these limitations, further prospective multiple-center observational studies are warranted.This study demonstrates the safety of exercise stress testing, including SET and CPX, in the Chinese patient population over the past 18 years. This is the largest sample size study to date that examines the safety of exercise stress testing and includes a wide spectrum of disease conditions. The low rate of adverse events related to exercise testing might be due to overall changes in clinical practice over time, such as improved patient screening, more skilled personnel, and rapid progress in the field of non-invasive imaging studies.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Ethics Committee of Xiangya Hospital of Central South University. Written informed consent for participation was not provided by the participants' legal guardians/next of kin because: Written informed consent was waived due to the retrospective nature of the study, and in accordance with national and institutional requirements.YD contributed to conceptualization, methodology, writing , and funding acquisition. TO contributed to conceptualization, writing (review and editing), and visualization. JR-G contributed to writing , visualization, and formal analysis. KX contributed to resources, validation, and supervision. WZ contributed to investigation, resources, and project administration. YC contributed to resources, data curation, and project administration. YL contributed to resources and project administration. YS contributed to investigation, resources, and project administration. NZ contributed to resources, data curation, and project administration. XG contributed to project administration and data curation. SL contributed to conceptualization, methodology, resources, supervision, and funding acquisition. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Systemic lupus erythematosus (SLE). Although their use has allowed controlling the disease and reducing acute mortality in severe conditions, the implementation of a scheme based on high doses for long periods has inevitably been accompanied by an increase in adverse effects and infections, including long-term damage. The objective of this review is to answer some important questions that may arise from its use in daily clinical practice, and to propose a paradigm based on the use of methylprednisolone pulses followed by medium-low doses and a rapid decrease of prednisone.Since the discovery of glucocorticoids (GCs), their important anti-inflammatory effect, rapid mechanism of action, low cost, and accessibility have made them one of the mainstays of treatment for  Systemic lupus erythematosus (SLE) is a complex disease characterized by autoimmunity, inflammation, and a variable degree of organ damage, which depends on the number and severity of flares but also on the treatments received. The management of SLE is often challenging. Most guidelines refer to “standard of care” as a combination of hydroxychloroquine, glucocorticoids (GCs), and, sometimes, an immunosuppressive agent. Such therapy often achieves disease remission, but too many times at the cost of a large degree of damage accrual.Irreversible organ damage is not only very frequent in SLE, but also particularly relevant considering that most patients are young or middle-aged women. According to a growing amount of scientific evidence, irreversible damage, as well as other serious side effects, such as infections, are strongly associated with the use of GCs ,2,3. IndThe purpose of this review is to answer ten daily clinical practice questions by updating the current evidence about the optimal doses of GCs in several scenarios, based on pharmacological and clinical evidence, as well as to offer our point of view regarding the “standard of care” of GC use.The first mechanism of action of GCs is to interfere with the genomic transcription of inflammatory molecules. This process starts by means of GCs binding the cytosolic-GC receptor (cGR). The GC-cGR complex is translocated into the nucleus where it modulates gene expression. This is called the genomic pathway ,6. The fThe use of low doses of prednisone (≤7.5 mg/day) is associated with a progressive saturation up to 50% of the cGR. At medium doses (>7.5 mg/day to 30 mg/day of prednisone), the receptor becomes progressively saturated from 50 to close to 100%, keeping a less lineal relation with the daily dose. It is estimated that the almost complete saturation of cGR occurs at approximately 30–40 mg/day of prednisone. At higher doses, up to 100 mg/day, the predominant effect is transactivation, and therefore the occurrence of unwanted effects with no major increase in anti-inflammatory actions ,12. ThisA second mechanism of action of GCs, the non-genomic pathway, acts by modulating inflammatory and immune cells by three molecular mechanisms independent from nuclear interactions. First, the GC-cGR complex directly blocks the activation of phospholipase A2 and thus the production of arachidonic acid by a transcription-independent mechanism. Second, the activation of the membrane-bound GR (mGR) leads to the reduction of lymphocyte activity via the p38 MAP kinase. Third, nonspecific interactions with the cellular membranes of immune cells result in the inhibition of ATP production and thus decrease cell activity . In addiThe activation of the non-genomic pathway starts at doses >100 mg/day of prednisone or equivalent. This pathway is especially sensitive to methylprednisolone (MP) and dexamethasone, which have non-genomic effects up to five times more potent than genomic ones .Non-genomic effects are responsible for the efficacy of pulse therapy with GCs at doses over 125 mg of MP . Work byThe “classical” standard 1 mg/kg/day prednisone dose is not supported by either basic pharmacology or clinical evidence  19,20].,20.19,20n = 42) and reduced dose prednisone groups , both associated with mycophenolic acid, during the induction phase of class III-IV lupus nephritis (LN). The complete remission rates at week 24 were similar for both groups, with fewer infections in the reduced prednisone dose group [Instead, the combination of MP pulses followed by doses of prednisone up to 30 mg/day, depending on severity, is more effective, more rapid, and safer than the use of the “classical” 1 mg/kg/day . Severalse group .Lupus-Cruces  and the Lupus-Bordeaux cohorts , the number of pulses of MP per patient (9.3 vs. 2.3), but not the cumulative dose, and the proportion of patients on hydroxychloroquine (100% vs. 63%) were higher in the CC. The maximum doses of prednisone (21 vs. 42 mg/day), the number of weeks until 5 mg/day (12 vs. 22), and the mean doses at six months (8.3 vs. 21 mg/day) were all lower in the CC. Complete renal remission rates were significantly higher in the CC at six (69% vs. 30) and 12 months (86% vs. 43%) [In an observational study of patients with class III-IV-V LN from the vs. 43%) . Of notevs. 43%) .The AURA–LV was a 48-week randomized clinical trial comparing the efficacy in the treatment of LN of two doses of voclosporin or placebo added to mycophenolate mofetil. All patients received a maximum initial dose of 25 mg/day of prednisone with tapering to 5 mg in 8 weeks and to 2.5 mg in 12 weeks. Remission rates at 48 weeks were 49.45% and 39.8% in both voclosporin groups . Even paThe “Rituxilup” schedule, which consisted of rituximab and MP, followed by maintenance treatment with mycophenolate mofetil and no oral steroids, resulted in 72% of patients with LN class III, IV, or V eventually achieving complete remission within a median period of 36 weeks .In patients presenting with an SLEDAI score ≥6 (those with severe LN excluded), initial therapy with doses of prednisone ≤30 mg/day resulted in a similar decrease in SLEDAI scores at one year and reduced damage at five years compared with initial doses >30 mg/day. It must be noted that, in order to reduce prednisone doses, hydroxychloroquine was used in 100% vs. 33% of patients and MP pulses in 34% vs. 10%, respectively [Thus, current evidence, based on large observational cohorts and a few clinical trials, supports the idea that low-medium initial doses of prednisone  are at least as effective as high-dose schemes and with a better safety profile ,33. MP pIn a study from 1987 including 21 patients with active SLE with severe manifestations refractory to other treatments, patients were either treated with intravenous MP 100 mg/day or 1000 mg/day for three days. The study did not find significant differences between the two groups . In addiLupus-Cruces cohort, the use of intravenous MP pulses, in all cases between 125 and 500 mg/day for three consecutive days, were not associated with long-term damage accrual [In the  accrual . In the  accrual .In 2018, Danza et al. compared the efficacy and rates of infections among patients with several autoimmune conditions, including SLE, treated with MP pulses, for a total dose over three days ≤1500 mg, <1500 to ≤3000 mg and >3000 mg . No diffIt is well assumed that MP pulses, due to their higher potency and faster mechanism of action compared to oral prednisone, are indicated in those patients with severe manifestations of SLE in whom a rapid effect is necessary ,14. HoweThere are several factors that contribute to organ damage accrual in patients with SLE. Among them, the role of GCs has proven fundamental. In 2003, Gladman et al. categorized damage as definite, probable and not related to GCs . In the A possible reason explaining this is the different toxicity associated with the activation of the genomic  and the non-genomic ways (free of genomic transactivation-related toxicity). Therefore, the use of MP pulses (activating non-genomic mechanisms), rather than prednisone doses >30 mg/day (fully activating the genomic way), for inducing rapid remission, followed by maintenance doses of prednisone ≤5 mg/day (activating less than 25% of the genomic way) may be a good approach to minimize GC-related side effects. In addition, hydroxychloroquine helps spare prednisone and, by itself, also prevents damage accrual . Ruiz-ArWhilst the eventual discontinuation of GC is the ultimate goal, a recent monocentric, 12-month, superiority, open label, randomized controlled trial compared the efficacy to prevent flares of maintenance versus withdrawal of 5 mg/day prednisone in patients with clinically quiescent SLE. The study found that maintenance therapy with 5 mg/day of prednisone prevents relapses, with no worsening of damage and no GC toxicity observed during the follow-up period . TherefoInfections represent one of the most important causes of morbidity and mortality in patients with SLE . The facSystemic Lupus Erythematosus (RELES), 6.4% of patients had a documented episode of major infection during the first year of follow-up and 5.67% during the second. Mean prednisone doses >30 mg/day during the first month and >7.5 mg/day during the first year independently predicted major infections within the