To evaluate the preoperative predictive value of radiomics in the diagnosis of breast cancer (BC).By searching PubMed and Embase libraries, our study identified 19 eligible studies. We conducted a meta-analysis to assess the differential value in the preoperative assessment of BC using radiomics methods.I2 = 76.44%) and 0.83 , respectively. The AUC based on the SROC curve was 0.91, indicating a high diagnostic value.Nineteen radiomics studies focusing on the diagnostic efficacy of BC and involving 5865 patients were enrolled. The integrated sensitivity and specificity were 0.84 (95% CI: 0.80–0.87, Radiomics has shown excellent diagnostic performance in the preoperative prediction of BC and is expected to be a promising method in clinical practice. Breast cancer (BC) is the most commonly diagnosed cancer among women, accounting for 23% of all female cancers worldwide, and its related mortality is increasing by 4% each year . TraditiPubMed and EMBASE databases were comprehensively searched by two reviewers (L-ZK and YJ) using the following keywords: radiomics and BC, breast carcinoma, breast tumor, or breast neoplasm. The deadline of this retrieval was September 10, 2021. Two reviewers independently screened the abstracts of all manuscripts, and full publications were downloaded when the decision of including an article was ambiguous. Discussion was conducted to resolve disagreements on article inclusion. The reference lists of eligible studies were also searched for potential additional studies.The inclusion criteria were as follows: (1) diagnosis of BC on the basis of pathologic criteria; (2) breast imaging, including US, MRI, and/or digital MMG, was performed before biopsy or resection; and (3) radiomics analysis based on breast images was conducted.The exclusion criteria were as follows: (1) preoperative administration of anticancer therapy (chemotherapy or radiotherapy); (2) the pathological diagnosis was not clear; and (3) imaging analysis based only on non-radiomics methods.Two investigators (L-ZK and YJ) independently extracted the number of BC and non-BC cases, sensitivity, and specificity reported in the eligible studies. Using these data, we calculated the number of true positive (TP), false positive (FP), true negative (TN), and false negative (FN) results. If there were more than one model in the same group of patients, we used the model with the higher diagnostic accuracy in our meta-analysis. All studies included were quality assessed using the QUADAS-2 scale  in RevmaI2 statistics. The summary receiver operating characteristic (SROC) curve and the area under the SROC curve (AUC) were also constructed to evaluate the diagnostic value of combined studies  and 0.83 , respectively. The AUC based on the SROC curve was 0.91 , study design (prospective and retrospective), data source (China and America), modeling method . Both conventional and functional imaging analyses provided a high diagnostic accuracy of BC. The results are displayed in We compared the preoperative predictive value of radiomics in the diagnostic performance of BC in different studies. The results showed that the diagnostic value of radiomics was high in predicting BC with an aggregated sensitivity, specificity, and AUC of 0.84, 0.83, and 0.91, respectively. Although the number and types of features varied among the 19 included studies, which may influence the aggregated sensitivity and specificity, radiomics was shown to have good predictive ability of BC in each study. Significant heterogeneity was identified in our study. Specifically, the screening methods, selection of the scanner manufacturer and model, acquisition methods, and reconstruction parameters were shown to contribute to the heterogeneity in imaging data.Sensitivity analyses showed that our results were reliable and stable after each study was sequentially removed, and the unreported adjusted variables were omitted.The specificity and AUC of conventional and functional imaging analyses were similar, but conventional imaging had a slightly higher sensitivity. A possible explanation is that conventional imaging analyses included in this meta-analysis were combined with special examination methods. Li et al. combined the radiomic analysis of breast tumors and the parenchyma to improve the diagnostic accuracy of BC . Luo et The preoperative diagnosis and clinical staging of BC are implemented mainly through the visual observation and analysis of medical images. The BI-RADS  score isOur meta-analysis of preoperative BC prediction using radiomics methods has two advantages. First, to the best of our knowledge, this study involving 19 articles and 5865 breast masses is the first meta-analysis to assess the diagnostic efficacy of radiomics models in predicting BC before surgery. Secondly, this study evaluated the diagnostic efficacy of radiomics models in predicting BC by comparing imaging modalities, modeling methods, and other subgroups, thereby providing ideas for subsequent radiomics research.There are several inherent limitations to this study that need to be discussed. First, the methodology of radiomics studies included in this analysis was different as different medical centers use various examination equipment, and the selection of imaging modality, feature extraction, and modeling methods provides an infinite number of combinations. Second, the code used for feature extraction and model building was not publicly available for any of the 19 studies included in this analysis, preventing replication and independent validation of the research results. Third, because our study used summary statistics rather than individual raw data, it was not possible to achieve more reliable results. However, it was possible to achieve more precise delineation and control potential residual confounding, a common limitation of meta-analyses.Our study shows that radiomics models based on preoperative imaging features are useful for the prediction of BC and have high diagnostic efficacy and consistency among studies. Radiomics is expected to provide a new quantitative diagnostic method for clinical work, but more well-designed prospective radiomics trials are needed to demonstrate its effectiveness and ability to translate into clinical practice.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Guarantor of the integrity of the study: HS. Study concepts: JY. Literature research: ZL. Data acquisition: HD and YW. Data analysis: DL and ZL. Statistical analysis: HS and FZ. Manuscript preparation: ZL and YC. Manuscript editing: ZL and YC. Manuscript review: DL, HS, and JY.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Consensus regarding the need for adjuvant radiotherapy (RT) in patients with atypical meningiomas (AMs) is lacking. We compared the effects of adjuvant RT after surgery, gross total resection (GTR), and subtotal resection (STR) on progression-free survival (PFS) and overall survival (OS) in patients with AMs, respectively.We performed a systematic review and meta-analysis of the literature published in PubMed, Embase, and the Cochrane Library from inception to February 1, 2021, to identify articles comparing the PFS and OS of patients receiving postoperative RT after surgery, GTR and STR.We identified 2307 unique studies; 24 articles including 3078 patients met the inclusion criteria. The sensitivity analysis results showed that for patients undergoing undifferentiated surgical resection, adjuvant RT reduced tumor recurrence  with no significant effect on survival . Postoperative RT significantly increased PFS  and OS  in patients undergoing GTR. The same improvement was observed in patients undergoing STR plus RT . A subgroup analysis of RT in patients undergoing GTR showed no change in PFS in patients undergoing Simpson grade I and II resection  but significant improvement in patients undergoing Simpson grade III resection .Regardless of whether GTR or STR was performed, postoperative RT improved PFS and OS to varying degrees. Especially for patients undergoing Simpson grade III or IV resection, postoperative RT confers the benefits for recurrence and survival. Meningiomas are the most common primary tumors of the brain, representing more than one-third of all intracranial tumors . AccordiAlthough the effect of postoperative RT on AMs has been analyzed in many reports, the results were inconsistent. Therefore, it is necessary to perform a meta-analysis to evaluate the efficacy of surgical resection with RT on survival outcomes, including overall survival (OS) and progression-free survival (PFS), in patients suffering from AMs.We comprehensively searched eligible studies using several electronic databases, including the PubMed, Embase, and Cochrane databases and followed PRISMA guidelines. Search terms included a strategic combination of ‘atypical’ AND ‘meningioma’, or ‘atypical meningioma’ or ‘grade II meningioma’. All papers published until February 1, 2021 were included. The titles and abstracts of each article searched were reviewed to exclude any apparently unrelated research. The full texts of the remaining articles were read to determine whether they contained information on the subject under review.Two investigators independently reviewed each eligible study, with a consensus being reached by the third investigator when there was a disagreement between the two investigators. Articles that satisfied the following criteria were included: (1) cohort studies or randomized controlled trials, (2) patients with atypical meningioma verified by pathology, (3) studies that investigated different treatment modalities, including GTR and STR plus RT, and (4) OS and/or PFS data that were provided or allowed for the calculation of hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). Studies were excluded based on any of the following criteria: (1) reviews, letters, case reports, and database-based studies; (2) studies with a sample size of less than 20; (3) non-English studies, studies with duplicate data; and (4) studies that lacked key information for calculation. The definitions of GTR and STR were based on the description in the original article. In general, GTR was defined as a Simpson Grade I or II tumor resection, or Simpson Grade I, II or III tumor resection, and STR was defined as a Simpson Grade IV tumor resection. In addition, to further clarify the potential impact of GTR plus RT on AM under real-world conditions, a subgroup analysis of the GTR group was performed according to Simpson’s classification. Radiotherapy was considered to include both conventional radiotherapy and stereotactic radiosurgery (SRS).Two investigators independently assessed the quality of each eligible study using the Newcastle-Ottawa Scale . Three a2 statistic and Cochrane Q test were used to analyze between-study heterogeneity  with a 95% CI was used to evaluate