Antimicrobials are widely used to cure intramammary infections (IMI) in dairy cows during the dry period (DP). Nevertheless, the IMI cure is influenced by many factors and not all quarters benefit from antimicrobial dry cow treatment (DCT). To evaluate the true effect of antibiotic DCT compared to self-cure and the role of causative pathogens on the IMI cure, a retrospective cross-sectional study was performed. The analysis included 2987 quarters infected at dry-off (DO). Information on DCT, causative pathogens, somatic cell count, milk yield, amount of lactation, Body Condition Score, and season and year of DO were combined into categorical variables. A generalized linear mixed model with a random cow, farm and year effect and the binary outcome of bacteriological cure of IMI during the DP was conducted. In the final model, a significant effect ( Clinical mastitis (CM) is one of the most important diseases in dairy cows when considering ecological aspects ,2, animaThe objective of this retrospective cross-sectional study was to determine farm-, cow-, and quarter-level factors associated with DP cure. Furthermore, the aim is to estimate the true effect of AB DCT on the cure of existing IMI, dependent on the causative pathogen by comparing the DP cure of non-treated quarters with those treated with AB at DO for different pathogen categories. Knowledge of pathogen specific AB-cure and self-cure rates can improve decision making in SDCT and support evidence-based reduction of AMU. post partum (p.p.), with a DP of more than 14 days, 6503 quarters of 1745 cows on 99 dairy farms were left for the analysis. Out of these quarters, 454 were included for more than one lactation. In order to examine the effects on the IMI cure during the DP, only quarters infected at DO were eligible for the analysis. Thus, the final dataset consisted of 2987 quarters of 1295 cows from 96 farms, with 92 quarters being included for more than one lactation.Eligible information for the analysis was found for 14,593 quarters in the primary dataset . Since only cow lactations with reported data on four quarters were considered, another 607 quarters (161 cows) were excluded. To adjust for DCT only, cows with CM, udder injuries, or other reported illnesses at DO were excluded to rule out DO unrelated AB treatment. Out of the remaining 13,326 quarters (of 2926 cows), homeopathic treated quarters (n = 83) were excluded to limit the treatment effect to AB DCT. Another 3039 quarters could not be used for the analysis due to contaminated milk samples. By including only milk samples taken within 5 days before DO as well as between calving and 19 days 3 cells/mL overall, this being higher in the AB treated group (625 × 103 cells/mL) than in the non-AB group (502 × 103 cells/mL), although the median was lower for each SCC measurement. In comparison, geometric means for milk yield, Body Condition Score (BCS), parity, and DP length were similar in both groups (The geometric mean of the SCC at DO was 546 × 10h groups . S. aureus showed a similar new IMI rate as streptococci as a group (8.8% and 8.7%), while 11.3% of the new IMI were caused by two different pathogens that were not isolated at DO. Missing values were detected for SCC (2.1%), milk yield (2.3%), BCS (12.8%), and parity (6.0%). The predominant pathogens at DO were non-aureus staphylococci (NAS) with 1094 (36.63%) infected quarters, followed by the category ‘other Gram-positive bacteria’ with 668 (22.36%) infected quarters at DO . AlthougStaphylococcus (S.) aureus, streptococci, coliforms and ‘other Gram-positive bacteria’ were associated with a higher chance of cure during the DP compared to mixed infections. AB treatment only showed a significant effect on DP cure in combination with some pathogens in the final model. More precisely, IMI caused by streptococci or ‘other Gram- positive bacteria’ presented a significantly higher chance of cure if treated with AB compared to non-AB treated quarters. Concerning the season of DO, cure was lower in cows dried off in spring (March until May) compared to cows dried off in the fall (September until November); see Only the categories of causative pathogen, season of DO, DCT (AB vs. non-AB), and the combination of causative pathogen group and DCT were kept in the final model as fixed effects. However, by including the interaction of the pathogen with DCT in the model, DCT alone did not show a significant effect anymore, but was kept in the model due to being part of the interaction . Farm, cpost hoc collection of missing data was not possible. Although quarter level information on DCT and infection status had to be complete, as the aim of the study was to evaluate the real effect of dry cow AB on the DP cure, quarters with missing information on other explanatory variables for the outcomes of cure  were still included in the trial. This might have led to the premature exclusion of these variables compared to those with information given for all quarters and bias in our results. However, the number of quarters with missing information was mostly still small, around 2–6% of all quarters, and therefore should not lead to major variation. Only information on BCS at DO was missing for 13% of all quarters  in our study. Since Gram-negative bacteria and NAS are often the cause of new IMI [Streptococcus spp. which showed a significant effect of AB DCT. Even though only a small number of cases were non-bacterial infections, these were grouped into an extra category so the outcome for the other categories would not be affected, since no effect of AB treatment was expected for this category. This leads to the assumption that only quarters infected with certain Gram-positive bacteria benefit from AB treatment at DO. This could be partly explained by the mainly Gram-positive range of efficacy of most dry cow AB used in Germany. In this study, about 57% of the treated quarters received a simple penicillin-based product . Furthermore, Bradley et al.  found co new IMI , an addi new IMI , new IMIAs the cure rate in AB treated quarters was about 9% higher than in non-treated quarters, the true benefit of AB (in addition to the self-cure) seems to be around 9% in infected quarters, dependent on the causative pathogen. Given that only 2987 quarters out of a total of 6503 that matched all of the criteria were infected at DO and hence included in the analysis, the absolute AB effect would be even smaller for the whole population with BDCT. Streptococcus spp. was similar. Gundelach et al. [Corynebacterium spp. as the predominant pathogen species, followed by NAS at DO [S. aureus infections, the true cure rate might be lower, because of possible false-negative samples at calving due to intermittent shedding of S. aureus, although single quarter samples are reported to be sufficient to identify S. aureus IMI [The overall cure rate of 78.4% was high in our study, with higher cure rates in the AB and non-AB group compared to the findings of Halasa et al. , who reph et al.  reportedh et al. ,31,32, wAS at DO ,29. So fAS at DO  found noAS at DO ,28. AlthAS at DO  showed hAS at DO ,32. Regareus IMI .The season of DO had a significant influence on the DP outcome, which is consistent with the findings of Dingwell et al. . Many fap.p udder health is associated with an increased risk of new IMI due to an insufficient closure of the teat canal in high yielding cows [An effect of the farm on the DP outcome can be explained by many farm-individual factors. Predominant pathogens, barn and pasture management, as well as DCT protocols are some factors that can vary between farms and influence the DP cure ,30,37. Iing cows ,42, not As previously described by Dingwell et al. , in our The application of ITS also did not show a significant effect on the DP cure in our model. This was expected, since the main function of ITS is to protect the udder from new IMI by forming a physical barrier for pathogens to enter the teat canal, not to cure IMI ,11. HoweCoryneforme spp., ‘other streptococci’ or ‘other coliforms’). However, not identifying pathogens at a species or even a strain level only has an impact on differentiating persistent from cured and re- or new infected quarters. Therefore, any IMI evaluated as persistent in this study might actually be a reinfection with the same pathogen or a new infection with another strain of the same group, indicating a higher true-cure rate than found here. For most strain-groups, however, only up to 8% of the IMI were regarded as persistent. The highest proportion of not cured IMI were found for Coryneforme spp. and NAS higher (13.8% and 28.2%), so the greatest bias would be expected for the outcome for these pathogens. Nevertheless, like in our study, NAS are not generally identified at the species level. This goes in line with previous studies investigating the DP cure of IMI, also using NAS as one pathogen category, without further separation [S. chromogenes, S. epidermidis, S. haemolyticus) as mastitis pathogens [p.p. before the p.p. sample was taken [Since the dataset was compiled from two previous studies, the samples used for this analysis were not recent Despite the fact that some were taken more than ten years ago, this should not lead to a major bias in our results. For one thing, the distribution of pathogens found at DO in our research is comparable with the results of a study conducted in Germany more recently . Furtherparation ,27,31. Wathogens ,46,47, aAlthough many studies have investigated the influence of different cow or farm level factors or the difference between SDCT and BDCT on the DP outcome, the effect of AB DCT adjusted for self-cure is rarely reported for different pathogens on a large number of quarters. In order to account for the specific influence of different dry cow products or the pathogens on a species level, more research is needed. Nevertheless, the findings of this cross-sectional study indicate that the absolute beneficial effect of AB DCT is mainly seen in some Gram-positive pathogens, while no significant benefit is expected for infections with NAS or Gram-negative bacteria. This can support future decision-making for SDCT and encourage farmers and veterinarians to further reduce AMU if the farm and herd conditions allow it. Future studies might investigate DCT protocols that include pathogen-based treatment decisions. The initial dataset used for this study was compiled from data originally collected for two previous studies that were conducted on organic dairy farms in Germany ,48. ConsFarm individual information such as herd size, bulk tank SCC, and specific DCT protocols was not given for all farms in the dataset and hence not included in the analysis. Reported AB used for DCT on these farms are shown in The cytomicrobiological diagnostics of quarter milk samples taken at DO and at calving had been performed in the laboratory of Hannover University of Applied Sciences and Arts, Hannover, Germany, in accordance with the guidelines of the German Veterinary Association . BacteriE. coli at DO and S. aureus at