first and the second year of follow-up, respectively [According to the data obtained from the Spanish Registry of ectively . Regardiectively .A number of prophylactic measures, such as the administration of vaccines, can be recommended in SLE, and the use of hydroxychloroquine is also protective against infections . HoweverSince the therapeutic possibilities are lower in pregnant women, GCs are one of main therapeutic resources during gestation in case of lupus flares . Indeed,The choice of GC will depend on whether our goal is to treat the mother or the fetus. According to the most recent EULAR and BSR guidelines, in the first case, the use of non-fluorinated GCs such as prednisone or MP will be of choice, while in the second case, the treatment will be with fluorinated GCs, such as betamethasone or dexamethasone ,47. ThisThe adverse effects observed are similar to those occurring outside pregnancy, however, hypertension, preeclampsia, insulin resistance, infections and premature rupture of membranes represent additional serious problems during gestation. For this reason, prednisone is recommended at doses not exceeding 20 mg/day for the treatment of severe manifestations of the disease, and 7.5 mg/day for minor manifestations, with rapid tapering in both cases to maintenance doses ≤5 mg/day. If necessary, in moderate-severe flares, intravenous pulses of MP 125–500 mg can be safely used .During the lactation, the amount of prednisone found in breast milk is very low, although it is advisable to delay breastfeeding until four hours after taking doses greater than 50 mg/day  .In women undergoing corticotherapy during pregnancy or lactation, adequate supplementation with calcium 1000 mg/day and vitamin D 800 IU/day is recommended for the prevention of GC-induced osteoporosis .The current recommendations are, once a SLE flare is diagnosed, to achieve remission or low disease activity as soon as possible, and then prevent new flares ,51,52. AWe advocate for a new paradigm in the use of GCs in SLE. The old, vague expression “the shortest time and at the lowest dose possible” is not enough, since many doctors feel that a rapid decrease in the dose of prednisone can precipitate a flare or a situation of adrenal insufficiency . NowadayGlucocorticoids may act by genomic and non-genomic pathways. The second way is faster and non-related to chronic damage.The classic glucocorticoid dose of 1 mg/kg/day is not evidence-supported and has a well-known range of serious adverse effectsRecruiting the non-genomic pathway by methylprednisolone pulses followed by a reduced dose scheme of prednisone may avoid adverse effect and chronic damageImmunosuppressive agents should be early introduced in the treatment of moderate-severe SLE to spare glucocorticoidsPrednisone maintenance doses ≤5 mg/day should be ideally achieved in no more than 12 weeks.Hydroxychloroquine is mandatory in SLE treatment, except in the exceptional cases with contraindications.


The deubiquitinating enzyme (DUB) OTUB1 can regulate the process of ubiquitination, but the influence of OTUB1 on immunity, apoptosis, autophagy, and the prognosis of digestive cancers requires further exploration.OTUB1 expression was analyzed with the Oncomine and TIMER database. Kaplan-Meier plotter was used to calculate the association between OTUB1 and clinical prognosis. The regulation of OTUB1 on cancer immunocyte infiltration was determined by the TIMER database. The interaction between OTUB1 and immune genes, gene expression profiling (GEP), key genes of apoptosis and autophagy were analyzed via GEPIA. Protein-protein interaction (PPI), gene expression profiling (GEP), and functional pathway enrichment were also performed with the STRING and Pathway Common databases, respectively.P = 0.002), with modifications by sex, stage, grade, and mutant burden. OTUB1 can promote the recruitment of B cells, CD8 + T cells, macrophages in ESCA, B cells, and neutrophils in LIHC. We determined a significant interaction between OTUB1 and USP8, RNF128, LRIG1, UBB, UBC, STAM2, RNF41, EGFR, RPS27A, and HGS by PPI. This functional pathway indicates the regulatory role of OTUB1on immune, apoptosis, and autophagy through its interaction with TP53 and ATG.High OTUB1 expression was found in CHOL, LIHC, READ, ESCA, and COAD, which was significantly associated with the poorer OS of LIHC (HR = 2.07, 95% CI = 1.30–3.30, OTUB1 performed as a molecular indicator of poor prognosis in digestive cancers, regulated the infiltration of tumor immunocytes, and exerted a significant influence on apoptosis and autophagy. OTUB1 is a potential antitumor target for digestive tumors. Digestive cancers account for the largest number of cancer-related deaths worldwide with increasing incidence and mortality . In ChinUbiquitination is crucial in the regulation of tumor development, innate and adaptive immune responses . The bioAt present, research on digestive cancers has largely focused on the role of OTUB1 in regulating the ubiquitination process, with few studies dedicated to clarifying the function of OTUB1 in autophagy, apoptosis, and the immune microenvironment. In this study, we systematically analyzed the expression, prognostic value, and function of OTUB1 with bioinformatics databases, to enrich understanding of OTUB1.1 4  is an on4 . We perf5 is an integrated resource of public biological pathways with various biochemical reactions. The database contains about 500 detailed human biochemical processes and millions of interactions. To enhance the usability of this large resource for end-users, researchers develop and maintain interactive web applications and training materials to enable pathway exploration and advanced analysis  database was designed to evaluate the protein-protein interaction (PPI) information, and visualize the functional interactions between the above proteins . The Patanalysis . We perfP or Cox P-values from a log-rank test. The correlation of gene expression was evaluated with Spearman’s correlation analysis. P-values < 0.05 were considered statistically significant.Kaplan-Meier plots were used to generate survival curves and displayed the results with HR and The expression levels of OTUB1 mRNA in digestive tumors and normal tissues were compared with the Oncomine database. No significant expression differences were observed in the above digestive tract tumors , except P = 0.002) in LIHC cohorts including 370 samples in the pan-cancer dataset (P < 0.001) and male  patients, and patients with stage 1 , stage 3 , grade 2 , grade 3 , and high mutation burden  and female  patients, and patient with grade 2 , the high expression of OTUB1 means a poor RFS  of digestive cancer patients was investigated with the Kaplan-Meier plotter database . High OT dataset . The higpoor RFS .The results show that the expression of OTUB1 in READ has significant correlations with tumor purity. The OTUB1 expression in READ also correlates with the infiltration levels of CD8 + T, CD4 + T, B cell, macrophage, neutrophil, and dendritic cells. OTUB1 expression in ESCA has significant correlations with the infiltrating levels of B cells, CD8 + T cells, and macrophages, and OTUB1 expression in LIHC has significant correlations with the infiltrating levels of B cells and neutrophils. The correlations between OTUB1 expression and tumor-infiltrating lymphocytes in PAAD, READ, and STAD are shown in The relationship between OTUB1 and immune infiltrating cells was investigated through analysis of the correlations between OTUB1 and the gene marker sets of immune cells in the tumor and normal tissues with GEPIA databases. This analysis was focussed on LIHC and ESCA, which are the major cancers of digestive cancers. The immune cells of interest included in our analysis were NK cells, DC cells, TAM, monocytes, neutrophils, B cells, M1, M2 macrophages, and different functional T cells . We founProtein-protein interaction (PPI) enrichment was constructed with the STRING database. The 10 most significant correlated genes of OTUB1 were USP8, RNF128, LRIG1, UBB, UBC, STAM2, RNF41, EGFR, RPS27A, and HGS . OTUB1 cWe performed analyses based on the gene-level to clarify the function of OTUB1 on the pathway-level. We selected OTUB1 and apoptotic genes BCL-2, BAX, autophagy genes TP53, DRAM, BECN, ATG5, and immune gene CD8A to clarify the effect of OTUB1 on the regulation of the above cytology functions . The resOTUB1 is a de-ubiquitinating enzyme (DUB) that belongs to the OUT-protein superfamily. It can remove the ubiquitin from the proteins and control protein transformation through the regulation of protein degradation  and is aImmunotherapy plays a prominent role in tumor treatment, and digestive tumors may benefit from treatments related to immunotherapy . The typOTUB1 overexpression can elevate the expression level of P53 transcriptional targets, and subsequently activate the apoptotic regulatory pathway, depending on P53. The ubiquitination of P53 was inhibited by OTUB1 non-canonically to promote its stabilization. In detail, OTUB1 could directly bind P53 and deubiquitinates it, which may further improve the stability of P53 mediated by OTUB1, and thus influencing the response to DNA damage and the damaged-regulated autophagy induced by P53. The abnormal expression of OTUB1 attenuated the above process, and its effect was that it was able to be rescued by restoring the normal construct of OTUB1 .Autophagy is the process that can degrade and recycle unnecessary or damaged cellular components . It has OTUB1 might play an important role in cell autophagy and apoptosis through ATG5, which is necessary for the formation of autophagic vesicles, and the abnormal expression of ATG5 will impact the initiation of autophagy. ATG5 negatively regulated the innate antiviral immune response and MHC-II antigen presentation, and participated in the maturation and apoptosis of lymphocytes . Thus, tDue to the functional complexity of OTUB1 in autophagy and immune response, researchers need to be more careful when evaluating the prognostic value of OTUB1 in different cancers. More molecular and animal studies are needed to verify the prospects for the clinical application of OTUB1 on tumor progress. Above all, our study analyzed the efficacy of OTUB1 in immunization regulation and the prognosis of gastrointestinal tumors, but further mechanism research and clinical validation are still needed. This research provides an important bioinformatics reference that will benefit future research into mechanisms and potential clinical applications. OTUB1 is a potent novel immunotherapy and antitumor target for digestive cancers.