the association of postoperative radiotherapy. The lnHRs were considered to obey a normal distribution. We extracted the HRs and corresponding 95% CIs of the multivariate analysis explicitly given in these articles; otherwise, the HRs and 95% CIs of the univariate analysis were utilized. If the above value was not provided in the paper, the Kaplan-Meier survival curve in the paper was used to transform the Figure into a data sheet and used the log rank test to obtain the lnHR, 95% CI and SE . The I2 The process of literature screening based on the inclusion and exclusion criteria is depicted in 2 statistic for heterogeneity were 0.00001 and 87%, respectively. Similarly, for OS, the P value and I2 were 0.004 and 68%, respectively. This result indicated that both studies were heterogeneous, so we applied a random-effects model. Benefits of RT were found in both the PFS and OS analyses . The publication bias of the PFS and OS analyses is shown as a funnel graph in 2 statistics for heterogeneity were 18% (p = 0.26) and 0% (p = 0.53), respectively, which indicates that the remaining studies are homogeneous. Thus, the fixed-effect model is used to present the results in In the analysis of PFS and OS in atypical meningioma patients treated with surgery and RT or surgery alone, 19 and 7 studies were included, respectively, and the results are shown in 2 statistic for heterogeneity were 0.00001 and 83%, respectively. In the OS analysis, the P value and I2 were 0.47 and 0%, respectively. This result indicated that the former was heterogeneous and the latter was homoplasmic, so we applied a random-effects model and fixed-effects model, respectively. Benefits of RT were found in both the PFS and OS analyses . As shown in the funnel diagram in 2 = 38%, P = 0.01), and a fixed-effects model was used to present the results . Benefits of RT were found in both the PFS and OS analyses . A funnel plot , so a fixed-effects model was used to present the results  and an 11% reduction in mortality (p=0.49) compared with surgery alone, especially for the former, indicating that postoperative RT was associated with a significant improvement in PFS. Therefore, it is considered reasonable to consider postoperative RT for patients when the extent of surgical resection cannot be determined.2 = 89%) and lack of statistical significance (p=0.22). We suggest that grade III resection should not be attributed to GTR but should be treated as STR based on a combination of surgical records and postoperative MRI examination. According to our clinical experience, tumors in sites such as the cavernous sinus, the paraclinoid process, and the petroclival region may adhere to important structures such as the internal carotid artery, the basilar artery, and the brain stem. Although postoperative MRI and other imaging studies have failed to detect residual tumors, the presence of residual parenchyma is noted in the surgical record, and postoperative RT is recommended, especially in view of OS improvement. In summary, we believe that for patients with GTR, postoperative RT should be given appropriately, but tumor recurrence should be closely monitored, especially in Simpson grade I or II resection patients. In addition, the ROAM/EORTC 1308 trial (ISRCTN71502099), a multicenter, phase III, randomized controlled trial, has been developed to better answer whether early adjuvant radiotherapy for patients who have undergone GTR of AMs reduces recurrences compared with monitoring (The debate over whether postoperative RT should be routinely performed in patients with GTR is most intense. Some people suggest that because of the thoroughness of resection, patients with GTR have fewer tumor recurrence events and longer survival times than patients with STR, so no postoperative RT is required , 29. A mnitoring .It is generally accepted that patients with STR should be treated with postoperative radiation due to residual tumors after surgery , especiaThere may be some side effects from radiotherapy, which must be considered for postoperative RT . The ComThere is significant clinical and methodological heterogeneity in our systematic review, which can be evidenced by the wide range of patient numbers, ages, follow-up times, radiation doses, modes of radiotherapy and definitions of GTR and STR classifications. The only known prognostic factor for AM is the extent of resection; however, age , tumor vThe WHO classification definition of AMs changed in 2000, 2007 and 2016. All the studies included were retrospective cohort studies. Therefore, more prospective and long-term follow-up studies are needed to better verify the impact of RT on prognosis. The large sample size also brings some heterogeneity. Finally, the exclusion of non-English literature may leading to potential language bias.Maximum surgical resection with guaranteed safety is currently recognized as the preferred treatment for AM, but whether to perform postoperative RT remains a controversial issue. To the best of our knowledge, the present study is the largest meta-analysis on this topic using high-evidence-level HR data and reveals the benefits of postoperative RT assistance in patients with AMs, especially for OS. Regardless of whether GTR or STR is performed, postoperative RT was found to effectively increase PFS and OS to varying degrees. Especially for patients undergoing Simpson grade III or IV resection, postoperative RT confers the benefits for recurrence and survival. Moreover, long-term surveillance should be tailored based on the Simpson grade of AMs. Clinical trials such as ROAM will investigate further.The original contributions presented in the study are included in the article/DS and DX have contributed equally. DS: data processing and manuscript writing, DX: conception and data collection. HH and GW: critical review. QG, MZ, and FW: data collection and evaluation. FG: conception and critical review. 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This special cohort reveals the effect of smoking cessation in occupational miners exposed to radon and arsenic.A total of 9,134 tin miners with at least 10 years of underground radon and arsenic exposure were enrolled beginning in 1992 and followed for up to 27 years. Detailed smoking information was collected at baseline, and information on smoking status was consecutively collected from 1992 to 1996. The Cox proportional hazards model was used to explore the relationship between time since smoking cessation and lung cancer.A total of 1,324 lung cancer cases occurred in this cohort over 167,776 person-years of follow-up. Among populations exposed to radon and arsenic, miners after quitting smoking for 10 years or more had almost halved their lung cancer risk , compared with current smokers. Among miners after quitting smoking for 5 years or more, lung cancer incidence approximately halved  for squamous cell lung carcinoma, while it showed no significant decline for adenocarcinoma .Smoking cessation for 10 years or more halved lung cancer incidence among miners exposed to radon and arsenic, and the benefit was more pronounced among squamous cell lung carcinoma. What is already known about this subject?Preliminary studies suggest that there exist joint effects between radon, arsenic, and smoking. Quitting smoking reduces not only smoking-related lung cancer, but also smoking-radon- and smoking-arsenic-related lung cancer. However, there is no prospective cohort to report the effect of years of smoking cessation on lung cancer incidence among miners exposed to radon and arsenic.What are the new findings?Among miners exposed to radon and arsenic, smoking cessation of at least 10 years would halve lung cancer incidence, and the benefit was more related to squamous cell lung carcinoma.How might it impact policy in the foreseeable future?To reduce the burden of lung cancer, smoking cessation is urgently needed among radon and arsenic miners. The longer years of smoking cessation should be emphasized among occupational miners than the general population.Lung cancer remains the most common cancer with respect to both incidence and mortality, both in China and throughout the world , 2. TobaWhile it is clear that smoking cessation reduces lung cancer risk in general populations, this topic has been rarely investigated in occupational epidemiological studies. Population-based studies suggested a sharp decrease in lung cancer risk for over 50% in the first 5 years after smoking cessation , 10. HowGlobally, no studies to date have reported the effect of smoking cessation on lung cancer in occupational populations exposed to radon and arsenic. Among occupational radon cohorts, although Colorado Plateau cohort and German uranium miners collected individual smoking data, they have not revealed the effect of smoking cessation, and other cohorts generally lacked complete smoking information –15. SimiAmong Chinese Tin miner studies, the results from case–control and cohort studies for several decades have identified that radon, arsenic, and smoking are the main risk factors for lung cancer –22. In aThe design and inclusion criteria of the Yunnan Tin Corporation (YTC) cohort was described previously , 23. BriAll miners were enrolled at baseline (in 1992) and information on age of start/stop smoking, type of tobacco , and smoking status was collected. According to the smoking status at baseline, we divided miners into smokers, former smokers, and never smokers. At baseline, individuals who had smoked regularly for 6 months or longer at any time in their lives were classified as smokers, and those who have a smoking duration of less than 6 months were considered never smokers and smokers who ceased smoking at enrollment were former smokers. In addition, to test the stability of smoking status, for each miner, information on smoking status and type of tobacco was collected for five consecutive years from 1992 to 1996. The change of smoking status for at least two consecutive years was identified as “the real behavior change” from 1992 to 1996. A total of 161 former smokers who restarted smoking were excluded.However, the impact of type of cigarette was not considered in this study, because most of the participants were mixed smokers: at baseline, 62.4%  used cigarette + waterpipe, 29.3%  used cigarette only, and 8.3%  used waterpipe only among current smokers; 53.6%  of cigarette-only and 53.6% (306/571) of waterpipe-only smokers became mixed smokers in the next 4 years. Thus, the impact of type of cigarette was not considered in the final analysis.Therefore, based on previous findings, we calculated a cigarette-equivalent variable adjusting conservatively: 1 g water pipe = 1 cigarette. Smoking intensity was measured by the number of cigarettes smoked per day and pack-years were calculated as the average number of cigarettes per day (divided by 