To explore the role of postoperative gonadotrophin releasing hormone agonist (GnRH-a) therapy before treatment with intrauterine insemination (IUI) for infertile females with stage I-II endometriosis.Ninety-seven patients diagnosed with stage I-II endometriosis before IUI were enrolled in this study. The clinical pregnancy rate, cumulative pregnancy rate, live birth rate and newborn conditions were compared between the two groups with and without GnRH-a therapy.p = .035). By logistic regression analysis, patients treated with GnRH-a had a higher clinical pregnancy rate than those without (adjusted odds ratio (AOR) 23.190, 95% confidence interval (CI) 1.238–434.312). The live birth rate per IUI cycle in the GnRH-a group was also higher than in the controls (12.94% vs. 10%). However, the difference was not statistically significant . The patients with GnRH-a therapy had a similar incidence of multiple pregnancy rate (0% vs. 0%), miscarriage rate (2.35% vs. 0.91%) and ectopic pregnancy rate (0% vs. 0.91%) as compared to the control group. The cumulative pregnancy rates were all higher in patients administered with GnRH-a than those without GnRH-a treatment in different cycles , but the difference was not statistically significant. Notably, there was no more pregnancy after the third IUI cycle. The gestation weeks of delivery in the two groups were 39.09 ± 1.04 and 38.60 ± 1.17, respectively (p = .323). Nor was there difference in birth weight between the two groups .The clinical pregnancy rate of IUI in the GnRH-a group was higher than that in the control group (15.29% vs. 11.82%, Endometriosis is a common cause of infertility, but the exact mechanism remains unclear.The administration of GnRH-a before IUI treatment is beneficial for patients suffering from stage I-II endometriosis.After three failed attempts, IUI should be stopped in patients with stage I-II endometriosis.The administration of GnRH-a in patients with stage I-II endometriosis could be beneficial to the outcomes of IUI. It is recommended that IUI should be discontinued after three failed attempts. Endometriosis, a common gynecological disease and steroid-dependent disorder, is characterised by the presence of functional endometrial-type mucosa outside the uterine cavity ,2. It isin vitro fertilisation (IVF) and is affected by various factors, such as female age, duration of infertility and indication [Intrauterine insemination (IUI) is recommended for infertile couples with stage I-II endometriosis. As a first line treatment of assisted reproductive technology (ART), the advantages of IUI treatment are low cost and less invasion . Howeverdication . EspeciaGonadotrophin releasing hormone agonist (GnRH-a) could be applied to lower the level of gonadotrophins which could inhibit the progression of endometriosis and prevent the formation of new lesions. In a recent meta-analysis, it has been concluded that both laparoscopy and GnRH-a alone could improve the clinical pregnancy outcomes of infertile women with endometriosis . HoweverIn this study, our aim was to confirm the effectiveness of GnRH-a therapy by comparing the clinical pregnancy rate and live birth rate of IUI in patients suffering from stage I-II endometriosis with and without drug treatment after laparoscopy.We conducted a retrospective study by reviewing the clinical data of 195 cycles from 97 infertile females at the Reproductive Medicine Centre of Ningbo First Hospital in China between January 2015 and March 2021. All the subjects had undergone laparoscopy surgeries combined with hysteroscopy before IUI treatment. The overall pelvic environment and intrauterine condition were evaluated during the surgery. Meanwhile, tubal patency examination was performed to check the function of fallopian tubes. Inclusion criteria in our research included: stage I or stage II endometriosis with two patent fallopian tubes. Our study was approved by the Institutional Review Board of Ningbo First Hospital (No. 2021RS060). Written informed consents for admission, surgery, special drugs, discharge and follow-up were obtained from all the participants during the whole medical process. The informed consents for the administration of GnRH-a were obtained prior to the injection postoperatively. All the procedures were in accordance with the approved guidelines.We followed up the patients until all surgical procedures, postoperative therapies with GnRH-a and IUI treatments were completed. If the participants got pregnant, we ended the follow-up lasted after they were delivered.Patients with endometriosis were diagnosed for the presence of endometriotic lesions during the laparoscopy surgery and were staged according to the revised American Society for Reproductive Medicine (ASRM) classification system . All pat6/ml; vitality <58% live; progressive motility <32%; total motility <40%; morphologically normal forms <4.0%) according to guidelines recommended by World Health Organization (WHO) [Exclusion criteria included ovulatory dysfunction , abnormal implantation , poor ovarian reserve and male factor infertility  .Forty-one patients received 3.6 mg goserelin  on day 2–3 after laparoscopy surgery were categorised as GnRH-a therapy group. All patients were informed about the potential side effects of GnRH-a therapy, including hot flushes, sexual hypoactivity, vaginal dryness, depression and slight but reversible bone loss. All these patients were subjected to GnRH-a treatment every 4 weeks for 1–3 cycles. Patients without GnRH-a therapy were considered as the controls.Follicle growth was monitored by transvaginal ultrasonography since day 10 in a natural cycle.Clomiphene citrate (CC): 50–100 mg/day starting from day 3–5 for 5 days.Letrozole (LE) 2.5–5.0 mg/day from day 3–5 for 5 days.Human menopausal gonadotrophin (HMG) 37.5–75 IU/day starting from day 3–5 for a variable duration depending on the response.Ovarian stimulation protocols were as follows:When at least one mature follicle had a diameter of 18 mm or more, ovulation was triggered with intramuscular injection of urinary human chorionic gonadotrophin (hCG) , or hypodermic injection of recombinant human chorionic gonadotrophin alfa , or hypodermic injection of Triptorelin (0.1 mg).On the day of IUI, husband’s semen was collected by masturbation after abstinence for 3–7 days and prepared with two-layer density gradient centrifugation after liquefaction. The volume of washed semen sample used for insemination was 0.3–0.5 ml.IUI was performed 36–40 h after injection by a gynaecologist in an operating room adjacent to the laboratory. After the operation, the women were advised to rest for at least 30 min. The luteal support was used routinely in all patients since the day of ovulation. It consisted of Duphaston  for 14 days. A blood test for hCG assay was performed 14 days after insemination to confirm whether pregnancy had occurred. If the patient got a positive hCG, ultrasound examination could be performed 3 weeks later to confirm foetal viability. Clinical pregnancy was confirmed when there was ultrasonographic evidence. The primary outcome was the clinical pregnancy rate calculated by dividing the numbers of clinical pregnant patients by the total number of patients who underwent IUI treatment. Other pregnancy outcomes included live birth rate, gestation weeks of delivery, preterm delivery rate and birth weight.t test. Pearson’s Chi-square test or Fisher’s test was used to compare the ratios between the groups. We also used logistic regression to model the clinical pregnancy rate and live birth rate with control group as the reference. A value of p less than .05 was considered statistically significant.Statistical analysis was performed using the Statistical Package for Social Sciences . Data were presented as the means ± SD or number (%). The baseline differences between the two groups were analysed by Student’s p = .000). There were no statistical differences in terms of female age, body mass index (BMI), Antimullerian hormone (AMH), basal hormones before laparoscopy surgery, duration of infertility, female education, unhealthy lifestyle and medical history between the two groups.The most common side effects of GnRH-a therapy included hot flash (7.32%), sexual hypoactivity (2.44%) and vaginal dryness (9.77%), which were mild and temporal. No other severe side effects were observed in all subjects. As shown in p = .000), while the ratio of the GnRH-a group was lower  in the secondary infertile women. The day 2–3 serum FSH and LH levels of the GnRH-a group were both lower than those in the control group . Totally, 105 natural cycles and 90 ovarian stimulated cycles were performed in our study, respectively. There was no significant difference with respect to ratio of natural cycle to ovarian stimulated cycle (p = .060). Besides, there was no difference in terms of follicle number, total motile sperm count (TMSC) and side effects of IUI treatment between the two groups. However, larger endometrial thickness was observed in the patients administered with GnRH-a when compared with the control group .As demonstrated in p = .035) .The clinical pregnancy rate of IUI treatment in GnRH-a group was higher than that in the control group (15.29% vs. 11.82%). The difference was statistically significant ( = .035) . As showp = .323). Meanwhile, there was no difference in birth weight between patients with and without GnRH-a therapy .Overall, the patients with GnRH-a therapy had a similar incidence of multiple pregnancy rate (0% vs. 0%), miscarriage rate (2.35% vs. 0.91%) and ectopic pregnancy rate (0% vs. 0.91%) as compared to the control group . As in Tp = .585; two cycles:29.27% vs 19.64%, p = .390; three cycles:31.71% vs 23.21%, p = .481; ≥four cycles:31.71% vs 23.21%, p = .481). But the difference was not statistically significant. As shown in In our study, the cumulative pregnancy rate was assessed in 97 patients were up to 6 IUI cycles, which was the maximum number of cycles. As shown in p = .000, p = .003). We consider the decreased serum FSH levels was due to the effect of GnRH-A therapy. The follicle number, TMSC and side effects of IUI treatment were similar between the two groups. However, the endometrial thickness in the GnRH-a therapy group was larger than that in the control group (p = .022), which might improve the clinical outcomes of IUI.In our study, when comparing the general characteristics, including female age, BMI, duration of infertility, female education, unhealthy lifestyle, medical history, AMH and basal hormones before surgery in stage I-II endometriosis patients with and without GnRH-a treatment, there was no significant difference. More patients with stage II endometriosis were given GnRH-a therapy compared to those women with stage I, which was obviously reasonable. The serum FSH and LH levels on day 2–3 of menstruation in women with GnRH-a treatment were significantly lower than that in the control group  . HoweverLin et al. reported that postoperative GnRH-a therapy was ineffective in improving reproductive outcomes in patients with both early  and advanced (moderate and severe) endometriosis . Bansal However, in our study, we found that the clinical pregnancy rate of IUI treatment could be elevated by GnRH-a therapy in patients with early endometriosis (stage I-II), which is consistent with a systematic review and network meta-analysis by Hodgson et al. . As demoNotably, the pregnancy rate of IUI treatment declined greatly after the second cycle in both GnRH-a group and control group. No more pregnancy occurred after the third cycle. Therefore, we recommend that IUI should be stopped in those patients after three failed attempts. We should review the cases and advise the patients to consider advanced ART treatments, such as IVF or ICSI.The strength of our study lies in its specific focus on the role of postoperative GnRH-a therapy before IUI treatment in infertile females with stage I-II endometriosis, which has not been targeted to explore thus far. The direct evidence comparing GnRH-a and blank control was very limited before. Meanwhile, all the patients were enrolled in our study without other causes of infertility to reduce the variation. All pregnant patients were followed up until delivery.The limit of our research is that the number of subjects was limited. Therefore, further studies with a larger sample should be carried out to confirm the role of GnRH-a in IUI treatment for stage I-II endometriosis patients.In our study, the clinical pregnancy rate of IUI in stage I-II endometriosis patients treated with postoperative GnRH-a therapy was higher than in patients without, which needs to be further investigated in a larger sample size. The administration of GnRH-a in patients with stage I-II endometriosis seems to be beneficial to the outcomes of IUI. Notably, no more than three IUI cycles should be recommended for those infertile patients.