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.WQ designed this study and wrote the manuscript. WQ and WZ extracted the information from the databases. WZ analyzed the data. Both authors revised the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Celiac disease (CD) is an autoimmune enteropathy associated with alterations of metabolism. Metabolomics studies, although limited, showed changes in choline, choline-derived lipids, and methionine concentrations, which could be ascribed to alterations in one-carbon metabolism. To date, no targeted metabolomics analysis investigating differences in the plasma choline/methionine metabolome of CD subjects are reported. This work is a targeted metabolomic study that analyzes 37 metabolites of the one-carbon metabolism in 17 children with CD, treated with a gluten-free diet and 17 healthy control siblings, in order to establish the potential defects in this metabolic network. Our results demonstrate the persistence of defects in the transsulfuration pathway of CD subjects, despite dietary treatment, while choline metabolism, methionine cycle, and folate cycle seem to be reversed and preserved to healthy levels. These findings describe for the first time, a metabolic defect in one-carbon metabolism which could have profound implications in the physiopathology and treatment of CD. Celiac disease (CD) is an autoimmune enteropathy, with a chronic and systemic trait, triggered by dietary gluten and related-prolamins in individuals that possess a genetic susceptibility ,2. ThereMetabolic changes seem to also be present in CD. Thus, metabolomics studies, despite being very limited and restricted to the use of nuclear magnetic resonance (NMR)-based methods, suggest minor but significant alterations in energy metabolism, lipid metabolism, and microbiome-derived metabolites ,15,16,17Choline and methionine, as well as other micronutrients such as folate, B vitamins, and betaine, participate in a complex metabolic network known as one-carbon metabolism ,18,19. FAs a consequence of these observations, it is plausible to postulate that CD patients have potential alterations in one-carbon metabolism. To date, no targeted metabolomics analysis investigating the differences in the plasma choline/methionine metabolome of CD subjects are reported. For this reason, we designed a study to detect and quantify a panel of metabolites, including 37different molecular species in 34 subjects, 17 CD patients, and 17 healthy control siblings. The CD patients are children treated with a GFD. This election is based on the assumption that GFD induces a reversion of CD symptoms and histological changes, as well as metabolic changes, and potential remaining or persistent metabolic alterations should be, if present, specific to the CD condition. Blood plasma was elected as source of information because it is easy to obtain, but also because it is the major carrier of metabolites in the body , and theThe metabolites selected and analyzed in the present study were—(a) methionine and its related metabolites, including the intermediates of the transmethylation pathway SAM, SAH, and homocysteine; betaine and spermidine as metabolites involved in the regeneration of methionine plasma levels; the intermediates of the transsulfuration pathway cysteine and cystathionine; taurine and glutathione as downstream metabolites of the transsulfuration pathway; and vitamin B6 metabolites pyridoxal, pyridoxal-5′-phosphate and pyridoxamine, as cofactors of the transsulfuration enzymes; (b) additional amino acids including 7 non-polar amino acids , 4 polar uncharged amino acids , 1 polar negatively charged amino acid (glutamate), and 2 polar positively charged amino acids (arginine and histidine); (c) TCA cycle metabolites, including pyruvate, citrate, isocitrate, α-ketoglutarate, succinate, fumarate, and malate; and (d) methionine-derived lipid intermediates such as choline and TMAO. The plasma metabolites profile was determined using an LC–MS/MS platform to systematically define the specific phenotypic patterns associated with the genotypes of CD.n = 17) and healthy control siblings (n = 17) between 4 and 17 years of age. Children with CD were divided according to time, on a GFD. The recruitment was carried out from January to December of 2018, attending the Gastroenterology, Hepatology, and Child Nutrition Service from the “Virgen de las Nieves” University Hospital in Granada, Spain. Infants with CD were diagnosed according to the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) criteria [This work was a cross-sectional study in children with CD  were assessed in the siblings and the celiac subjects. Height was measured to the nearest 5 mm, using a stadiometer . Body weight was measured using the same mechanical balance .Blood samples were obtained by venipuncture in the morning (between 7 and 8 AM) after fasting overnight (8–10 h), and collected in one vacutainer CPT  containing sodium heparin as the anticoagulant. Plasma fractions were collected after blood sample centrifugation, and immediately frozen in liquid nitrogen, and transferred before 4 h to a −80 °C freezer for storage, to be used later for metabolomic analyses.Unless otherwise Specified, All Reagents were from Sigma-Aldrich, and of the Highest Purity Available.g for 3 min. Finally, the supernatant was filtrated through a 0.22-μm organic diameter filter  and transferred to Agilent  vials, with glass inserts, for further analysis.Plasma metabolites extraction was performed based on the methodology previously described (Method 1 ). In briv/v), 0.05 % trifluoroacetic acid (v/v), and 1 µg/mL of Phe-13C as the internal standard was added to the sample, and the solution was vortexed for 2 min. Then, the samples were incubated at room temperature for 15 min and centrifuged at 12,000× g for 3 min. Finally, the supernatant was filtrated through a 0.22-μm organic diameter filter  and transferred to Agilent  vials, with glass inserts, for further analysis.Sulphur-containing metabolites were extracted on the basis of the methodology previously described (Method 2 ). In briv/v) and solvent B was composed of methanol containing 0.2% acetic acid (v/v). The gradient started at 0% of solvent B and increased to 10% B in 5 min, 10% of solvent B increased to 100% B in 3 min, and held for 1 min. Post-time was established in 5 min. Electrospray ionization was performed in both positive and negative ion mode (depending on the target metabolite), using N2 at a pressure of 50 psi for the nebulizer, with a flow of 12 L/min and a temperature of 325 °C, respectively.For the non-sulfur-containing metabolites, 2 µL of the extracted sample was injected, based on the method described (Method 1 ). Chromav/v). Electrospray ionization was performed in both positive and negative ion mode (depending on the target metabolite) using N2 at a pressure of 50 psi for the nebulizer, with a flow of 12 L/min and a temperature of 325 °C, respectively.For the sulfur-containing metabolites, 10 µL of the extracted sample was injected, based on the method described (Method 2 ). Chroma13C.The individual conditions for the detection and quantification of plasma metabolites are listed in t-test or Welch-test to explore the differences in the continuous variables. Furthermore, we assessed differences in categorical variables by using the chi-squared test.We used the mean and standard deviation for the quantitative variables and percentage of participants (%) for categorical variables, to describe the baseline characteristics of the population. We conducted Student’s t-test was used to measure sibling differences. Minimum signification level was set at p < 0.05. Plots were performed using the GraphPad Prism (v8.0.1).Multivariate statistics were performed using the Metaboanalyst software on transformed data . Univariate statistics were performed using R version 3.6.1. Paired-The baseline clinical characteristics of the study sample are shown in A targeted metabolomic approach to analyze 7 energetic metabolism intermediates , 12 aminFirst, and in order to have a global view of how CD affects these 37 metabolites, a multivariate statistics approach was applied. As Second, and in order to specifically determine whether the plasma levels of each metabolite were affected by the CD condition, a univariate statistic (Paired T-Test) was applied. In line with the multivariate statistics, this analysis confirmed small changes in the metabolome analyzed. Specifically, no differences were found for plasma energetic metabolism intermediates , and theWhen we focused on choline and methionine metabolism, we observed similar results. Thus, any difference was verified for metabolites involved in choline metabolism, folate cycle, methionine savage pathway, and methionine cycle . In contThe genetic, immunological, and environmental components of the CD condition determines the variability in the clinical expression of this pathology. The variety of symptoms and signs induced by the recent findings of CD suggest that metabolic alterations in subjects with CD must be added. Although today in most cases the diagnosis of CD requires confirmation that the disease has a positive biopsy, a better knowledge of the metabolic processes underlying this pathology could offer the opportunity to uncover potential new biomarkers, which could be useful for both the diagnosis of doubtful cases due to the histological results, as well as for the follow-up of the disease. At present, a very limited number of metabolomics studies of CD are available, but they seem to verify the existence of minor but significant metabolic differences between healthy individuals and celiac patients (children and adults) ,14,15,16Considering the transsulfuration pathway, the decreased concentration of cysteine and cystathionine in CD patients could be due to defects in the enzymes that participate in its biosynthesis. Thus, the step from homocysteine to cystathionine is mediated by cystathioninebeta-synthase , and the conversion of cystathionine to cysteine is catalyzed by the enzyme cystathionine gamma-lyase or cystathionase  ,28,29. IA possible alternative or additional interpretation is that a mutation in the SAH hydrolase  could lead to reduced levels of HCys (not significant in this study), and therefore, reduced cystathione and Cys. According to Malacards , SAH hydp-value was higher than 0.05, so further studies are needed to confirm our results. (5) Although the difference was not statistically significant, there were differences in both sex and age and it is known that many metabolites could vary according it.The present work has some limitations—(1) the present study sample size was relatively small, and, consequently, the present results must be interpreted with caution. The fact that 5 of the celiac children were on a GFD for less than 12 months could influence the results, since a long-term GFD could act on the metabolic pathways after 12 months, as other studies showed in an adult population . On the In conclusion, the data presented here, suggest for the first time, significant alterations in the transsulfuration pathway of CD subjects despite being under a GFD, as a result of expression of a new physiopathological mechanism underlying the CD pathology, which needs further studies to be verified.