20) times the number of years of smoking. Finally, smoking pack-years as a continuous variable was included into the multiple Cox proportional hazards model.3, medium group: ≥40 and <100 mg/m3, and high group: ≥100 mg/m3. Finally, we combined these groups into three new groups named occupational exposure groups: lowly exposed group: low radon group and low arsenic groups; moderately exposed group: low radon–medium arsenic, medium radon–low arsenic, and medium radon–medium arsenic; highly exposed group: either high radon group or high arsenic group . In addition, other information including age, sex, education level, and prior lung disease was also collected for each participant.Detailed definitions of occupational radon and arsenic exposures were given elsewhere , 23. In From 1992 to 1999, annual follow-up was conducted combined with screening by chest radiography and sputum cytology. In 2005 and 2006, the first post-screening follow-up was performed and participants were followed until December 31, 2001. In 2019, an extended follow-up was conducted, and the survival status, total cause of death, cancer diagnosis, and death information were collected.The primary outcome was lung cancer incidence, which was from the local cancer registration agency, medical record system, and funeral parlor, and face-to-face interviews with relatives and workmates of the participants. In the process of information extraction, participants’ name, age, work units, and home address were taken into consideration. By the end of December 31, 2018, 187 participants (2.1%) were lost to follow-up, with a follow-up rate of 97.9%.via the following ways: (1) histology ; (2) cytology (from sputum sample or endoscopy brushing); (3) x-ray; and (4) others .Lung cancer cases were confirmed Person-years of follow-up were calculated from the date of enrollment to the date of lung cancer incidence or date of death or censoring as of December 31, 2018. Descriptive statistics was used to show various characteristics among never, former, and current smokers at the baseline. The association between time since smoking cessation and risk of lung cancer incidence was analyzed by the Cox proportional hazards model. Schoenfeld residuals were used to check the proportional hazards assumption. To control the effect of occupational exposures (radon and arsenic), Cox proportional hazards model was performed to calculate the hazard ratio (HR) and 95% confidence interval (95% CI) in three different occupational exposure subgroups . Furthermore, to reduce potential residual confounding by occupational exposure, we also modeled occupational exposure as continuous variables into the statistical analysis within each exposed stratum. In addition, in the multiple Cox proportional hazards model, other variables including age at entry, sex, education level, family history of lung cancer in first-degree relatives, and prior lung disease  were adjusted to eliminate confounding effects. Finally, since the loss of follow-up rates and missing data were very low, those with missing values were not included in the analysis. SAS and R software were used for statistical analysis.The characteristics of the YTC miners in subgroups of smoking status at baseline are shown in The evaluation of the stability of smoking status for 5 consecutive years in the YTC cohort is shown in p < 0.001 for trend test) of lung cancer incidence was observed with increasing years of smoking cessation for all former smokers, despite the fact that significant risk reduction did not manifest within the first 1 year , 2–5 years , and 6–10 years  of cessation. Furthermore, the risk of lung cancer incidence was nearly halved for 10+ years . Furthermore, we observed the effect of smoking cessation stratified by radon and arsenic exposure. Among miners from the highly exposed group, they showed similar patterns to all miners, which is shown in p < 0.001 for trend test), and finally, the risk in those quitting for over 5 years was 0.52 (95% CI: 0.30-0.92), which was similar to the risk in never smokers .As most women in our cohort were never smokers, a sensitivity test had been conducted and indicated that our analysis was robust Table S2The YTC cohort with about 27 years of follow-up firstly reported that smoking cessation was associated with a substantial reduction in lung cancer incidence among underground miners exposed to radon and arsenic. For all lung cancer, about a 50% decrease in the risk of lung cancer incidence was shown in nearly 10 years for miners exposed to radon and arsenic. In addition, the long-term beneficial effect was weakened for adenocarcinoma, compared with squamous cell carcinoma.In male participants among YTC miners, the risk of lung cancer among current smokers was lower than that of Western countries, Japan, Hong Kong, and the rest of mainland China –26. It cIn addition, our results showed that the longer the smoking cessation time at baseline, the lower relapse rates for former smokers during the follow-up period. In cohort studies, smoking status at baseline might change over time, which resulted in bias in the true association between exposure (smoking status) and outcome (lung cancer risks). Therefore, a definition of smoking cessation with stable relapse rate was crucial in the cohort study, and our data showed that the relapse rate of quitting smoking at least 5+ years was as low as 7.8%. Because the definition of former smoker varied by study—quit smoking at least 6 months+ , 1+ yearExisting lines of evidence have illustrated a definitive benefit of smoking cessation in relation to lung cancer risks. Notably, smoking cessation is associated with a decrease in relative risk of lung cancer in former smokers compared to current smokers, but the absolute lung cancer risk in former smokers does not decrease from smoking cessation. However, the temporal pattern of this risk after smoking cessation is still controversial. In a previous case–control study in Hong Kong, Lap et al. observed that compared to current smokers, there is a rapid decrease in lung cancer risk across most histological types of lung cancer within the first 5 years of quitting, and then it almost remained constant. However, Sadik et al. had conducted a meta-analysis and found that a continued progressive reduction in lung cancer risk resulting from smoking cessation would remain at least 15 years . In addiGenerally, most epidemiological studies regarding smoking cessation and lung cancer risk were conducted in the general population, and it has been rarely investigated in occupational epidemiological studies. It appeared that this delayed decrease in lung cancer risk was more common among individuals with occupational exposure. A cohort study conducted among Australian workers exposed to asbestos found that the lung cancer mortality rate ratio among insulators dropped steeply during the first 10 years after quitting smoking . A largeIn the YTC, the risk of SQC incidence among workers highly exposed to radon and arsenic was nearly halved after 15 years or more since cessation, but the reduction was smaller for ADC. The benefit of smoking cessation was more prominent for SQC, which was consistent with findings from other studies , 27, 37.The strength of this study was that it was a large, prospective population-based cohort that included detailed personal, occupational, and smoking information. There were still some limitations. The closed underground mines and the high smoking rate might have resulted in secondhand smoke exposure to non-smokers, and further biased risk estimates downward (toward the null). Moreover, the histology information was lacking for nearly half of lung cancer cases, which would decrease the statistical power when the analysis was conducted according to histology. Finally, 4.0%  of lung cancer cases was measured by the face-to-face interviews with relatives and workmates of the miners, which may be inaccurate and lead to recall bias. In this study, we had added the exposures (radon and arsenic) together without any weights, which might bias the results due to the different risks of lung cancer by radon and arsenic. Therefore, studies directly comparing the lung cancer risks from radon or arsenic should be conducted in the future.In conclusion, our study firstly reported that among workers exposed to radon and arsenic, the benefit of smoking cessation is more related to squamous cell lung carcinoma. A tailored smoking cessation strategy is needed among the occupational population exposed to radon and arsenic.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 institutional review boards of the National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences. The patients/participants provided their written informed consent to participate in this study.Y-GF and F-HZ had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Conception and design: Y-LQ. Data collection: ZS and Y-GF. Analysis and interpretation: ZS. Drafting the article: ZS and X-HJ. Manuscript revision: ZS, Y-GF, and Y-LQ. All authors contributed to the article and approved the submitted version.This work was supported by Cancer Foundation of China (grant No. CFC2020KYXM001) and Key R & D projects of Science and Technology Department of Sichuan (grant No. 2020YFS0212). Tianjin Key Medical Discipline  Construction Project (grant No. TJLCMS2021-02).