Dementia cases are expected to triple during the next 30 years, highlighting the importance of finding modifiable risk factors for dementia. The aim of this study was to investigate whether adherence to conventional dietary recommendations or to a modified Mediterranean diet are associated with a subsequent lower risk of developing all-cause dementia, Alzheimer disease (AD), vascular dementia (VaD), or with future accumulation of AD-related β-amyloid (Aβ) pathology.Baseline examination in the prospective Swedish population-based Malmö Diet and Cancer Study took place in 1991–1996 with a follow-up for incident dementia until 2014. Nondemented individuals born 1923–1950 and living in Malmö were invited to participate. Thirty thousand four hundred forty-six were recruited . Twenty-eight thousand twenty-five had dietary data and were included in this study. Dietary habits were assessed with a 7-day food diary, detailed food frequency questionnaire, and 1-hour interview. Main outcomes were incident all-cause dementia, AD, or VaD determined by memory clinic physicians. Secondary outcome was Aβ-accumulation measured using CSF Aβ42 (n = 738). Cox proportional hazard models were used to examine associations between diet and risk of developing dementia .Sixty-one percent were women, and the mean (SD) age was 58.1 (7.6) years. One thousand nine hundred forty-three (6.9%) were diagnosed with dementia . Individuals adhering to conventional dietary recommendations did not have lower risk of developing all-cause dementia , AD , or VaD . Neither did adherence to the modified Mediterranean diet lower the risk of developing all-cause dementia (HR 0.93 0.75–1.15), AD , or VaD . The results were similar when excluding participants developing dementia within 5 years or those with diabetes. No significant associations were found between diet and abnormal Aβ accumulation, conventional recommendations  or modified Mediterranean diet .In this 20-year follow-up study, neither adherence to conventional dietary recommendations nor to modified Mediterranean diet were significantly associated with subsequent reduced risk for developing all-cause dementia, AD dementia, VaD, or AD pathology. In addition to a large burden for patients and relatives, there is a tremendous burden for the health care system, with a global cost of US$1 trillion annually.2 As acknowledged by the 2020 report of the Lancet Commission on Dementia prevention, intervention, and care, modifiable risk factors account for 40% of worldwide dementia cases.2The estimated number of dementia cases was globally 47 million in 2015 and is expected to triple during the next 30 years.3-5 However, there are several important methodological weaknesses in many of the previous studies, including (1) exclusively relying on data from retrospective food frequency questionnaires (FFQs) with possible report biases; (2) insufficient follow-up time; (3) inclusion of participants older than 70 years, with a possible cognitive impairment already affecting diet ; and (4) usage of all-cause dementia as outcome, missing the possibility of diet being differently associated with specific dementia diseases, such as Alzheimer disease (AD), which is the most common accounting for 60%–70% of all dementia cases, and the second most common caused by cerebrovascular disease vascular dementia (VaD), which exhibit different genetic and lifestyle risk factor patterns.A modifiable and controversial risk factor for cognitive impairment and dementia is dietary habits. Several studies have examined how dietary habits affect incidence in dementia disorders, with inconsistent results. Systematic reviews and meta-analyses conclude that adhering to Mediterranean diet may contribute to a slowing of cognitive decline and a lower incidence in dementia.1 However, large-scale longitudinal studies evaluating potential associations between midlife diet and amyloid pathology are lacking.To further understand the mechanisms between a potential dietary influence on the incidence of specific dementia disorders, it would be an advantage to examine the association between diet and the underlying disease pathology. Accumulation of amyloid-β (Aβ) in the brain is the cause of AD, and it can be detected using CSF analysis of Aβ42 or Aβ PET imaging.In this observational study, we prospectively collected detailed dietary data in midlife from a large population-based study of more than 28,000 individuals. The aim was to examine the association between adherence to general dietary guidelines and Mediterranean diet of dementia incidence. Development of any kind of dementia during 20 years was used as primary outcome. Secondary outcomes were development to specifically AD dementia or VaD, respectively. In a convenience subsample (n = 738), we performed an exploratory analysis studying the association between dietary components and future accumulation of AD-related pathology measured using CSF analysis of Aβ42.All participants received information about the study and gave written consent to participate. Ethical approval was given by the Ethical Committee of Lund University, Lund, Sweden (LU 90-51).6Data were obtained from the Malmö Diet and Cancer study (MDCS), which is a population-based prospective cohort study from the city of Malmö, Sweden. Between 1991 and 1996, men born in 1923–1945 and women born 1923–1950 living in Malmö were deemed eligible and invited to participate. Exclusion criteria were language problems and mental incapacity, which could preclude participants from fulfilling the questionnaires properly. In all, 30,446 individuals attended at least a part of the baseline examination, which included a self-administrated questionnaire that assessed education, occupation, physical activity, social network, use of tobacco and alcohol, current health, medical history, current medication, and family history of disease in close relatives, along with body composition measurements and dietary assessments. Participation reached 40.8% of the eligible population.A subpopulation of the study participants underwent lumbar puncture with analyses of CSF Aβ42 when referred to the Memory clinic at Skåne University Hospital, Malmö, after developing clinical signs of cognitive impairment. This represents a convenience subsample of the MDCS and should not be regarded as a representative subsample of the whole study.7 Detailed information on the dietary data collection procedure, including administration of the FFQ and diary, was given at the first visit by trained research nurses. In the 7-day food diary, participants recorded cooked meals, cold beverages, drugs, natural remedies, and dietary supplements. In the 168-item FFQ participants stated, with reference period last year, regularly consumed foods not covered by the food diary , portion size (based on pictures of 4 portion sizes for 48 food items), and frequency of food consumed. In addition, participants underwent a 1-hour interview with trained personnel collecting additional information on cooking methods, food choices, and portion sizes and to make sure the information from the diary and FFQ was correct. Halfway through the baseline data collection (in 1994), the interview routines changed to reduce interview time to 45 minutes.8 Average daily food intake (g/d) was calculated by combining the data from the food diary and the FFQ. Energy and nutrient intakes were calculated by combining the data on average food intake with the MDCS database originating from the Swedish National Food agency database. The combined dietary method used in MDCS has been validated against 18 days of weighted food records with correlation coefficients for men/women of 0.60/0.74 for sugar, 0.74/0.69 for fiber, 0.65/0.58 for vegetables, 0.60/0.77 for fruits, 0.35/0.65 for fish, 0.82/0.91 for meat, and 0.50/0.65 for wine.9Information on dietary habits was obtained from all participants at baseline through (1) a diet diary and (2) a self-administered FFQ, which provided complementary information, and (3) a 45–60 minute interview with trained personnel.10 which are in line with dietary recommendations in the United States11 and United Kingdom,12 was calculated for each participant based on average daily food intake. The SDGS is based on consumption of 5 dietary domains: dietary fiber ≥2.4 g/MJ from nonalcohol energy; added sugar ≤10% of nonalcohol energy; fish and shellfish ≥300 g/wk; fruit and vegetables ≥400 g/d; and red and processed meat ≤500 g/wk. Reaching recommendations yielded 1 point/domain, with a maximum SDGS of 5 points. A similar index has previously been developed within MDCS.13 In the modified index, we included added sugar (instead of sucrose) and red and processed meat (instead of saturated and polyunsaturated fat). Based on the SDGS, participants were divided into the following groups: low adherence (0–1 points), moderate adherence (2–3 points), and high adherence (4–5 points).A Swedish dietary guidelines score (SDGS), designed to portray a healthy dietary pattern, based on Swedish nutrition recommendations and dietary guidelines,14 The mMDS consists of 10 dietary domains: (1) Vegetable oils (≥54 g/d); (2) Vegetables including legumes (≥300 g/d); (3) Fruits (≥300 g/d); 4) Red and processed meat (<125 g/d); (5) Butter, margarine, cream (<12 g/d); (6) Soda (<200 g/d); (7) Wine (≥100 g/d); (8) Fish and seafood ; (9) Pastries and candy ; and (10) Nuts and seeds (≥12.8 g/d). Reaching recommendations yielded 1 point/domain with a maximum mMDS of 10 points . Domain “legumes” was incorporated in the vegetable domain. In addition, “sofrito,” a typical Mediterranean sauce, was excluded in the mMDS because of low consumption in Nordic countries and the lack of information from the food records. Two domains were further excluded from the index (olive oil as main culinary lipid and poultry more than red meats) because of lack of questions referring to this in the present FFQ.14 However, the consumption of olive oil was added to the intake of other vegetable oils because the consumption of these oils is usually low in the Nordic population. Based on the mMDS, participants were divided into the following groups: low adherence (0–1 points), moderate adherence (2–4 points), and high adherence (5–10 points). The regrouping was performed to have enough discrepancies between groups regarding dietary habits and to avoid too small groups .A modified Mediterranean diet score (mMDS) was created based on the original 14-item score used for the Prevención con Dieta Mediterránea (PREDIMED) study.15 was calculated scoring 0–50 (poor to good adherence to Mediterranean diet recommendations). The original score is from 0 to 55, but here, the domain legumes was incorporated in the domain “vegetables” because of low consumption in Nordic population. As in the case of mMDS, all vegetable oils were considered rather than olive oil alone .A Mediterranean diet score according to a study2 Information on alcohol consumption was derived both from the questionnaire and the 7-day record. Zero consumers had reported no consumption during the past year. The other participants were stratified in quintiles separately in men and women , with the following spans: 0–3.4, 3.4–9.1, 15.7, and 25.7 g/d (men) and 0–0.9, 4.3, 8.1, and 14.0 g/d (women). APOE-ɛ4 interaction analysis was performed to investigate a potentiating