On March 11, 2020, World Health Organization announced that severe acute respiratory syndrome coronavirus 2 caused COVID-19 was a global pandemic. COVID-19 is associated with venous thromboembolism including deep vein thrombosis and pulmonary embolism. To further identify the current role of antiplatelet/anticoagulant therapy in the prophylaxis and treatment of COVID-19 patients is important.We will conduct a systematic review based on searches of major databases  and clinical trial registries from inception to present without limitations of language and publication status. All published randomized control trials, quasi-randomized trials, retrospective and observational studies related to prophylactic antiplatelet/anticoagulant for severe COVID-19 will be included. Primary outcome includes incident acute thrombosis events. Second outcome is the incidence and severity of adverse effects. Full-text screening, data extraction and quality assessment will be conducted by 2 reviewers independently. The reporting quality, risk of bias, sensitivity analysis and subgroup analysis will be performed to ensure the reliability of our findings by other 2 researchers. The statistical analysis will be performed by RevMan V.5.3 software and Stata V.12.0 software.The result of this systematic review will provide valid advice and consultation for clinicians on the management of prophylactic antiplatelet/anticoagulant for severe COVID-19 patients.This systematic review will provide evidence for prophylactic antiplatelet/anticoagulant of severe COVID-19 patients.CRD42020186928. Of these severe patients, a high prevalence of acute cardiovascular events has been observed.–7Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused COVID-19 has been officially announced as a global pandemic by the World Health Organization since March 11, 2020. As of May 26, a total of 5495061 cases have been confirmed worldwide and 346232 deaths have been reported across 188 countries or regions. Currently, with over 1.3 million confirmed cases and over 82,000 deaths, the United States leads all countries.,8 It means that similar with SARS-CoV, SARS-CoV-2 is likely to be complicated with coagulopathy namely disseminated intravascular coagulation (DIC) or pre-DIC secondary to an increased inflammatory state. Patient with DIC has a rather prothrombotic character with high risk of venous thromboembolism (VTE).–10SARS-CoV-2 and SARS-CoV have shared cellular target and some clinical manifestations, such as thrombocytopenia, prolonged thrombin time and elevated D-dimer levels. Emerging evidence shows that with a profound hypercoagulable state, complicating VTE in patients with COVID-19 are common.–14 The incidence of VTE in ICU patients without thromboprophylaxis was 25% with a mortality rate of 40%. The prevalence of VTE in the study of Cui et al seems to be higher than other studies including patients admitted in ICUs for other disease conditions.,16 A meta-analysis indicated that patients with VTE in ICU had a marginally increased risk of in-hospital mortality . In a study of 449 patients with severe COVID-19, patients with markedly elevated D-dimer or sepsis-induced coagulopathy were benefit from anticoagulant therapy, especially low molecular weight heparin. Meanwhile, VTE is associated with infection. COVID-19, as a special infection, may has an increased VTE risk due to endothelial damage, microvascular thrombosis and occlusion, or even autoimmune mechanisms. Thus, it appears that severe COVID-19 patients are in the high risk of VTE and high rate of mortality, and prognosis may be improved by anticoagulant therapy.Previous study reported that COVID-19 is associated with venous thrombotic events including deep vein thrombosis and pulmonary embolism (PE). In the study of Bowles, 216 patients with severe SARS-CoV-2 were received for coagulation screening, and 44 (20%) presented with a prolonged aPTT, and most aPTT prolonged patients were positive for lupus anticoagulant (91%). No bleeding tendency has been observed. Thus, prolonged aPTT should not be a barrier to the use of thromboprophylaxis therapies with COVID-19. All these observations raise a challenging question that is what the current role of antiplatelet/anticoagulant therapy in the prophylaxis and treatment of COVID-19 patients is.However, patients with COVID-19 may have a prolonged activated partial-thromboplastin time (aPTT), which may indicate a clotting factor deficiency or the presence of an inhibitor.22.1 It is registered in the PROSPERO database (CRD42020186928).The protocol will be performed following the recommendations from the Cochrane Handbook of Systematic Review of Intervention and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement Fig. .[23] It 2.2Inclusion criteria followed the PICOS principles: patients, intervention, comparisons, outcome, and study design type.2.2.1Gender, ethnicity, disease duration or ethnicity are not restricted for all participants diagnosed with severe pneumonia caused by COVID-19 according to the laboratory conformation  and chest CT findings and required advanced life support.2.2.2The aim of study is to assess the role of antiplatelet or anticoagulant as preventive agents for thrombosis events in patients with severe COVID-19, especially presenting with respiratory deterioration and/or hemodynamic instability. Therefore, patients will be assigned to intervention or control group. The intervention groups will include but not be limited to: antiplatelets , anticoagulants , antiplatelets plus anticoagulants. The control group will include placebo or no thromboprophylaxis therapies at all. All therapeutic doses, the time of dosing, duration and means of administration  are no restricted.2.2.3The primary objective is the efficacy of antithrombotic treatment in preventing the first thrombosis. The primary outcomes are incident acute thrombosis  events confirmed by appropriate imaging studies or death. The secondary outcomes are security index, which will be measured by the incidence and severity of adverse effects, including:(1)bleeding events .(2)changes in aPTT, D-dimer and platelet levels.(3)survival assays . Each adverse event will be separately assessed.Thrombosis events were defined as 1 of the following events:(1)deep vein thrombosis.(2)PE.(3)sudden death with no obvious cause .(4)brain ischemia.(5)acute myocardial infarction.2.2.4We will include randomized controlled trials, quasi-randomized trials, retrospective and observational studies, clinical trials and case series, irrespective of blinding, language, or publication status.2.3We defined the following exclusion criteria:(1)Studies in which the same patients have been enrolled.(2)Commentaries, editorials, case reports, letters, editorials, and expert opinions.(3)Missing or insufficient data that cannot be obtained after contacting original authors.(4)Unpublished records such as conference papers, theses, and patent.(5)Studies in which the patients are under 18 years old.2.42.4.12 reviewers will research Pubmed, Web of Science, Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Excerpa Medica database, Science Citation Index Expanded (SCI-EXPANDED), Conference Proceedings Citation Index-Science, Chinese Biomedical Literature Database, China Network Knowledge Information and Chinese Science Journal Database, Wanfang database (Wanfang Data) from their inception to the present. The full search strategy for Pubmed is provided in Table 2.4.2https://covid-19.cochrane.org/ ) and COVID-evidence (https://covid-evidence.org/).In addition, Reference lists of relevant trials and reviews will also be searched. For any unidentified clinical trials, we will search clinical trial registries, such as the International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, websites of US Food and Drug Administration (FDA), and European Medicines Agency (EMA) and contact the authors to receive the relevant data. We will also seek the COVID-19 Study Registry  and illustrated with the PRISMA statement.2.5.2Relevant data will be extracted independently from included trials in a predefined form by 2 independent reviewers, which include the following information:(1)The basic information of each study: first author, title, journal, time of publication, country, funding source, study design, and so on.(2)characteristics of patients: average age, gender, past medical history, severity of COVID-19 pneumonia, comorbidity, and so on.(3)interventions and comparators: types, doses, frequencies and lengths of thromboprophylaxis therapies and comparators where applicable, and so on.(4)outcomes: measures, main conclusions, mortality, length of stay, rates and types of incident acute thrombosis  and adverse events, and so on.In order to assume the integrity of extracted items, we will contact original authors via email to request for missing data or clarification necessary. If there is no response, with repeated contacts, the data will be reconsidered, or deleted if necessary. 