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objectives: This study aimed to investigate the role of serum levels of transient receptor potential cation channel subfamily V member 1 (TRPV1), vasoacive intestinal peptide (VIP), and pituitary adenylate cyclase-activating polypeptide (PACAP) in the development and also the transformation of migraine in patients suffering from migraine.Methods: Eighty-nine participants with a mean age of 39 years were divided into 23 episodic migraine (EM), 36 chronic migraine (CM), and 30 healthy control groups. Demographic, anthropometric, and headache characteristic information, and also blood samples, was collected. Serum levels of TRPV1, VIP, and PACAP were measured using the enzyme-linked immunosorbent assay (ELISA) technique.Results: Based on our findings, the serum level of TRPV1 was significantly higher in CM compared to the control group (p < 0.05), whereas serum levels of VIP (p < 0.01) and PACAP (p < 0.05) in the EM group were significantly more than the control group. There was no significant difference between EM and CM groups.Conclusions: An elevation in the serum levels of TRVP1 among chronic migraineurs and increments in the levels of VIP and PACAP were observed among EM patients compared to healthy subjects. However, our data failed to demonstrate the probable role of these biomarkers in migraine progression, and more studies are needed to clarify the molecular mechanisms involved in migraine progression. Migraine is a prevalent debilitating neurological disorder with moderate to severe headache which lasts 4 or 72 h. Headache is often unilateral with associating symptoms of photophobia, phonophobia, nausea, or vomiting . In one-Migraine imposes a heavy socioeconomic burden on society and this is while its exact mechanism is not yet fully known , 4–9. Ge+ and Ca2+ permeable channel, is among the other factors which are assumed to play a role in migraine pathogenesis. TRPV1 could be activated by capsaicin, severe heat, low pH, inflammatory factors, and some lipid-derived substances such as anandamide , individuals with episodic migraine , and healthy subjects . Based on the convenience sampling method, the sampling process was performed from September 2017 to June 2020 at Sina University Hospital Headache Clinic, Tehran University of Medical Sciences, Tehran, Iran. Following an advertisement using posters describing the study aims placed all over the hospital (primarily in headache clinic), the patients with migraine and the age- and sex-matched non-headache controls, who were healthy subjects from the hospital staff or patient companions, were included in this study. Diagnosis of EM and CM was performed by a neurologist based on the third edition of International Headache Society criteria (ICHD-III)  with an average age of 39 years who were divided into three groups including subjects with chronic migraine  .2, not being pregnant or breastfeeding, and not having a positive medical history for any of the following disorders: cardiovascular, infectious, or endocrinological diseases, renal, hepatic, immunological, and allergic disorders, and also other chronic neurological diseases such as Alzheimer's disease, multiple sclerosis, epilepsy, or Parkinson's disease. Besides, having migraine headaches (with or without aura) for at least 6 months prior to the study and excluding the diagnosis of medication overuse headache (MOH) were the specific inclusion criteria for the case group. Subjects who did not meet the mentioned conditions or were unwilling to fill out a questionnaire were excluded. The study protocol was approved by National Institute for Medical Research Development (NIMAD) (grant number 957537) and confirmed by the ethical committee of NIMAD with ID: IR.NIMAD.REC.1396.054. After a complete explanation of the research process, all participants filled out the consent forms.The inclusion criteria considered for enrolling in this study were as follows: age range between 18 and 65, having a body mass index (BMI) between 18.5 and 35 kg/m2). For the purpose of body weight measurement, Seca Clara 803 digital scale  was used. Height was also measured using a Seca 216 wall-mount stadiometer  in bare feet. The patients were also questioned about the number and type of abortive or analgesic medication use 30 days after the first visit.After the initial interview and demographic data collection, anthropometric measurements were performed based on the method provided by the World Health Organization. Height and weight were measured to calculate BMI that was obtained as weight (kg) divided by height squared  and migraine and its type were determined based on ICHD-III criteria . PatientA 10-ml blood sample was collected from each EM participant at the second visit, about 30 days after the first visit and at least 72 h after his/her last headache attack to be more indicative of the interictal phase of migraine. For CM cases, since the headaches lasted more than 15 days (between 15 and 30 days) per month, it was not possible to collect blood samples in the interictal phase. Blood samples were divided into 18 microtubes that were stored in −80°C freezers and 10 microtubes that were kept in −20°C freezers. All serum samples were sent to the laboratory of Sina Hospital for biochemical studies. Serum levels of target factors  were then measured using commercial enzyme-linked immunosorbent assay (ELISA) kits from Bioassay Technology Laboratory  and Crystal day Biotech Co. . Serum levels of these biomarkers were measured as per instructions of the manufacturers of the ELISA kits. All assays were carried out in triplicate. The intraassay and interassay coefficient of variation (CV) was <8 and <10%, respectively.t-test, or Mann–Whitney U-test was applied for analyzing the categorical or continuous variables between the studied groups. Kruskal–Wallis and its related post hoc t-test were used for making comparisons between the groups. In all statistical tests, a p-value < 0.05 was considered significant.SPSS software version 24 was used for data analysis. The normality of the data was evaluated using the Shapiro–Wilk test. All quantitative data were reported as mean [standard deviation (SD)] or median  and all qualitative data as percentage and frequency. Chi-squared test, independent-sample n = 30), CM (n = 36), and EM (n = 23). The mean (SD) of age and BMI of participants are presented in Eighty-nine participants (71 women and 18 men) with a mean age of 39 years were divided into three groups including control  vs. 6.00 (4.17), p-value < 0.001].The mean of headache characteristics including frequency, duration, and severity of headache and also the use of abortive drugs were compared between episodic and CM groups. As presented in n = 16 (69.6%)] compared to the CM [n = 14 (38.9%)] group. No significant differences were observed between EM and CM groups on the use of other mentioned drugs.The medication consumption of studied subjects at baseline and after the intervention consisted of abortive  and prophylactic drugs  were also compared between chronic and episodic migraineurs. Based on the results, there was a significant increase in NSAID intake in the EM group [p-value = 0.034], but no significant differences were observed in the comparison of the EM and the control groups. Also, a comparison of serum levels of TRPV1 between the EM and the CM showed an insignificant difference. On the other hand, there was a significant increase in the median (IQR) value of VIP in the EM group when compared to the control group . However, no significant differences in the serum level of VIP were found in the CM group as compared to the EM or control subjects. In addition, it was demonstrated that the median (IQR) value of PACAP in the EM group was significantly greater than that of the control group . However, PACAP elevation in the EM group was not significant compared to the CM group. Furthermore, the increment in PACAP levels in the CM group was insignificant when compared to the control group.The serum levels of TRPV1, VIP, and PACAP in the control, CM, and EM groups are presented in In this study, to investigate some molecular alterations involved in migraine chronification, serum levels of TRPV1, VIP, and PACAP were evaluated in patients with episodic and CM, and also healthy individuals. Based on our findings, the elevation of serum levels of VIP and PACAP was observed in patients with EMs but TRPV1 levels were higher in the serum samples of patients suffering from CMs when compared to the healthy subjects. The current findings might suggest a possible role for these factors in migraine pathogenesis, though more research is required in this area.Unfortunately, migraine headache in 14% of episodic migraineurs can change to chronic type, which are much more severe and prolonged –25. So fDuring the recent decades, the activation of sensory neurons in trigeminal ganglion has received more attention in the pathophysiology of migraine. TRPV1, a non-selective cation channel, is abundantly expressed in the trigeminal ganglion and its activation might lead to release of several neuropeptides involved in central sensitization including CGRP, VIP, PACAP, and substance P. These molecules are peripherally secreted from trigeminal afferents and induced intracellular elevation of cAMP or cGMP with consequent vasodilation and inflammatory events within both the dura mater and trigeminal ganglion, which is important in triggering and amplification of pain , 29. TRPRecent research has revealed that TRPV1 single-nucleotide polymorphism may be considered as a risk biomarker of episodic to CM transformation . CM patiVasoactive intestinal peptide is one of the most important neuropeptides secreted from parasympathetic perivascular nerve fibers in the trigeminovascular system and acts as a potent vasodilator . Parasym1 and VPAC2, with similar affinity. PACAP has an additional specific receptor, PAC1, which has a higher affinity for PACAP than for VIP  in CM patients, they do not have a true interictal phase of migraine and it was not possible to assess their serum biomarkers between attacks. A number of limitations can be mentioned for this study; first, as the peripheral levels of TRPV1, VIP, and PACAP were assessed merely in the interictal phase of migraine in EM patients, to achieve more comprehensive results, it is necessary to measure the CSF and serum levels of these biomarkers both between and during attacks in EM patients. Another limitation of this study was the lack of a prior sample size estimation. Moreover, applying a powered longitudinal study design, especially for exploring intraindividual longitudinal changes in these biomarkers and also the confounding factors (including medications use and comorbidities), could further clarify the associations between levels of TRPV1, VIP, and PACAP and migraine progression or reversion, which needs additional studies in the future.In conclusion, compared to healthy controls, a significant elevation in the serum levels of TRVP1 was noted among chronic migraineurs. Besides, significant increments in the levels of VIP and PACAP were observed among EM patients. These findings might be a point to investigate new strategies for antimigraine drugs. However, our data failed to demonstrate the probable role of these biomarkers in migraine progression, and more studies are needed to clarify the molecular mechanisms involved in migraine progression.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by National Institute for Medical Research Development (NIMAD) (grant no. 957537) and confirmed by the ethical committee of NIMAD with ID: IR.NIMAD.REC.1396.054. The patients/participants provided their written informed consent to participate in this study.Content preparation, study design, acquisition, and analysis of data were all done by MT and ZG. SR, ZG, and MT drafted the manuscript. The manuscript was critically revised by MT, ZG, FK, and FZ. All authors contributed to the article and approved the submitted version.This research was supported by National Institute for Medical Research Development (NIMAD) (grant number 957537).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