effect of this well-established genetic risk factor for AD. Owing to possible seasonal variations in dietary intake, and that dietary interview was shortened in 1994, season and diet assessment method were included in the analyses.Sociodemographic factors included age, sex, and education. At baseline, participants completed a questionnaire including lifestyle factors and health status. Education level was divided into 3 subgroups as per study design: primary/elementary school (≤8 years), secondary school/high school (9–12 years), or higher education/university (≥13 years), based on information from the questionnaire. From the questionnaire smoking status was divided into 3 groups  and physical activity as metabolic equivalent hours/week (METh/week). One METh is defined as the metabolic intensity when a person is at rest. METh/week was computed by multiplying time (hours) spent on each activity by the respective MET (intensity) factor.Exploratory outcome CSF Aβ42 below).The primary outcome was progression to all-cause dementia disorders. The secondary outcomes were progression to AD dementia and VaD. The exploratory outcome was abnormal Aβ status measured as increased levels of CSF Aβ42 , VaD , Parkinson disease dementia (F023), dementia with Lewy bodies , frontotemporal dementia , or unspecified dementia . After the register data delivery, trained physicians with special interest in dementias, but not yet board-certified specialists, at the Memory Clinic at Skåne University Hospital reviewed and validated all registered dementia diagnoses based on symptoms, results of cognitive tests, brain imaging (CT or magnetic resonance imaging reviewed by radiologists), and CSF concentrations of Aβ42 and tau phosphorylated at Thr181  in accordance with the specific major neurocognitive disorders in DSM-5 . In uncertain cases, 2 specialists in Neurology and Geriatrics, (O.H. and K.N.), respectively, with more than 10 years of experience in the field of dementia were involved. In cases where CSF was available, AD diagnosis was based on the NIA-AA criteria.16 Of the 1,943 cases with dementia, 1,507 (77.6%) were diagnosed at a specialized Memory Clinic.The primary and secondary diagnostic outcomes were based on registered dementia diagnoses from the Swedish National Patient Register (NPR) throughout 2014. The NPR covers both the Swedish Inpatient Register and the hospital-based outpatient register. Diagnoses included AD dementia . Presence of significant cerebrovascular disease on neuroimaging led to a mixed AD diagnosis if AD was considered the primary cause.19 CSF concentrations of Aβ42 were measured using INNOTEST ELISA .CSF data were available for participants with signs of cognitive decline who had been referred to the Memory Clinic at Skåne University Hospital for further investigation. With lumbar puncture, CSF was collected between 1995 and 2015 according to a structured protocol.17-22 Because of a slight, assay-dependent drift in levels of CSF Aβ42 during the collection period 1995–2015, 2 different cutoffs were established for the period 1995–2003 (Aβ42 < 484.8 pg/mL) and 2004–2015 (Aβ42 < 577.1 pg/mL). This drift in INNOTEST CSF Aβ42 values during this period is well known.19Cut-off values for CSF Aβ42 were established using mixture modeling.all-cause dementia (primary outcome) or specific dementia disorder (secondary outcome). Censoring occurred at the recorded date of dementia, time of death, or at time of register data delivery . By using this approach, the competing risk of death was assessed by estimating cause-specific hazard ratio (HR) for dementia, in accordance with recommendations when the study objective is etiologic.23 All analyses were adjusted for age, sex, education, season, dietary sampling method, and total energy intake (kJ) in model 1. In model 2, the following lifestyle variables were also included: smoking , alcohol consumption (sex-specific quintiles), body mass index, and physical activity (METh/week). In model 2, a total of 243 cases had missing data in any of these lifestyle variables and were thus excluded. Logistic regression analysis was used to examine the association between SDGS and Aβ42 accumulation, using CSF Aβ42 status as outcome.Demographic data are presented as means (SDs) or numbers (n) and percent (%). Cox proportional hazard models, with years between baseline and event as time variable, were used to examine associations between SDGS and mMDS and risk of developing dementia. Event was defined as 24 . A total of 73 were excluded in this analysis. In another sensitivity analysis, participants with prevalent and incident diabetes mellitus were excluded to investigate the dietary association without being influenced by diabetes and the dietary restrictions that may accompany that disease.25 A total of 5,221 participants with diabetes were excluded; of which, 405 developed dementia. Sensitivity analysis was also performed excluding participants that had made substantial changes in their dietary habits at any time before the baseline examination. In addition, another sensitivity analysis was performed only including individuals diagnosed at the Memory Clinic. Using the Mediterranean diet score according to a study15 was used in another sensitivity analysis.In sensitivity analyses, participants diagnosed with dementia <5 years from baseline were excluded, to reduce the possible bias of cognitive impairment affecting dietary intakep-value <0.05 was considered significant.All statistical analyses were performed using R (version 3.6.3). A The data that support the findings of this study are available from the Malmö Population-Based Cohorts Joint Database, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors on reasonable request and with permission of the Malmö Population-Based Cohorts Joint Database.links.lww.com/WNL/C345). links.lww.com/WNL/C345).Individuals who underwent dietary assessments were included  in this study. Participants with incomplete data on education (n = 71) and where time to event was zero, meaning present dementia (n = 2), were excluded, resulting in a complete data set of 28,025 individuals, which was used for the main analysis. See Associations between SDGS and development of all-cause dementia, AD dementia, and VaD are presented in Neither did adherence to the modified Mediterranean diet lower the risk of developing all-cause dementia in model 1  or model 2  when using mMDS as a continuous variable. Individuals adhering to the modified Mediterranean diet (mMDS 5–10) did not have lower risk of developing all-cause dementia  in model 1 and (HR 0.95 95% CI: 0.76–1.18) in model 2 .As shown in links.lww.com/WNL/C345).Neither did adherence to modified Mediterranean diet lower the risk of developing AD dementia (HR 0.99 95% CI: 0.94–1.05) or VaD (HR 1.04 95% CI: 0.96–1.12) when analyzing mMDS as a continuous variable. Individuals with the highest adherence to the modified Mediterranean diet (mMDS 5–10) did not have lower risk of developing AD dementia (HR 0.90 95% CI: 0.68–1.19) or VaD (HR 1.00 95% CI: 0.65–1.55) . Adjustelinks.lww.com/WNL/C345).In sensitivity analyses, we excluded participants with incident dementia diagnosis within 5 years after baseline and participants with prevalent or incident diabetes, respectively. As for the main results, no significant effect of lowering the risk of dementia was found between SDGS or the mMDS with development of all-cause dementia, AD dementia, or VaD .Furthermore, in sensitivity analyses excluding participants indicating a substantial change in their dietary habits before baseline, no significant effect of lowering the risk of dementia was found between SDGS or the mMDS with development of all-cause dementia, AD dementia, or VaD .In sensitivity analysis using the Mediterranean diet score according to a study,APOE ε4 .Furthermore, there were no significant interaction effects between SDGS or the mMDS and the AD risk genotype Excluding participants not diagnosed at a Memory Clinic did not change the results (data not shown).links.lww.com/WNL/C345). No significant association between SDGS and CSF Aβ42 at follow-up was found. Individuals with the highest adherence to dietary recommendations (SDGS 4–5) did not have lower risk of having abnormal Aβ42 in CSF .A total of 777 participants underwent lumbar puncture. Participants with missing CSF Aβ42 data were excluded (n = 39), resulting in a sample of 738 participants with available CSF Aβ42 data. Median time from baseline to CSF collection was 12.9 (IQR 7.4) years. Associations between SDGS and CSF Aβ42 status  are shown in the eTable 15 (links.lww.com/WNL/C345). No significant associations between mMDS and CSF Aβ42 at follow-up were found. Individuals with the highest adherence to the mMDS (5–10) did not have lower risk of having abnormal Aβ42 in CSF . In addition, adjusting for time between baseline and CSF collection did not change the results. No significant association was found between Mediterranean diet score measured according to another study,15 and abnormal Aβ42 in CSF .Associations between mMDS and CSF Aβ42 status  are shown in eTable 16  diet and cognitive decline as well as dementia, in 1,220 participants over a 12-year period. A systematic review3 including 32 studies, concluded that adherence to a Mediterranean diet may contribute to better cognitive performance and decreased risk of developing dementia. This review reflects the current state of knowledge because the studies included are very heterogeneous in their designs. A majority of them used retrospective FFQs, which may be associated with misreporting by the participants considering difficulties to remember historical details about food intake many years or even decades back in time.29 In addition, a majority of the studies included in the review are based on dietary habits in older populations (older than 65 years). Considering the relatively high prevalence of prodromal dementias in such populations, there is a risk of reversed causality. Early cognitive decline with possible mood changes could also affect dietary lifestyle habits.30 Hence, inclusion of an older population may bias the correlation between diet quality and cognitive decline. In addition, the varying follow-up time between studies might be one reason of the heterogeneous study results regarding dietary habits and incidence of dementia disorders. However, the authors of the systematic review concluded and emphasized the importance of confirmation based on large longitudinal epidemiologic studies with prospective registration of dietary habits, thus highlighting the value of this study. As expected, known cardiovascular risk factors such as coronary event or stroke, diabetes, and arterial hypertension were all more common at baseline in the group with incident dementia , with a median follow-up time of 24.8 years, neither the quality of midlife diet nor the Mediterranean diet was associated with incident all-cause dementia,dementia .32 or have short follow-up time (4 weeks–1.2 years).33 This further highlights the importance of this study examining the association between dietary habits and later CSF Aβ-pathology, with 13 years of follow-up. However, 1 review, including 7 RCTs, 7 cross-sectional studies, and 1 longitudinal study on diet and biomarkers of AD, concludes that adherence to Mediterranean diet and reduction