2 reviewers will cross-check the received data and transfer into the Stata file. Disagreements will be judged by a third reviewer. Finally, the data will be recorded in a unified form.2.6 Each of the domains will be scored as “low risk” or “high risk” depending on the extracted information from each study. “Unclear” record will be made if there is insufficient detailed in the publication and will contact to authors of primary studies for missed or unpublished data. Disagreements will be judged by a third reviewer. The RevMan V5.5.3 software will be used to evaluate each study.As with the previous process, pilot risk of bias of the included studies will be assessed by 2 independent reviewers at study level in accordance with the guidance in the latest version of Cochrane Handbook for systematic reviews of interventions, which covers: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessments, incomplete outcome reporting, selective reporting and other sources of bias.2.72.7.1We will analyze heterogeneity by considering the variability in the population characteristics, interventions and outcomes among included trials using RevMan V.5.3 software and Stata V.12.0 software. Dichotomous outcomes such as occurrence of thrombosis events will be determined by using risk ratios with a confidence interval of 95%. Continuous variables will be recorded as the mean differences with 95% confidence interval. When identical method or unit of measure of the intervention effect in all studies is observed, weighted average difference is preferred. On the other hand, standard mean difference will be used to express the size of the same intervention effect in each study related to the variability observed in that study.I2 statistic and Chi-squared test will be used to assess the presence of statistical heterogeneity and calculate the heterogeneity severity. When P > .1, I2 < 50%, it is considered that there is acceptable heterogeneity between the trials, and the fixed effect model will be chosen;,26 otherwise, the random effect model will be considered and we will try to explain the underlying cause of heterogeneity by subgroup or sensitivity analysis . If heterogeneity is high, the meta-analysis should be avoided.To explore the impact of the statistical heterogeneity on the meta-analysis, we will primarily use forest plots to assess any sign of potential heterogeneity visually. Then 2.7.2When heterogeneity is identified, we will apply subgroup analysis to explore the source of heterogeneity. As the first step in the analysis of subgroup, make sure that the number of studies is adequate. Then we will stratify the subgroup by different subdomains. The criteria are as follows: population characteristics, complications, research quality, type of control interventions, dose and duration of intervention, follow-up period.Moreover, we will also perform analysis for any other subgroups as reported in the included studies. It should be noted that selective reporting bias should be paid attention and minimized.2.7.3To check the robustness of pooled data of the review process, we will perform sensitivity analysis. The principle decision nodes included methodological quality, the effect of missing data, type of study, sample size. We will delete every eligible study 1 by 1 and a second meta-analysis will be performed. The result will be compared and discussed in order to test whether the results could have been influenced by a single study.2.8,29 Egger bias indicator test will be used to plot a regression line, which shows the symmetry of the plotted studies and examine for the presence of any publication bias. If insufficient number of articles are included, the test for funnel plot asymmetry will be inappropriate. If publication bias is significant, trim and fill method will be constructed for correcting the probable publication bias.As most publications process tends to favor positive results or large-scale studies, the meta-analysis that aims to pool and analyze prepublished studies should be examined for the presence of any publication bias. We will use funnel plots, Egger test and Begg tests to assess the publication bias if more than 10 of the studies are included.2.9 Quality of evidence for each outcome will be graded as high, moderate, low, or very low.The strength of evidence will be assessed on the Grading of recommendations, assessment, development, and evaluation system according to eight criteria: indirectness, inconsistency (heterogeneity), imprecision, and/or publication bias in addition to 4 criteria of risk of bias assessment tool.2.10Research ethic approval will not be required because no individual patient data will be collected. We expect this systematic review will be published in a peer-reviewed journal.3COVID-19 has been officially announced as a global pandemic, which are associated with a high rate of coagulopathy and high risk of VTE. Emerging evidence shows that anticoagulant therapy might improve the prognosis of severe COVID-19 patients. However, whether antiplatelet/anticoagulant therapy should be used in COVID-19 patients who required advanced life support until diagnostic assessment for VTE is still controversial. In addition to its safety and effectiveness, the current study also provides the evidence on the characteristics of therapy  and participants. Therefore, we will summarize the current systematic analysis to figure out what the role of antiplatelet/anticoagulant therapy in prophylaxis of patients with severe COVID-19 is.Currently, this is the first systematic review to evaluate the application of antiplatelet/anticoagulant therapy as preventive agents for patients with severe COVID-19. It will be reported following Cochrane Handbook for Systematic Reviews of Interventions and PRISMA statement guidelines. The potential limitations that inherent to systematic reviews and meta-analyses include publication bias, poor statically analyses and methodological quality, information bias, as well as inadequate reporting of methods and findings of the included studies. This review will provide valid advice and consultation for clinicians on the management of prophylactic antiplatelet/anticoagulant for severe COVID-19 patients.Not applicable.Conceptualization: Can Chen, Wei Hu.Data curation: Yiwei Li, Ying Xu.Formal analysis: Can Chen, Yiwei Li, Ying Xu.Funding acquisition: Wei Hu.Methodology: Can Chen, Yiwei Li.Project administration: Can Chen, Wei Hu.Software: Yiwei Li, Ying Xu.Supervision: Can Chen, Wei Hu.Validation: Yiwei Li, Ying Xu, Pengfei Shi, Ying Zhu, Can Chen, Wei Hu.Writing – original draft: Yiwei Li, Ying Xu, Can Chen.Writing – review and editing: Yiwei Li, Ying Xu, Pengfei Shi, Ying Zhu, Can Chen, Wei Hu.


Knee osteoarthritis (KOA), a concerning public health problem, seriously threatens well being of human beings. At present, studies have shown that massage therapy is effective in relieving related symptoms of KOA. However, the evidence of massage for KOA has not been systematically evaluated. Therefore, the study is conducted to systematically assess the reliability of patients with KOA treated by massage.We will retrieve the relevant literature of massage for KOA from PubMed, Cochrane Library, EMBASE, Web of Science, Wanfang, Chongqing VIP, CNKI, and Chinese Biomedical Literature Database from the establishment of the databases to August 1, 2020. Two researchers will independently perform the screening of literature and extract the basic information of the data. In addition, RevMan V.5.3 software will be used for data analysis.The study will comprehensively assess the effect of massage for KOA.The study will provide comprehensive evidence for evaluating whether massage therapy is useful in treating patients with KOA.INPLASY202080115. Currently, the incidence of KOA in the elderly is quite high, and it is reported that 30% to 50% of the elderly population more than 60 years of age suffer from KOA. With the coming of the aging of the world population, KOA has become a concerning public health problem that not only brings an increasing social and economic burden but also threatens the physical and mental health of patients as well as reduces the quality of life of the elderly.,6 Meanwhile, studies have shown that besides joint discomfort, patients with knee osteoarthritis are more likely to have poor sleep and feel anxiety and depression compared with healthy people.–9 Therefore, it is very important to find effective treatments for improving patients’ quality of life and reducing the medical burden.Osteoarthritis is the most prevalent joint disorder in the world, and the site most often affected by osteoarthritis is the knee.,11 Drug treatment, as a method recommended by clinical guidelines, is useful in alleviating pain and inflammation of KOA.,13 However, long-term use of drugs may bring a variety of adverse impacts such as hepatic toxicity, renal toxicity, and gastrointestinal complications. Besides, although knee replacement is effective for advanced KOA, some patients are not able to undergo the operation due to economic burden and physical condition. Hence, seeking a safe and effective alternative treatment is urgently required to alleviate the distress of patients who have been diagnosed with KOA.At present, the common treatments for KOA mainly include health education, pharmacological and non-pharmacological treatments as well as surgery. Compared to pharmacological therapy and surgery, massage has unique advantages because of its characteristics of high safety, low-cost, and easy access. It is reported that 15.4 million Americans used massage therapy to treat KOA in 2012. Besides, a large number of trials have shown that massage therapy is an effective non-drug intervention that can improve pain, stiffness, and functional status of patients diagnosed with KOA.,19–21 Previous studies have also demonstrated that massage can relieve the related symptoms of knee osteoarthritis by promoting the blood circulation around the joint, improving the tension of the muscle as well as increasing the flexibility of the joint.,23Massage, as 1 of the most widely used Complementary and Alternative Medicine therapies, is defined a method of touching or manipulating body soft tissues by hand to provide comfort.To our knowledge, there is no systematic review discussing whether massage therapy is safe and effective for patients who have been diagnosed with KOA. Therefore, we perform this protocol to comprehensively assess the effect of massage for KOA.22.1 statement guidelines.This protocol was registered on the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) on August 27, 2020 (registration number INPLASY202080115). We will strictly perform this protocol by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P)2.22.2.1We will only include randomized clinical trials (RCTs) about massage for KOA, with language restrictions in English or Chinese. Case report, experience report, and laboratory studies will not be included.2.2.2All patients with KOA will be included without limitation of age, race, sex, economic level, and severity.2.2.32.2.3.1The intervention of the experimental group will only include massage therapies, which mainly include general massage, acupressure, Chinese massage, relaxation, manual lymphatic drainage, and so on. There is no limitation on the methods, duration, and frequency of massage.2.2.3.2The interventions of the control group will involve any therapies other than massage 2.2.42.2.4.1The Western Ontario and McMaster Universities Osteoarthritis Index scale.2.2.4.2(1)Visual analog scale.(2)Symptom score.(3)Lysholm knee scoring scale.