calving was considered as cured and new infected, while an infection with E. coli at DO and calving was considered as not cured and not new infected, hence persistent . A quarter infected with NAS at DO and at calving was also considered as persistent .In this analysis, only bacteriological cure was examined. IMI cure was evaluated for each single udder quarter, by comparing the isolated pathogens of the DO and calving quarter milk samples. The IMI cure was defined as quarters that showed one or two pathogens in the DO sample and were either bacteriologically negative in the calving sample or infected with one or two pathogens other than those in the DO sample. Quarters that had at least one similar pathogen in the DO and the calving sample were considered as not cured, even if one of the two pathogens (if mixed at DO) was not found in the calving sample anymore. Pathogens found in the calving sample that were not isolated in the DO sample were regarded as new IMI. Samples with two different pathogens were considered as mixed infections, while quarter milk samples with more than two pathogens were classified as contaminated. IMI cure or new IMI were evaluated at the species level or, if the pathogen species was not determined, on the genus level or as a species group . For example, a quarter infected with p ≤ 0.20) using univariable analysis. Variables with p ≤ 0.20 were kept for the final multivariable model. Afterwards, statistically significant variables were included in a generalized linear mixed model (GLMM) with logit link function. To perform the dataset analysis, Microsoft Excel (2016) and SPSS 28.0, Chicago IL, USA were used, with the udder quarter as the statistical unit. For the binary outcome of IMI cure, independent variables were tested for statistical significance  spp. including Sc. uberis, Sc. dysgalactiae, Sc. canis and other not further specified streptococcal bacteria;Escherichia coli, Klebsiella spp., Serratia marcescens, and other not further specified coliforms;coliforms, including Aeromonas, Pseudomonas, Proteus, Alcaligenes, Bordetella, Moraxella, and Acinetobacter spp.;other Gram-negative bacteria, including Trueperella pyogenes, Corynebacteriaceae, Bacillus spp., and Enterococcus spp.;other Gram-positive bacteria, including Prototheca spp.);non-bacterial pathogens .The variables farm, cow, quarter, and year of DO were considered as random effects. The main explanatory variables were DCT (antibiotic or non-antibiotic treatment) and the causative pathogen. Since some pathogens were only isolated in a few milk samples, pathogen categories were built for the statistical analysis:p.p. udder health than the BCS at DO [p ≤ 0.20) and were therefore further investigated in the multivariable model. These variables had been tested for multicollinearity before inclusion in the multivariable model, although no high correlation (>0.7) was found between the variables. Hence all of the significant variables in the univariable model were tested in the multivariable analysis. While the IMI cure for each quarter was still determined for each single pathogen, the aforementioned pathogen groups were used in the statistical model to evaluate the influence of different pathogens or pathogen groups on the chance of cure during the DP. Further explanatory variables were the use of ITS at DO (dichotome), categorical SCC at DO ; season of DO , categorical milk yield at DO , number of lactation , BCS at DO , the change of BCS during the DP , and the categorical length of the DP . Categories were formed taking previous studies and commonly used methods into account. For example, for SCC, 100,000 and 200,000 cells/mL are thresholds often used by farmers in Germany and also described as reliable thresholds for identifying infected quarters at DO in previous studies ,15, whilp-value was excluded from the model until all variables had p ≤ 0.05. Confounding was monitored by the change in the coefficient of a variable after removing another variable. If the change of the estimates exceeded 25% or 0.1 when the value of the estimate was between −0.4 and 0.4, the removed variable was considered a potential confounder and was re-entered in the model. The multivariable analysis was performed using a backward elimination procedure. After each run, the variable with the highest 2) was calculated to measure the proportion of variance explained by the model. Statistical significance was set at a p value of <0.05 in the final model. Finally, estimated means were calculated for the explanatory variables included in the model.In the final model, all possible two-way interactions were tested. With the pathogen-DCT interaction being kept in the model, the fix effects used in the model for the final analysis were the pathogen category at DO, the season of DO, the combination of DCT and pathogen category at DO as well as the DCT alone for being part of the interaction-term. Farm, cow, and year of DO were included as random effects. The robustness of the final model was checked by carrying out the same procedure with forward selection. The residuals of the final model were tested for normality and the coefficient of determination (rS. aureus, were more likely to benefit from AB DCT compared to IMI caused by Gram-negative bacteria. An overall difference of 9% was seen in the cure rates between AB and non-AB treatment. Farm, cow, and season of DO also have a significant influence on the DP cure. Our findings indicate that the absolute effect of AB DCT depends on the pathogen causing the infection. To prevent AB resistance, a further reduction in AB treatments at DO might be possible with suitable selection protocols. Further research is needed to investigate the role of pathogens at the species level and the active compounds of dry cow AB. Additionally, DCT protocols considering IMI cure on the pathogen level need to be evaluated in future studies. Quarters with Gram-positive IMI, except NAS and


Though significant correlations between rheumatoid arthritis (RA) and hypothyroidism have been found in earlier observational studies, their underlying causal relationship is still unknown. Mendelian randomization (MR) was used in the current study to assess the bidirectional causation between RA and hypothyroidism.We gathered summary data from genome-wide association studies (GWASs) of RA and hypothyroidism in people of European descent. Then, using data from the FinnGen consortium, we replicated our findings. Three approaches were employed to assess the causal link between RA and hypothyroidism: MR-Egger, weighted median (WM), and inverse variance weighted (IVW). The pleiotropy and heterogeneity were examined using a variety of techniques, including the MR-Egger intercept, the MR-PRESSO approach, the leave-one-out method, and the Cochran’s Q test.P = 8.30E-10), as did the risk of secondary hypothyroidism . The results of reverse MR analysis revealed that hypothyroidism  and secondary hypothyroidism  were linked to an increased risk of RA. Additionally, we obtain the same results in the duplicated datasets as well, which makes our results even more reliable. This study revealed no evidence of horizontal pleiotropy.The study looked at a bidirectional incidental relationship between RA and hypothyroidism. The risk of hypothyroidism increased with RA (IVW odds ratio (OR) = 1.28, 95% confidence interval (CI) = 1.18–1.39, The present study established a bidirectional causal link between RA and hypothyroidism. However, it differs slightly from the findings of prior observational studies, suggesting that future research should concentrate on the interaction mechanisms between RA and hypothyroidism. Chronic and systemic autoimmune illness rheumatoid arthritis (RA) can cause ongoing inflammatory polyarthritis and joint damage, increases the likelihood of deformity or disability. A recent study determined that over the past 40 years, the prevalence of RA was nearly 0.46 percent worldwide and is expected to increase in the future . In addiRA and hypothyroidism are the most prevalent chronic specific autoimmune diseases. The etiology of these two diseases remains to be clarified, but they mainly involve genetic, environmental, and other factors, and the genes that lead to the pathogenesis of these two diseases still overlap. But that’s not enough to explain the relationship. Previous research found that RA patients frequently have thyroid dysfunction, with a prevalence of 6% to 34% . AutoimmLimitations of traditional observational studies include confounding variables and reverse causality. Due to possible biases in confounding factors, these previous observational data may be limited in correlation inference, and the conclusions may even be disputed. A randomized controlled trial (RCT) may determine the causal connection between RA and hypothyroidism, but it consumes a lot of money and time. Therefore, the Mendelian randomization (MR) method is used specifically for demonstrating whether the link between risk variables and outcomes can be explained by causal effects . MR studIn the European population, to examine the association between RA and hypothyroidism, we used a two-sample MR study. During the MR analysis process, the effective instrumental variables (IVs) must satisfy three key assumptions in order to gain reliable results: 1) The IVs and exposure are tightly associated; 2) The IVs and any confounding factors that might impact both the exposure and the outcome are unrelated; and 3) The IVs only affect the outcome through the exposure . To valihttps://gwas.mrcieu.ac.uk/datasets/). All RA cases were either determined to have RA by a qualified rheumatologist or diagnosed with RA according to the 1987 American College of Rheumatology criteria. In addition, we selected another recently published RA dataset from the GWAS Catalog (https://www.ebi.ac.uk/gwas/) to validate our conclusions. It contained 35,871 RA patients and 240,149 control individuals of European, East Asian, African, South Asian, and Arabian ancestry from 37 cohorts; we selected only the European population  as our data for analysis , we downloaded summary statistics for hypothyroidism (phenotype field: 20002_1226) and secondary hypothyroidism (phenotype field: 41204_E03), which contained 289,307 and 244,890 individuals from the UK Biobank, respectively   . In the -8) SNPs were employed in this study as IVs to evaluate the causal association between RA and hypothyroidism. Second, to remove SNPs linked to significant linkage disequilibrium (LD), we employed a clumping approach with R2<0.001 and a window size of 10 Mb. We then manually searched the PhenoScanner database (http://www.phenoscanner.medschl.cam.ac.uk/phenoscanner) to exclude SNPs that potentially alter the result features. SNPs that were palindromes or ambiguous were eliminated. Additionally, our results were also adjusted for horizontal pleiotropy by applying the MR-Pleiotropy Residual Sum and Outlier (MR-PRESSO) method. We evaluated the strength of the IVs for the screened SNPs using F-statistics and variance (R2) in order to avoid weak-tool bias (F>10): F = R2*(N-K-1)/K*(1-R2)  .The MR-Egger , weighteFirstly, we employed the MR-Egger intercept to determine whether pleiotropy was present. The heterogeneity of IVW estimates was quantified using Cochran’s Q test. Also, the MR-PRESSO test was run to check for outliers. If outliers are discovered, we will eliminate them and reevaluate the MR effect. In order to evaluate the robustness of the results, we apply the leave-one-out method to remove certain SNPs that have a negative impact on the research outcomes and then recalculate the results. The whole analysis was carried out in RStudio (version 4.2.1) with the “TwoSampleMR” (version 0.5.6) and “MRPRESSO” (version 1.0) packages.The MR results of RA on hypothyroidism are listed in As a result of significant heterogeneity  Table 2,Surprisingly, the reverse study yields extremely meaningful results as well. The MR results are listed in Consistent with the original study hypothesis, we used MR analysis in this work to find that there is indeed a two-way causal relationship between RA and hypothyroidism. This study used aggregated GWAS data to investigate the causal relationship between RA and hypothyroidism. To our knowledge, this is the first study to estimate the bidirectional causal inference between rheumatoid arthritis and hypothyroidism using magnetic resonance techniques. Compared with previous studies, this study not only found a correlation between RA and hypothyroidism but also provided a reference for the early routine examination of hypothyroidism in future clinical RA patients.As an autoimmune ailment, RA increases a patient’s risk of developing thyroid issues, notably hypothyroidism . 76% of Patients with hypothyroidism frequently experience various rheumatic symptoms, including the possibility of fatigue, myalgia, and joint pain in RA , 29. NumThe advantage of the bidirectional approach is that it enables the inference of both causal axes between RA and hypothyroidism. The MR is built using the publicly available GWAS summary statistics. Without incurring additional fees for experiments, it is practical for mining reliable genetic data. Second, we validated our findings using extra datasets to make our conclusions more credible. Another benefit is that, for the first time, we utilized MR to find out if RA susceptibility is linked to a higher risk of thyroid disease. The findings of this study indicate that RA is related to an elevated risk of hypothyroidism.There are also more limitations to our study. Firstly, the samples for RA and hypothyroidism were quite small, which may have caused some false positives and negatives. The causal relationship between RA and hypothyroidism was not stratified by age or gender, which is the second flaw. Thirdly, the exposure and outcome analyses included only Europeans in the study population. It has to be determined if this outcome might be repeated in other populations. Some heterogeneity existed in the study. As a result, the conclusions are less credible because we were unable to reduce the heterogeneity. Other ethnic groups also need to have MR studies conducted, and these studies must be supported by extensive GWAS data.Finally, RA and hypothyroidism shared a bidirectional causal connection. Our findings suggest that RA patients should routinely be checked for hypothyroidism. At present, there are few studies on RA and hypothyroidism, so it is suggested that future studies focus on the mechanisms between them.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 from the participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.DC, YS: conception, technique, formal analysis, data collection, first draft preparation, and visualization; LD, SY: preparation of the first draft preparation, visualization, and data curation in writing; SD, YF: editing, monitoring, and writing evaluation. The final draft of the manuscript was approved by all writers, who also made contributions to the work.


In recent years, with the rapid development of molecular biology techniques such as polymerase chain reaction and molecular biochip, the etiological diagnosis of viral encephalitis has a very big step forward. At present, the etiological examination of viral meningitis mainly includes virus isolation, serological detection and molecular biological nucleic acid detection. This article reviews the progress in etiological diagnosis of viral meningitis. It iLaboratory diagnostic methods include microscopic examination of clinical specimens, viral culture, serological studies, immunodetection of viral or viral antigens and even sequence reading of DNA or RNA . Early s2.This study was conducted using a comprehensive search of PubMed and Web of Science databases. The keywords used to search for information were meningitis, virus, etiology, and diagnosis. The articles studied are currently published and the criteria included in this paper are: (1) the disease studied is viral meningitis; (2) the subjects are human; and (3) diagnostic techniques of etiology. Meanwhile, exclusion criteria were: (1) clinical symptoms of viral meningitis and routine, biochemical, and cytological examination of cerebrospinal fluid; and (2) research on animal experiments. Data collected, registered, and reported for this study were independent of seasonal and geographical factors, and the study considered publications relevant to patients of all age groups. The included articles were perused and summarized, and the retrieved content was used for descriptive analysis. The relevant information on disease etiology, etiology and its diagnostic methods were extracted and documented from the selected publications. And a narrative presentation followed the compilation of these data.3.3.1.6–107 particles/mL) (Transmission electron microscopy (EM) is a method that determines the pathogens by examining the cellular morphology of specimens. It lacks specificity for any specific group of viruses, which broadens the clinical outcomes and delays treatment , 27. Thecles/mL) , requiricles/mL) , it reli3.2.Judging accurate pathogens by performing virus isolation from clinical specimens is the “gold standard” for diagnosis since the 1900 s, and this phenomenon has been going on for decades . For exa3.3.3.3.1.Enzyme-linked immunosorbent assay (ELISA) is a qualitative and quantitative detection method, using antigen–antibody binding specificity . One stuBeforehand, the role of EBV-specific humoral immune response in pathogenetic process of MS remained unknown, since the attempt to detect EBV-infected B cells in MS brain lesions had failed –45. In c3.3.2.Immunofluorescence is a technique for the detection of microbial samples by using fluorescence microscopy . Pierro 3.3.3.Hemagglutination inhibition test is to use the nature that the virus concentration is positively correlated with the degree of hemagglutination of red blood cells, add specific antibodies to the suspension of the virus, then prevent the contact between red blood cell surface receptors and virus particles or their hemagglutinins, and thus inhibit the hemagglutination of red blood cells. Indirect hemagglutination inhibition testing was found to be very sensitive for antibody detection in convalescent animals as well as in chronic lymphocytic choriomeningitis virus-infected mice in a study of mice infected with chronic lymphocytic choriomeningitis virus isolated in 1976 . During 3.4.3.4.1.Molecular biological nucleic acid testing for viral meningitis is performed primarily by PCR. PCR is a widely used method for multiplex replication of specific DNA fragments in molecular biology . Using P3.4.1.1.Real-time polymerase chain reaction, also known as real-time fluorescence quantitative polymerase chain reaction (qPCR), is a molecular biology laboratory technique based on PCR. It uses fluorescence signal accumulation to monitor the amplification of target DNA molecules during PCR in real time, rather than at their ends as in traditional PCR. Khumalo et al.  develope3.4.1.2.Reverse transcription polymerase chain reaction (RT-PCR) is a variant of PCR and is a common technique for detecting RNA expression in molecular biology. RT-PCR is used to qualitatively detect gene expression by creating complementary DNA (cDNA) from RNA. Traditional PCR techniques allow exponential amplification of the target DNA sequence. RT-PCR is the reverse transcription of RNA of interest into its complementary DNA using reverse transcriptase and is mostly used to clone expressed genes. Subsequently, newly synthesized cDNA was amplified with traditional PCR. In addition to qualitative studies of gene expression, RT-PCR can be used for quantitative detection of RNA. Raouf et al.  collecte3.4.1.3.Nested polymerase chain reaction (nPCR) is a modification of polymerase chain reaction that can reduce non-specific binding in products. Nested PCR involves two sets of primers for two consecutive polymerase chain reactions, and the second set of primers can only amplify the expected product from the first round, but not non-specific products. It therefore allows for a greater number of cycles while reducing non-specific products. Drago et al.  comparedThe combined technique of qPCR and RT-PCR is called quantitative RT-PCR, usually referred to as qRT-PCR, which is considered to be the most powerful and sensitive method for detecting RNA levels relative to other RNA quantification methods, such as northern blot. It is commonly used for expression analysis of single or multiple genes, as well as for identifying expression patterns in infections and diseases. But the qRT-PCR assay was not sensitive enough to detect samples with low viral loads, especially in CSF of patients. Shen et al.  proposedBecause PCR not only shortens the time and reduces the risk of contamination in the detection of pathogens , but als3.4.2.NGS technology is also called massive parallel sequencing (MPS) or high-throughput sequencing (HTS), and there are two main methods for the detection of pathogenic microorganisms, including metagenomic metagenomic Next Generation Sequencing (mNGS) and targeted sequencing (tNGS).3.4.2.1.n = 44) or suspected (n = 24) CNS viral infections from a single New England center and assessed enhanced methods to improve CNS pathogen detection and identify pathogens traditionally not identified by nucleic acid testing. Leon et al. (Metagenomic Next Generation Sequencing (mNGS) is a novel and promising method that can simultaneously and unbiased identify all microorganisms in human samples –77. Yu en et al.  applied n et al. . Howevern et al. , 82. At n et al.  found th3.4.2.2.Targeted sequencing (tNGS) refers to the sequencing of specific regions using PCR or probe hybridization methods. Korimbocus et al.  successfMajor pathogens can be detected in most samples by metagenomics, but the results obtained are affected by low concentrations of pathogens, massive contamination and collation, and the range of reference databases for bioinformatics analysis , 84, so 4.Nowadays, viruses are increasingly emerging