of AD biomarkers, as well as high-glycemic and high saturated fat diet, were all associated with an increase in biomarker levels of AD.34 A study showed that adherence to the Mediterranean diet was associated with better cognitive performance in midlife.35 However, we emphasize using dementia diagnoses as outcome is the most clinically relevant.This study does not exclude a possible association between diet quality and subsequent development of dementia. However, the present Swedish dietary recommendations, which are in line with those in the United Kingdom and United States, or according to the Mediterranean dietary pattern, could not be confirmed to be associated with prevention of dementia. There is however a risk of self-reported dietary and lifestyle habits being misreported to some extent. There is also a possible risk of alteration in dietary habits, although dietary habits remain relatively stable during life. Previous studies on diet and CSF Aβ measures are either cross-sectionalConsidering that no systematic cognitive testing was available during follow-up , and that the reviewed dementia diagnoses were retrieved from the NPR, there could be an underestimation of the number of dementia cases. The advantage, however, is that all surviving participants were under risk for dementia during the study period and only those completing follow-up visits. Note also that to improve the quality of the dementia diagnoses, fulfillment of diagnostic criteria was validated retrospectively by trained physicians at the memory clinic. Dietary data were only collected at baseline, and there is a risk of alterations in dietary habits during follow-up. This was however somewhat accounted for by excluding participants who reported a substantial alteration in dietary habits at any time before baseline in sensitivity analysis, with the same results as in the main analyses. Although participants were followed for a median period of 19.8 years, we cannot rule out that even longer follow-up might have resulted in a slightly different result. Using vegetable oils instead of olive oil could be a limitation of the mMDS; however, the vegetable oils in the mMDS are all of vegetable origin, with a high proportion of monosaturated and polyunsaturated fatty acids. Furthermore, participants with CSF samples were not randomized but recruited based on clinical indications, which is a limitation of this study. Although multiple baseline characteristics were adjusted for, additional possible confounding factors cannot be ruled out, such as health selection bias. Randomized controlled trials are needed to provide additional evidence regarding the potential role of diet in relation to AD pathology. However, it is probably not feasible to design a 20-year randomized controlled trial with strict dietary habits to adhere to.27 implicate this will not be the case.Adherence to conventional dietary recommendations or to a modified Mediterranean diet during midlife were not associated with a lower incidence in all-cause dementia over a 20-year period, nor was the diet associated with AD dementia, accumulation of Aβ pathology, or to VaD. Large intervention studies are needed to clearly understand whether diet quality can affect incidence of dementia disorders, even if the results from this study together with other large prospective longitudinal studies


Virtual reality (VR) has the potential to improve pain and pain-related symptoms. We examined the feasibility, acceptability, safety, and impact of a 30-min virtual underwater/sea environment (VR Blue) for reducing pain and pain-related symptoms in advanced colorectal cancer patients. A qualitative exit interview was conducted to understand preferences, thoughts, and feelings about the VR session.N = 20) had stage IV colorectal cancer and moderate-to-severe pain. Participants completed a 30-min VR Blue session that visually and aurally immersed them in virtual ocean scenarios. Feasibility was assessed by accrual (N = 20), protocol adherence (≥80% completing VR Blue), and completed data (≥80% assessment completion). Acceptability was determined by patients reporting ≥80% intervention satisfaction. Safety was determined by ≥80% of patients completing the session without self-reported side effects. Measures of pain, tension, relaxation, stress, anxiety, and mood were collected before, during, and after the VR Blue session. A semi-structured qualitative interview was conducted after VR Blue to assess participants’ VR experiences.Participants (M = 3.3 (SD = 0.4) (83%). No significant side effects were reported. Pain decreased by 59% . Tension decreased by 74% . Relaxation improved by 38% (Pre-M = 62 [21]); Post-M = 86 [17]). Stress decreased by 68% . Anxiety decreased by 65% . Mood improved by 70% . Qualitative data suggested a positive response to the VR Blue protocol.All participants (100%) completed the VR Blue session. There was 100% data collection at the pre- and post-assessments. Satisfaction with VR Blue was high This work supports the feasibility, acceptability, and safety of VR Blue for advanced colorectal cancer patients. Participants showed significant pre-post improvement in pain and pain-related symptoms hinting to the potential feasibility of VR interventions in this population. Larger, randomized trials with a control condition are needed to examine the efficacy of VR-based interventions for patients with advanced colorectal cancer and pain. Colorectal cancer is the fourth most commonly diagnosed malignancy in the USA . AdvancePain and distress among patients with advanced colorectal cancer are often not adequately treated. Traditional analgesic and other medication regimens for pain and pain-related symptoms do not provide full relief and patients report significant side effects  that limit the use of analgesic medications . There ipersistent pain. As outlined in the NIH Stage Model for Behavioral Intervention Development, determining whether an intervention is feasible and acceptable is crucial for successful intervention development  . The current pilot study will explore pre-post VR changes in primary outcome variables of pain, tension, distress , and relaxation. An MCID of 30% has been cited in the pain literature (Recent evidence suggests VR interventions can lead to reductions in pain for patients with acute pain conditions . VR provStage 1) . Since aterature  and willStage 1 pilot work is also an ideal opportunity to begin assessing mechanisms of change. Due to their late-stage disease and persistent pain, advanced colorectal cancer patients report negative pain-related cognitions  and low confidence that they can control pain without medical intervention . These cognitive pathways have been shown to be important for pain reduction within the context of cognitive-behavioral pain management protocols . VR may This pilot study extends preliminary research conducted by N = 20) were adult colorectal cancer patients with advanced disease (stage IV). Other eligibility criteria included: (1) age 18–85; (2) at least moderate pain  on most days of the month for ≥3 months; (3) English-speaking; and (4) self-reported normal or corrected to normal vision and hearing. Patients were excluded if they had (1) a serious mental illness  or medical condition  that would contraindicate safe participation; or (2) visual, hearing, or cognitive impairment that would interfere with engagement in the VR Blue session. All participants continued to receive their usual medical care and were not asked to change or decline any adjunct strategies for pain management. The Institutional Review Board at the Duke University Health System approved the study (Pro00103248) and all procedures complied with HIPAA guidelines. This study is registered on ClinicalTrials.gov (NCT04069702).Participants  “How would you rate your pain today on a scale from 0 (no pain) to 10 (pain as bad as you could imagine)?” (2) “Have you had pain on most days of the month for the past 3 months?” (3) “Do you take medication for your pain?” and (4) If you did not take medication for your pain, how would you rate your pain on a 0–10 scale?” To be eligible, patients were required to report current pain (without medication) at ≥4 on a 0–10 scale, and the pain must have been present on most days for the past 3 months. Vision and hearing, as well as cognitive status ; (2) protocol adherence (≥80% completing VR Blue); and (3) completed data (≥80% assessment completion). Acceptability was determined by ≥80% satisfaction on the CSQ at the post-VR Blue timepoint. Safety was determined by ≥80% of patients completing the session without significant side effects .Participants participated in a single, 30-min VR session of underwater/sea environments (VR Blue). Pre-, mid-, and post-VR Blue session assessments were completed online via REDCAP using an iPad, and measured self-reported pain, tension, distress , relaxation, pain catastrophizing, and self-efficacy for pain management. Participants also provided self-report demographic and medical data that were confirmed with electronic chart review. After the VR Blue session, participants completed a 10–15 min semi-structured exit interview to assess their preferences, thoughts, and feelings about the VR experience. Participants were compensated $40. Feasibility was assessed by (1) study accrual  reaching study accrual (N = 20) over 6 months; (2) ≥80% adherence to the protocol ; and (3) ≥80% data collected at the study appointment.α = 0.84). Acceptability was demonstrated by participants reporting ≥80% satisfaction (M = 3.2/4.0) with the intervention.The 10-item CSQ was used to assess acceptability post-VR Blue session . Items wSafety of the VR Blue session was assessed based on participants’ self-report (yes/no) of significant cybersickness side effects, such as dizziness, headache, nausea, or any other negative physical reactions.α = 0.85). Pain interference was assessed by the 7-item Pain Interference subscale of the BPI (α = 0.88). Pain severity and pain interference were only assessed at the pre-VR Blue timepoint. The single, “pain right now” item from the BPI was assessed pre-, mid-, and post-VR Blue. The BPI is recommended for assessing pain in clinical trials and has been readily used in cancer samples  . Partici the BPI . Partici samples .Tension, stress, anxiety, mood, and relaxation levels were measured using a Visual Analog Scale (VAS) ranging from 0 = no tension, stress, anxiety, relaxation, no problem with mood to 100 = maximum tension, stress, anxiety, relaxation, extreme problem with mood. The timeframe referenced was “right now.” Tension, stress, anxiety, relaxation, and mood levels were assessed at the pre-, mid-, and post-VR Blue timepoints.α = 0.72). The CSQ has been previously used in patients with cancer (Pain catastrophizing was assessed with six items from the Coping Strategies Questionnaire (CSQ) . Particih cancer , 2016.