(4)Adverse events.2.3RCTs of massage for KOA will be searched from PubMed, Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, Chinese Biomedical Literature Database, Wanfang Database, Chongqing VIP Database, and Chinese National Knowledge Infrastructure from inception to August 1, 2020. In addition, The Clinicaltrials.gov, Chinese Clinical Trial Registry will also be carefully retrieved to obtain unpublished or ongoing relevant studies. The specific PubMed retrieval strategy is presented in Table 2.42.4.1We will import all retrieved literature into EndNote software (V.x9) and remove duplicate literature. The 2 qualified reviewers (SQ and ZC) will make a preliminary screening to exclude irrelevant literature by reading the title and abstract independently. Then, the researchers (SQ and ZC) will eventually decide whether the literature will be included in the study by reading the full text. Finally, any divergence arising from the above process will be solved or discussed through the third researcher (LJ). The specific literature screening flow chart is shown in Figure 2.4.2The researchers (SQ and YX) will extract relevant data from the included literature, mainly including the following information:(1)Research Characteristics: Publication year, study title, basic information of the first author.(2)Patient information: Sex, age, the severity of KOA, duration of disease, nationality, sample size.(3)Study methods: Randomization, allocation concealment, blinding, result analysis method.(4)Intervention: The method of massage, treatment sites, and frequency.(5)Outcomes measurement: Included primary and additional outcomes.2.5 to evaluate the risk of bias of the included RCTs. It includes 7 domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias. In addition, the risk of bias can be categorized as high, low, and unclear risk bias levels. If there is any divergence, it will be resolved by consulting a third researcher (LJ).The 2 independent researchers (SQ and ZC) will use the Cochrane bias risk assessment tool2.6P > .1 or I2 < 50%). We will use the random-effect model if there is an obvious heterogeneity (P ≤ .1 or I2 ≥ 50%), and subgroup analysis or sensitivity analysis will be carried out to find the possible causes of the heterogeneity between groups.RevMan 5.3 software will be used to perform the statistical analysis. For discontinuous variables, the risk ratio (RR) with 95% confidence interval (CI) will be selected. For continuous variables, the Weighted Mean Difference (WMD) with 95% CI will be selected when the measurement instruments are the same, and the Standardized Mean Difference (SMD) with 95% CI will be selected when the measurement instruments are different. We will use the fixed-effect model if there is no obvious heterogeneity  will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)2.12The patients’ privacy is not involved in the study, so ethical approval is not needed. In addition, the systematic review will be disseminated in a peer-reviewed journal.3 Even though pharmacological treatments and surgery are effective in alleviating the symptoms of patients who have been diagnosed with KOA, they may have some side effects. Massage as a complementary and alternative therapy is widely used to relieve the pain of patients who are diagnosed with KOA due to its features of high safety, low-cost, and easy access. Previous studies have also confirmed that massage therapy is useful in improving pain, stiffness, and functional status for patients with KOA.,19–21 However, at present, the evidence of massage for KOA lacks comprehensive system evaluation. So, we hope that the study can provide valuable information to patients, physicians, and health authorities.Knee osteoarthritis, 1 of the main causes of disability worldwide, seriously threatens the physical and mental health of people.However, the study may have some potential limitations. First, greater heterogeneity may exist due to different massage methods. Second, the quality of the study may be affected because we only include clinical trials published in Chinese or English.Data collection: Siyu Qin, Zhenhai Chi.Funding acquisition: Lin Jiao.Methodology: Siyu Qin, Yuanyi Xiao.Software: Daocheng Zhu.Supervision: Lin Jiao.Writing – original draft: Siyu Qin, Zhenhai Chi.Writing – review & editing: Lin Jiao.


This study aimed to evaluate and compare with healthy control subjects the levels of indirect inflammatory markers such as mean platelet volume (MPV), platelet to lymphocyte ratio (PLR), and neutrophil to lymphocyte ratio (NLR) in adults and children with brucellosis.  White blood cell, neutrophil, lymphocyte, and platelet counts, and C-reactive protein (CRP) levels were retrospectively recorded for all participants.  NLR and neutrophil counts were significantly higher in adult patients compared to those in pediatric patients.  Indirect inflammatory markers such as NLR, PLR, MPV, red distribution width, and CRP levels may be helpful for follow-up of brucellosis. Brucellosis can progress with multiple organ involvement, such that misdiagnoses and delays in treatment are common, leading to increased complications. The diagnosis of brucellosis is made by clinical examination, and serological and culture testsMedical records of patients between the ages of 0 and 86 diagnosed with brucellosis admitted between 2011 November and 2015 December were obtained from the patients’ follow-up cards; 137 adults and 71 children with brucellosis and 141 adults and 81 children as healthy controls were included in the study. Subjects were classified into four groups: adult patients (Group 1), adult controls (Group 2), pediatric patients (Group 3), and pediatric controls (Group 4).The diagnosis of brucellosis was made based on all of the following features: presence of clinical signs compatible with brucella; isolation of the brucella microorganism in the blood; and a positive brucella serology test of above 1/160 according to the Standard Agglutination Test (SAT). Adult and pediatric patients were identified, and laboratory data were obtained from patient cards filled out at admission and from hospital databases.Hematologic parameters such as white blood cell (WBC) count, lymphocyte count, neutrophil count, platelet count, RDW, platelet distribution width (PDW), MPV, NLR and PLR, and CRP, were recorded at admission. PLR was measured as the ratio of platelets to lymphocytes, while NLR was measured as the ratio of neutrophils to lymphocytes.Both patient and control group comparisons were carried out with respect to demographic features (age and sex) and hematologic inflammatory parameters. These parameters and CRP values were also used for comparing adult and pediatric patient groups. All blood samples were tested for hematological parameters using the same analyzers, which were regularly calibrated.Patients with inflammation-related diseases such as acute bacterial infections, fever related with other etiologies, chronic disorders, connective tissue and various bone and joint diseases, rheumatic disorders, and anemia or other hematological diseases, and patients whose data are not available, were excluded from the study. Patients included in the child and adult groups were selected from those who applied to the hospital for routine control. Patients with systemic disease or infection were not included in the control group.The mean age of Group 1 was 43.1 ± 15.4 years and 54% (n=74) of the patients were women. The mean age of Group 2 was 40.7 ± 13.4 years and 51.1% (n=72) were men. The mean age of Group 3 was 9.5 ± 3.6 years and 50.7% (n=36) were men. The mean age of Group 4 was 9.0 ± 3.8 years and 50.6% (n=41) were men. There was no statistically significant difference between the patient groups and control subjects in terms of mean age and sex (p > 0.05). In the comparison of groups 1 and 2 at admission, Group 1 had significantly lower PLR, platelet counts, NLR, neutrophil counts, MPV, and RDW values, and higher lymphocyte counts (p < 0.05). No statistically significant difference was identified between Groups 1 and 2 in terms of WBC counts (p < 0.05). Group 3 had significantly higher lymphocyte counts and PDW, as well as lower PLR, platelet counts, NLR, neutrophil counts, and MPV values at admission compared to Group 4 (p < 0.05). No statistically significant difference was found between Groups 3 and 4 in terms of WBC counts (p < 0.056) .Adult patients had significantly higher NLR (p < 0.001) and neutrophil counts (p = 0.019) at admission than did pediatric patients. No statistically significant difference was found between adult and pediatric patients in terms of WBC, lymphocyte, and platelet counts, and in MPV, RDW, PLR, and CRP values .R2 = 0.061, p = 0.006) and NLR  in Group 1. There was no correlation between MPV, RDW, and CRP values.There was a positive correlation between CRP and PLR (,Delayed diagnosis and inadequate treatment of brucellosis, a commonly observed disease among both in children and adults, not only leads to higher rates of morbidity and mortality, but also to significant increases in national health expensesInfection parameters such as neutrophil counts, WBC counts, and CRP values have limited value for the early diagnosis of bacteremia. In the literature, higher NLR values have been observed in inflammatory processes compared to non-inflammatory processes. De jager et al. showed the presence of lymphocytopenia in their study, and concluded that NLR was able to predict bacteriemia with a higher rate,,,,Thrombocytes are also listed among the affected hematological parameters in cases with brucellosisWhile Togan et al.,,,,Several inflammation markers have been used in the diagnosis of infections. One of these is CRPThe small sample size and the retrospective nature of the study are among the limitations of our study. Therefore, we believe that a larger series and a larger sample size should be included in future studies.In conclusion, we suggest that complementary indirect hematological markers such as PLR, NLR, and RDW values may be help in the diagnosis of brucellosis in adult and pediatric patients as inexpensive and easily applicable new inflammatory markers. However, there is still a need for prospective multicenter studies with large sample sizes, to elucidate this further.