as important etiologies of meningitis –87. AlthNow, molecular techniques are the gold standard for detecting the etiology of viral meningitis, not only improving the detection rate of pathogens without affecting viral viability in specimens , but alsReliable and appropriate diagnostic techniques are urgently needed for patients suspected of having viral meningitis, particularly in coma, while communicating effectively with the patient’s family. If direct selection of PCR or NGS techniques is unreasonable, it is like serum and cerebrospinal fluid immunoglobulin M antibody detection is the preferred diagnostic test for arboviruses , which rHowever, our paper solely starts with etiological diagnosis methods, and does not analyze the signs and routine biochemical tests of patients, so needs to be used in combination with other literatures, guidelines and clinical experience. At the same time, considering the complex pathophysiology of SARS-CoV-2, it remains difficult for choosing the optimal methods . Finally5.Viral meningitis remains a major human medical problem, and diagnostic techniques for etiology are also continuously innovating. Choosing rational diagnostic techniques to understand the etiology and pathogenesis of this disease allows for faster therapeutic intervention, which will help to improve outcomes. In this COVID pandemic, though neuroinvasion has been rarely reported, it is worth noted that this rare neuroinvasion might be explained by the inappropriate detection methods. In the future, etiology diagnosis could be made in a more rapid and precise way, as the progress of etiology diagnose technique, together with the advance of the understanding on the pathology of infective agents.HX, PC, and SG worked together to collect the data and write the manuscript, with subsequent revisions and improvements. XS revised and polished the manuscript. YL was responsible for the conception of the work, as well as the drafting of the work and constructive comments on the content of the article, paying close attention to all aspects of the article to ensure the accuracy and completeness of any part of the article. All authors contributed to the manuscript and approved the version as submitted.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.


Chondrosarcoma is the second largest bone malignancy after osteosarcoma and mainly affects middle-aged adults, where patients with distant metastasis (DM) often have a poor prognosis. Although nomograms have been widely used to predict distant tumor metastases, there is a lack of large-scale data studies for the diagnostic evaluation of DM in chondrosarcoma. Data on patients diagnosed with chondrosarcoma from 2004 to 2015 were obtained from the Surveillance, Epidemiology, and End Results database. Independent risk factors for having DM from chondrosarcoma were screened using univariate and multivariate logistics regression analysis. A nomogram was created to predict the probability of DM from the screened independent risk factors. The nomogram was then validated using receiver operating characteristic curves and calibration curves. A total of 1870 chondrosarcoma patients were included in the study after data screening, of which 157 patients (8.40%) had DM at the time of diagnosis. Univariate and multivariate logistic regression analysis screened four independent risk factors, including grade, tumor number, T stage, and N stage. receiver operating characteristic curves and calibration curves showed good accuracy of the nomogram in both training and validation sets. The current study screened for independent risk factors for DM from chondrosarcoma, which will help clinicians evaluate patients. Chondrosarcoma mainly affects middle-aged people,,4 and the most common sites are the proximal femur and the pelvis.–8 Currently, the treatment for chondrosarcoma is mainly surgery and chemotherapy,–11 which can achieve good results for patients who do not have distant metastasis (DM) in the early stage. However, for patients with chondrosarcoma with DM, the prognosis is poor, and few patients survive surgical treatment and chemotherapy.–14 Nomograms are very effective in predicting DM and have been widely used in other fields to predict DM.–18 Although studies are currently available that consider high-grade tumors, T3 stage, and large tumor size as independent risk factors for DM in chondrosarcoma. But different data may lead to different conclusions, and using larger data leads to more reliable conclusions, as well as validating the conclusions of previous studies. Therefore, this study selected data from the Surveillance, Epidemiology, and End Results (SEER) database of patients diagnosed with chondrosarcoma from 2004 to 2015 and plotted the nomogram to assess the prediction of DM in chondrosarcoma.Chondrosarcoma is the second largest bone malignancy after osteosarcoma,Data on patients diagnosed with chondrosarcoma from 2004 to 2015 were obtained from the SEER database. The inclusion criteria were as follows: (1) the patient was a chondrosarcoma patient; (2) complete demographic variables were available, including age, sex, race, and marital status; (3) it had complete clinical and pathological information, including primary tumor location, tumor number, grade, histological type, T stage, N stage, tumor size, and tumor stage. 1870 patients with chondrosarcoma were eventually included in the study through screening.P < .05. The distribution of variables in the 2 groups was compared using the chi-square test and Fisher exact test.This study was statistically analyzed using SPSS 26.0 and R software (version 4.2.1), and the results were considered statistically significant when P < .10 variables were included in multivariate logistic regression analysis, and when P < .05 variables were identified as independent risk factors. The independent risk factors identified were used to plot the nomogram inside the R software.The 1870 patients included in the study were randomly divided into training and validation sets in a 7:3 ratio. Data from the training set were first subjected to univariate logistic regression analysis in SPSS. Univariate analysis when The receiver operating characteristic curves were first plotted in the R software and the corresponding area under the curve was calculated to assess the accuracy of the nomogram. In addition, calibration curves were also plotted in the R software to evaluate the accuracy of the nomogram.A total of 1870 patients with chondrosarcoma were screened for inclusion in the study, with 1310 patients divided into the training set and 560 patients divided into the validation set according to the 7:3 ratio. As shown in Table A total of 157 (8.40%) of the included 1870 patients with chondrosarcoma had DM and 1713 (91.60%) had no DM. As shown in Table The screened independent risk factors were plotted to predict the risk of DM from chondrosarcoma on the nomogram Fig. . Then th Giuffrida et al found that patients without DM had a 30-year survival rate more than four times that of patients with DM.Chondrosarcoma is the second largest bone malignancy after osteosarcoma and has been of interest to bone oncologists. According to related studies, about 8% of chondrosarcoma patients have DM at the time of diagnosis. in addition to IDH1/2 and COL2A1 as possible therapeutic targets for chondrosarcoma. However, these studies are based on the molecular level and not on clinical features. In addition, most of these studies are single-center studies and have small sample sizes, resulting in insufficient reliability of these indicators and making it difficult to use them for management with clinicians.There have been many studies on DM from chondrosarcoma. For example, DDX10 and BYSL are presumed to be potential targets for chondrosarcoma,–18 Therefore, it is necessary to construct nomograms with clinical features to predict DM of chondrosarcoma.Nomograms have been widely used to predict DM of tumors due to their predictive accuracy. on clinical characteristics showed that age, primary location, grade, and tumor size were independent risk factors for chondrosarcoma metastasis, while another study suggested that grade, T stage, and tumor size were independent risk factors for DM from chondrosarcoma. The current study included new data and the current data was larger and found the incidence of DM to be 8.40% and identified four important predictors of DM in chondrosarcoma patients: serial number, grade, T stage, and N stage.Currently, a study However, some studies showed that size was associated with DM, which was related in this study when a univariate analysis was performed, but not when a multifactorial analysis was performed. It was considered that the covariance was due to the existence of covariance between the T stage and size, and the covariance was excluded when the multifactorial analysis was performed. None of the previous studies included the number of tumors at diagnosis in the analysis, but the present study did and found that tumor number was also an independent risk factor. This study showed that the N stage was also an independent risk factor, but other studies,22 showed that it was not, which was considered to be due to the different sample sizes, and more and larger samples are needed to verify.Previous studies have confirmed the relationship between chondrosarcoma grade and T stage and DM.Although the predictive nomograms in this study showed good predictive power, there are some limitations to consider. First, to avoid interference caused by the different diagnostic codes in different years, the included data are only from the clinical data of patients diagnosed with chondrosarcoma in the SEER database from 2004 to 2015, not the data of all chondrosarcoma patients since the establishment of the database. Second, because our study was retrospective, some patient data loss was unavoidable. Third, although the SEER database involves diverse ethnic groups, the United States is still mainly composed of whites and blacks, and there are fewer clinical data records of Asians, which may make the nomogram have certain limitations. Fourth, if the nomogram can be externally detected with large sample data from other databases, the detection result will be more credible, and at the same time, it can also be used to analyze whether the nomogram is universal.The current study screened for independent risk factors for DM from chondrosarcoma, which will help clinicians evaluate patients.Conceptualization: Guang-Hua Deng.Data curation: Guang-Hua Deng, Rong Chen.Formal analysis: Guang-Hua Deng, Rong Chen.Funding acquisition: Guang-Hua Deng.Investigation: Guang-Hua Deng, Zhe Tan, Rong Chen.Methodology: Guang-Hua Deng, Zhe Tan, Rong Chen.Project administration: Guang-Hua Deng.Resources: Guang-Hua Deng, Zhe Tan.Software: Guang-Hua Deng, Zhe Tan.Supervision: Guang-Hua Deng.Validation: Guang-Hua Deng, Hong Wang.Visualization: Guang-Hua Deng, Hong Wang.Writing – original draft: Guang-Hua Deng, Hong Wang.Writing – review & editing: Guang-Hua Deng, Hong Wang.