α = 0.62). The Chronic Pain Self-Efficacy Scale has been widely used in cancer samples  Use of VR Technology; (2) Timing of VR Blue Session; (3) Enjoyment of VR Blue Session; (4) VR Blue Graphics; and (5) Areas for Improvement and Next Steps. Interview questions are presented in Consistent with guidelines for pilot studies, we did not conduct formal statistical analyses . We compn = 14). One-quarter of the sample identified as Black/African-American (n = 4). The majority of participants were non-Hispanic (90%). Most participants reported a college education, with 40% obtaining a graduate degree.Demographic and medical characteristics are reported in active recruitment time across the 15-month period was 6 months. This was aligned with our feasibility benchmark to recruit 20 participants in 6 months.Of the 175 patients who met inclusion criteria and were contacted for a telephone screening, 91 were unreachable and 21 were ineligible (see All participants (100%) completed the single 30-min VR Blue session. This was above our 80% completion rate to indicate feasibility.There was 100% data collected at the pre-, mid-, and post-VR Blue assessments. This was above our feasibility benchmark of 80% completed data across all assessment timepoints.M = 3.2/4.0) to indicate feasibility.Participants found the VR Blue protocol to be highly acceptable with a mean satisfaction rating of 3.30 out of 4.0 (SD = 0.41). This was above our 80% satisfaction benchmark (All participants (100%) completed the VR Blue session without self-report of significant side effects . One participant noted that if he moved his head too quickly, he noticed mild dizziness, but otherwise did not experience dizziness and said he was not bothered by this. This met our feasibility benchmark of 80% completion without significant side effects.r = −0.455, p < 0.05). Although no other correlations reached statistical significance, the following were in the expected direction: (1) change in pain catastrophizing and changes in pain, tension, stress, and anxiety and (2) change in pain self-efficacy and changes in stress, anxiety, and relaxation. These results should be interpreted cautiously due to the small sample size.Means and standard deviations for main study variables are reported in Data from the exit interview is detailed in n = 19) and comfortable (n = 17). Most participants reported they felt immersed in the VR Blue scenery (n = 17). Several participants reported they were open to engaging in VR in either the medical setting or at home (n = 4), but the majority preferred their home (n = 13).The majority of participants reported the VR headset was easy to use (n = 11) said they would use VR Blue multiple times per week. Many (n = 12) stated they would use VR Blue for pain and symptom management at the time of their cancer treatment appointments. Participants stated they were most interested in using VR Blue when pain, anxiety, and/or depression are high (n = 13).Approximately half of the participants stated the length of the VR Blue session was appropriate, while the other half reported they would like it to be longer. Most participants  noted if they had regular access to VR, they would like the option to change scenic genres .All participants reported they enjoyed the VR Blue scenery. Many participants (n = 12) were open to having caregivers involved in the VR Blue session and thought caregivers would be amenable to participating. Recommended improvements included a cordless headset and a higher resolution picture.Most participants  and indicated a preference for use in the home. Several participants shared they were most interested in using it when symptom  levels are high. Participant suggestions for improving the protocol included recommendations for other scenery options and a cordless headset. Another area for further consideration is the inclusion of caregivers in the VR Blue session. During the qualitative interviews, most participants indicated they were open to having caregivers involved. There is a known dyadic relationship between a cancer patient and the caregiver, such that the way a patient copes with symptoms  can influence how a caregiver copes with their own caregiving burden, and vice versa . Involvia priori MCID of 30%, suggesting that these outcomes are meaningfully affected by the VR intervention. Furthermore, the correlation between pre- to post-VR Blue change in relaxation and change in the secondary outcome of pain catastrophizing was significant. This finding may be particularly important as patients with pain that have high levels of pain catastrophizing are much more likely to experience persistent pain and other negative pain-related outcomes  and/or serve as a scheduled pleasant activity. Ultimately, larger, randomized clinical trials with a control condition are needed to examine the efficacy of VR-based interventions for patients with advanced colorectal cancer and pain. This research could lead to VR-based interventions that could benefit other advanced-stage cancer populations and/or other palliative care populations who are experiencing persistent pain and distress.


Phaeocremonium rubrigenum was the predominant biomarker fungus in the TL of “Guan Xiang” agarwood samples. Among the seven isolated fungi, P. rubrigenum exhibited a significantly heightened ability to induce the production in Aquilaria sinensis seedlings, especially for sesquiterpene. Tracing the proteome profile changes in P. rubrigenum-induced A. sinensis calli for 18 ds showed that the fungus-induced sesquiterpene biosynthesis increased mainly through the mevalonate (MVA) pathway. Specifically, the phosphorylation modification level, instead of the protein abundance of transcription factors (TFs), showed corresponding changes during sesquiterpene biosynthesis, thus indicating that induced phosphorylation is the key reason for enhanced sesquiterpene production.The present study aimed to explore the factors that promote persistent agarwood accumulation. To this end, we first investigated the morphological changes and volatile compound distribution in five layers of “Guan Xiang” agarwood. The agarwood-normal transition layer (TL), an essential layer of persistent agarwood accumulation, showed clear metabolic differences by microscopy and GC-MS analysis. Microbiome analysis revealed that IMPORTANCE Agarwood is an expensive resinous portion derived from Aquilaria plants and has been widely used as medicine, incense, and perfume. The factors involved in steady agarwood accumulation remain elusive. Our current study suggests that as a TL marker fungus, P. rubrigenum could persistently promote agarwood sesquiterpene accumulation by inducing phosphorylation of the TFs-MVA network in A. sinensis. Moreover, our work provides strategies to improve agarwood industry management and sheds light on the potential molecular mechanisms of plant adaptation to native microbial conditions. Living organisms are part of a highly interconnected web of interactions. Vast networks of microbes play important roles in stimulating host plant growth, antagonizing pathogens, tolerating stress, and controlling plant diseases , 2. ThisAquilaria . This includes Aquilaria sinensis (Lour.) Gilg, the only certified source of agarwood listed in the 2020 Chinese Pharmacopoeia  form an upstream response network. This study integrates microbiome, proteome, and phosphoproteomics to profile the fungal composition in five layers of agarwood and identified that P. rubrigenum could harmlessly and continuously promote sesquiterpene accumulation by inducing the phosphoralated TF-MVA network in A. sinensis.In this study, we stratified the “Guan Xiang” agarwood into five layers based on agarwood abundance and profiled the phenotypic, metabolic, and fungal diversity of layers. Our results showed that fungal diversity is negatively correlated with the abundance of sesquiterpenes and chromones. Several marker species were enriched in the agarwood-normal transition layer. Of these A. sinensis tree, also known as “Guanxiang” in Dongguan 5 years after employing the physical wounding method . All metabolites in each layer were profiled, and the principal-component analysis (PCA) results showed remarkable differences in the composition of metabolites in each layer  , and P. rubrigenum was the most abundant fungal species in the AL and TL . Linear discriminant analysis (LDA) effect size (LEfSe) also revealed that P. rubrigenum was the TL biomarker with a statistical difference , suggesting that P. rubrigenum may play a key role in persistent agarwood accumulation.To investigate the role of fungal partners in continuous agarwood accumulation, fungal communities associated with different layers of agarwood were investigated by high-throughput sequencing. Approximately 80,055-80,335 high-quality reads were obtained from agarwood samples, which belonged to 6 phyla, 27 classes, 74 orders, 135 families, 189 genera, and 247 species of fungi, with 305 to 660 OTUs detected at 97% similarity . The alpha diversity of fungal species observed was significantly higher in DL than in the other four layers (fference . The corP. rubrigenum in persistent agarwood accumulation (P. rubrigenum cannot be isolated by incubation on potato dextrose agar (PDA). Therefore, we isolated P. rubrigenum onto malt extract agar (MEA) and confirmed the identity by phenotypic and molecular characterization , suggesting that the interaction between A. sinensis and P. rubrigenum could play a key role in promoting the persistent accumulation of volatiles in agarwood. To investigate their interaction, 1-year-old A. sinensis seedlings were holed and infected with or without P. rubrigenum. A. sinensis stems were collected every 5 days over a 30-day treatment period. Compared with the control group (samples holed without P. rubrigenum), the sesquiterpenes and chromone were only detected in the infected group using GC-MS (Table S4). The relative contents of total sesquiterpenes and chromones after 30 days of treatment were 5.572% and 0.260%, respectively . After 3 days of treatment, four sesquiterpenes were induced in A. sinensis calli  labeling technology based on nanoscale liquid chromatography-mass spectrometry analysis (LC-MS/MS). Principal-component analysis (PCA) indicated that the protein profiles in the 0-day control group were distinct from those in the P. rubrigenum treated groups, especially in the 18-day group . Therefore, there may be another TF regulatory mechanism involved in sesquiterpene biosynthesis promoted by P. rubrigenum.A growing number of findings have demonstrated that transcription factors (TFs) and plant immunity signaling proteins are involved in the regulation of sesquiterpene biosynthesis of sinensis , 24, 25.A. sinensis before and after P. rubrigenum stress. The phosphorylated proteins were annotated in the molecular function of protein and nucleic acid binding, containing TFs  and PlantCARE . To further investigate the potential relationship between phosphorylated TFs and sesquiterpene biosynthetic genes, the promoter sequences of sesquiterpene biosynthetic genes were retrieved, and their regulatory sites of these promoters were identified by RegSite , were physically wounded using a machete, as described in a previous study  for 3 min. Similarly, sections were stained with periodic acid-Schiffe’s reagent (PAS) for 10 to 20 min to investigate the change of polysaccharides. To observe the nuclei, the sections were stained with DAPI (1 μg/mL in PBS) for in the dark 10 min at room temperature. After staining, the sections were washed with PBS three times, covered with coverslips, and observed under a fluorescence microscopy .Fresh agarwood samples were washed in distilled water, trimming into small pieces, and sections  were cut at a thickness of ~20 μm using a freezing stage sliding microtome and washed with phosphate-buffered saline (PBS). For light microscopic observation of starch grains and brown resin-like materials, sections were stained with iodine-potassium iodide  were obtained using a Thermo Scientific MicRoM HM 325 sliding microtome. For light microscopic observations, sections were stained with Fast Green stain. After staining, the sections were washed with PBS three times, dehydrated with alcohol , cleared with xylene, sealed with neutral gum, and observed using a fluorescence microscope (Zeiss AX10).To analyze the tissue and cell structures of uninfected and The dried powders from different layers of agarwood and variously treated stems (0.1 g) were weighed and placed in a 2 mL centrifuge tube. Ethyl acetate (1.5 mL) was then added to the tubes. The sample was incubated overnight at room temperature and extracted for 45 min using the 40 kHz ultrasonic cold extraction method. The upper solvent phase was separated by centrifugation at 12,000 rpm for 10 min at 4°C. After adding ethyl acetate to supplement weightlessness, the volatile oil was filtered using a 0.22 μm PTFE filter membrane and then stored in a dark glass bottle at 4°C prior to GC-MS analysis.