Introduction: Relative age effects (RAEs) refer to the overrepresentation of players born earlier in the selection year compared to late-born players within the same age category. To date, the origins and mechanisms of RAEs are still unclear. To evaluate the development of RAEs in terms of age group and selection level, we analyzed data of all registered child and adolescent football players in Switzerland.Methods: Age category, selection level, and birthdate from all licensed 101,991 Swiss child and youth football players assigned to a specific team  were analyzed. Additionally, out of 1,128 clubs, 54 clubs provided their documented waiting lists . Birthdate distributions were split by age category, sex, and birth quarter . RAEs were calculated using odds ratios (Q1 vs. Q4) with 95% confidence intervals (95% CI).Results: We found small RAEs among U8 players  and U10 . The RAE was negligible in all other age categories, independent of gender. In children's football, 5,584 (71.3%) teams performed selections. In teams without selection, there were no obvious RAEs. However, teams with selections for the same age category showed small RAEs with an overrepresentation of Q1 athletes in the first team  and inverse RAEs with an underrepresentation of Q1 athletes in the last team . Only small RAEs were observed on the waiting lists for the U8 .Discussion and Conclusion: RAEs have a small, but consistent effect on participation in Swiss children's football at the grassroots level. Contrary to expectations, no inverse RAEs were found on the waiting lists. Nonetheless, first time coach selections seem to be the origin of RAEs. To protect young athletes from discrimination, RAE biases should be analyzed and eliminated at all stages of sport participation, selection, and dropout situations. Modifications to the organizational structure of sport and athlete development systems are recommended to prevent RAE-related discrimination in youth sports. The practice of annual age grouping occurs throughout and across youth sport. In football (soccer), players are typically categorized into annual age groups to reduce developmental differences during childhood and adolescence. However, there is a potential gap of up to 12 months in chronological age between individuals in the same age category. Relative age effects (RAEs) are defined as the overrepresentation of chronologically older participants within one selection category  on the occurrence of RAEs, by analyzing a population-based sample of youth football players in Switzerland.The objectives of this study therefore were (i) to investigate RAEs in a nationwide analysis of football players (5–20 years of age), who are registered as active players assigned to an individual team in the database of the Swiss Football Association (SFA) and (ii) to evaluate the effects of different selection procedures on RAEs.Following ethical approval from the Swiss Federal Institute of Sport (App. No: 082_LSP_150819), RAEs of 101,991 junior football players  participating in one of 1,128 football clubs were analyzed. Age categories ranged from under- (U) 8 to U20 for male and from U12 to U19 for female football (FF) players. Including cases where players played in two teams (different levels or different categories), we analyzed 109,469 single data points in Swiss Football Juniors' leagues during the year 2019 .N = 1,128 clubs) were contacted via email and asked whether they have (a) no waiting list; (b) anonymous waiting list, but not documented; or (c) anonymous documented waiting list. Under the term waiting list, we understand that some children sometimes cannot enter a club due to a lack of infrastructure or coaches, for example, and have to wait for a place in a football team. Out of the 1,128 clubs, 556 (49%) responded and 54 delivered their documented waiting lists, which included 1,271 players. Due to the low number of girls on waiting lists in general and of boys in the age groups older than the U12 age category, only the waiting lists of boys in the categories from U8 to U12 were analyzed .Data were taken from the national football database with permission of SFA. In addition, all Swiss football clubs with children football's sections  and four relative age quarters (Q) according to their birth month independently of birth year . The observed birthdate distributions were calculated for every relative age quarter. The expected birthdate distributions were obtained from the actual corresponding distributions (1999–2013) as the number of live births registered with the Swiss Federal Office of Statistics . The relBirthdate distributions were split according to gender, age category, selection level, and birth quarter. There were up to seven selection levels possible in the same age category, from the best league to the last team of each age category within the same club. Age categories were analyzed as given by the SFA as follows: U8, U10, U12, U14, U16, U18, and U20 for the boys' categories in which girls are allowed to play, and FF-12, FF-15, and FF-19 for the only-girls' categories.RAEs were calculated using odds ratios (Q1 vs. Q4 and S1 vs. S2) with 95% confidence intervals (95% CI). The OR for the Q1 vs. Q4 comparison was interpreted as follows: we assumed the existence of an RAE if the CI did not include 1 and interpreted an OR <1.22, 1.22 ≤ OR <1.86, 1.86 ≤ OR <3.00, and OR ≥ 3.00, as negligible, small, medium, and large, respectively  shows a negligible RAE. When analyzing specific age categories, there are small RAEs in children's football (U8 and U10) and negligible RAEs in all other age categories, including FF-12 and FF-15. The FF-19 category shows an inverse RAE .Across all 1,128 clubs in childrens' football, 925 (82.0%) select multiple teams and 203 (18.0%) only select one team. Across all clubs 5,584 (71.3%) teams were built by selections and 2,250 (28.7%) were created without selection. Overall, there is a small RAE in the highest-level/first/top teams  and an inverse RAE for the lowest-level teams . Regarding specific age categories, there is a small RAE that decreases with age in the first/highest-level/top U8 to U14 teams. There is no RAE in older age categories for the first/highest-level/top teams, although OR is larger in the top/first/highest-level teams over all age categories . An inveN = 1,271 players . The analysis of the boys' waiting lists shows a small RAE in the category U8 only  have no waiting list, 54 (9.7%) have a documented waiting list, 54 (9.7%) have a waiting list, but not documented, 16 (2.9%) have a periodic waiting list and 8 (1.4%) can offer an alternative program. All 54 clubs that delivered their waiting lists were included in the analysis. In total, the documented waiting lists contain  U8 only .The main findings of this study are: (i) no relevant overall RAE, (ii) a small RAE in the youngest age group, i.e., at entry into the official football system, which decreases with age, (iii) a small effect of the current playing level of the team within the club, but not necessarily of the first adult team's playing level, and (iv) a small RAE on the waiting list of the youngest age category (U8).The results of our study show that RAEs already exist in the youngest category for both sexes. In other words, children born at the beginning of the selection year are more likely to participate in children's football. Older children are generally biologically more mature, taller, and heavier, with more body mass for body height than younger children. This leads to advantages in athletic performance and psychological aspects, which are referred to as the maturation-selection hypothesis  and/or rotating age-group cutoff dates . Such data may provide a more complete picture of RAEs (Coelho et al., RAEs have a small but consistent effect on participation in Swiss children's football at the grassroots level. The effect is highest at entry level and decreases from U8 to U20. Contrary to expectations, no inverse RAEs were found on the waiting lists. As U8 is the first possible club entry, RAEs could partly originate from self-selection. Nonetheless, clubs using a selection system seem to increase RAEs. The first-time coach selection at the grassroots level is the origin of RAEs and increases the magnitude of RAEs during following selection processes. To protect young athletes from discrimination, RAE biases should be analyzed and eliminated at all stages of sport participation, selection, and dropout situations. Modifications to the organizational structure of sport and athlete development systems are recommended to prevent RAE-related inequalities.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the ethics review board of the Swiss Federal Institute of Sport Magglingen. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To investigate the efficacy and safety of compound glycyrrhizin (CG) combined with antihistamines in the treatment of chronic urticaria (CU).We will use computers to search all databases including Medline, Embase, Pubmed, Web of Science and Cochrane Central Register of Controlled Trials and China's 4 databases: China National Knowledge Infrastructure Database, China Biomedical Literature Database, China Science Journal Database, and Wanfang Database. Find data from creation date to July 2020. In addition, we will manually search the list of medical journals as a supplement. The scope of the search included randomized controlled clinical studies related to CG combined with antihistamines for CU. The primary outcome is the disease activity control. Secondary outcomes include response rate, adverse events, and recurrence rates. The Cochrane RevMan V5.3 Deviation Assessment Tool will be used to assess bias assessment risk, data integration risk, meta-analysis risk, and subgroup analysis risk (if conditions are met). The average difference, standard mean difference, and binary data will be used to represent continuous results.This study will comprehensively review the existing evidence on CG combined with antihistamines for CU.This systematic review will provide a basis for judging the effectiveness and safety of CG combined with antihistamines in the treatment of CU.PROSPERO, CRD42020156153 Among them, the incidence of chronic spontaneous urticaria is about twice that of chronic inducible urticarias. The pathogenesis of CU may be related to multiple mechanisms, including autoimmunity, allergy and blood coagulation, each mechanism may have a different weight in each patient. The quality of life of patients with CU is considerable. People with CU often suffer from fatigue, pain, lack of sleep or insomnia due to persistent itching, according to research data.,10 Visible damage can lead to emotional distress and withdrawal from social activities, as well as psychological complaints such as anxiety, depression, or irritability.,12,13 It has a great impact on the life and work of patients with CU.Chronic urticaria (CU), defined as the recurrent occurrence of wheals with or without angioedema for longer than 6 weeks, Attack twice a week or more,,15 and the guidelines ,16,17 published these years, the initial treatment for CU is second-generation H1 antihistamines (sgAH). If there is no improvement after 2 to 4 weeks, the dose can be increased to 4 times the manufacturer's recommended dose. Omalizumab should be added when long-term use of sgAH fails to achieve the desired results. If there is still no improvement in half a year, it is recommended to use cyclosporine and sgAH treatment.