However, ACTH (n = 10), rituximab (n = 7), immunoglobulins (n = 4), cyclophosphamide (n = 3), and mycophenolate (n = 2) were also administered. ACTH was associated with a high percentage of patients who healed (80%) and, as a first-line therapy, was associated with a lower incidence of relapses. An early treatment was associated with a favorable long-term outcome. Long-term sequelae occurred in 42% of patients who were treated early and in all of those who were treated late. It is advisable for the affected children to be identified at an early time, as they may benefit from an early treatment. ACTH represents an effective treatment with a high probability of recovery and low rate of relapses.Opsoclonus-myoclonus syndrome (OMS) is a neurological non-fatal disease that usually responds to immunotherapies. However, the real challenge is to counteract the high frequency of relapses and long-term developmental sequelae. Since the OMS is extremely rare, a common consensus regarding therapeutic guidelines is still lacking. The goals of this study were to test whether ACTH was superior to other immunotherapies and to investigate whether an early treatment could improve the outcome. Sixteen children affected by OMS were retrospectively reviewed. Eight children had a neuroblastic tumor. The other eight patients were affected by non-paraneoplastic OMS. Overall, the most commonly used treatment was corticotherapy ( Opsoclonus-myoclonus syndrome (OMS), also known as “dancing eye syndrome”, is a rare neurological disorder characterized by rapid, involuntary, chaotic eye movement (opsoclonus), myoclonus, and ataxia. Opsoclonus consists of sudden, involuntary, chaotic, arrhythmic, and multidirectional  conjugate saccadic ocular movements. OMS is often associated with additional manifestations, such as irritability and sleep disturbances.The etiology is still not clear and is different between children and adults. In about 50% of pediatric cases, the disorder is associated with neuroblastoma or ganglioneuroblastoma, with abdominal or thoracic localization, and generally with favorable histological features . The symThe incidence of pediatric OMS is 0.18 cases per million total population per year . The meaThe lack of specific criteria for the identification of OMS disease leads to a delay in diagnosis. Due to the earlier appearance of ataxia, OMS is often misdiagnosed as acute cerebellar ataxia, especially when opsoclonus is not detectable. The differentiation of OMS from acute cerebellar ataxia is crucial since, according to some studies, early diagnosis and treatment may prevent some residual neurological and behavioral consequences of this disease ,9,10,11.Since the OMS is extremely rare, no randomized control trials concerning the treatment are available and, accordingly, therapeutic guidelines are missing. At the present time, immunotherapies such as steroids, adrenocorticotropic hormone (ACTH), intravenous immunoglobulin (IVIG), and different other therapies  are the main tools for the treatment of neurological symptoms ,13. FurtRemarkably, the outcome seems to be independent of the presence of neuroblastoma.In the present retrospective study, we describe the clinical characteristics and outcome of 16 pediatric patients with OMS. We aimed to investigate whether an early treatment could improve the outcome and to test whether ACTH was superior to the other immunosuppressant drugs.Medical charts of 16 children  with OMS, consecutively hospitalized in Bambino Gesù Childrens’ Hospital from January 2007 to December 2020, were reviewed. The mean age of the patients was 32.2 months (range of 8–186 months). Their clinical and demographic characteristics are shown in Moreover, we took into account the putative trigger of OMS . The diagnosis of the tumor was confirmed by a histopathological examination. The tumor location was abdominal or thoracic . The tump-value of <0.05 was considered statistically significant.The prevalence of different categories for each variable was analyzed. Chi-square (ꭓ²) statistics were used to determine the difference in the distribution of categorical variables among the study groups. Z-score statistics were used to determine the difference in the distribution of numerical variables. A All of the patients underwent brain MRI or TC, which resulted as normal. In addition, all of the patients underwent chest-abdomen CT or MRI. In eight children, neuroblastoma or ganglioneuroblastoma were found. The other eight patients were affected by non-paraneoplastic OMS. All of the patients were tested for the presence of neurotropic virus Herpes simplex, Varicella-Zoster, Epstein-Barr, Cytomegalovirus, HHV-6, Parvovirus, Coxsackie, Adenovirus, and auto-antibodies in cerebrospinal fluid (CSF). Two children were found positive for HHV-6 and two patients were diagnosed with anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis, while for the other four patients the trigger factor remained unknown. Nine of the sixteen patients underwent electroencephalography (EEG) that resulted as normal in seven subjects. In a child affected by neuroblastoma, EEG was characterized by slow waves in the right temporal region, while in the remaining patient who is affected by the anti-N-methyl-D-aspartate receptor (NMDAr) antibody encephalitis, EEG showed an asymmetric cerebral electric activity with slow waves on the left hemisphere.p = 0.3 for ataxia, p = 0.25 for opsoclonus, p = 0.25 for behavioral disorders, and p = 0.13 for insomnia).The clinical characteristics of OMS patients are shown in The treatment differed between patients with paraneoplastic OMS and patients with idiopathic OMS.2/die, 3 consecutive days per month for 12 months). Three patients (37.5%) had a good response, while the remaining five (62.5%) had a neurological relapse and required a second-line medication. In the latter group, two patients recovered after the ACTH and cyclophosphamide treatment, respectively. The remaining three children are still under treatment, with rituximab, chemotherapy (etoposide and carboplatin), as well as ACTH and steroids, respectively. They did not achieve full recovery from the neurologic symptoms.Eight patients affected by the tumor were treated with a multimodal approach, based on the tumor removal and followed by a 12-month-cycle of corticosteroids. Specifically, they received dexamethasone , probably due to the small number of patients. Other immunotherapies  were more rarely administered. Therefore, reliable information on their effectiveness cannot be issued from our population. In our group, more than half of the children had neurological relapses after the first treatment (10/16) (63%). Interestingly, no patient who had ACTH as a first-line treatment showed a relapse. A statistically significant correlation was observed between the use of ACTH as a first-line treatment and the lower incidence of relapses (p = 0.01).Most of our patients were treated with more than one immunotherapy . CorticoNo significant side effects were observed in patients treated with corticosteroids or immunosuppressants. Only one patient treated with ACTH showed mild irritability, while two patients had weight gain during the treatment period. The side effects subsided after the withdrawal of ACTH.Among our patients, 13 have had a complete recovery of neurological capabilities and are currently neurologically normal. The remaining three patients had long-term neurological sequelae (cases 4 and 6 still show ataxia and case 7 shows tremor and ataxia) . Seven cp = 0.07).We tested the hypothesis that an early treatment could avoid the persistence of neurological or neuropsychiatric sequelae. In our patients, the mean time that elapsed between the onset of the symptoms and the start of treatment was 33.44 days (ranging from 1 to 240 days). The treatments that started before and after 15 days from the disease onset were considered as “early” and “late”, respectively. Therefore, 12 patients were early-treated and four patients were late-treated. Among the twelve patients treated early, 42% had neurological and/or neuropsychiatric sequelae (five patients) and 58% did not (seven patients). Neuropsychiatric sequelae included mild cognitive disabilities. All of the four late-treated patients developed sequelae (100%). The mean interval time between the OMS onset and treatment of patients with sequelae was 50.7 (±80) days, while it was 11.3 (±5.4) days for the patients who have fully recovered. The difference approached the statistical significance (OMS is a non-fatal disease that usually responds to immunotherapies. However, the real challenge is to counteract the high frequency of recurrence and sequelae. The most effective drug has not been defined yet and a common consensus regarding therapeutic guidelines is still lacking. This is mainly due to the poor knowledge of the pathophysiologic mechanisms of the disease. The pathogenesis of OMS involves the activation of the immune system and the elevation of T and B cells and other neuroinflammatory elements in CSF and blood . This obAlthough the role of ACTH in the OMS treatment has been well established since 1962  carried ACTH could work through a multiplicity of mechanisms, some immunological, others neural. Recently, corticotropin was found to reduce the elevated levels of B cell activating factor in opsoclonus-myoclonus cerebrospinal fluid .A study by Hammer et al. showed that a therapeutic response can be obtained only with ACTH, both for initial symptoms and relapses . In our A special note should be reserved for rituximab. Rituximab is a monoclonal antibody against CD20, which is expressed on B cells. Based on the identification of B cell expansion in many OMS patients by Pranzatelli et al. , rituximDespite the proven role of T cells in the OMS pathogenesis, suggested by the expansion of Gamma delta T cells subsets and the lower percentage of CD4+ T cells in CSF , targeteSome previous studies suggested that a prompt treatment is associated with a better outcome. De Grandis et al. reported a higher frequency of neurological sequelae in children treated after 2 months from the symptom onset than in those treated at an earlier time . SimilarThe present study shows that an early treatment is associated with a better prognosis with the reduced risk of neurological or neuropsychiatric sequelae. Regarding the type of drug, the patients who were treated with ACTH compared to corticosteroids showed a lower frequency of relapses and sequelae than those treated with other corticosteroids or an immunosuppressant. Although the response rate to the ACTH therapy for OMS is high, the general neurological prognosis is poor for more than half of the patients. Finally, it is not possible to draw unambiguous recommendations since it is a retrospective review with a few described patients. Furthermore, the generalization of the data is not possible. Therefore, additional studies are worthy of consideration.