Although higher consumption of ultra-processed food (UPF) has been linked to a higher risk of metabolic syndrome (MetS), the results remain controversial. Herein, we performed a systematic review and meta-analysis of observational studies to clarify the relationship between UPF consumption defined by the NOVA framework and risk of MetS.2). Publication bias was investigated using the visual inspection of asymmetry in funnel plots and Begg's and Egger's tests.An extensive literature search on PubMed, ISI Web of Science, EBSCO and China National Knowledge Infrastructure (CNKI) databases was conducted to search for the relevant articles published priori to January 2023, and newly published articles between January 2023 and March 2023 were re-searched. Random-effects or fixed-effects models were adopted to calculate the pooled relative risks (RRs) and 95% confidence intervals (CIs). The between-study heterogeneity was explored using the Cochran's Q test and I-square (IP < 0.0001). Subgroup analyses revealed a positive association between consumption of UPF and MetS risk in cross-sectional studies , and no significant association in cohort studies , respectively. In addition, a more significant association between UPF consumption and increased risk of MetS was found in the subgroups of study quality <7  than study quality ≥7 . Similarly, when we performed analyses separately by sample size, there was a significant association between UPF consumption and MetS risk in sample size ≥5,000 , and in sample size <5,000 , respectively.Nine studies  totaling 23,500 participants with 6,192 MetS cases were included in the final analysis. The pooled effect size for the highest vs. lowest categories of UPF consumption indicated a positive association with the risk of MetS (RR: 1.25, 95%CI: 1.09–1.42, Our findings suggest that higher consumption of UPF is significantly associated with an increased risk of MetS. Further longitudinal studies are needed to confirm the effect of UPF consumption on MetS. Metabolic syndrome (MetS) is a pathophysiological state and cluster of ≥3 different cardiovascular risk factors, including abdominal obesity, insulin resistance, elevated blood pressure and dyslipidemia . Parallen = 4). Since then, several new epidemiological studies have also been published evaluating the association of UPF consumption with the risk of MetS  did not use the NOVA food classification system ; (4) studies not reported as HRs, RRs or ORs with 95%CIs; (5) unrelated articles.Two authors (C.-J. S and L.S.) independently screened and crosschecked each article from the literature search, and a third author (Q.Z.) was consulted to settle any discrepancies. After comprehensive screening all the titles and abstracts, the full-text versions of the articles were reviewed according to the inclusion and exclusion criteria of this meta-analysis. Studies were included in our analyses when they met all the following eligibility criteria: (1) were observational studies ; (2) were carried out in humans of any age; (3) UPF was considered as the main exposure of interest (according to the NOVA food classification system); (4) evaluated the association with MetS risk; (5) reported adjusted estimates of the RRs [e.g. hazard ratios (HRs) or odds ratios (ORs)] and 95%CIs for the link between UPF consumption and MetS risk. Where the original studies didn't provide sufficient data, the corresponding author of the study was contacted by email for additional information. Studies were excluded if they met one of the following criteria: (1) non-observational studies, e.g. reviews, editorials, case reports and conference letters; (2) animal, cell culture, and Data were extracted by two independent authors (X.-Y. Z and J.-Y. Z) from the identified eligible studies, including first author's last name, year of publication, study design, study area, sample size, number of MetS cases, mean age or age range of participants, duration of follow-up for cohort studies, method of UPF assessment, adjustments for confounding factors, and effect sizes  for the relationship between UPF consumption and risk of MetS.In the NOVA food classification system, UPF is characterized by high intake of foods made up entirely or mostly from unhealthy components, including food products having high energy density, added sugar, salt, saturated and trans fats, and low amounts of dietary fiber, vitamins and minerals, e.g. pizza, instant noodles, hamburger and smoking meats .The authors (L.S. and X.-Y. Z) independently assessed each included study's quality using the Newcastle-Ottawa Scale (NOS), which was designed for case-control and cohort studies . In the 2) statistics. P-values of Cochran's Q test <0.10 and I2>50% were considered to show substantial heterogeneity among the included studies, and subsequently the random-effects models (DerSimonnian and Laird method) were used to summary the pooled RRs. Otherwise, the fixed-effects models were adopted , moderate (25%~75%) and high (I2 ≥ 75%), respectively. In the case of significant between-study heterogeneity (I2 > 50%), the potential sources of heterogeneity across studies were explored using subgroup and sensitivity analyses. In our analyses, subgroup analyses were performed based on the study design , exposure assessment , study quality (≥7 or <7), mean age (≥55 or <55), study area (developed countries or developing countries) and sample size . Sensitivity analysis was performed, excluding one study removed at one time to confirm whether the results were robust or sensitive to the influence of individual study. Publication bias was assessed through examining the funnel plots, and statistical assessment of funnel plot asymmetry was quantified by Begg's or Egger's tests , the outcome of interest was components of metabolic syndrome (n = 2), the main exposure was processed meats (n = 2), conference abstract (n = 2), reported data as β coefficient (n = 1) and reported the same participants (n = 1). Finally, nine articles met the inclusion criteria and were included in our main analyses.The main characteristics of all included studies are outlined in P < 0.0001). The high heterogeneity was observed among the included studies , thus random-effects model was used to calculate the pooled RRs.Nine studies  including 6192 cases and 23500 participants were included in this meta-analysis that investigated the association between UPF consumption and MetS. 2 = 85.0%, P < 0.0001), we performed subgroup analyses to find the potential sources of heterogeneity. The results of subgroup analyses were presented in P = 0.002). However, there was evidence of heterogeneity between studies . Meanwhile, there was no significant association between UPF intake and MetS risk in cohort studies , with more evidence of heterogeneity . For exposure assessment, there was a significant association between UPF intake and risk of MetS  in 24-h dietary recall, with less evidence of heterogeneity . In addition, we also found significant association between UPF intake and MetS risk in FFQ , and there was more heterogeneity . For mean age, the positive association between UPF intake and risk of MetS was observed in the subgroups of age <50 , and there was evidence of significant heterogeneity . Moreover, we also observed the significant positive association between UPF intake and MetS risk in the subgroups of age ≥50 , and there was evidence of heterogeneity . For study area, there was a significant association between UPF intake and risk of MetS in developed countries  and the between-studies heterogeneity decreased from 85.0% to 74.3%. However, the statistical association was also observed between UPF intake and risk of MetS in developing countries . For sample size, we found a positive association between UPF intake and risk of MetS in sample size <5,000 . However, the heterogeneity was apparent . In contrast, we also found a significant association between UPF intake and MetS risk in sample size ≥5,000 , and there was no heterogeneity . For study quality, significant positive association was found between UPF intake and MetS risk in the subgroups of study quality ≥7 , and there was more heterogeneity . In addition, there was less evidence of heterogeneity in the subgroups of study quality <7 , where significant positive association with risk of MetS was observed .Given the significant heterogeneity of this meta-analysis (IP = 0.001). However, in our analyses, Begg's test for publication bias was not statistically significant (highest vs. lowest level of UPF consumption: Begg's test: P = 0.917). When trim and fill was applied filling added no study to the funnel plot, indicating a low degree of asymmetry and no change in the overall effect.As shown in P < 0.0001). In addition, the heterogeneity of included studies decreased from 85.0 to 59.2%.Based on the findings of sensitivity analysis , a cohorThe quality of included studies using NOS criteria is shown in In the present study, the pooled results illustrated that high consumption of UPF was significantly associated with an increased risk of MetS. Nonetheless, the results of this meta-analysis must be interpreted with caution due to the high heterogeneity among the included studies. Moreover, subgroup analyses showed the positive association between high consumption of UPF and risk of MetS was more robust in cross-sectional studies and the subgroups of study quality <7. Likewise, the results of sensitivity analysis indicated that Magalhãesas et al.' study might be the source of heterogeneity. To the authors' knowledge, this is the first comprehensive systematic review and meta-analysis to assess the relationship between consumption of UPF and MetS risk. Our findings confirm the positive association results of previous studies and add to the growing evidence for the role of UPF consumption in diet-related chronic diseases, including MetS.2 = 85.0%; P < 0.001). This is in agreement with findings from some previous studies reporting that high UPF consumption is associated with an increased