–19 In addition, there may be a high financial burden through direct medical costs and loss of productivity due to symptoms.According to the consensus 1.2 At the same time, Glycyrrhizin as the main component, together with aminoacetic and methionine, constitute compound glycyrrhizin (CG). CG has been used to treat abnormal liver function in chronic hepatitis for more than 30 years in Japan, it is also known as Stronger Neo-Minophagen C,23 Studies have shown that glycyrrhizin not only has significant anti-inflammatory, anti-allergy, and anti-ulcer activities, but also has immunomodulatory and antiviral effects. It is metabolized into glycyrrhetinic acid in the body. It is similar to glucocorticoid in structure, but has few adverse reactions to steroids. Therefore, in recent years, glycyrrhizin has been widely used in clinical treatment of skin diseases, such as urticaria, dermatitis, alopecia areata, psoriasis, vitiligo, and so on.–28Glycyrrhiza uralensis (Gan cao) is one of the key herbs used in Chinese medicine, its main active ingredient is glycyrrhizin.,30 but many CU patients have circulating antibody that is able to bind to mast cells, thereby causing histamine release and weal formation. And Antihistamines control symptoms just by competing for receptors of corresponding target cells, so they control the condition rather than cure it. Therefore, most patients need long-term medication. Studies have shown that long-term use of antihistamines can cause many adverse reactions such as headaches, drowsiness, fatigue, dry mouth and so on –34Antihistamines, specifically H1 antihistamines, are the main treatment for CU. The root cause of CU cannot be determined,,36 have shown that, compared with a single medication, CG combined with cetirizine can significantly improve the symptoms and signs of CU with fewer adverse reactions. In summary, a more comprehensive SR of CG combined with antihistamines for CU is needed.Therefore, in recent years, CG combined with antihistamines has been widely used in clinical treatment of CU. Two systematic reviews (SRs)22.1 And has been registered in Prospero (ID: CRD42020156153).This research registration strictly follows the systematic review and meta-analysis plan  preferred report item.2.2The results of this SR are to evaluate the published randomized controlled trials (RCT) on the efficacy and safety of CG combined with antihistamines in the treatment of CU, so as to help clinicians and patients choose appropriate treatment options. This review does not require ethical approval and will be published in a peer-reviewed journal.2.3We will use computers to search all databases including Medline, Embase, Pubmed, Web of Science and Cochrane Central Register of Controlled Trials and China's 4 databases: China National Knowledge Infrastructure Database, China Biomedical Literature Database, China Science Journal Database, and Wanfang Database. Find data from creation date to July 2020 by using the following search terms: Urticaria, Chronic urticaria, Nettle-rash, Hives, Rubella, Wind cluster, Angioedema, Compound Glycyrrhizin, Glycyrrhizin, Gan cao, Glycyrrhizic, Glycyrrhiza uralensis, Antihistamine, Antihistaminic, H1-antihistamine. Boolean operators “and” and “or” will be used within the search to combine the search terms. The example search strategy in Table 2.42.4.1This article only reviews the RCT of CG combined with antihistamines as the main treatment. The control group included no treatment, placebo, separate antihistamines, and other effective treatments. In addition, both Chinese and English publications are subject to language restrictions. RCTs that are not subject to release status will be included, excluding the remaining types of documentation.2.4.2 or the Chinese guidelines for the diagnosis and treatment of urticaria version.No matter what race, gender, age, and education, in our SR patients must comply with the European Academy of Allergology and Clinical Immunology, the Global Allergy and Asthma European Network, World Allergy Organization (EAACI/GA2LEN/EDF/WAO) guidelines 2.4.3Qualified interventions in the experimental group can only be combined with CG and antihistamines, which will be excluded if combined with other methods  or a separate drug. The following processes will be compared:(1)CG combined with antihistamines therapy compared with no treatment.(2)CG combined with antihistamines therapy compared with placebo or sham drugs therapy.(3)CG combined with antihistamines therapy compared with a separate antihistamines therapy.(4)CG combined with antihistamines therapy compared with other active therapies.2.4.42.4.4.1The primary outcome was disease activity control, measured by the urticaria activity score, urticaria control test, or other validated symptom scores.2.4.4.2(1)Response rate.(2)Recurrence rate during the follow-up period.(3)Adverse events.2.52.5.1The references in the search results will be added to the EndNote software (V.X8) document management software, and the duplicate content will be deleted. The 2 review authors (XX and LZ) will conduct an independent screening of the titles, abstracts, and keywords of all search studies to confirm qualified trials. Reviewers will receive a complete report for further evaluation. The excluded explanations will be recorded in the excel dataset. If the differences between the reviewers (XX and LZ) are not resolved through discussion, third-party arbitration (YC) determines. The research flow chart is shown in Figure 2.5.2The 2 authors (LW and QZ) will extract data independently from the selected report or study and fill out the data extraction form. Extract the following information: general information, participants, methods, interventions, results, adverse events, main conclusions, conflicts of interest, ethical approval, and so on. When the reported data is insufficient, we will contact the author for more information. In this process, any inconsistencies will be resolved through discussion between the 2 authors or judged by the third author (YL).2.6The 2 authors (WC and QZ) will evaluate the quality of the research by using a list of risk assessment tools by Cochrane Collaborative bias, to evaluates the presence of potential selection bias , performance bias (blinding of investigators and participants), detection bias (blinding of outcome assessors), attrition bias (incomplete outcome data), reporting bias (selective reporting), and possible other sources of bias (funding bias). This review uses L, U, and H as the key to these assessments, where L (low) indicates a lower risk of bias, U (unclear) indicates that the risk of bias is uncertain, and H (high) indicates a higher risk of bias. If inconsistent results appear, the third author (SZ) makes the final decision.2.7For dichotomous data, risk ratio with 95% confidence intervals (CIs) will be used to measure the treatment effect. For continuous data, mean difference and 95% CIs were used to measure treatment effectiveness.2.8We will handle with the missing data according to the Cochrane Handbook guidelines for systematic review interventions. In particular, the following methods will be used:(1)Contact the corresponding author for missing data requests.(2)Execution analysis is available.(3)Discuss the potential impact of lost data.2.9 If the results are statistically significant, the reasons will be discussed through narrative, subgroup analysis, and sensitivity analysis.We will evaluate the statistics of heterogeneity through Cochran's Q test and quantify them through I2 value.2.10We will evaluate publication bias using the Egger test and funnel plots.2.11We will use Review Manager 5.3 for all statistical analyses. The data will be pooled for the meta-analysis when the included studies are sufficiently homogeneous with respect to subjects, interventions, and outcomes. All similar studies will be pooled for a random-effects model to obtain the pooled intervention effect. The pooled intervention effect will be expressed in terms of the mean difference and 95% of CI if the outcome was reported as a continuous variable. If different scales were used to assess the outcome, the standard mean difference will be used. If the outcome was measured as a dichotomous variable, we will convert the OR into the standard mean difference as long as the underlying continuous measure followed an approximately normal distribution.2.12To solve some potential problems, we will perform a subgroup analysis. We will compare the results of different types, dosages, and duration of antihistamine drugs and different dosage forms of CG.2.13To verify the robustness of the conclusions, a sensitivity analysis will be conducted to test the inclusion of low-quality studies in the meta-analysis and exclude the impact of studies with high or fuzzy bias risks.2.14We will grade the recommendations, assessments, developments, and assessment methods of the working group to judge the quality of the evidence of the results. Risk of bias, consistency, directness, accuracy, publication bias, and additional points were the areas we assessed. The assessment results will be divided into 4 levels: high, moderate, low, or very low.3 However, simple antihistamines are only suitable for some patients. The symptoms of more than 70% of CU patients will continue for 2 to 5 years, 20% will last for more than 5 years,,19,42,43 many patients are not satisfied with the current treatment because of the need for long-term medication. CG has been repeatedly tested clinically, and many studies at home and abroad in recent years have shown that it has a good effect on CU, especially the treatment of CG combined with antihistamine drugs. Not only improves the overall efficiency, also greatly reduces the adverse effects\response rate and recurrence rate.–48 but there are also reports showing that long-term use of CG will produce adverse reactions. This article will provide a more comprehensive summary of the validity and safety of the existing evidence, hoping to provide convincing evidence for patients and clinicians in the decision-making process.CU is a high-incidence disease, easy to relapse. It has a serious impact on the quality of life and work of patients.Conceptualization: Wei CaoData curation: Xianjun Xiao, Leixiao Zhang, Ying Liu, Lu Wang, Yue Cao, Qianhua Zheng,Formal analysis: Wei Cao, Siyuan Zhou.Investigation: Lu Wang, Zihao ZouMethodology: Wei Cao, Xianjun Xiao.Project administration: Leixiao Zhang.Supervision: Ying Li.Writing – original draft: Wei Cao.Writing – review & editing: Chunxiao Li, Ying Li.