Accordingly, RFS was significantly longer in patients operated on in HVC (p = 0.04). The difference in RFS remained significant after controlling for age, gender, tumor size, Ki-67 index, Weiss score, and type of surgery . In addition, there is a tendency towards longer DSS in patients in the HVC group compared to those in the LVC group (p = 0.05). These results point to the centralization of adrenal surgery as a key prerequisite for improving the outcomes of ACC patients.Complete surgical removal of adrenocortical carcinoma (ACC) represents the only chance of long-term cure. In this study, we compared the long-term outcomes of ACC patients depending on whether they had adrenal surgery performed in a high-volume (HVC) or in a low-volume (LVC) center. This retrospective study included 49 patients from the Croatian ACC Registry with the European Network for the Study of Adrenal Tumors (ENSAT) stage I–III ACC, of which 35 underwent surgery in a HVC whereas 14 of them were operated in one of the LVCs. Patients operated in the LVCs had a significantly higher rate of ACC recurrence (57.1% vs. 22.9%;  Management of rare diseases poses a major challenge to health systems in many ways. Patients with a rare disease commonly face the problem of a lack of specialized and coordinated medical care, resulting in a poorer outcome of their treatment. In this regard, centralized management of such patients is essential to improve the quality of their health care. Adrenocortical carcinoma (ACC) is a rare and aggressive neoplasm in which complete surgical removal of the tumor represents the only chance of a long-term cure . AccordiHowever, although several studies reported the results of adrenal surgery in patients with ACC, a relatively small number of them compared patients’ outcomes depending on center volume and surgeon expertise. Furthermore, the retrospective nature of these studies, with results potentially affected by important confounding factors, makes it difficult to draw definite conclusions. To add to the existing knowledge, this study compared the long-term outcomes of ACC patients depending on whether they had adrenal surgery performed in a high-volume (HVC) or in a low-volume (LVC) center.In this retrospective study, we included patients from the Croatian ACC Registry with the European Network for the Study of Adrenal Tumors (ENSAT) stage I–III ACC who had adrenal surgery between 2008 and 2020. Of 49 eligible patients, 35 underwent surgery in a HVC by a single surgeon, whereas 14 of them were operated on in one of the LVCs. Data on demographics, hormonal status, imaging, surgical and pathology reports, adjuvant treatment, and follow-up were collected from hospital records. The study was approved by the University Hospital Centre Zagreb Ethics committee. The diagnosis of ACC was based on Weiss histopathological criteria, except in patients with oncocytic ACC, in whom Lin–Weiss–Bisceglia scoring was used ,11. TumoThe centers were considered HVC if they had an average of >20 adrenal surgeries per year per surgeon in the last 10 years, of which at least two patients per year had ACC. All patients in the HVC were operated on by a single surgeon who was a urologist, whereas in the LVC, patients were operated on by a urologist or abdominal surgeon.The main outcomes of the study were differences between the groups in recurrence-free survival (RFS) and disease specific survival (DSS). RFS was calculated from the date of the ACC surgery to the date of tumor recurrence or the last imaging follow-up. DSS was calculated from the date of ACC surgery to the date of death related to ACC or the last follow-up visit. 2 test was applied for testing the difference between two categorical variables. Survival analysis was performed using the Kaplan–Meier method and differences were assessed with the log-rank test. For multivariate analysis, the Cox regression model was applied. A confidence interval of 95% was used. The statistical significance level was set at p < 0.05.Statistical analysis was performed using SPSS version 17.0 for Windows. Variables were described as median (minimum-maximum) and as numbers (percentages). The difference between two independent numerical variables was tested using the Mann–Whitney test, and the χp = 0.05). The laparoscopic method was more frequently used in the HVC group compared to the LVC group . Twenty-one patients in the HVC group and six in the LVC group received adjuvant mitotane treatment. The patient characteristics are shown in In this retrospective study, we included 49 patients with ACC, ENSAT stage I–III, of whom 35 were operated on in the HVC, whereas 14 patients underwent surgery in one of the seven LVCs. There were no differences between the groups regarding age, gender, ENSAT tumor stage, excess glucocorticoid secretion, Weiss score, Ki-67 index, adjuvant mitotane treatment, and duration of follow up. There was a trend to a larger tumor size in the LVC group (80 (26–176) mm vs. 107.5 (70–250) mm; p = 0.02). Eleven patients had local tumor recurrence or peritoneal carcinomatosis, with four (11.4%) in the HVC group and seven (50%) in the LVC group (p = 0.02). Furthermore, three patients in the LVC group, of which one had an intraoperative tumor spillage, and none in the HVC group had disease recurrence within six months after the surgery. No difference in recurrence rate was observed between the open and laparoscopic approach (p = 0.157). Disease recurrence was observed in 16 patients, eight in each group . Patients in the HVC group had significantly longer RFS than those in the LVC group (p = 0.03). There was no difference between the groups in overall survival. However, there is a trend to better DSS in patients in the HVC group compared to those in the LVC group , and in four of them (1 HVC and 3 LVC), the death was related to ACC . Furthermore, in three patients from the LVC group and in none from the HVC group, ACC recurrence was noted already within six months after the surgery. Overall, surgeon experience has an impact predominantly on the risk of local recurrence and spreading of cancer cells inside the abdominal cavity. In our cohort, four patients (11.4%) operated on in the HVC had local recurrence, whereas none of the patients had peritoneal carcinomatosis. In contrast, in the LVC group, local recurrence and peritoneal carcinomatosis were observed in six and in one patient, respectively . Regarding the type of surgery, laparoscopic adrenalectomy was used more frequently in the HVC group (p = 0.005). In a multivariate analysis, after controlling for age, gender, tumor size, Ki-67 index, Weiss score, and type of surgery, the difference between the groups in RFS remained significant. In addition to surgeon expertise, other clinical and biochemical factors might influence the risk of ACC recurrence ,17. In tVarious factors may contribute to a more favorable ACC treatment outcome in expert centers. Center volume and surgical experience are crucial in this regard ,19, but The retrospective nature and a small number of patients are major shortcomings of the study. Furthermore, the study results might be affected by selection bias, as there is a possibility that a certain proportion of patients who were operated on in the LVCs and had a low risk of disease recurrence were not referred to the HVC for further management. However, given the ACC incidence of 0.5–2 cases per million people, we believe that our group of 49 patients almost represents the entire cohort of Croatian patients with ACC ENSAT stage I–III. Another limitation refers to the criteria we used to define adrenal surgery HVC. Although there is no consensus on that subject, the recent ESMO-EURACAN clinical guidelines suggest that centers having >20 adrenal surgeries per year meet the criteria for HVC [


Shotgun sequencing was used to characterize taxonomic and functional composition and diversity of the microbiome in fecal samples collected from each animal. Fecal samples were analyzed for copper (Cu), lead (Pb), nitrogen (N), phosphorous (P), selenium (Se), and zinc (Zn) and stable isotopes of carbon (13C) and nitrogen (15N). The fecal microbiome was influenced by the beef production systems with greater functional and lower taxonomic diversity in beef cattle feces from I systems compared with that from T systems. The concentration of N, P, and Zn was higher in beef cattle feces from I systems compared with that from T systems and was associated with taxonomic and functional profile of fecal microbiome in I system, suggesting the role of fecal nutrients in shaping system-specific microbiome. Semi-intensive management practices led to a more complex but less connected fecal microbiome in beef cattle. The microbial community in beef cattle feces from I systems was characterized by greater abundance of beneficial bacteria . In addition, the fecal abundance of microbial genes related to immune system, nutrient metabolism, and energy production was greater in beef cattle raised under I systems compared with that under T systems. Findings of the current study suggest that semi-intensive management practices could facilitate the development of a healthier and more efficient fecal microbiome in beef cattle by driving an increase in the abundance of beneficial bacteria and functional genes.The importance of beef production for economy of Brazil and the growing demand for animal protein across the globe warrant an improvement in the beef production system. Although most attention has been on modulation of the rumen microbiome to improve ruminant production, the role of the lower gut microbiome in host health and nutrition remains relatively unexplored. This work aimed to investigate the taxonomy and functional variations in the fecal microbiome of Brazilian beef cattle reared in two different production systems using a metagenomic approach. Sixty male beef cattle from six farms representing semi-intensive (I,  Brazil is the largest beef exporter in the world with an annual export of 2.49 million tons of carcass weight in 2019 . In addiIn the recent years, there has been an increasing acknowledgment of the need to examine host-microbiome interactions in the rumen and in the lower gut to fully exploit the potential of the gut microbiome for sustainable ruminant production . In addiAlthough investigation of the microbiota provides useful information about the composition of the microbial community, this does not of itself provide a meaningful insight into functional changes in the microbiota. Therefore, we investigated the fecal microbiome by characterizing the functional metagenome and the composition of microbial communities in the feces of beef cattle raised under semi-intensive (fed concentrate supplement) or traditional (without concentrate supplement feeding) management systems. Because the diet plays a key role in manipulating the composition and metabolism of the gut microbiota and the Brazilian beef production systems are distinguished primarily by their difference in dietary management , we hypon = 2) and traditional  Brazilian beef production systems. This classification was based on the practice of feeding supplements (silages and concentrates), rotational grazing, and pasture fertilization by the nominally semi-intensive systems. Feed and nutrient composition of the diets are presented in Standard practices of animal management and sampling procedures were approved by the Ethics Committee on the Use of Animals of the Center for Nuclear Energy in Agriculture, University of São Paulo, Piracicaba, Brazil, under protocol no. 007-2018. Six farms from the northwest region of São Paulo, Brazil, were recruited in this study and were representative of semi-intensive  were collected from the rectum into sterile cryogenic tubes  and stored immediately in liquid nitrogen for further molecular analysis. A subset of fecal samples was collected