−1 flow rate. Separation was performed under the following conditions: an initial temperature of 50°C for 1 min, ramped to 150°C at 10°C·min−1, held at 150°C for 15 min, ramped to 280°C at 8°C·min−1, and held at 280°C for 10 min. The relative contents of individual components in different sections of agarwood and variously treated stems were expressed as the percent peak area relative to the total peak area. Identification of these constituents was based on comparing retention times and mass spectra with standards or mass spectra in the Wiley or National Institute of Standards and Technology 11 (NIST11) libraries combined with the Kovats retention index (RI). For the determination of RI, a series of n-alkanes (C9-C23) was used under the same experimental conditions. For all GC-MS analyses, six biological replicates were used to analyze the volatile oil in samples.GC-MS analysis was performed with a Thermo TRACE1310/TSQ 8000 GC-MS (USA) equipped with an HP-5 capillary column  and a mass spectrometer with an ion-trap detector in the full-scan mode under electron impact ionization (70 eV). Helium was used as the carrier gas at a 1 mL · minhttp://www.ehbio.com/test/venn/.Five layers of agarwood samples  were collected, and total genomic DNA was extracted using hexadecyl trimethyl ammonium bromide (CTAB). The ITS1 gene was amplified in all samples using the universal ITS5-1737F primers with a barcode used as a marker to distinguish samples. PCR was performed using the Phusion High-Fidelity PCR Master Mix . The PCR products were mixed in equimolar ratios. The mixed PCR products were purified using the Qiagen Gel Extraction kit . Sequencing libraries were generated using the TruSeq DNA PCR-Free Sample Preparation kit , following the manufacturer’s recommendations, and index codes were added. The quality of the libraries was assessed using a Qubit 2.0 Fluorometer (Thermo Scientific) and an Agilent Bioanalyzer 2100 system. High-quality libraries were sequenced on an Illumina HiSeq 2500 platform, which generated 250 bp paired-end reads. High-quality sequences were clustered into operational taxonomic units (OTUs) defined at 97% similarity . These OThe agarwood samples were surface-sterilized with 70% ethanol for 30 s and 2% sodium hypochlorite solution for 1 min, rinsed five times in sterile water, and dried on sterile filter paper. Small pieces of agarwood samples were cut just below the surface, plated onto malt extract agar , and incubated at 25°C in the dark for 5 to 10 days. Hyphal tips that grew from the agarwood samples were subcultured onto fresh plates. After 3 to 5 rounds of purification, the fungal strains were identified by morphological characteristics and sequence analysis.P. rubrigenum hyphae and fermentation media are available in the Supplementary Methods.Detailed protocols on the detecting the volatile of Detailed protocols on the quantitative proteomics and phosphoproteome are available in the Supplemental material.PRJNA842211.The sequencing data have been deposited in the Sequence Read of the NCBI under the BioProject accession numbers


Internal validation suggested a good predictive performance of the models. Males, those with a smoking habit, LVH, and high-normal clinic BP are indicators of MUCH and models including these factors provide good diagnostic accuracy in identifying this ambulatory BP phenotype.The aim of this study was to provide prediction models for masked uncontrolled hypertension (MUCH) detected by ambulatory blood pressure (BP) monitoring in an Italian population. We studied 738 treated hypertensive patients with normal clinic BPs classified as having controlled hypertension (CH) or MUCH if their daytime BP was < or ≥135/85 mmHg regardless of nighttime BP, respectively, or CH or MUCH if their 24-h BP was < or ≥130/80 mmHg regardless of daytime or nighttime BP, respectively. We detected 215 (29%) and 275 (37%) patients with MUCH using daytime and 24-h BP thresholds, respectively. Multivariate logistic regression analysis showed that males, those with a smoking habit, left ventricular hypertrophy (LVH), and a clinic systolic BP between 130–139 mmHg and/or clinic diastolic BP between 85–89 mmHg were associated with MUCH. The area under the receiver operating characteristic curve showed good accuracy at 0.78 (95% CI 0.75–0.81,  Masked uncontrolled hypertension (MUCH), that is, normal clinic but high out-of-office blood pressure (BP), in treated patients has been broadly studied in the past two decades ,25,26,27We studied 738 treated hypertensive patients with normal clinic BPs selected from 2264 sequential treated individuals aged 30 to 90 years who were prospectively recruited from December 1992 to December 2012. All patients had been referred to our hospital outpatient clinic for evaluation of BP control. One hundred and three patients were lost during follow-up. Subjects with secondary hypertension were excluded. All subjects underwent clinical evaluation, electrocardiogram, routine laboratory tests, echocardiographic examination, and non-invasive ambulatory BP monitoring. The study population came from the same geographical area . Clinic BP was recorded by a physician using a mercury sphygmomanometer and appropriate-sized cuffs. Measurements were performed in triplicate, 2 min apart after at least 5 min of rest, and the mean value was used as the BP for the visit. Clinic systolic BPs (SBP) and diastolic BPs (DBP) were defined as normal when <140/90 mmHg.Ambulatory BP monitoring was performed with a noninvasive recorder  on a typical day, within 1 week of the clinic visit. Technical aspects have been previously reported . We eval2.7 and LV hypertrophy was defined as LV mass/height2.7 > 50 g/m2.7 in men and >47 g/m2.7 in women [Left ventricular (LV) measurements and calculation of LV mass were made according to standardized methods . LV massin women . t test for continuous variables and Pearson’s Chi-square or Fisher’s exact test for categorical variables. Univariate and multivariate logistic regression analyses were used to estimate potential predictors of MUCH by odds ratio (OR) and corresponding 95% confidence interval (CI). Variables that were significantly associated with MUCH in univariate analysis were included in multivariate analysis. A prediction scoring system for MUCH was produced using the ORs of predictors. The largest among the ORs of predictors was set as the higher value and the other ORs were rescaled relative to the maximum point. The total score was calculated as the sum of the points assigned to all predictors. A receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic accuracy of the models, including the variables that were associated with MUCH in multivariate analysis and by the created scoring systems. The goodness of fit was evaluated using the Hosmer–Lemeshow test. Sensitivity and specificity were calculated at an optimal cut-off point derived from Youden’s J-index. We also performed internal validation of the models using k-fold cross validation. The original sample was randomly partitioned into 10 equal sized subsamples for ROC curve comparison of the predictive model. The mean ROC for each k-fold was then reported with 95% CI. Statistical significance was defined as p < 0.05. Analyses were made with the SPSS 21  and STATA 17 .Descriptive analysis was carried out using mean and standard deviation for the quantitative variables and percentage values for the qualitative variables. Normality distribution for quantitative variables was assessed using the Shapiro–Wilk Test. Comparison between CH and MUCH according to various definitions was performed using an unpaired Student’s We detected 215 (29%) patients with daytime MUCH regardless of nighttime BP (42 had daytime MUCH only and 173 had daytime and nighttime MUCH) and 275 (37%) patients with 24 h MUCH regardless of daytime or nighttime BP .Characteristics of patients with CH, daytime MUCH regardless of nighttime BP, and 24 h MUCH regardless of daytime or nighttime BP are shown in BP values and the therapeutic strategy of study groups are reported in Use of aspirin and statin was not different between patients with CH and MUCH for each definition . In univariate logistic regression analysis, male sex, smoking, LV hypertrophy, clinic systolic BP in the range of 130–139 mmHg, and clinic diastolic BP in the range of 85–89 mmHg were significantly associated with MUCH defined by both thresholds .p = 0.43; MUCH defined according to 24 h BP, Chi-square = 6.0, p = 0.65).All variables that were significant in the univariate analysis, except smoking habit for MUCH defined according to 24 h BP threshold which approached significance, remained significantly associated with MUCH . The HosTen-fold cross validation showed that cross-validated mean AUC, standard deviation, and bootstrap bias corrected 95% CI were 0.77 ± 0.06 and 0.72–0.79, respectively, for the model predicting MUCH defined according to daytime BP threshold, and 0.77 ± 0.05 and 0.73–0.80, respectively, for the model predicting MUCH defined according to 24 h BP threshold .When we applied to our population the prediction model suggested by Kim et al. , the AUCThe present study shows that: 1) male sex, smoking habit, LV hypertrophy, a clinic systolic BP in the range of 130–139 mmHg, and/or a clinic diastolic BP in the range of 85–89 mmHg are associated with MUCH defined by both daytime and 24 h BP thresholds; (2) prediction models based on the abovementioned variables were appropriate in identifying the presence of MUCH; (3) internal validation indicated a good predictive performance of the models. Though characteristics of patients with MUCH have been described in previous studies  male sex,31,32,33Male sex, smoking habit, presence of LV hypertrophy, and high-normal clinic systolic and/or diastolic BPs are predictors of MUCH and models including these factors appear to provide good diagnostic accuracy in identifying this ambulatory BP phenotype and show a good predictive performance. The suggested prediction models may be a useful tool to select patients eligible for out-of-office BP evaluation.