risk of MetS . Although between-study heterogeneity is common in meta-analysis (In our analyses, it is important to point out that there was evidence for high between-study heterogeneity among all included studies (Ianalysis , exploriThis study has several strengths and limitations. First, to our knowledge, this is the first comprehensive systematic review and meta-analysis to evaluate the relationship between consumption of UPF and the risk of MetS. Our findings add to the growing evidence for the impact of UPF consumption on MetS and help inform public policy for the prevention and management of MetS. Second, a rigorous selection of articles was conducted based on the predetermined inclusion criteria, with the inclusion only of studies in which the classification of UPFs faithfully followed the characteristics proposed by the NOVA system. Third, MetS cases were ascertained through medical records, reducing the risk of misclassification. Fourth, the quality of the included studies was moderate to high, and the reported RRs were multivariate and adjusted for some known confounders, such as sex, age, physical activity and total energy intake. Meanwhile, we also performed subgroup and sensitivity analyses to explore the potential sources of heterogeneity. Fifth, no signs of publication bias were evident in the funnel plot, and the Begg's test for publication bias was non-significant. Despite the above-mentioned strengths, this study also has some limitations that should be acknowledged. First, although our findings show a positive relationship between UPF consumption and MetS risk, the majority of included studies are cross-sectional in design, which are limited by the potential for reverse causality. Second, five of the included studies used the FFQs that were not specifically designed to assess the NOVA classification groups, which might have led to an under- or over-estimation of the size of the observed associations. Likewise, information bias, as a consequence of self-reported data on dietary intake, might have occurred. Third, even though all of included studies in this meta-analysis have adjusted for a wide range of important confounders, residual confounding from unmeasured factors cannot be completely ruled out. Also, there was also an inconsistent adjustment for potential confounders in the all included studies. Consequently, the data included in this meta-analysis might suffer from differing degrees of completeness and accuracy. Fourth, high heterogeneity was found in this meta-analysis, which might have distorted the reliability of our results. Although we performed subgroup and sensitivity analyses to explore the potential sources of heterogeneity, we were unable to adequately ascertain and explain the sources of inter-study heterogeneity. Finally, given the limited number of included studies and the fact that most of them were performed in developing countries, caution is advised in the interpretation and extrapolation of our findings.In summary, findings from this study suggest that higher consumption of UPF is significantly related to an increased risk of developing MetS. Our findings add valuable evidence to the existing literature showing a positive relationship between UPF consumption and risk of MetS, and highlight the importance of limiting UPF consumption in decreasing the modifiable burden of MetS. Thus, active discouragement of UPF consumption should be considered as part of MetS prevention strategies. Considering the high level of evidence provided in the included studies, more well-designed prospective studies, particularly in different geographic regions and settings, are warranted to further confirm these findings.The original contributions presented in the study are included in the article/CS conceived and designed the systematic review, meta-analysis, and interpreted the results. XZ and JZ acquired the data. LS and QZ performed the statistical analysis and obtained the funding. LS conceived the idea and drafted this manuscript. All authors critically revised the manuscript for important intellectual content. All authors contributed to the article and approved the submitted version.


Oligometastasis is defined as the presence of several limited metastatic lesions and is generally limited to three or fewer than five metastatic lesions. Previously, the treatment of metastatic cancer aimed to alleviate symptoms rather than cure them; however, the use of immunotherapy or targeted therapy has greatly improved patient life expectancy. Additionally, the effectiveness and safety of local treatment have recently been proven for oligometastatic cancers and have significantly improved patient survival and decreased recurrence rates. A few metastatic studies on lung cancer have demonstrated the usefulness of combining radiation therapy and immunotherapy. Recently, local and targeted therapy combinations have shown promising results in treating non-small cell lung cancer, predominantly caused by the epidermal growth factor receptor and anaplastic lymphoma kinase gene mutations, suggesting the potential of these new treatment strategies. It is well known that oligometastasis has better clinical results than polymetastasis; however, research on the biological profile of oligometastasis is still lacking. Studies using circulating tumor DNA and circulating tumor cells are at the initial stages of providing a better understanding of oligometastatic cancers, and the biological characteristics of these cancers may be revealed based on more diverse studies. With the development of these treatments, the prognosis for patients with oligometastatic cancers is steadily improving, and if the biological profile is revealed, customized treatment may be provided. Oligometastasis is a compound word derived from the Greek word oligo, meaning small number, and metastasis. Although no exact definition has been established, it is generally described as a disease with 3–5 metastatic foci. It is also defined as a disease that can be treated using active local therapies, including surgery or radiation therapy (RT)  Figure . DistantIn traditional oncology, cancer spreads throughout the body as tumors invade the primary and surrounding lymph nodes and evolve to a level that invades the blood flow, thereby limiting the potential of local treatment. Local treatments, including surgery or RT for patients with metastatic cancer, provide symptom relief rather than radical treatment. Anticancer treatment can increase the life expectancy of patients with metastatic cancer; however, it is unlikely to cure them, and it can reduce their quality of life.Oligometastasis is a disease where metastatic lesions are generally limited to fewer than three to five, and local treatment is expected to be beneficial . Since tJournal of Clinical Oncology, establishing the term “oligometastasis” and proposing it as “a spectrum of disease from purely localized to widespread”. This is clinically significant, as the oligometastatic state could currently be viewed as a point at which to apply the curative strategy, even though it relates to metastatic cancer [In 1995, Samuel Hellman and Ralph Weichselbaum wrote an editorial in the c cancer . This waWe hope patients with metastatic cancer will experience a near-cured prognosis (even if only some). However, even after successfully resecting metastatic cancer, approximately two thirds of the patients will experience disease recurrence and metastasis. In this situation, surgical resection can be somewhat burdensome, and depending on the patient’s health status or the location of the metastatic lesion, surgery is frequently difficult. Owing to the development of technology based on computerized tomography, RT can precisely focus high-dose radiation on target tumors and show a local control rate similar to that of early lung cancer surgery . RT is lPrevious studies involving RT for oligometastasis were mainly single-group studies. The results of these studies suggested that, even in cases of metastatic cancer, active RT yielded better results than what is conventionally considered reasonable. Notably, stereotactic body radiotherapy (SBRT), a technique that delivers high doses of radiation to a small target in a short period, has been adopted in treating oligometastatic disease . SBRT hap = 0.022; and median OS: 41.2 vs. 18.9 months, p = 0.017). Furthermore, Iyengar et al. [p = 0.01). These two studies included a relatively small number of patients whose enrollment was prematurely discontinued because of the apparent good progress reported in the group that received local treatment during enrollment. Palma et al. conducted a randomized study of 99 patients with five or fewer metastatic lesions, including patients with lung cancer. The group that underwent SBRT showed better results than the group that received the palliative standard of care ; however, in a randomized study of 86 patients with small cell lung cancer comprising fewer than four lesions in the extended stage, the addition of consolidative extracranial irradiation (thorax + metastatic sites) to Prophylactic Cranial Irradiation (PCI) after chemotherapy did not significantly affect the patient survival rate . However, the PFS was longer in the consolidative RT group, suggesting a benefit to including the additional radiation treatment  [Due to the excellent results obtained from these single-group studies, a significant number of randomized studies were conducted in the mid-2010s. Research was conducted on various carcinomas; however, the most successful areas entailing randomized research were those pertaining to lung and prostate cancers. Gomez et al. ,14 condur et al.  conducte = 0.01)  (Table 2p = 0.007) and failure-free survival , especially in the subgroup with the low metastatic burden (less than three metastatic lesions). In a phase 2 randomized study by Ost et al. [In addition to lung cancer studies, a randomized study was conducted on the treatment of oligometastatic prostate cancer. Parker et al.  conductet