for the analysis of carbon (13C) and nitrogen (15N) stable isotopes and minerals to trace the feed recently consumed by the animals and frozen in liquid nitrogen. Pasture samples (in triplicate) were collected in the paddock where the animals were grazing, using a 0.25-m2 mold cut at a height of 10 cm above the soil surface to represent the available biomass for grazing. Forage samples were immediately stored at 4°C, until processing for analysis of chemical composition. Any weed or shrubs spread within the paddock were identified and the most abundant ones were sampled and stored at 4°C until processing. Samples of supplementary feed and mineral supplements that were offered to the animals were collected as well. All forages, shrubs, and supplements were dried at 40°C until constant weight was achieved. The dry weight of forages was used to determine dry matter (DM) content and thus to estimate the biomass available for grazing at each farm. Dried feed samples were ground through a 1-mm screen and analyzed for residual DM, organic matter (OM), crude protein (CP), neutral detergent fiber (NDF), acid detergent fiber (ADF), and lignin (LIG) according to the established methods of the Association of Official Analytical Chemists  were identified by sex  and age . Within each age group, five animals were randomly selected for feces collection, i.e., 10 animals per farm. Fecal samples . Total C, N, and isotopic composition (13C and 15N) were determined in an elemental analyzer  interfaced to an isotope ratio mass spectrometer . The concentration of C and N was expressed in percent, and the stable isotopic ratio was expressed in the classical “δ” notation according to equation (nX = (Rsample/Rstandard – 1) × 1,000 (1), where X is C or N; n is the mass number of the heavier isotope (13C or 15N); and Rsample and Rstandard are the isotopic ratio of the samples and the standard, respectively. Pee Dee Belemnite for C and atmospheric air for N were used as the primary standards. Minerals  were determined in feces using a triple quadrupole inductively coupled plasma mass spectrometer . Briefly, the samples were microwave-assisted acid digested (Milestone ETHOS UP). Isotopes 75As, 63Cu, 66Zn, 208Pb, and 78Se were monitored to quantify As, Cu, Zn, Pb, and Se mass fractions. Internal standard solution (Agilent Part Number 5188–6525) containing Sc (m/z = 45), Ge (m/z = 72), and Rh (m/z = 103) was used to correct the plasma stability. SRM 1643d Trace Elements in Water (NIST) was used for analytical quality control. For determination of inorganic P, feces were weighed in a precise scale and DM and ash were determined. The ash residue is digested, filtered, and then P-quantified by colorimetry, using the ammonium molybdate-vanadate method, as described by For δequation : δnX =  according to the protocol of the manufacturer. The quality of extracted DNA was checked by 0.8% agarose gel electrophoresis and NanoDrop 8,000 spectrophotometer . Qubit 2.0 fluorometer  was used to measure the concentration of extracted DNA. In total, 60 DNA samples that qualified for library preparation were sequenced using the Illumina HiSeq 2500 platform [2 × 150 base pairs (bp)]  at Novogene Corporation, Inc. (U.S. Subsidiary and UC Davis Sequencing Center).Total DNA was extracted from freeze fecal samples (0.25 g) using the DNeasy E-value cutoff of E < 1 × 10–5). The matrices generated about taxa and potential functions were exported and used for statistical analyses. The metagenome data are available at MG-RAST server under the project “Cattle fecal metagenome” (ID mgp89663).Approximately 1.5 billion sequences were obtained from samples using the shotgun metagenomic approach, with an average of 22–32 million sequences per sample. Raw sequences were filtering to discard those with low-quality bases  under default parameters using HiSeq software (Illumina). Sequences were paired using software PEAR, a paired-end read merger , and lowt-test, and P ≤ 0.05 was considered statistically significant. Both analyses were performed on PAST v3 software  SparCC correlations with a magnitude of > 0.95 or < −0.95 were included into the analysis. The nodes of the reconstructed networks represent microbial genus, whereas the edges represent significantly positive or negative correlations between nodes. The topology of the networks was calculated on the basis of a set of measurements including the number of nodes and edges, modularity, number of communities, average path length, network diameter, average degree, and clustering coefficient  and the Shannon diversity index. The means were compared by Tukey software , using asoftware  with Brasoftware  using tw     and func 0.0001) . The RDAP < 0.05) with fecal bacterial diversity (P < 0.05). Here, we highlight beneficial bacteria, such as the families Bifidobacteriaceae, Clostridiaceae, and Erysipelotrichaceae and genera Lachnospiraceae (P < 0.05), Anaerostipes, Butyrivibrio, Eubacterium, Roseburia, Ruminococcus, Succinivibrio, and Blautia had a higher relative abundance in the feces of cattle reared on I beef farms (P < 0.01).The taxonomic diversity was lower, whereas functional diversity was higher in the fecal microbiota of I farms compared with T farms . Bacteriiversity . In the iversity . Interesiversity , whereasiversity . SpecifiP < 0.05). In contrast, genes involved in virulence, disease and defense, lipopolysaccharide (LPS) biosynthesis, sphingolipid metabolism, cell growth and death, environmental adaptation, and the degradation of valine, leucine, isoleucine, and lysine that were more abundant, in the feces from T farms (P < 0.05).Accompanied with the distinct changes in taxonomic composition, we also observed changes in the fecal functional metagenome composition between I and T farms. In general, we observed a difference between the systems in 106 functional genes . Here, wTo explore the interaction between the fecal microbial communities within the two different management systems, we reconstructed co-occurrence networks at the genus level on the basis of the metagenome data . In geneThe present study, to our knowledge, was the first to compare the cattle fecal microbiome from Brazilian traditional and semi-intensive beef production systems. The bovine fecal microbiota is complex, and management practices play an integral role in shaping the establishment of the fecal microbial community . The datIn addition, the correlation of the fecal microbiome with CP, NDF, and %N on I farms and with %C on T farms suggested a strong influence of the feed composition on the fecal microbiome. Relatively higher concentration of CP and NDF in forages and supplements used on I farms compared with that on T farms  indicates higher nutrient intake by the cattle reared in I systems, with potentially better synchronization of energy and N availability for the fecal microbiota that are essential for the fermentation process.Succinivibrio in the gut of possibly more efficient beef cattle reared in I system is consistent with another report evaluating the gut microbiota and feed efficiency in cattle . Although hematological parameters were not influenced by the production system, blood urea concentration was higher in beef cattle reared on I farms, and blood glucose concentration was higher in beef cattle reared on T farms. This indicates that differences that were observed in the microbiome were not reflected in the hematological response of the animals, but there were differences in blood biochemistry, which would be expected as a result of the differences in the diet.In addition to the dietary factors mentioned above, it is likely that the fecal microbiome in beef cattle was influenced by dietary mineral supply, as indicated by a significant correlation between the microbial diversity and fecal mineral concentrations observed in the current study. Considering that feces can be a bioindicator of dietary nutrient supply, which has proven to be a cost-effective and reliable method in studies of ruminants , relativLachnospiraceae and genera Anaerostipes, Blautia, Butyrivibrio, Eubacterium, Roseburia, and Ruminococcus) in I farms. All these bacteria are known to produce butyrate in the gut  can be found below: The animal study was reviewed and approved by Ethics Committee on the Use of Animals (CEUA) of the Center for Nuclear Energy in Agriculture, University of São Paulo (CENA/USP), Piracicaba, Brazil. Written informed consent was obtained from the owners for the participation of their animals in this study.HL, CR, PR, and AA: conceptualization, validation, supervision, and funding acquisition. PC: performed the data analysis and writing original draft. CJ: performed the laboratory work and writing. LM: performed bioinformatics analysis. LG and VS: collected the samples. ED: contributed to lab analysis. All authors read and approved the final 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The purpose of this study is to investigate the mediating role of exercise value cognition between family function (FF) and exercise behavior and the moderating role of an only-child status. A questionnaire survey was conducted on 504 Chinese college students using the FF scale, the exercise value cognition scale, and the exercise behavior scale. The analysis yielded four main findings. (1) There are significant differences between an only-child and a non-only-child for negative exercise behavior and FF. The only-child group has a higher average FF score and a lower average negative exercise score. (2) Exercise behavior and four of its dimensions—exercise autonomy, attention control, exercise planning, and situational induction—are each significantly positively correlated with FF and exercise value cognition. (3) FF is a significantly positive predictor of exercise behavior, both directly and through exercise value cognition, which plays a partial mediating role. (4) Only-child status significantly moderates the mediating effect of exercise value cognition in the link between FF and exercise behavior. The intergroup differences mainly manifest in the influence of FF on exercise behavior and the influence of exercise value cognition on exercise behavior. In the only-child subsample, exercise value cognition plays a complete mediating role. The results of the current study demonstrated the important role that FF and exercise value cognition played in promoting the exercise behavior of college students. These findings have important implications for exercise behavior in adolescents by maintaining sound communication between family members and developing a healthy lifestyle or value cognition. Interpretation of scholars and the intervention angle on individual exercise behavior have gradually shifted from focusing on a single factor or the individual level to considering the entire social ecosystem. Family, the basic unit of society and one of the mesosocial ecosystems affecting exercise behavior . To ensure the accuracy of the data and the sound operation of the structural equation model, the retrieved questionnaires were strictly screened to remove any missing responses, straight-line responses , and pattern responses . Finally, 504 valid questionnaires were obtained (88.42% effective response rate). The final sample comprised 165 men (32.74%) and 339 women (67.26%); 220 freshmen (43.65%) and 141 sophomores (27.98%); 96 juniors (19.05%) and 47 seniors (9.33%). The average age was 19.39 ± 1.29 years. A small gift (such as tips or vouchers) was given to each participant as an appreciation for participating in the survey. According to local legislation and institutional requirements, there is no need for the study to undergo ethical review or obtain signed informed consent forms from participants. However, a process to ensure that all participants have informed consent to participate is still included in the survey. When subjects enter the e-questionnaire, all