Stem cell transplantation from a donor can be a potential cure for several blood cancers. We have maintained the characteristics and outcomes of patients receiving these transplants at our institution, the Ohio State University, since 1984. In this study, we looked at these outcomes, including how long patients lived after transplant, how long before their cancer came back, and if they developed other complications related to receiving a transplant, and evaluated how they changed over the years. We conclude that patients are now living longer with a lower chance of their cancer returning or of developing other complications, likely as a result of improvements in supportive care for transplant patients.p < 0.001). However, cumulative incidence of NRM decreased since 2004 (p < 0.001). Conclusions: Our data show improved OS, PFS, and GRFS post allo-SCT over decades. This may be attributed to advances in supportive care and treatments focused on mitigation of GVHD and relapse. Allogeneic hematopoietic stem cell transplantation  is a potentially curative treatment for many hematological disorders, but is often complicated by relapse of the underlying disease, graft-versus-host disease (GVHD), and infectious complications. We conducted a retrospective analysis on patients undergoing allo-SCT from 1984 to 2018 to better understand how survival has changed longitudinally with therapeutic advancements made to mitigate these complications. Method: We analyzed data from 1943 consecutive patients who received allo-SCT. Patients were divided into groups (gps) based on the year (yr) of transplant. Primary endpoints were overall survival (OS), progression free survival (PFS), and GVHD-free relapse-free survival (GRFS). Secondary endpoints were the cumulative incidences of grade II–IV and grade III–IV acute GVHD (aGVHD), chronic GVHD (cGVHD), and non-relapse mortality (NRM). Results: Our study found statistically significant improvements in OS, PFS, and GRFS. Five-year PFS among the groups increased from 24% to 48% over the years. Five-year OS increased from 25% to 53%. Five-year GRFS significantly increased from 6% to 14%, but remained relatively unchanged from 2004 to 2018. Cumulative incidences of grade II–IV aGVHD increased since 2009 ( In the past 50 years, over one million hematopoietic stem cell transplants have been performed, with approximately 42% percent being allogeneic hematopoietic stem cell transplants  . While aMultiple single institution and registry database studies have evaluated time–trend analysis of transplant-related outcomes over time ,15,16,17Hence, through this study, we investigated survival outcomes and GVHD incidence across the years from 1984 to 2018 at the Ohio State University.This study included all adult patients (age > 18) who received their first allo-SCT at the Ohio State University from 1984 to 2018. Patients under the age of 18 were excluded. Patients were divided into seven groups based on the year of transplant consisting of 5-year increments: 1984–1988, 1989–1993, 1994–1998, 1999–2003, 2004–2008, 2009–2013, and 2014–2018. These increments were selected to maximize the relative distribution of patients as well align roughly with institutional changes in the transplant protocol.9/L. Platelet engraftment was defined as the first of 7 days with a platelet of ≥20 × 109/L without platelet transfusion. Conditioning regimen and type were included as defined by the Center for International Blood and Marrow Transplantation (CIBMTR) research definitions for myeloablative (MA) and RIC [Data collected in this study included demographic information including age, self-reported race, gender, and zip code, as well as disease type, treatment regimens and responses, Karnofsky Performance Scale (KPS), and comorbidity index (CI). The following transplant characteristics were also collected: donor type , tissue type , graft-versus-host-disease (GVHD) prophylaxis, CD34 amount infused, day of neutrophil and platelet engraftment, human leukocyte antigen (HLA) loci match, gender of receipt, gender of donor, and CMV and EBV status of both the recipient and donor. Neutrophil engraftment was defined as the first of 3 consecutive days with an ANC ≥ 0.5 × 10 and RIC . TransplThe primary objective of this study was to assess how survival changed at our institution from 1984 to 2018. The primary endpoints of overall survival (OS), progression free survival (PFS), and GVHD-free relapse-free survival (GRFS) were used to compare outcomes across transplant years. The composite endpoint GRFS was assessed as the absence of grade III–IV acute GVHD (aGVHD), chronic GVHD (cGVHD) requiring system treatment, relapse, or death ,22.p-value of <0.05 was considered statistically significant. Analyses were performed using Stata 16 .The Mann–Whitney U test for continuous variables and chi-squared or Fisher’s exact test for categorical variables were used to compare patient-, disease-, and transplant-related characteristics among the seven groups. The Kaplan–Meier method was used to calculate the probabilities of OS, PFS, and GRFS and they were compared using the log-rank test. Owing to the differences in length of follow-up, considering the median follow-up of 3.5 years in the most recent transplant group, all of the survival outcomes were censored at 3 years in the analysis. Gray’s test, accounting for competing risks, was utilized to estimate cumulative incidence rates for relapse, NRM, and acute and chronic GVHD. The competing risks for GVHD were relapse and death; the competing risk for relapse was death; and the competing risk for NRM was disease-related deaths. A p < 0.001). Complete comorbidity index data were available from 2004 based on the hematopoietic stem cell transplant comorbidity scoring system (HCT-CI) developed by Sorror et al [Our analysis included 1943 consecutive patients who received an allo-SCT at the Ohio State University from 1984 to 2018 . The medor et al . Most paAs expected, the allo-SCT performed across the years consisted mainly of match-related and unrelated donors with 46.7% (n = 908) and 38.9% (n = 756), respectively . Yet, wip < 0.001) and no significant difference for grade III–IV aGVHD (p > 0.655) over the years. In our grade II–IV aGVHD model, a significantly increased risk for grade II–IV aGVHD in patients was seen with matched unrelated, haploidentical, and mismatch-unrelated donors compared with match-related donors (p < 0.001). However, a significantly increased risk for grade III–IV was only seen in patient with mismatched-unrelated donors (p = 0.048). Both grade II–IV and III–IV aGVHD risk was also significantly increased in patients receiving myeloablative conditioning compared with those receiving reduced-intensity conditioning . The incidence of cGVHD (both extensive and limited) increased - across the years.Complete GVHD data were available starting with the 1999–2003 group. The cumulative incidence of grade II–IV aGVHD increased over the years with 36%, 27%, 38%, and 52% at day 100 and 37%, 31%, 44%, and 55% at day 180 from the 1999–2003 to the 2014–2018 group , Table 3p < 0.001) compared with 1984–1988.The cumulative incidence of NRM significantly improved across the years, with 1-year NRM at 40%, 38%, 42%, 46%, 21%, 15%, and 15% and 5-year NRM at 54%, 51%, 51%, 57%, 31%, 22%, and 24% from 1984–1988 to 2014–2018 . A Cox pp = 0.004 and p = 0.019, respectively). Reduced-intensity conditioning predicted significantly higher risk for relapse compared with myeloablative conditioning ((p < 0.001); The cumulative incidence of relapse increased across the years at both the 5-year and 10-year marks. The rate of 5-year relapse was as follows: 22% (1984–1988), 21% (1989–1993), 28% (1994–1998), 24% (1999–2003), 38% (2004–2008), 38% (2009–2013), and 29% (2014–2018). The rate of 10-year relapse was as follows: 23% (1984–1988), 24% (1989–1993), 28% (1994–1998), 25% (1999–2003), 40% (2004–2008), 39% (2009–2013), and not reached (NR) (2014–2018). After adjusting for the covariates as described previously, similar results were found with significantly increased relapse in the last three groups . Notablyp < 0.001 for all; The median follow-up time was 31.3, 26.7, 22.2, 17.2, 12.9, 8.1, and 3.5 years, respectively, across the years 1984–1988, 1989–1993, 1994–1998, 1999–2003, 2004–2008, 2009–2013, and 2014–2018. From 1999 to 2018, Kaplan–Meier analysis showed statistically significant improvements in PFS, OS, and GRFS (p = 0.022). Donor gender mismatch (M–F and F–M) predicted worse OS outcomes , while only F–M mismatch was a factor in PFS outcomes (p = 0.003). Myeloablative compared with reduced-intensity conditioning did not influence outcomes in OS and PFS, but marginally predicted worse GFRS outcomes (p = 0.052), likely owing to its role on GVHD.Cox proportional hazard models were each established for PFS, OS, and GRFS. Overall, these models confirmed the findings from the Kaplan–Meier analysis for PFS, OS, and GRFS. However, GRFS modeling showed no significant increased risk among the different donor types , while OS modeling indicated significantly increased risk with haploidentical and mismatched-unrelated donors and PFS modeling showed increased risk in mismatch-unrelated donors only , and infectious complications. One factor that likely contributed to the decrease in these toxicities was the increased use of RIC regimens, particularly in older patients. The use of high-dose cyclophosphamide in conditioning regimens has also decreased over time, which likely accounts for the reductions in the incidence of hemorrhagic cystitis ,25. SeveWhile our study showed a decrease in several key complications over time, it demonstrated an overall increase in the rate of grade II–IV aGVHD, but a relative stability of grade III–IV aGVHD. Several other studies also examined trends in aGVHD over time. In a single-center study, Gooley et al. first compared allo-SCT in 1993–1997 to 2003–2007 and later performed similar comparison between cohorts in 2003–2007 to 2013–2018 ,16. The Relapse of primary disease continues to be the biggest challenge with allo-SCT. Our study showed increased risk of relapse of the years after adjusting for covariates. While Penack et al. and Mcdonald et al. showed a decrease in relapse, the improvements were minimal ,16. AddiOur study also conducted an analysis using the novel GRFS composite endpoint, useful for understanding the ideal recovery period with a balance between disease cure and ongoing morbidity . The oneOverall, in the context of several other studies, our study contributes to foundational knowledge to guide future work in allo-SCT. While aGVHD increased over the years, we saw a decrease in NRM and improvements in both OS and PFS. With GRFS being a composite endpoint balancing both aGVHD and relapse, focus should be on relapse mitigation and development of better treatment regimens for acute GVHD. We are aware of the limitations of our study. The retrospective design could introduce selection bias into our patient cohort. We were limited by the data variables available. Additionally, the increase in aGVHD II–IV could be because of the fact that there was an improvement in documentation in more recent years. Continued efforts to evaluate quality of life following allo-HCT will also be essential to tailor treatment to optimize patient-reported outcomes and minimize morbidity. Both treatment of relapse and potential maintenance therapies following transplant to mitigate relapse are also important areas of research and are the subject of several clinical trials. Studies are needed on these mechanisms and interventions for relapse to bring lasting clinical change following allo-SCTs.