et al. , androgep < 0.001) and PFS . In studies with three or fewer metastatic lesions, the use of local treatment was beneficial for both the survival  and the PFS  rates. Regarding the survival and PFS in the OWG subgroup analysis that examined non-small cell cancer studies exclusively, the degree of benefit was similar to the values analyzed in this study. However, no local treatment benefit was found in the OWG subgroup analysis of small-cell lung cancer studies.Over the last decade, many institutions have published research results on the treatment of oligometastasis  for oligometastatic cancers, targeted treatment, and immunotherapy are currently being conducted, especially in the field of lung cancer.p = 0.19), and the objective response rate at week 12 was significantly beneficial (36 vs. 18%). Notably, in this study, the PFS and overall survival (OS) improved even at 0% of the programmed death-ligand 1 (PD-L1) tumor proportion score . In the randomized MDACC trial [p = 0.004), demonstrating the same trend observed in previous studies. Theelen et al. [p = 0.0045) and OS  also showed significant benefits when radiotherapy was added. No significant difference was observed in the response rate according to PD-L1 expression; however, at low expression levels, radiotherapy combined with immunotherapy showed a better response rate than pembrolizumab alone. Overall, these studies indicate that the combination of programmed cell death protein (PD-1)/PD-L1 inhibitors and SABR increases the abscopal response, improving the response and survival rates.The development of immunotherapy has achieved a breakthrough improvement in treating metastatic NSCLC, and advances in RT for NSCLC treatment have been promising with acceptable safety profiles. In the randomized PEMBRO-RT phase 2 study , the pemCC trial , one gron et al.  reissuedp = 0.035), the abscopal effect reached 41.3%, and a significant synergic effect of immunotherapy and RT was observed. In a retrospective review conducted by Chen et al. [p = 0.005)  .p < 0.001), and the median OS was 40.9, 34.1, and 30.8 months, respectively (p < 0.001). The results of SINDASTAL, a phase 3 randomized study in China, have been recently published; this study involved 133 patients with oligometastasis (fewer than five lesions) in the first-generation TKI, categorized into TKI and RT . Benefits for both OS  and PFS  were observed in the TKI-RT group [Studies on combination treatments of local therapy for oligometastasis are currently being conducted in NSCLC, which is primarily caused by specific gene mutations, including the epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) mutations. Wu et al.  reportedRT group  Table 3p < 0.001The NORTHSTAR, BRIGHTSTAR, and LONESTAR trials are currently being conducted. The NORTHSTAR trial  compares the utility of early vs. optional local treatment in combination with osimertinib treatment, and the BRIGHTSTAR trial  follows the adjuvant brigatinib after 8 weeks of local treatment. After using ipilumamab/nivolumab as an induction, the LONESTAR trial  selectively uses local treatment.p = 0.002; induced vs. repeat median survival: 28.1 vs. 50.3 months, p < 0.001). The results of the CURB trial [p = 0.004). No benefit of SBRT was observed in the breast cancer group .Research is also being conducted to further subcategorize the disease status of oligometastatic cancer and perform patient-specific treatment. The European Society for Therapeutic Radiology and Oncology and the European Organization for Research and Treatment of Cancer have classified oligometastatic cancer into nine disease conditions, including de novo oligometastatic disease, repeat oligometastatic disease, and induced oligometastatic disease. This distinction is based on the number of metastatic lesions and the timing of diagnosis . WillmanRB trial , which sp < 0.001), and lower detection rates in thoracic metastasis than extrathoracic metastasis . They reported that ctDNA driver mutations influenced the decrease in PFS. Sud et al. [p = 0.007).It is well known that oligometastasis has better clinical results than polymetastasis, which includes a large number of lesions; however, studies on the biological profiles of oligometastasis that can demonstrate the state of these independent diseases are still lacking. Lussier et al.  reportedd et al.  considerThese studies provide an important basis for understanding the biological properties of oligometastasis; however, they are still in their infancy because they are difficult to verify in large-scale clinical studies or for use in actual treatment . AdditioThe flow of clinical research on oligometastatic cancer is summarized as follows: Since the beginning of the 20th century, studies have attempted active local treatment for patients with early metastatic cancer to achieve excellent oncological results and open up the possibility of rooting. In the 2010s, these results were established through random- or large-scale studies. In the field of lung cancer treatment, immunotherapy and targeted treatment have recently rapidly developed, and the prognosis has significantly improved for patients with advanced stages of cancer compared to those of the past. These new drugs are thought to be effective in patients with oligometastasis. Thus, future studies should consider the benefit and safety of local treatments, including RT or surgery, and the combined use of these new drugs. Research aimed at enhancing our understanding of the biological properties of oligometastatic cancers is continually advancing, although it may require a considerable amount of time to reach comprehensive conclusions; however, the results will help develop new treatments and provide patient-specific therapies. Various organizations and committees, domestic and abroad, have established clinical definitions and detailed classifications of oligometastatic cancers. Here, the number of lesions, the number and type of organs involved, and the timing of diagnosis are considered. This can improve our understanding of the disease properties of oligometastatic cancers and assist in making therapeutic decisions in the field. Additionally, the active local treatment of oligometastatic diseases may increase the number of radiation treatments, increasing the ecological burden. However, local treatment may have socioeconomic benefits if the cost of managing progressive metastatic disease is reduced and a gain in patient quality of life or survival is obtained ,38. Furt


Assessment instruments play an essential role in the management of knee osteoarthritis. This study aimed to verify the clinimetric properties and validate the short version of WOMAC’s (SV-WOMAC) knee with two domains, pain (four items) and physical function (eight items) in individuals with knee osteoarthritis (KO).Reliability and internal consistency Construct, criterion validity, Ceiling, and floor effects analyses were performed. In addition to the SV-WOMAC, the following instruments were used: the numerical rating scale (NRPS), International Knee Documentation Committee (IKDC), the Short Form Health Survey (SF-36), and WOMAC’s original version. Spearman’s correlation coefficient (rho) was used to determine the magnitude of the correlation between the AFAQ and the other instruments. Moreover, the test–retest reliability and internal consistency were assessed using the intraclass correlation coefficient (ICC) and Cronbach’s alpha, respectively. In addition, standard error of measurement (SEM) and minimum detectable change (MDC) were calculated.One hundred and thirteen subjects with KO were included for validity analysis, and a subsample of 53 subjects was used for test-retest reliability. Adequate reliability and internal consistency were observed with ICC ≥ 0.76, SEM ≤ 1.85, MDC ≥ 5.1, and Cronbach’s alpha ≥ 0.84. Regarding construct validity, correlations greater than 0.50 were observed with the IKDC, NRPS, and functional domains of the SF-36. The SV-WOMAC showed a correlation > 0.70 with the original version and did not show ceiling and floor effects.The SV-WOMAC knee has adequate measurement properties to analyze pain and physical function in Brazilian individuals with KO. With risk factors such as obesity, advanced age, female gender, previous traumatic joint injury, joint malalignment, genetic predisposition, and loss of muscle mass, osteoarthritis is a multifactorial disease related to genetic, hormonal, mechanical, metabolic, and aging factors and characterized initially by molecular disorders  followed by anatomical and/or physiological conditions . Although it can affect any joint, the hand, hip, and knee joints are the most affected –5.Due to all this complexity and miscellany of causes and impairments, Patient-reported outcome measures (PROMs) and functional tests have become, over the years, essential components in the assessment of osteoarthritis, especially when it comes to knee osteoarthritis (KO). PROMs express and reflect the individual’s experiences that often cannot be observed by direct measurements .Among the PROMs most used in individuals with KO, the following stand out: the International Knee Documentation Committee (IKDC) which assesses improvement or worsening in symptoms, function, and sports activities; the Medical Outcome Study 36 – Item Short-Form Health Survey SF-36 assesses the quality of life; the numeric rating scale (NRPS) that assesses pain; the Knee Injury and Osteoarthritis Outcome Score (KOOS), which evaluates the quality of life-related to the knee, pain, symptoms, difficulties in performing sports activities and activities of daily living; Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS) which assesses physical function and the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) which assesses pain, stiffness and physical function .Some studies assessed WOMAC’s structural validity and used factorial and Rasch analysis. According to Gandek , when caRegarding Brazil, the study that carried out the translation, cross-cultural