the information in a document appeared on the first page. The document stated that the investigation was anonymous, and that its results would only be used for scientific research and would not pose any risk to them in their daily life. It also informed them that participation in the research was entirely voluntary. Subjects could only proceed to the questionnaire after confirming they had read the document and agreed to participate in the study. The method of protecting the privacy of the subjects has been presented in the The survey was conducted in Henan Province, China. Three universities, namely Zheng Zhou University, Henan University, and Henan University of Technology, covering multiple fields and disciplines, were selected. The participants were undergraduate students (from freshmen to seniors). The electronic questionnaire was distributed to participants Cronbach's α is 0.83. Following the recommendations of DeVellis (x2/df) = 3.027, comparative fit index (CFI) = 0.985, goodness of fit index (GFI) = 0.975, Tucker–Lewis index (TLI) = 0.977, root mean square error of approximation (RMSEA) = 0.063, standardized root mean square residual (SRMR) = 0.024]. Following the recommendations of Schumacker and Lomax . Following the recommendations of Schumacker and Lomax  scale of this study draws on theories of exercise behavior and the exercise attitude scale—subscale of behavioral control and behavioral habits Mao, . The EB Autonomous exercise (AE): Individuals are willing to exercise and develop exercise habits.Attention control (AC): individuals are able to devote to the process of exercise.Exercise planning (EP): Individuals can make and stick to exercise plans.Situation induction (SI): Individuals often actively participate in exercise due to exams or health problems.Negative exercise (NE): Individuals withdraw from exercise after being thwarted and frustrated.x2/df = 3.084, CFI = 0.932, GFI = 0.890, TLI = 0.921, RMSEA = 0.064, SRMR = 0.053). Following the recommendations of Schumacker and Lomax  were set as dependent variables. In the preliminary analysis phase, the reliability and validity of the scales were determined using Cronbach's alpha and average variance extracted after CFA, which was conducted in AMOS 22.0. On the basis of the hypothesis, a structural equation model (SEM) was used to determine the moderated mediation association between FF, exercise value cognition, exercise behavior, and only-child status. The hypothesis was tested in two steps.SPSS 21.0 and AMOS 22.0 were used to analyze the data. The descriptive statistics and independent sample x2/df, TLI, CFI, GFI, RMSEA, and SRMR were selected to evaluate model fit. To further examine the mediating effect of exercise value cognition, bootstrapping was used to test the significance of the mediating effects in M1  were constructed. Following the recommendations of Jackson  and Schrp < 0.05 was considered statistically significant.Second, the moderated mediation model with latent interaction was tested by using multigroup analysis. To analyze which path of the mediation model the only-child status moderates, a multigroup analysis technique was adopted. Taking only-child and non-only-child as group variables, nested models were constructed on the basis of the mediation model to conduct the multigroup invariance test. First, the unconstrained M2 (freely estimating each path coefficient) was constructed. Then, M3  was built based on M2. Finally, based on M3, M4 was constructed . Further details of each model are provided in the Having identified the unbalanced gender composition of the sample during data analysis, we sought to ensure the scientific rigor of the study by testing for gender difference in the variables and testing the moderating effect by multigroup comparison see .Process control and Harman's single-factor test were, respectively, used to minimize and examine common method bias. The process control steps included, for example, explaining the anonymity and confidentiality of completed questionnaire responses, and assuring that the data would only be used in academic research. The results of Harman's single-factor test show that the factors with initial eigenvalues >1 are explained between 5.63 and 20.83% of the variance; the average explained variance was 10.73% and the standard deviation was 5.48%. The maximum explanatory power of any factor is not two standard deviations (10.96%) greater than the average explanatory power. Therefore, it can be concluded that the survey is unaffected by the common method bias.p = 0.038 < 0.05) and FF (p = 0.002 < 0.01), but not for EB overall, the other four dimensions of EB or EVC (The results show significant differences between only-child and non-only-child for negative exercise (B or EVC . Specifip < 0.01) in the full sample, only-child subsample, and non-only-child subsample. Since negative exercise behavior was not significantly correlated with FF or exercise value cognition, this variable was not included in subsequent analysis.The results of the Pearson correlation analysis  showed tAs reported in As reported in x2 = 17.105, Δdf = 12, p > 0.05), but it reveals a significant difference between M2 and M4  and between M3 and M4 . The results show that the models are invariant and the path coefficients between groups have significant differences.The fit indicators of the three models all reached acceptable levels see . The resTaking M4 as the baseline model, the same method was used to test the equality of path coefficients for each research variable, so as to further test the difference between only-child and non-only-child on each path.x2 = 7.789, Δdf = 1, p < 0.01; Δx2 = 17.057, Δdf = 1, p < 0.01). However, there is no significant difference between only-child and non-only-child in the regression coefficient for path “FF → EVC” .The results show significant differences between only-child and non-only-child in the regression coefficients of the two paths “FF → EB” and “EVC → EB” . The bootstrapping results show that the CI of the indirect effect in only-child group is , and the CI of the indirect effect in non-only-child group is , meaning that the mediating effect is significant in only-child group. The path analysis results show that see  in only-This study found that only-children and non-only-children differ significantly in FF and negative exercise, but not in exercise behavior overall, the four other dimensions of exercise behavior, and exercise value cognition. Relative to the non-only-child group, the only-child group has a higher average FF score and a lower average negative exercise score. These better results for only-child college students are consistent with prior findings. Against the background of the OCP and traditional cultures, the “pampered” one-child family model has become predominant in China. Under this model, the child not only receives more care from family members but also shoulders more expectations . The significant predictive effects of FF on the exercise behavior and exercise value cognition of college students, respectively, support Hypothesis 1 and Hypothesis 2. Moreover, the significant predictive effect of exercise value cognition on exercise behavior supports Hypothesis 3. The mediating effect test found that exercise value cognition partially mediates the influence of FF on the exercise behavior of college students, meaning that this relationship is both direct and indirect , thus supporting Hypothesis 4. The results of this study are consistent with the prior findings that the better an individual's cognition of FF, the more positive is their exercise value cognition, and the easier it is for them to plan and engage in regular physical exercise. For example, Berge et al.  found thSecond, the study found that the mediating effect of exercise value cognition between FF and exercise behavior differs significantly between only-child and non-only-child college students. Specifically, exercise value cognition plays a complete mediating role in the only-child group but is non-significant in the non-only-child group. This finding supports Hypothesis 5 on the moderating role of only-child status. Further analysis revealed that only-child status regulated the two paths “FF → EB” and “EVC → EB.” This means that the intergroup differences mainly manifest in the influence of FF on exercise behavior and the influence of exercise value cognition on exercise behavior. These results show that exercise value cognition plays a greater mediating role between FF and exercise behavior in the only-child group. There are two main reasons for this. First, affected by the OCP, family education methods have undergone profound changes in China. Some concepts in family life and education have been weakened, such as the preference for a son and the prevailing importance of academic performance. The educational philosophy of Chinese parents has gradually shifted their main focus from intellectual development to comprehensive development. In China, compared with non-only-children, only-children will receive more care and love from their parents and even grandparents, which leads some only-children to cultivate specific behaviors and cognitive systems. For example, only-children differ significantly in terms of family-member interaction, family intimacy, and parental investment in education , focus should be placed on improving awareness of health among parents or family members, enhancing communication between families, and increasing family physical activities. Such efforts would help to provide better environmental support for the physical and mental health of children.From the perspective of family system theory, this research reveals the mechanism through which FF influences on the exercise behavior of college students. However, the cross-sectional design adopted in this study and the results for the mediating effect cannot fully and concretely explain the relationships between the variables. Different family structures have different FFs. The one-child family includes multiple subsystems, such as “father–son/daughter” and “mother–son/daughter.” Therefore, future studies could explore the systematic changes in the exercise behaviors of college students over time, including how these are affected by various dimensions of family structure  and exercise value cognition. By clarifying the mechanism among these and related variables, empirical evidence can be generated and analyzed to inform the promotion of exercise behavior among college students. Scholars have already started to refine FFs based on family structure and the relationships between family members, and have begun developing valid and reliable tools for systematically evaluating the characteristics and mechanisms of individual FFs (Liu et al., This study drew the following conclusions. First, the FF of college students is a significantly positive predictor of their exercise value cognition and exercise behavior, and also indirectly affects exercise behavior through exercise value cognition. Second, college the exercise value cognition of students plays a partial mediating role between FF and exercise behavior in the full sample and a completely mediating role in this relationship in the only-child subsample. Finally, only-child status significantly moderates the mediating effect of exercise value cognition between FF and exercise behavior, and exercise value cognition plays a greater mediating role between FF and exercise behavior in the only-child subsample.The original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.MW conceived and designed the research, undertook data analysis, and wrote the Chinese manuscript. PY-W and MW wrote and supplemented the English manuscript. JY participated in the manuscript revision. MW and XL participated in the collection and sorting of data. 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.