ChiCTR-PNR-16007706.We aimed to explore the expression of IL-11 in ischemic stroke patients and its correlation with rehabilitation training and prognosis. The present randomized control study recruited ischemic stroke patients who were admitted during March 2014 to November 2020. All patients underwent computer tomography (CT) and magnetic resonance imaging (MRI) examination. All patients were randomly divided into two groups, including rehabilitation training (RT) group and control group. The patients in the RT group were received rehabilitation training within 2 days after the vital signs were stable while control group received routine nursing. The serum interleukin- (IL-) 11 levels were measured by enzyme-linked immunosorbent assay (ELISA) when patients were just hospitalized and 6 h, 24 h, 48 h, 72 h, and 90 h after treatment. Demographic, clinical statistics, imaging data, and the National Institutes of Health Stroke Scores (NIHSS) were recorded. The modified Rankin Scale (mRS) scores were measured after 90 days treatment to assess the prognosis of ischemic patients. The serum IL-11 levels of the RT group elevated more quickly during the study time compared with the control group. In addition, the NIHSS and mRS scores of ischemic stroke patients in the RT group were significantly lower than that in the control group. The NIHSS score, the proportion receiving rehabilitation training, and the levels of IL-11, triglyceride (TG), and high-density leptin cholesterol (HDLC) of ischemic stroke patients in the mRS score ≥ 3 group were remarkably elevated than that in the mRS score ≤ 2 group. However, the serum IL-11 levels of ischemic stroke patients were obviously decreased in the mRS score ≥ 3 group. IL-11 could be a potential diagnostic biomarker of poor prognosis of ischemic stroke patients. Furthermore, IL-11, NIHSS score, and rehabilitation training were the risk factors for poor prognosis of ischemic stroke patients. This study demonstrated that the ischemic stroke patients in the RT group had higher serum IL-11 levels and better prognosis. This study might provide a new approach to improve the prognosis of patients with ischemic stroke. This trial is registered with  As a major reason of permanent disability , 2, stroin vivo, including anti-inflammatory, cardioprotective, and reducing apoptosis 2/δ was used. We used the NIHSS scores 3 months after admission as the main variable and the difference of NIHSS scores between two groups at least 1 as effective. The mean NIHSS scores were about 5 ± 3 after 3 months after admission according to the clinical experience. Thus, δ = 1, s = 3, α = 0.05, and β = 0.10. And the minimal sample size was 189.All patients were randomly divided into two groups using a computer-generated list by Rv, including rehabilitation training (RT) group and control group. Uniform formula uses SPSS software . For calculation of sample size, the formula of [. The serum cytokine levels were measured when patients were just hospitalized and 24 h, 48 h, 72 h, and 90 h after treatment.The serum IL-11 and other inflammatory factors levels were measured by enzyme-linked immunosorbent assay (ELISA). Blood samples of fasting cubital venous (5 mL) were collected within 24 h after admission for all cases. Samples were centrifuged at 2000 g for 15 min, following with ELISA tested using commercially available kits , systolic blood pressure (SBP) and history of hypertension, hyperlipidemia, and diabetes were collected. Using an automatic biochemical analyzer to performed whole blood test by Hitachi 7600 of Hitachi Corporation, the total cholesterol (TC), fasting plasma glucose (FPG), triglyceride (TG), low-density leptin cholesterol (LDLC), and high-density leptin cholesterol (HDLC) levels were recorded. Imaging indexes of MRI and CT including infarct location, infarct volume, multiple or single, and vulnerable plaque were collected. The National Institutes of Health Stroke Scores (NIHSS) were recorded when the subjects were hospitalized to assess the severity of stroke. Using the modified Rankin Scale (mRS) to assess the prognosis after 90 days of treatment, mRS score ≥ 3 indicated a bad prognosis, and mRS score ≤ 2 indicated a good prognosis.t test was used for comparison between two groups. Chi-square test was used for rates. ROC curves assess the diagnostic value of IL-11 for poor prognosis of ischemic stroke patients. Logistic regression was performed for risk factors of bad outcome of ischemic stroke. P < 0.05 is regarded as significantly different. All data used SPSS 18.0 to statistical analyses.Data were expressed by mean ± SD or median (range) according to distribution, which was confirmed by Kolmogorov-Smirnov analysis. Mann–Whitney test or Student's n = 197) and control group (n = 207). The basic characteristics of two group patients were shown in This study enrolled 404 ischemic stroke patients. All patients were randomly divided into the RT group (P < 0.05), while IL-6 and TNF-α decreased quickly in the RT group. To further investigate the correlation between the recovery of ischemic stroke patients and rehabilitation training, we measured NIHSS and mRS scores after 90 days treatment. The results indicated that the NIHSS and mRS scores of ischemic stroke patients in the RT group were significantly lower than that in the control group (P < 0.05). Spearman's analysis showed that IL-11 was negatively correlated with NIHSS and mRS scores . In addition, the serum IL-11 levels of ischemic stroke patients were obviously decreased in the mRS score ≥ 3 group.All patients measured mRS scores after 90 days of treatment and divided into two groups including the mRS score ≤ 2 group and mRS score ≥ 3 group. Compared with the demographic and clinical data of two groups when the patients were hospitalized, we found no significant differences in age, sex, BMI, smoking proportion and levels of FPG, TC, and LDLC between the mRS score ≤ 2 group and mRS score ≥ 3 group . The NIHWe draw ROC curves to assess the diagnostic value of IL-11 for poor prognosis of ischemic stroke patients. The result showed that IL-11 could be a potential diagnostic biomarker of poor prognosis of ischemic stroke patients , the AUCP = 0.03), NIHSS score, infarct volume, TG, HDLC, and IL-6 were the risk factors for bad prognosis of ischemic stroke patients (Finally, the risk variables for poor prognosis in ischemic stroke patients were calculated using binary regression analysis. It was found that IL-11 (95% CI 0.346~0.799, patients .Although intravenous thrombolysis and thrombectomy can be effective in the treatment of ischemic stroke, progressive neuronal degeneration and functional loss remain difficult to resolve during treatment and rehabilitation. Cerebral ischemia promotes the production of proinflammatory mediators and induces cell death and cell dysfunction, thus inducing neuroinflammation. Excessive inflammation can produce neurotoxins and brain edema. Recently, poststroke immune response has recently a new breakthrough goal in the treatment strategy of ischemic stroke , 25. In Rehabilitation training can improve the prognosis and daily living of ischemic stroke patients. A nationwide retrospective cohort study in Japan confirmed that early rehabilitation training can improve the daily living of ischemic stroke patients . The relSome biomarkers have been found correlated to the prognosis of ischemic stroke patients. Kwan et al. found that the increasing of IL-6 was related to the severity and infection of ischemic stroke patients, and serum IL-6 levels could predict the mortality in the first two years after stroke . Wang etThis present research also has some limitations. First, this is a single-center study. Secondly, we only checked a small number of biomarkers. Thirdly, the molecular mechanism of IL-11 affecting ischemic stroke development is unclear.In summary, the present study showed that the ischemic stroke patients in the RT group had higher serum IL-11 levels and better prognosis, indicating that rehabilitation training might improve the prognosis of ischemic stroke patients and elevate the levels of IL-11. This study may provide a new approach to screen ischemic stroke patients with worse prognosis in advance, as well as provide a new approach to improve the prognosis of ischemic stroke patients.