adaptation, and validation of the original version of the WOMAC’s knee into Brazilian Portuguese used the original English version of the instrument, with 3 domains as a basis and obtained adequate values for the reliability and construct validity and is currently used for research and clinical evaluations of individuals with knee and hip osteoarthritis in Brazil . HoweverThis study aimed to verify the clinimetric properties and validate the SV- WOMAC knee with two domains, pain (four items) and physical function (eight items) in individuals with KO. We hypothesized a magnitude of correlation greater than 0.50 (similar construct) of the SV- WOMAC knee with the original version of the WOMAC Knee, NRPS, IKDC, and SF 36, between 0.30 and 0.50 with the non-functional capacity domain of the SF -36 (related but different constructs), and less than 0.30 with the others SF-36 domains (unrelated constructs).This questionnaire validation study was carried out according to the Guidelines for the Process of Cross-cultural Adaptation of Self-Report Measures and Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) , 14.Research participants were recruited by verbal invitation and phone from a list of participants in the care group for individuals with chronic musculoskeletal pain in basic healthcare units, clinics, and healthcare offices in the city of São Paulo  between January 2020 and ended in October 2022. Data was collected using the free Google Forms platform . The assessment instruments were self-reported. The responsible researcher was present throughout the completion of the evaluation instruments to clarify doubts about the completion.All participants signed an informed consent form. This study was approved by the Research Ethics Committee of Universidade Nove de Julho (nº 32675720.9.0000.5511).The sample size was established according to the COSMIN recommendation of 7 times the number of items in the questionnaire, provided that this value is not less than 100 participants .Thus, the following inclusion criteria were considered: Individuals with KO diagnosed by physicians specializing in osteoarthritis, both sexes, aged over 40 years, Kellgren-Lawrence radiologic scale grades 2 and 3, experiencing knee pain ≥ 3 on the visual analog scale, complaint of pain and/or change in knee function lasting ≥ 12 weeks, morning stiffness and those with native language, Brazilian Portuguese, literate, able to read and write in Brazilian Portuguese. The exclusion criteria included Mini-Mental State Examination (MMSE) score below cutoff values (highest education: score ≤ 23 and lowest education: score ≤ 17) , acute iThe measure properties of structural validity, construct validity, and test-retest reliability were chosen to analyze the SV- WOMAC knee. For this, two applications of the SV- WOMAC were performed with an interval of 1 week between applications. This interval was long enough to avoid memory bias and short enough to ensure no changes were found in the measured construct , 16, 17.Regarding the instruments used, the NRPS is validated in Portuguese to assess pain intensity. Composed of a sequence of numbers ranging from 0 (no pain) to 10 (worst pain imaginable) . It was The IKDC was validated for the Brazilian population , an instThe SF-36 was translated, cross-culturally adapted to Brazilian Portuguese, and is considered valid and reproducible. It aims to assess the quality of life . This isThe WOMAC is one of the most used instruments for evaluating individuals with knee osteoarthritis. Translated and cross-culturally adapted into Brazilian Portuguese, it contains 24 items divided into three domains: pain with 5 items, stiffness with 2 items, and physical function with 17 items. For each item, a Likert scale with 5 answers is used . The higher the score, the greater the pain, stiffness, or worse the individual’s physical function , 22.The SV-WOMAC knee resulted from the factor analysis (exploratory and confirmatory) of the original version of WOMAC . This veDescriptive statistics were performed, and variables were presented as mean and standard deviation (SD) or absolute and relative frequency. SPSS software  was used for descriptive statistics, reliability, internal consistency, and construct validity analyses.Therefore, the internal consistency was calculated using Cronbach’s alpha to identify whether redundant or heterogeneous items were in the questionnaire. We considered adequate value on Cronbach’s alpha > 0.70 . We evalOn the construct validity, we used Spearman’s correlation coefficient (rho) to determine the correlation magnitude between the SV- WOMAC knee and the other instruments. Our hypothesis is a correlation greater than 0.50 between WOMAC versions. And NRPS, IKDC, and SF-36 , between 0.30 and 0.50 and less than 0.30 with the other SF-36 domains.Ceiling and floor effects were evaluated. This, by definition, occurs when more than 15% of the study participants reach the minimum or maximum values of the final score of the questionnaire evaluation instrument .We included one hundred-three participants in the study. Fifty participants were used to calculate the construct and criterion validity and to verify the presence of ceiling and floor effects. The data from the fifty-three were used to calculate the reliability and internal consistency.Most of the sample comprises females, elderly, married, and with complete secondary education, as shown in Table n = 53) participated in this analysis for reliability and internal consistency analyses. As shown in Table A subsample (We hypothesized the magnitude of correlation greater than 0.50 (similar construct) of the SV-WOMAC knee with the WOMAC of the knee, IKDC, and SF 36, between 0.30 and 0.50 with the non-functional capacity domain of the SF -36 (related but different constructs), and less than 0.30 with the other research instruments (unrelated constructs).Thus, we confirmed our hypothesis, as the SV-WOMAC knee presented a correlation magnitude greater than 0.50 with the IKDC with the SF-36 domains and the NRPS  participant achieved the minimum score, while 2 (1.9%) completed the maximum score. Therefore, in the physical function domain of the SV-WOMAC knee, none of the participants reached the minimum score, while 2 (1.9%) reached the maximum score.This study identified that the short Brazilian Portuguese version of the SV- WOMAC knee has adequate measurement properties. Precisely, this version has adequate values for reliability, internal consistency, construct validity, and criterion validity, not showing ceiling and floor effects. Characteristics that make this version a reliable assessment tool to assess pain and physical function in individuals with KO.The hypothesis tested in the study was based on the magnitude of correlation greater than 0.50 between WOMAC versions. And NRPS, IKDC, and SF-36 , between 0.30 and 0.50. And less than 0.30 with the other SF-36 domains. Indeed, the tested hypothesis was confirmed. It indicated that the SV-WOMAC has a great magnitude of correction with the original instrument and a great relationship with instruments that evaluate recurrently indicated constructs for assessing KO, pain intensity, and functionality . The lowThe results of Ferreira et al.  and thisBecause it is understood that the establishment of the measurement properties of an instrument within a group of individuals is a continuous and changing process,50 studies questioning the measurement properties related to the WOMAC are not exclusive to the Brazilian Portuguese version . McConneThe findings by McConnell et al.  reinforcReduced versions of WOMAC are not exclusive to the Brazilian Portuguese version. Short questionnaires improve patient compliance and present more reliable response rates . As a reAs for internal consistency, Collins et al.  found CrRegarding the construct validity, the Brazilian Portuguese SV- WOMAC knee presented an excellent correlation magnitude with all other instruments used for comparison in this study. As a reference, a valid correlation is above 0.50 compared to other instruments with similar constructs . The cutRegarding criterion validity, the correlation magnitude of the SV- WOMAC knee was analyzed with the original version; an adequate correlation was attested (> 0.70) in the pain and physical function domains, with no correlation above 0.70 only with the stiffness domain. This finding indicates that even with the deletion of 12 items, the measurement ability of the SV-WOMAC knee for pain and physical function remained very close to the original version. With the advantage of being shorter, with a shorter application time. And consequently, better accuracy.The validation of the SV- WOMAC knee into Brazilian Portuguese presents a new possibility for clinicians and researchers. Its greater simplicity and ease of application will enhance and increase its acceptability and usefulness in research and clinical management routines of individuals with KO. In clinical management and conducting clinical research, participants often need to fill in several extensive assessment instruments, which implies a significant burden and may compromise responses. It is understood that short questionnaires result in greater patient compliance and better response rates .Some limitations of this study must be recognized. First, the assessment instruments were completed in person, and the digital filling was used. However, instruments such as the WOMAC already have validation to be self-administered or used through interviews, for personal use, by telephone, or electronically (via cell phone or computer) –30. FurtThe results demonstrated in this study offer several opportunities for future studies. Although the extended version of WOMAC, which gave rise to the version tested in this study, has a good linking process with the International Classification of Functioning, Disability and Health (ICF) , 32. NewThe SV-WOMAC knee has adequate measurement properties to analyze pain and physical function in Brazilian individuals with KO.